*' NLM 00036100 1 IVNOIIVN 3NIDIQ3W dO AHVaail IVNOIIVN 3NIDIQ3W dO ASVaan IVNOIIVN 3NIDI MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIO IVNOIIVN 3NIDI03W JO AHVJian IVNOIIVN 3NIDIQ3W dO A8V88n IVNOIIVN 3NI3I / 1 ^ MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MED 6! IVNOIIVN 3NIDIQ3W dO AHVaan IVNOIIVN 3NIOI03W dO AHVaan IVNOIIVN 3NOI MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIC IVNOIIVN 3NIDIQ3W dO AHVaail "IVNOIIVN 3NIDIQ3W dO Aavaail IVNOIIVN 3NID 6 i^Mfffl 4 \W NLM000381009 l\3 NAII%F MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE IS). I 2 !Noiajian 1VNO)iVN 3NiDia3w do Aavaan ivnoiivn snidiosw do Aavaan ivnoiivn A' NATIONA. DF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE JNIDKMgn IVNOIIVN 3NIDI03W dO AaVaail IVNOIIVN 3NIDI03W dO AHVaan IVNOIIVN NATION; .OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE KfMy \ Man ivnoiivn SNiDiasw do Aavaan ivnoiivn snidiqsw do Aavaan ivnoiivn #7 OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE /*>? MINOR SURGERY *"r BANDAGING INCLUDING THE TREATMENT OF FRACTURES AND DISLOCATIONS, TRACHEOTOMY, INTUBATION OF THE LARYNX, LIGATIONS OF ARTERIES AND AMPUTATIONS. BY HENRY R. WHARTON, M.D., DEMONSTRATOR OF SURGERY AND LECTURER oTT"STrRfltfCAL DISEASES OF CHILDREN IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE PRESBYTERIAN HOSPITAL, THE METHODIST EPISCOPAL HOSPITAL, AND THE CHILDREN'S HOSPITAL; CONSULTING SURGEON TO THE PRESBYTERIAN ORPHANAGE. SECOND EDITION, THOROUGHLY REVISED AND ENLARGED, WITH FOUR HUNDRED AND SIXTEEN ILLUSTRATIONS. PHILADELPHIA: LEA BEOTHERS & 1893. CO. { Entered according to the Act of Congress, in the year 1893, by LEA BROTHERS & CO., In the Office of the Librarian of Congress. All rights reserved. DORNAN, PRINTER. PREFACE TO SECOND EDITION. The author has been much gratified at the favorable reception which has been accorded to this work, and has endeavored in the preparation of a second edition to make it more worthy of a continuance of that favor. The aseptic and antiseptic methods of wound treatment have been thoroughly revised, and a considerable amount of new matter, with a number of new illustrations, have been added. Tlie author's thanks are due to Dr. Joseph P. Tunis for his kind assistance in revising the proof- sheets. 112 South Eighteenth St., Philadelphia, July, 1893. PREFACE TO THE FIRST EDITION. The author has, in this work, endeavored to present, in as concise a manner as possible, a description of the various bandages, surgical dressings, and minor surgical procedures which are employed in the practice of surgery at the present time. The preparation and application of the antiseptic dressings now most commonly used have also received full consideration. The article upon Ban- daging is fully illustrated with cuts, mostly new and taken from photographs, which, it is hoped, will prove of value as furnishing an accurate representation of the most important bandages used in surgical practice; the same is in a measure true of the article upon the dressing of Fractures and Dislocations, in which many new cuts of the same kind appear. The work also contains short articles upon Trache- otomy, Intubation of the Larynx, Ligation of Arteries, and Amputations, and, although these procedures are scarcely to be included with those of Minor Surgery, it is hoped that their description will increase the value of the work to medical students, for whose use it has vi PREFACE TO FIRST EDITION. been prepared. The author's thanks are due to Dr. Walter D. Green for his kind assistance in revising the proof-sheets, and to Mr. James Wood for the skilful photographic work used in illustrating several of the articles. 112 South Eighteenth St., Philadelphia, August, 1891. CONTENTS. PAET I. BANDAGING. PAGES Varieties of Bandages......13-33 Bandages for the Head and Neck . . . 33-49 Bandages of the Upper Extremity . . . 49-66 Bandages of the Trunk......66-72 Bandages of the Lower Extremity . . . 72-84 Special Bandages.......84-91 Fixed Dressings or Hardening Bandages . . 91-108 PART II. MINOR SURGERY. Theory of Asepsis and Antisepsis in Wound Treatment........109-111 Antiseptic Agents Employed.....111-119 Preparation of Materials Used in Aseptic Sur- gery and Dressings......120-126 Preparation of Gauze Dressings .... 126-131 Methods and Dressings Employed in the Treat- ment of Wounds to Secure Asepsis . . 132-133 Preparation for Aseptic Operation . . . 133-143 Materials Used in Surgical Dressings . . 144-158 Procedures Employed in Minor Surgery . . 158-209 Anesthetics.........209-220 Trusses..........220-224 viii CONTENTS. PAGES Use of Catheters and Bougies .... 224-234 Sutures..........235-253 Ligatures Used in the Treatment of Vascular Growths.........254-259 Treatment of Hemorrhage.....259-281 Opening and Dressing of Abscesses . . . 282-285 Dressing of Wounds, Burns and Scalds, Bed- sores, Sprains.......285-294 Tracheotomy, Laryngotomy, and Laryngo-Tra- cheotomy........294-306 Intubation of the Larynx.....306-311 PART 111. FRACTURES . . . 312-325 Treatment of Special Fractures .... 325-385 PART IV. DISLOCATIONS . . . 386-388 Special Dislocations.......388-417 PART Y. LIGATION OF ARTERIES . . 418-420 Ligation of Special Arteries.....420-452 PART VI. AMPUTATIONS ... 453 Special Amputations.......467-509 Index 511 PART I. BANDAGING. Bandacks constitute one of the most widely used and important surgical dressings; they are employed to hold dressings in contact with the surface of the body, to make pressure, to hold splints in place in the treatment of frac- tures and dislocations, and to restore to their natural posi- tion parts which may have become displaced. Bandages may be prepared of various materials, such as linen, crinoline, flannel, cheese or tobacco cloth, rubber sheeting, or muslin, bleached or unbleached; the latter ma- terial is the most commonly employed, by reason of the ease with which it is obtained and its cheapness ; flannel, from its elactieity, is sometimes used, but its employment for bandages is now generally limited to its use in dressings for operative work in connection with the eye, and for a primary roller in the application of the plaster-of-Paris dressings. Bandages are either simple, when composed of one piece of material such as the ordinary roller bandage, or com- pound when prepared of one or more pieces, adapted by size and shape to peculiar objects. Bandages are also described as uniting, dividing, com- pressing, expelling, or retaining bandages, according to the purposes they serve by their application. The importance of being perfectly familiar with the gen- eral rules of bandaging and proficient in the application of the roller bandage cannot be overestimated, and both the student and general practitioner will never have cause to 2 14 BANDAGING. regret the time occupied in learning to apply neatly this form of surgical dressing. A well-applied bandage adds to the comfort of the pa- tient, and the method of its application often secures for the physician the confidence both of the patient and of his friends, while, on the other hand, a badly applied bandage is apt to be uncomfortable and insecure, and to meet with their adverse criticism. The Roller Bandage. The roller bandage consists of a strip of woven material, prepared from some of the materials previously mentioned, of variable length and width according to the portion of the body to which it is to be applied ; this, for ease of application, is rolled into a cylindrical form. The material commonly employed for the roller bandage is unbleached muslin, although, for special purposes, linen, Fig. i. Bandage winder. flannel, rubber sheeting, crinoline or cheese-cloth mav be used. It is important that the roller bandage should con- sist of one piece, free from seams and selvage, for if made of a number of pieces sewed together, or if it contains THE ROLLER BANDAGE. 15 creases or selvage, it cannot be so neatly applied, and it is not so comfortable to the patient, as it is apt to leave creases upon the skin. In preparing the ordinary muslin bandage the material is torn in strips varying in length and width according to the part of the body to which it is to be applied, and it is then rolled into a cylinder, either by the hand or by a machine constructed for the purpose. * (Fig. 1.) It is important that every student and practitioner should be able to roll a bandage by hand, for in practice Fig. 2. Rolling a bandage by band. the medical attendant may at any moment be called upon to roll a bandage, in order to apply a dressing, and as the art of preparing a bandage is acquired by a little practice, it should be familiar to every student and physician. To roll a bandage by hand the strip should be folded at one extremity several times until a small cvlinder is formed ; this is then grasped by Its extremities by the thumb and index finger of the left hand ; the free extremity of the strip is then grasped between the thumb and index finger of the right hand, and by alternate pronation and supina- tion of the right hand the cylinder is revolved and the 16 BANDAGING. roller is formed ; the firmness of the roller will depend upon the amount of tension which is kept upon the free extremity of the strip during the revolution of the cylinder. (Fig. 2.) Fig. 3. Single roller. Fig. 4. Double roller. A bandage rolled in the form of a cylinder is called a single or single-headed roller ( Fig. 3); if rolled from each extremity toward the centre so that two cylinders are GENERAL RULES FOR BANDAGING. 17 formed joined by the central portion of the strip, the double or double-headed roller is formed. (Fig. 4.) Double rollers are not much used, and in practice the single roller will be found to be amply sufficient for the application of almost all the bandages employed in surgical dressings. The free end of the roller bandage is called the initial extremity ; the end which is enclosed in the centre of the cvlinder is its terminal extremity; and the portion between the extremities the body; a roller has also two surfaces, external and internal. I )LMEXSI(>NS OF B A XDA(; i-;s. Bandages vary in length and width according to the pur- poses for which they are employed, and in practice it will be found that a small variety of bandages will be amply sufficient for the application of the ordinary surgical dressings. The following list comprises those most frequently used and will show their dimensions : Bandage one inch wide, three yards in length, for ban- dages for the hand, fingers, and toes. Bandage two inches wide, six yards in length, for head bandages and for the extremities in children. Bandage two and a half inches wide, seven yards in length, for bandages of the extremities in adults; a roller of this size is the one most generally used. Bandage three inches wide, nine yards in length, for ban- dages of the thigh, groin, and trunk. Bandages four inches wide, ten yards in length, for ban- dages of the trunk. General Rules for Bandaging. In applying a roller bandage the operator should place the external surface of the free' extremity of the roller upon the part, holding it in position with the fingers of the left hand until fixed by a few turns of the roller, the cylinder being held in the right hand by the thumb and fingers; 18 BANDAGING. for thus as the bandage is unwound it rolls into the operator's hand, thereby giving him more control of it; care should also be taken that the turns are applied smoothly to the surface, and that the pressure exerted by each turn is uniform. If a bandage be applied to a limb the surgeon should sec that the part is in the position it is to occupy as regards flexion and extension when the dressing is completed, for a bandage applied when the limb is flexed will exert too much pressure when the limb is extended, and then may, by the pressure it exerts, become a matter of discomfort or even of danger to the patient, or if applied to an extended limb will become uncomfortable upon flexion. Fig. 5. Method of removing a bandage. My experience has been that, as a rule, those who have had little experience with the application of the roller bandage are apt to apply their bandages too tightly, and VARIETIES OF BANDAGES. 19 this may lead to disastrous consequences, especially in the dressing of fractures. Professor Ashhurst, in his clinical teaching, advises students to make use of a larger number of turns of a bandage in securing fracture dressings rather than to depend upon a few turns too firmly applied ; advice which certainly conduces to the safety and comfort of the patient. When the bandage has been applied the terminal extremity should be secured by a pin or safety-pin applied transversely to the bandage, and if a pin be used its point should be buried in the folds of the bandage; if the Fig. 6. Bandage scissors. bandage is a narrow one, the end may be split and the two tails resulting may be secured around the part by tying. In removing a bandage the folds should be care- fully gathered up in a loose mass as the bandage is unwound, the mass being transferred rapidly from one hand to the other, thus facilitating its removal and pre- venting the part from becoming entangled in its loops. (Fig. ").) If it is desirable to cut the bandage to remove it, the use of scissors made for this purpose Avill be found most satisfactory. (Fig. (i.) Varieties of Bandages. The Circular Bandage. This bandage consists of a few circular turns around a part, each turn covering accurately the preceding turn. This varietv of bandage may be used to retain a dressing 20 BANDAGING. to a limited portion of the head, neck, or limbs, to make compression upon the veins of the arm before performing venesection. (Fig. 11, 6.) The Oblique Bandage. In this form of bandage the turns are carried obliquely over the part, leaving uncovered spaces between the suc- Oblique bandage. cessive turns. (Fig. 7.) Its principal use is for the application of temporary dressings. The Spiral Bandage. In this bandage the turns are carried around the part in a spiral direction, each turn overlapping a portion of the Fig. 8. Ascending spiral bandage. preceding one, usually one-third or one half, it mav be applied as an ascending spiral (Fig. 8) or as a descending VARIETIES OF BANDAGES. 21 spiral (Fig. !)). This bandage may be used to cover a part which does not increase too rapidly in diameter, for instance the abdomen, chest, or arm. Descending spiral bandage. The Spiral Reversed Bandage. This bandage is a spiral bandage, but differs from the ordinary spiral bandage in having its turns folded back or reversed as it ascends a part, the diameter of which gradu- ally increases. By its use it is possible to cover by spiral turns a part conical in shape, so as to make equable pressure upon all parts of the surface. The reverses are made as follows : After fixing the initial extremity of the roller, as the part increases in diameter the bandage is carried off a little obliquely to the axis of the limb for from four to six inches ; the index finger or thumb of the disengaged hand is placed upon the body of the bandage to keep it securely in place upon the limb, the hand hold- ing the roller is carried a little toward the limb to slacken the unwound portion of the bandage, and by changing the position of the hand holding the bandage from extreme supination to pronation the reverse is made. (Fig. 10.) Care should be taken not to attempt to make the reverse while the bandage is tense, for by so doing the bandage is 22 BANDAGING. twisted into a cord which is unsightly and uncomfortable to the patient, instead of forming a closely fitting reverse. Fig. 10. Method of making reverses, The reverse should be completed before the bandage is carried around the limb, and when it has been completed the bandage may be slightly tightened so as to conform to the part accurately. The reverses should be in line to have the bandage present a good appearance, and care should be taken that the reverses should not be made over salient parts of the skeleton, for if they occupy such positions they cause creases in the skin and become uncomfortable to the patient. To make reverses neatly and to have them in line requires skill and practice ; a well-applied spiral reversed bandage is a test of a competent bandager. Spica Bandages. When the turns of the roller cross each other in the form of the Creek letter lambda, leaving the previous turn VARIETIES OF BANDAGES. 23 about one-third uncovered, the bandage is known as a spica bandage. (Fig. 11, a.) These spica bandages are especially serviceable as a means of retaining surgical dressings upon particular portions of the surface of the body, such as to the shoulder, groin, or foot. Fig. 11. Spica bandage. Circular bandage. Figure-of-eight Bandage. This bandage receives its name from the turns being applied so as to form a figure-of-eight. This method of application is made use of in the Barton's bandage, the bandages of the knee and elbow, and many other bandages. Fig. 12. Recurrent bandage. 24 BANDAGING. Recurrent Bandage. This bandage derives its name from the fact that the roller after covering a certain part of the surface is re- flected and brought back to the point of starting; it is then reversed and carried toward the opposite point, and this manipulation is continued until the part is covered by these recurrent turns, which are then secured by a few circular turns. (Fig. 12.) This is the bandage usually employed in the dressing of stumps. Compound Bandages. These bandages are usually formed of several pieces of muslin or other material, and are employed to fulfil some special indication in the application of dressings to par- ticular parts of the body. The most useful of the com- pound bandages are the T-bandages and the many-tailed bandages. T-bandages. The single T-bandage consists of a horizontal band to which is attached, about its middle, another having a ver- FlG. 13. Single T-bandage. tical direction ; the horizontal piece should be about twice the length of the vertical piece. (Fig. 13.) The single T- COMPOUND BANDAGES. 25 bandage may be used to retain dressings to the head, the horizontal piece being passed around the head from the occiput to the forehead, the vertical piece being passed over the head and secured to the horizontal piece; the shape and width of the two pieces being varied according to the indications. In applying dressings to the anal region, or perineum, or in securing a catheter in a perineal wound, the single T-bandage will be found most useful. In applying a T-bandage for this purpose the body of the bandage is placed over the spine, just above the pelvis, and the horizontal portion is tied around the abdomen. The free extremity is split into two tails for about two-thirds Fig. 14. Single T-bandage for chest. of its length, and is carried over the anal region and brought up between the thighs, the terminal strips passing one on each side of the scrotum and being secured to the horizontal strip in front. The single T-bandage may be variously modified according to the indications which are to be met ; for instance, in applying a dressing to the breasts the horizontal strip passing around the chest may be made ten or twelve inches in width, the vertical strip, two inches in width, passes from the back over the shoulder and is secured to the horizontal strip in front. (Fig. 14.) The single T-bandage may be variously modified, according to the ideas of the surgeon, so as to meet the indications 26 BANDAGING. presented in special cases. For the groin a piece of muslin six inches wide at its base and thirty inches long Fig. 15. T-bandage of groin. is sewed to a horizontal strip of muslin one and a half yards long and two inches in width. It may be applied as in Fig. 15 to hold a dressing to this part. Double T-bandage. The double T-bandage differs from the single bandage in having two vertical strips attached to the horizontal strip, and it may be used for much the same purposes as the single T-bandage. (Fig. 16.) It may be conveniently used for retaining dressings to the chest," breasts, or abdo- men ; when used for this purpose the horizontal portion should be from eight to twelve inches wide and long enough to pass one and a quarter times about the chest; two vertical strips, two inches wide and twenty inches long, should be attached to the horizontal strip a short COMPOUND BANDAGES. 27 distance apart near its middle. In applying this bandage to the chest, the horizontal strip is placed around the chest so that the vertical strips occupy a position on either side Fig. 16. Double T-bandage. of the spine; the overlapping end of the horizontal portion is secured by pins or safety-pins, and the vertical strips Fin. 17. Fig. 18. Double T-bandage of chest. Double T-bandage of nose. are next carried one over either shoulder and secured to other portions of the bandage in front of the chest. (Fig. 17.) 28 BANDAGING. The double T-bandage may also be used to secure dress- ings to the nose, in which event the strips should be quite narrow, about one inch in width, and should be applied as shown in Fig. 18. Many-tailed Bandages or Slings. These bandages are prepared from pieces of muslin of various lengths and breadths, which are split at each ex- tremity into two, three, or more tails up to within a few inches" of their centres, their width and length being regu- lated by the part of the body to which they are applied. Fig. 19. Fig. 20. The four-tailed bandage may be found useful as a tem- porary dressing in cases of fracture of the jaw, or to hold dressings to the chin. It may be prepared by taking a portion of a roller bandage three inches wide and one yard in length, and splitting each extremity up to within two inches of the centre; it is then applied as seen in Fig. 19. The four-tailed bandage may also be used to retain dressings to the scalp, and can be prepared by taking a piece of muslin one yard and a quarter long and six or HANDKERCHIEF BANDAGES. 29 eight inches in width, splitting it at each extremity into two tails within three inches of the centre; it may then be applied as seen in Fig. 20. The four-tailed bandage may also be used in the tem- porary dressing of fractures of the clavicle—the body of the bandage being placed upon the elbow of the injured side, two tails passing around the body, fixing the arm to the side, and two tails passing over the sound shoulder. The many-tailed bandage may also be used for holding dressings in contact with the abdomen or trunk, and is the bandage which many surgeons employ to hold the dressings to a cu'liotomy wound, and to give support to the abdom- inal walls after this operation. In preparing this bandage, a strip of muslin, one and a half yards in length and eighteen to twenty inches in width, is required, and the extremities may be *plit so as to form an eight-tailed bandage. In applying this bandage to the abdomen, the body is placed upon the patient's back and the tails are brought around the abdomen and overlap each other, and when sufficiently firmly drawn to make the desired amount of pressure, they are secured by means of safety-pins. Handkei:< iiief Baxdages. The use of handkerchiefs or square pieces of muslin for the temporary or permanent dressing of wounds, fractures, or dislocations was advocated many years ago by M. Mavor, a Swiss surgeon, who wrote an extensive work upon this subject, in which he reduced their application to a system. He employed a handkerchief or a square piece of muslin, and by various modifications in the application of these, developed a number of very ingenious bandages. The various forms which the handkerchief or square (Fig. 21) is made to assume are as follows: The oblong, made by folding the square once or twice on itself ( Fig. 22). The triangle, made by bringing together the diagonal angles of the square (Fig. 23). The line of folding is known as the base, the angle opposite the base the apex, and the other angles the extremities. BANDAGING. Fig. 21. Fig. 22. .^ i* \ _.=~^ 1! ii iiji .Jur:^_______ -"\- ""....._|| jil-. 1' j; ■=;;:■,... ■ -;-r:r"f i, [! il : : JL---- i!'':: _.,,_ ._.lv—*____ _... -:=:=== J-- Jheb 1: "fL-. 1....... iif \ - :i; - =— '4 _______'iii-------^ 'SL - ■: ., - The square. The oblong. Fig. 23. The cord. The cravat is prepared from the triangle by bringing the apex to its base, and folding it a number of times upon itself until the desired width is obtained. (Fig. 24.) HANDKERCHIEF BANDAGES. 31 The cord is formed from the cravat twisted upon itself ( Fig. 25). The names of the various handkerchief ban- dages are derived from the shape of the handkerchiefs used and the parts to which they are applied; the names serve as guides in their application. It is to be remem- bered that the base of the triangle or the body of the cravat is to be placed upon the portion the designation of which forms the final portion of the name of the bandage; thus, in the.fronto-occipitaI triangle, the shape of the hand- kerchief is given, and we know that the base of the triangle is to be applied to the forehead and then pass to the occiput. In using the cravats the same rule applies; thus, in the bis-axillary cravat, the body of the cravat is Fig. 26. Bis-axillary cravat. to be placed in the axilla of the affected side, the extremi- ties crossed over the corresponding shoulder and carried over the chest, one before, the other behind, to the axilla of the opposite side, where they arc secured. To apply the bis-axillary cravat (Fig. 26), a piece of muslin a yard and a quarter long and eighteen inches in width folded into a cravat is required; this bandage maybe used to hold dressings to the axilla. 32 BANDAGING. The Cruro-pelvic Triangle. This bandage may be applied with a piece of muslin folded into a triangle a yard and a half long and two feet deep. It is applied by placing the base of the triangle obliquely across the right groin and conducting the superior extremity around the left side, across the loins to the right groin, when it is secured. The inferior end should be carried around the upper part of the right thigh between it and the scrotum, to a point near the superior extremity, and fastened with a pin (Fig. 27); this bandage may be employed to secure dressings to the groin, hip, and upper portion of the thigh. Fig. 27. Cruro-pelvic triangle. I have described a few of the many very ingenious ban- dages devised by Mayor to substitute the use of the roller bandage, which will give the student some idea of their design and application. It is well to bear in mind this system of dressing, for the occasion might occur in which the other means of bandaging could not be obtained, and the use of handkerchiefs might answer a useful purpose as temporary dressings. I think their principal use is for temporary dressings, and I do not think tliev will ever take the place of the roller bandage, which can be applied barton's bandage. 33 with much greater nicety and exactness, and certainly pre- sents a much neater appearance. Barton's Handkerchief This dressing may be employed to make extension in cases of fracture of the leg or thigh. It is applied by taking a handkerchief folded into a narrow cravat and placing the body of it on the extremity of the os ealcis below the insertion of the tendo Achillis, so that two-thirds of the cravat comes around under the outer malleolus, and the other third remains on the inside. The inside portion remaining parallel with the sole of the foot, the outside piece is carried over the instep and passed around it so as to form a knot, and also passed under the sole of the foot to be turned around the first turn and to form another knot at the metatarsal articulation, when both ends are carried off perpendicularly from the foot. REGIONAL BANDAGING. Bandages for the Head and Neck. Barton's Baxdage. Roller Tiro Inches in Width, Six Yards in Length, Application.—The initial extremity of the roller should be placed on the head just behind the mastoid pro- cess, and the bandage should then be carried under the • occipital protuberance obliquely upward under and in front of the parietal eminence across the vertex of the skull, then downward over the zygomatic arch, under the chin, thence upward over the opposite zygomatic arch and over the top of the head, crossing the first turn, which was made as nearly as possible in the median line of the skull, carrying the turns of the roller under the parietal eminence to the point of commencement. The bandage 34 REGIONAL BANDAGES. Fig. 28. Barton's bandage. is then passed obliquely around under the occipital pro- tuberance and forward' under the ear to the front of the chin, thence back to the point from which the roller started. These figure-of-eight turns over the head and the circular turns from the occiput to the chin should be repeated, each Fig. 29. Barton's bandage showing crossing of turns at vertex. MODIFIED BARTON'S BANDAGE. 35 turn exactly overlapping the preceding one until the ban- dage is exhausted. (Fig. 28.) The extremity should then be secured by a pin; and pins should be introduced at the points where the turns cross each other to give additional fixation to the bandage. In applying the bandage care should be taken to see that the turns overlap each other exactly, and that the turns passing over the vertex cross as near as possible in the median line of the skull (Fig. 2!)). Modified Barton's Bandage. To obtain additional security in the application of the Barton's bandage a turn of the bandage passing from the occiput to the forehead may be made, this turn being interposed between the turns of the bandage as ordinarily applied. (Fig. 30.) In applying this bandage after the Fig. |30. first set of turns has been completed, that is after the bandage has been brought back to the occiput, the bandage is carried forward upon the head just over the ear, around the forehead and backward above the ear on the opposite side to the occiput; this being done, the ordinary figure- of-eight and circular turns are made, and when these have been completed another occipitofrontal turn may be made as described above, and this may be repeated as often as is 36 REGIONAL BANDAGES. desired until the bandage is exhausted, when the extremity is fastened with a pin, and pins are also introduced at all points at which the turns cross. Use.—This bandage is one of the most useful of the bandages of the head, being employed to secure fixation of the jaw in cases of fracture or dislocation, and for the application of dressings to the chin. I have also employed it in place of the head-gear in slinging patients for the application of the plaster-of-Paris bandage in eases of* disease of the spine, a stout cord or a piece of bandage about three inches wide and one yard long being passed under the turns crossing over the vertex; this cord is then secured to the cross-bar of the extension apparatus; this will be found quite as comfortable to the patient as the ordinary head-gear employed and much less likely to slip out of place and interfere with the breathing of the patient, A firmly applied Barton bandage holds the jaws so closely together that care should be taken in applying it to patients who are under the influence of an anaesthetic, for if vomiting occurs the material mav not be able to escape from the mouth and suffocation might occur unless the bandage were promptly removed. This accident I once saw occur and the patient's condition was alarming until the bandage was cut, allowing the jaw to be opened and the contents of the mouth to escape. Gibson's Bandage. Roller Two Inches in Width, Six Yards in Length. Application. — The initial extremity of the roller should be placed upon the vertex of the skull in a line with the anterior portion of the ear ; the bandage is then carried downward in front of the ear to the chin, and passed under the chin, and is carried upward on the same line until it readies the point of starting. The same turns are repeated until three complete turns have been made; the bandage is then continued until it reaches a point just above the ear, when it is reversed and is carried backward GIBSON'S BANDAGE. 37 around the occiput, and is continued around the head and forehead until it reaches its point of origin; these circular turns are continued until three have been made. When the bandage reaches the occiput, having completed the third turn, it is allowed to drop down to the base of the skull, and it is then carried forward below the ear and around the chin, being brought back upon the opposite side of the head and neck to the point of origin ; these turns are repeated until three complete turns have been made, Fig. 31. Gibson's bandage. and upon the completion of the third turn the bandage is reversed and carried forward over the occiput and vertex to the forehead, and its extremity is here secured with a pin. Pins should also be applied at the points where the turns of the bandage cross each other. (Fig. 31.) Fsk.—This bandage may be used to fix the lower jaw in cases of fracture or dislocation of the jaw, but is more apt to change its position, and is, therefore, not so satis- factorv as the Barton's bandage for this purpose. 38 REGIONAL BANDAGES. Oblique Bandage of Angle of the Jaw. Roller Two Inches in Width, Six Yards in Length. Application.—The initial extremity of the roller is placed just in front of and above the left ear, and if the left angle of the lower jaw is to be covered in, the bandage is to carried from left to right, making two complete turns around the cranium from the occiput to the forehead. If the right angle of the lower jaw is to be covered in, the turns should be made in the opposite direction. Haying made two turns from the occiput to the fore- head, the bandage is allowed to drop down upon the neck, and is carried forward under the ear and under the chin Fig. 32. Oblique bandage of angle of the jaw. to the angle of the jaw ; it is now carried upward close to the edge of the orbit, and obliquely over the vertex of the skull, then down behind the right ear, continuing this oblique turn under the chin to the angle of the left jaw, where it ascends in the same direction as the previous turn. Three or four of these oblique turns are made, each turn overlapping the preceding one and passing from the edge RECURRENT BANDAGE OF THE HEAD. 39 of the orbit toward the ear until the space is covered in ; the bandage is then carried to a point just above the ear on the opposite side, is reversed, and finished with one or two circular turns from the occiput to the forehead, the extremity being secured by a pin. (Fig. 32.) F*E.—This will be found to be one of the most useful of the head bandages; it may be used with a compress in treating fractures of the angle of the lower jaw, for holding dressings to the lower part of the chin and to the vault of the cranium, and is especially useful in retaining dressings to the sides of the face and the parotid region. As before stated, it may be applied to cover either the right or left side of the face, and, by reason of the oblique turns, holds its position most securely, having little tendency to become displaced. Recurrent Bandage of thi: Head. Roller Tiro Inches in Width, Eight Yards in Length. Application-.—The initial extremity of the roller is placed upon the lower part of the forehead and the ban- dage is carried twice around the head from the forehead to the occiput to secure it. When the bandage is brought back to the median line of the forehead it is reversed and the reversed turn is held by the finger of the left hand while the roller is carried over the top of the head along the sagittal suture to a point just below the occipital pro- tuberance ; here it is reversed again and the reverse is held by an assistant while the roller is carried back to the forehead in an elliptical course, each turn covering in two- thirds of the preceding turn. These turns are repeated with successive reverses at the forehead and occiput until one side of the head is completely covered in, and when this is accomplished a circular turn is made from the fort- head to the occiput to hold the reverses in place. The opposite side of the head is next covered in by elliptical reversed turns made in the same manner, and when this has been accomplished two or three circular 40 REGIONAL BANDAGES. turns are carried around the head from the forehead to the occiput to fix the previous turns. Pins should be applied at the forehead and occiput at the points where the re- versed turns concentrate. (Fig. 33.) Fig. 33. Recurrent bandage of the head. Use.—This bandage when well applied is one of the neatest of the head bandages, and it will be found useful to retain dressings to the vault of the cranium in the treat- ment of wounds of the scalp in this region. It will also be found of service in holding dressings to fractures of the cranium and to wounds after the operation of trephining. In restless patients it will sometimes become displaced, and it may be rendered more secure by pinning a strip of bandage to the circular turn in front of the ear and carry- ing it down under the chin and up to a corresponding point on the opposite side, where it is pinned to the cir- cular turn; or one or two oblique turns passing from the circular turn over the vertex of the skull downward behind the ear, under the chin and up to the circular turn in front of the ear may be applied. The course of these turns is the same as those employed in the oblique bandage of the angle of the jaw, the extremity being secured by a pin. TRANSVERSE RECURRENT BANDAGE. 41 TliAXSVEPSE IvFCI'IiHEXT BAXDAGE OF HEAD. Roller Tiro Inches in Width, Six Yards in Length. Application'.—The initial extremity of the roller is placed upon the lower part of the forehead and the ban- dage is carried twice around the head from the forehead to the occiput to secure it. The head is then covered in by transverse turns of the bandage; the first turn, starting from a point behind the ear on one side, is carried below the occiput to a corresponding point behind the opposite ear, and ascending transverse turns are then made and carried over the head, each turn covering in about two- thirds of the preceding turn, until the forehead is reached, and when this has been reached two or three circular turns Fig. 31. Transverse recurrent bandage of head. are carried around the head from the forehead to the occiput to fix the recurrent turns. Pins should be applied at the point of starting of the reversed turns behind the cars, and at the occiput and forehead. (Fig. 34.) Fsf.—This bandage may be employed to secure dress- ings to the scalp in case of wounds, or in injuries to the 42 REGIONAL BANDAGES. skull, and is used for the same purposes as the recurrent bandage of the head. © V-BANDAGE OF THE HEAD. Roller Two Inches in Width, Four Yards in Length. Application.—The initial extremity of the roller is secured by two turns of the bandage around the cranium from the forehead to the occiput, and when the roller reaches the occipital protuberance it is allowed to drop slightly a little below this and is carried forward below the ear around the front of the chin and lower lip, then Fig. 35. V-bandage of the head. backward to the point of starting. These turns passing from the occiput to the forehead and from the occiput to the chin are alternately made until a sufficient number have been applied, and the extremity is secured by a pin over the occiput. (Fig. 35.) This bandage may be modified by carrying the turns from the occiput forward under the ear and around the upper lip and back to the occiput and alternating these turns with the oecipito-frontal turns ; if employed in this HEAL) AND NECK BANDAGE. 43 way a bandage of one and one-half inches in width should be used. Use.—This bandage may be employed to hold dressings to the front of the chin, to the upper and lower lips in cases of wounds, or to give support to these jtarts after plastic operations. Head and Xeck Bandage. Roller Tiro Inches in Width, Four Yards in Length. Application.—The initial extremity of the roller is placed upon the forehead and carried backward just above the ear to the occiput and is then brought forward around the opposite side of the head to the point of starting. Two Fig. 36. Head and neck bandage. of these circular turns are made to fix the bandage, and when it is carried back to the occiput it is allowed to drop down slightly upon the neck and is then carried around the neck, the turns around the head alternating with the neck turns until a sufficient number of these have been applied, 44 REGIONAL bandages. when the extremity of the bandage is secured by a pin at the point of crossing of the turns at the back of the head. (Fig. 36.) Use.-—This bandage may be found useful m securing dressings to the anterior or posterior portion of the neck or to the region of the occiput. Care should be taken to apply it in such a manner that too much pressure is not made by the turns around the neck, which would be uncomfortable to the patient, and might seriously interfere with respiration. Crossed Bandage of One Eye. Roller Two Inches in Width, Four Yards in Length. Application.—The initial extremity of the bandage is placed upon the forehead and fixed by two circular turns passing around the head from the occiput to the forehead; Fig. 37. Crossed bandage of one eye. the roller is then carried back to the occiput and passed around this and brought forward below the ear, and pass- ing over the outer portion of the cheek is carried upward to the junction of the nose with the forehead, and is then crossed bandage of both eyes. 45 conducted over the parietal protuberance downward to the occiput; a circular fronto-occipital turn is next made, and when the bandage is brought back to the occiput it is brought forward again to the cheek and ascends to the forehead, covering in two-thirds of the previous turn, and is again conducted back to the occiput; these turns are repeated, the oblique turns covering the eye alternating with circular turns around the head until the eye is com- pletely enclosed (Fig. 37), and the bandage is finished by making a circular turn about the head and introducing a pin to secure its extremity. It will be found more com- fortable to the patient to include the ear on the same side on which the eye is covered in the turns of the bandage. Use.—This bandage will be found useful in retaining dressings to one eye. It will be more comfortable to the patient if a flannel roller be used to apply this bandage, as well as the bandage which includes both eyes. Citossi:i> Bandage of Both Eyes. Roller Tiro Inches in Width, Six Yards in Length. Application.—The initial extremity of the roller is placed upon the forehead and secured by two circular turns of the bandage, passing around the head from the forehead to the occiput; the roller is then carried downward behind the oceiput and brought forward below the ear to the upper portion of the cheek; it is then carried upward to the junction of the nose with the forehead and conducted over the parietal protuberance to the occiput; a circular turn is now made around the head from the occiput to the fore- head, and the roller is carried from the occiput over the parietal protuberance of the opposite side forward to the junction of the nose with the forehead, then downward over the eve and outer portion of the cheek below the ear and back to the occiput; a circular turn around the head is next made, and this is followed by a repetition of the previous turns, ascending over one eye, descending over the other eve, each turn alternating with a circular turn 3* 46 REGIONAL bandages. around the head. These turns are repeated until both eyes are covered in, and'the bandage is finished by making a circular turn around the head, the extremity being se- cured by a pin. (Fig. 3N.) In this bandage both ears may be covered in, or left uncovered. Crossed bandage of both eyes. Use.—This bandage may be used to apply dressings to both eyes, and both of these bandages covering the eves are used where it is desired to make pressure; but, for the simple application of a light dressing or of a bandage for the exclusion of light, the Liebreich's bandage (Fig. 76) will be found more comfortable to the patient. OCCIPITO-FACIAL BANDAGE. Roller Two Inches in Width, Four Yards in Length. The initial extremity of the roller is placed upon the vertex of the head, and the bandage is carried downward in front of the ear and under the jaw, and upward upon the. opposite side in the same line to the vertex; two or three of these turns are made, one turn accurately cover- ing in the other, and a reverse is made just above and in OBLIQUE BANDAGE OF THE HEAD. 47 front of the ear, and two or three turns are made around the head from the occiput to the forehead, which completes the bandage. (Fig. 39.) Pins should be inserted at the points where the turns of the bandage cross each other. Fia 39. Occipito-facial bandage. Use.—This bandage is employed to secure dressings to the vertex, temporal, occipital, or frontal regions. Obliqce Bandage of the Head. Roller Two Inches in Width, Four Yards in Length. The initial extremity of the bandage is placed upon the forehead, and is secured by two circular turns passing around the head from the forehead to the occiput. From the occiput the bandage is carried obliquely over the highest part of the lateral aspect of the head, which is to iKM-overed in, and is passed over the forehead and back to the occiput, and is then carried to the forehead by a cir- cular turn, then conducted obliquely over the other side of the head and back to the occiput. These turns arc repeated, so that each sueeeedinir turn covers in three-fourths of the 48 REGIONAL BANDAGES. preceding turn until the sides of the head are covered in by descending turns, and the bandage is completed by a circular turn passing around the head from the forehead to the occiput, (Fig. 40.) This bandage may be applied with descending or ascending turns. Fig. 40. Oblique bandage of the head. Use.—This bandage is employed to make pressure upon or to hold dressings to the lateral aspects of the head. OCCIPITO-FRONTAL BANDAGE. Roller Two Inches in Width, Four Yards in Length. Application.—The initial extremity of the bandage is placed upon the forehead and a circular turn is made around the forehead and occiput to fix it, A circular turn is then made passing around the head from a point below the occiput to a point just above the forehead; the next circular turn is made around the head ascending pos- teriorly and descending anteriorly, and after a sufficient number of turns have been made to cover in the front and back of the head, the end of the bandage is secured with a pin. (Fig. 41.) SPIRAL BANDAGE OF THE FINGER. 49 Fig. 41. Oecipito-frontal bandage. Use.—This bandage will be found useful in securing dressings to the forehead and anterior and posterior portion of the scalp. Bandages of the Upper Extremity. Simijal Bandage of the Finger. Roller One Inch in Width, One and a Half Yards in Length. Application.—The initial extremity of the roller is secured by two or three turns around the wrist; the ban- dage is then carried obliquely across the back of the hand to the base of the finger to be covered in, then to its tip by oblique turns; a circular turn is then made and the finger is covered by ascending spiral or spiral reversed turns until its base is reached ; the bandage is then carried obliquely across the back of the hand and finished by one or two circular turns around the wrist; the extremity may be pinned or may be split into two tails, which are tied around the wrist. (Fig. 42.) 50 REGIONAL BANDAGES. Fig. 42. Spiral bandage of the finger. Use.—This bandage is employed to retain dressings upon the finger and to secure splints in the treatment of fractures or dislocations of the phalanges. Gauntlet Bandage. Roller One Inch in Width, Three Yards in Length. Application.—The initial extremity of the roller is fixed at the wrist by one or two circular turns of the ban- dage; it is then carried down to the tip of the thumb by an oblique turn of the roller, and this is covered in by spiral or spiral reversed turns to the metacarpo-phalangeal articulations; the roller is then carried back to the wrist and a circular turn is made around it, and the bandage is now carried down to the tip of the next finger by an oblique turn, which is covcred-in in the same manner. When all the fingers have been covered in, the bandage is DEMI-GAUNTLET BANDAGE. 51 finished bv circular turns around the hand and wrist. (Fig. 43.)" Fig. 1«. Gauntlet bandage. Use.—This bandage may be employed to apply dress- ings to the fingers and hand in case of wounds or frac- tures. It was formerly much employed in the treatment of burns of the fingers to prevent the opposed ulcerated surfaces from adhering, but its use for this purpose has been supplanted by wrapping each finger in a separate dressing and applying a dressing over the whole with a few recurrent and spiral turns of a wide roller, the applica- tion of this dressing being much less painful to the patient, and being at the same time equally satisfactory. DEMI-GALNTLET BANDAGE. Roller One Inch in Width, Four Yards in Length. Application.—The initial extremity of the bandage should be placed upon the wrist and fixed by two circular 52 REGIONAL BANDAGES. turns passing from the ulnar to the radial side; then carry the roller obliquely across the back of the hand to the base of the index finger, pass the bandage around this and carry the roller back to the wrist, making a circular turn ; it Fig. 44. Demi-gauntlet bandage. should then be carried obliquely across the hand to the base of the next finger, and so successively until the base of each of the fingers and of the thumb has been included; the bandage is then completed by a circular turn around the wrist. (Fig. 44.) The demi-gauntlet bandage may be also applied in such a manner as to covcm- the palm of the hand and leave the back of the hand uncovered. Use.—This bandage may be employed to retain light dressings to the dorsal or palmar surface of the hand. SPIRAL REVERSED BANDAGE. 53 Spica Bandage of the Thumb. Fig. 45. Roller One Inch in Width, Three Yards in Length. Application.—The initial extremity of the roller is placed upon the wrist and fixed by two circular turns ; then carry the roller obliquely over the dorsal surface of the thumb to its distal extremity; next make a circular or spiral turn around the thumb, and carry the bandage upward over the back of the thumb to the wrist, around which a circular turn should be made. The roller is next car- ried around the thumb and wrist, making figure-of-eight turns, each turn overlapping the pre- vious one two-thirds as it as- cends the thumb, and each figure- of-eight turn alternating with a circular turn about the wrist, These turns are repeated until the thumb is completely covered in with spica turns, and the bandage is finished by a circular turn around the wrist. (Fig. 45.) Use.—This bandage is employed to apply dressings to the dorsal surface of the thumb, and for the retention of splints in the dressing of fractures or dislocations of the bones of the thumb. Spica bandage of the thumb. Siuit.vL Reversed Bandage of the Upper Extremity. Roller Tiro and a, Half Inches in Width, Seven Yards in Length. Application.—The initial extremity of the roller is placed upon the wrist, and secured by two turns around 54 REGIONAL BANDAGES. the wrist; the bandage is then carried obliquely across the back of the hand to the second joint of the fingers, where a circular turn should be made; the hand is covered in by two or three ascending spiral or spiral reversed turns. When the thumb has been reached, its base and the wrist are covered in by two figure-of-eight turns; the bandage is then carried up the forearm by spiral and spiral reversed turns until the elbow is reached; this may be covered in with spiral reversed turns, and the bandage is next car- ried up the arm with spiral reversed turns to the axilla. (Fig. 46.) If, on reaching the elbow, the arm is bent or Fig. 46, Spiral reversed bandage of the upper extremity. is to be flexed in the subsequent dressing, the elbow should be covered in with figure-of-eight turns, and when this has been done the arm may be covered in with spiral reversed turns: When properly applied, the reverses should be in line, and should not be made over the promi- nent ridge of the ulna. Use.—This is one of the most generally employed of all the roller bandages; it constitutes the primary roller which is applied in the dressing of fractures of the humerus, and is also the bandage employed in holding dressings to the arm and forearm, and in securing splints to these parts in the treatment of fractures and dislocations. FIGURE-OF-EIGHT BANDAGE OF ELBOW. 55 Kl(iI'KE-OF-EIGHT BANDAGE OF THE ELBOW. Roller Tiro Inches in Width, Four Yards in Length. Application.—The initial extremity of the bandage is placed upon the forearm a short distance below the elbow- joint, and fixed by one or two circular turns, the arm being Fig. 47. Figure-of-eight bandage of the elbow. Hexed. The bandage is then carried by an oblique turn across the flexure of the elbow-joint, and passed around the arm a few inches above the elbow; a circular turn is then made, and the roller is next carried across the fiexure of the elbow and passed around the forearm. These turns are repeated, the turns from the forearm ascending and those from the arm descending, each set of turns crossing in the flexure of the elbow until it is covered in, and a final turn is passed circularly around the elbow-joint. (Fig. 47.) This bandage is sometimes applied by first making one or two circular turns around the elbow and then applying the figure-of-eight turns as previously described. ,* > 56 REGIONAL BANDAGES. Use.—This bandage is often employed as a part of the spiral reversed bandage of the upper extremity when the arm is to be flexed, and is also used to hold dressings to the region of the elbow-joint, It was formerly much used to hold the compress upon the wound resulting from venesec- tion at the elbow. Spica Bandage of the Shoulder (Ascending). Roller Two and a Half Inches in Width, Seven Yards in Length. Application.—The initial extremity of the roller is placed obliquely upon the outer surface of the arm opposite the axillary fold, and fixed by one or two circular turns. If Fig 48. Spica bandage of shoulder (ascending). the right shoulder is to be covered, the bandage is next carried across the front of the chest to the axilla of the opposite side, then around the back of the chest to the point of starting upon the arm ; then conduct the roller around the arm of this side up over the shoulder, across SPICA BANDAGE OF THE SHOULDER. 57 the front of the chest, through the opposite axilla and back over the posterior surface of the chest to the point of starting; continue to make these ascending turns, each turn overlapping the preceding one about two-thirds until the shoulder is covered in (Fig. 48), when the extremity of the bandage may be secured by a pin at the point of end- ing, or the last turn may be carried from the shoulder around the back of the neck and brought forward over the opposite shoulder and pinned to the turns which pass around the axilla. It should be remembered that the turns of the roller overlap each other exactly in the opposite axilla, and it will be found more comfortable to the patient to apply a little cotton wadding in the axilla to prevent the bandage from excoriating the skin of this part. Care should be taken to see that the turns are made in such a manner that the spica turns occupy, as nearly as possible, the median line of the shoulder. AVhen this bandage is applied to the left shoulder, after fixing the initial extremity by circular turns around the arm, the roller should be carried over the back of the chest to the axilla of the opposite side and then brought back to the point of starting; the succeeding turns are then applied in the same manner. Spica Bandage of the Shoulder (Descending). Roller Tiro and a Half Inches in Width, Seven Yards in Length. Application.—The initial extremity of the roller should be fixed upon the arm as near as possible to the axillary fold by one or two circular turns, and if it is applied to the right shoulder the bandage should be passed under the axilla and carried obliquely over the shoulder to the base of the neck, then downward across the front of the chest to the axilla of the opposite side ; from the axilla the roller is carried over the back of the chest to the base of the neck so as to cross the first turn at this point; it is then carried to the axilla and through this, then back to 58 REGIONAL bandages. the neck, the turns descending toward the shoulder. These turns, taking the same course, are repeated, each turn overlapping two-thirds of the previous one until the shoulder is covered in and the circular turn around the arm is reached, at which point the extremity is secured by a pin. (Fig. 49.) Fig. 49. Spica bandage of shoulder (descending). Use.—The spica bandages of the shoulder are employed to hold dressings to the shoulder, to hold compresses over the acromial end of the clavicle in case of dislocation of that portion of the bone, to retain the shoulder-cap used in the treatment of fractures of the upper portion of the humerus, and to retain dressings to the axilla. y FlGURE-OF-EIGHT BaXDAGE OF THE NECK AND Axilla. Roller Two Inches in Width, Five Yards in Length. Application.—The initial extremity of the roller is fixed upon the side of the neck and secured by one or two velpeau's bandage. 59 Fig. 50. loosely applied circular turns; if applied to the right axilla carry the bandage from left to right over the right shoulder to the posterior part of the axilla under which it passes, to ascend in front over the same shoulder to the back of the neck ; these figure-of- eight turns around the neck and axilla, each turn over- lapping two-thirds of the previous turn, are repeated until the desired space is covered, and the bandage is completed by a circular turn around the neck. (Fig. 50.) Use.—This will be found a useful bandage to secure dressings to the base of the neck, the upper part of the shoulder, and to the axilla, as it does not restrict the motions of the arm unless drawn too tight. Figure-of-eight bandage of the neck and axilla. Velpeau's Bandage. Two Rollers Tiro and a Half Inches in Width, Seven Yai'ds in Length. Application.—The patient should place the fingers of the hand of the affected side on the opposite shoulder; the initial end of the roller should be placed on the body of the scapula of the sound side and secured by a turn made by carrying the bandage over the shoulder of the affected side, near its outer portion, then conducting it downward over the outer and posterior surface of the arm of the same side, behind the point of the elbow, and obliquely across the front of the chest to the axilla of the opposite side, thence to the point of starting. This turn should be repeated, to fix the initial extremity of the bandage. Having completed the second turn, carry the roller trans- versely around the thorax, passing over the flexed elbow 60 regional bandages. of the affected side, from this point to the axilla, and through this to the back. From this point the roller^ is carried over the shoulder and clown the outer and posterior surface of the arm behind the elbow and obliquely across the front of the chest through the axilla to the back, and Fig. 51. Velpeau's bandage. continuing, passes transversely across the back of the chest to the elbow, which it encircles, then passing to the axilla. These alternating turns are repeated until the arm and forearm are bound firmly to the side and chest. The vertical turns over the shoulder, each turn covering in two-thirds of the previous turn and ascending from the point of the shoulder toward the neck and from the posterior surface of the arm toward the elbow, are applied until the point of the elbow is reached. The transverse turns passing around the chest and arm are so applied that thev ascend from the point of the elbow toward the shoulder, each turn covering in one-third of the previous one, and the last turn should pass transversely around the shoulder and chest, covering the wrist. (Fig. 51.) The extremity of the bandage should be secured by a desault's bandage. 61 pill where it ends, and additional fixation will be secured by introducing a number of pins at the points where the turns of the bandage cross each other. Use.—This bandage is employed to fix the arm in the treatment of certain fractures of the clavicle and scapula, also to secure fixation of the humerus after the reduction of dislocations of the shoulder-joint. Desault's Bandage. Three Rollers Two and. a, Half Inches in Width, Seven Yards in Length. A wedge-shaped pad to fit in the axilla is also required. These rollers are known as the first, second, and third rollers. First Roller of DesauWs Bandage. Application.—Before applying the first roller the arm of the patient on the injured side should be elevated and Fig. 52. First roller of Desault's bandage. carried off at right angles to the body; the wedge-shaped pad with its base in the axilla should next be applied to the side of the chest, and the initial extremity of the roller 4 62 regional bandages. is placed upon the middle of the pad and fixed by two or three circular turns around the chest; the bandage is then carried down the chest by oblique circular turns until the lower extremity of the pad is reached, and it is then carried up the chest until the upper extremity of the pad is reached, when it is conducted obliquely across the front of the chest to the sound shoulder and passed under the axilla, brought over the shoulder and conducted around the chest, where it is secured. (Fig. 52.) Second Roller of DesauWs Bandage. Application. — The arm should be brought down against the side so as to press upon the pad previously applied, and the forearm should be flexed upon the arm and brought across the lower portion of the chest. The initial extremity of the roller is placed in the axilla of Fig. 53. Second roller of Desault's bandage. the sound side, and the bandage is carried around the chest and over the arm of the injured side, making a circular turn around the chest to fix it; then spiral turns are made around the chest from above downwaSKi until the elbow is reached, the turns being more firmly applied as thev de- desault's bandage. 63 scend, and when this point is reached the end of the ban- dage is secured. Or the initial extremity of the bandage may be placed upon the chest of the sound side and a circular turn may be made to fix it, and then spiral turns including the chest and arm may be made from below up- ward until the axilla is reached. (Fig. 53.) Third Roller of Desault's Bandage. Application.—The initial extremity of the roller is placed in the axilla of the sound side, and the bandage is carried obliquely over the front of the chest to the shoulder of the injured side, passed over this, and conducted down the back of the arm to the elbow, thence obliquely upward over the upper fifth of the forearm to the axilla of the sound side. From this point it is carried backward ob- liquely over the back of the chest to the shoulder; crossing the previous shoulder-turn it is conducted down the front Fie. 54. Third roller of Desault's bandage. of the arm to the elbow, then around this and backward obliquely over the back of the chest to the axilla of the sound side. These turns are repeated until three sets of turns have been applied, which should overlie each other exactly. (Fig. 54.) The course of the turns of the 64 regional bandages. third roller is considered the most difficult to remember, and the student may be assisted in its correct application by remembering that all the turns start at the axilla, pass Fig. 55. Posterior view of turns of third roller of Desault's bandage. to the shoulder, and then to the elbow, and from the elbow always return to the starting-point—the axilla. The turns of the third roller make two triangles, one on the anterior surface of the chest, the other upon the back. (Fig. 55.) ARM AND CHEST BANDAGE. 65 After the application of the three rollers the hand and uncovered portion of the forearm should be supported in a sling suspended from the neck. Use.—This bandage, applied completely, or some one of its various rollers, is employed in the treatment of fractures of the clavicle. Arm and Chest Bandage. Roller Two and a Half Inches in Width, Seven Yards in Length. Fig. 56. Arm and chest bandage. Before applying this bandage the arm should be placed against the side of the chest and a folded towel or a pad 66 regional bandages. of cotton should be placed in the axilla and allowed to extend from the axilla to the elbow ; the latter is used to prevent the opposing surfaces of skin from becoming ex- coriated by contact, Application.—The initial extremity of the bandage is placed upon the spine at a point opposite the elbow- joint, and it is fixed by a turn or two passing around the arm and chest; the bandage is then continued by making ascending spiral turns, covering in the arm and chest until the axilla is reached ; at this point the bandage is carried through the axilla and over the back of the chest to the top of the opposite shoulder, and it is then conducted down the front of the arm to the elbow, is passed between the arm and chest and carried up the back of the arm to the shoulder, and is then passed obliquely across the front of the chest and is secured upon the back of the chest. Pins should be introduced at the points of crossing of the bandage. (Fig. 56.) Use.—This bandage will be found useful in fixing the arm to the body and in fixing the shoulder-joint where it is desirable to allow the forearm to be free. It is em- ployed in the treatment of fractures of the shaft and neck of the humerus to fix the arm and hold splints in position. Bandages of the Trunk. Spiral Bandage of the Chest. Roller Three Inches in Width, Nine Yards in Length. Application.—The initial extremity of the roller is applied to the anterior portion of the waist, and fixed by one or two circular turns; the bandage is then carried upward, encircling the chest by ascending spiral turns, each turn covering in one-half of the previous turn until the axillary fold is reached; the roller is next carried around the axilla to the back, and obliquely over this to the base of the neck of the opposite side, and then it mav anterior figure-of-eight bandage. 67 be passed down over the chest and pinned to the spiral turns at several points; a pin should also be inserted at the point where the last turn of the roller leaves the spiral turn upon the back of the chest. (Fig. 57.) Fig. 57. Spiral bandage of the chest. Use.—This bandage is employed to hold dressings to the chest, and may be used as a temporary dressing in fractures of the ribs or sternum. Care should be taken that the bandage be not so tightly applied as to interfere with respiration. Anterior Figure-of-eight Bandage of the Chest. Roller Two and a Half Lnches in Width, Seven Yards in Length. Application.—The initial extremity of the roller should be placed in the axilla of one side, and the ban- dage is then carried obliquely across the anterior portion of the chest to the shoulder of the opposite side ; it is then carried backward around the shoulder and through the axilla, and is next conducted obliquely over the anterior 68 regional bandages. portion of the chest to the opposite shoulder, through the axilla and again back to the anterior portion of the chest, the turns crossing in the median line over the sternum. These turns should be repeated, ascending from the shoulder toward the neck, each turn overlapping three- fourths of the preceding one, until five or six turns have been applied, the end of the bandage being secured by a pin (Fig. 58), or it may be completed by a circular turn around the chest. Fig. 58. Anterior figure-of-eight bandage of the chest. Use.—This bandage may be employed to bring the shoulders forward, and to hold dressings to the anterior portion of the chest. Posterior Figure-of-eight Bandage of the Chest. Roller Two and a Half Lnches in Width, Seven Yards in Length. Application.—The initial extremity of the roller should be placed in the axilla of the left side, and the bandage is then carried obliquely across the back of the chest to the tip of the opposite shoulder; it is next carried through the axilla and conducted across the posterior por- tion of the chest to the tip of the opposite shoulder, and suspensory and compressor bandage. 69 passed through the axilla to the point of starting. These turns are repeated, ascending from the shoulder toward the neck, until five or six have been applied, the end of the bandage being secured by a pin. (Fig. 59.) In Fig. 59. Posterior figure-of-eight bandage of the chest. applying both of these bandages the crosses of the ban- dage, either anterior or posterior, should be made in the median line of the chest. Use.—This bandage may be employed to hold dressings to the posterior portion of the chest and to draw the shoulders backward. Suspensory and Compressor Bandage of the Breast. Roller Two and a Half Inches in Width, Seven Yards in Length. Application.—The initial extremity of the roller should be placed upon the scapula of the affected side, and secured by two oblique turns carried over the opposite shoulder and conducted downward under the breast to be covered in, and then carried to the axilla of the same side. Next carry the roller transversely around the chest, 4* 70 REGIONAL BANDAGES. covering in the lowest portion of the affected breast. These turns should be repeated, the oblique turns from the axilla over the shoulder alternating with the transverse turns around the chest until the breast is covered in, each series of turns ascending, and covering two-thirds of the preceding turn. (Fig. 60.) Fig. 60. Suspensory and compressor bandage of the breast. Use.—This bandage is employed to support the breast and to make compression at the same time; it may also be employed to hold dressings to the breast. Suspensory and Compressor Bandage of Both Breasts. Two Rollers Two and a Half Inches in Width, Seven Yards in Length. Application.—The initial extremity of the bandage should be secured by oblique turns of the axilla and shoulder as in the preceding bandage; the roller should next be carried transversely around the back to the breast, then under the breast and upward over the opposite SUSPENSORY AND COMPRESSOR BANDAGE. 71 shoulder, then obliquely downward around the chest to the other side, being carried transversely over the lower por- tion of both breasts to the point of starting upon the back. Repeat these oblique turns from the shoulder to the breast and from the breast to the shoulder, and alter- Fig. 61. Suspensory and compressor bandage of both breasts. nate them with a transverse turn around the chest and over both breasts. Both scries of turns should ascend, and each turn should overlap two-thirds of the preceding one. (Fig. 61.) Use.—This bandage is employed to support and com- press both breasts and to retain dressings to them. 72 REGIONAL BANDAGES. Bandages of the Lower Extremity. Single Spica Bandage of the Groin (Ascending). Roller Two and a Half Inches in Width, Seven Yards in Length. Application.—Place the initial extremity of the ban- dage upon the anterior portion of the right thigh just below the groin and secure it by one or two circular turns around the thigh, or place the initial extremity of the roller obliquely upon the upper part of the thigh and carry it Fig. 62. Ascending spica bandage of the groin. behind the limb and upward around the outer side of the thigh to the abdomen, omitting the circular turns; then carry the bandage obliquely across ,4he lower part of the abdomen to a point just below the crest of the left ilium and conduct it transversely around the back of the pelvis to a corresponding point on the opposite side; then bring it obliquely downward to the groin over to the inner por- tion of the thigh, carrying it around the limb, crossing the starting-turn in the middle line of the thigh. These single spica bandage of the groin. 73 turns are repeated, each turn ascending and covering in two-thirds of the previous turn, until six or eight complete turns have been made, and the bandage is secured at any point where it ends. (Fig. 62.) Single Spica Bandage of the Groin (Descending). Roller Two and a Half Inches in Width, Seven Yards in Length. Application.— Place the initial extremity of the roller obliquely upon the anterior surface of the right thigh and secure it by one or two circular turns .around the limb, or Fig. 63. Descending spica bandage of the groin. start the bandage with an oblique turn, as previously described ; then carry the bandage obliquely across the abdomen to a point just below the crest of the ilium, and conduct it transversely around the back of the pelvis to a corresponding point on the opposite side; then bring it obliquely down over the lower portion of the abdomen, crossing the first turn, to the junction of the thigh with the scrotum, pass it under the thigh and bring it up over the lower part of the abdomen, and let it follow the course ^ 74 REGIONAL BANDAGES. of the first turn. These turns are repeated, each turn descending and overlapping two-thirds of the previous turn until the groin is covered (Fig. 63). AYhen either of these bandages is applied to the left groin, after the initial extremity of the roller is fixed, it is carried first to the crest of the ilium of the same side, then around the back of the pelvis to a corresponding point on the opposite side, then obliquely across the lower part of the abdomen to the outer aspect of the thigh, being conveyed under this and brought uj) between the thigh and the scrotum, passing obliquely over the groin to follow the course of the original turn. Double Spica Bandage of the Groins. Roller Three Inches in Width, Nine Yards in Length. Application.—The initial extremity of the roller is placed upon the abdomen just above the iliac crests and Fig. 64. Double spica bandage of the groins. secured by one or two circular turns; the bandage is then carried from a point just below the crest of the right ilium obliquely across the lower portion of the abdomen to the SPICA BANDAGE OF BUTTOCK. 75 outer portion of the thigh, and is carried around this and brought up between the scrotum and the thigh, and is passed obliquely over the groin, crossing the previous turn in the median line, and is conducted to a point just below the crest of the ilium on the same side. The bandage is then continued around the pelvis to the same point on the opposite side, and from this point is made to pass obliquely over the groin to the inner side of the thigh, passing around this and coming up on its outer side, crossing the previous turn at the middle line of the groin, to be carried obliquely across the groin and lower part of the abdomen to the crest of the ilium on the opposite side. These turns arc repeated, each turn covering in two thirds of the pre- vious turn, until both groins have been covered (Fig. 64). The turns may be so applied as to ascend or descend, forming the ascending or descending double spica bandage of the groin. When properly applied, this bandage pre- sents three sets of crossing turns, one in each groin and one in the median line of the abdomen. Use.—The spica bandages of the groin, either single or double, are employed to hold dressings to wounds in the inguinal region—for instance, those resulting from herni- otomy, or from operation upon the glands of the groin. They are also employed to make pressure upon this region, and will often prove of use in the securing of compresses applied for the temporary retention of hernias. Spica Bandage of Buttock. Roller Two and a Half Lnches in Width, Seven Yards in Length. Application.—The initial extremity of the bandage is placed upon the back of the thigh just below the gluteal fold, and is carried around the thigh and brought back to the posterior aspect of the limb so as to fix and cross the starting turn near the middle of the thigh. It is next conducted obliquely across the thigh and buttocks and carried to the rim of the pelvis of the opposite side, when 76 REGIONAL BANDAGES. it is brought obliquely over the abdomen and back to the posterior surface of the thigh. There ascending turns are applied, each turn covering in about three-fourths of the preceding one, until the buttock is covered, and the ban- dage is then finished by one or two circular turns around the pelvis and abdomen. (Fig. 65.) Fig. 65. Spica bandage of buttock. Use.—This bandage is employed to hold dressings to the upper posterior portion of the thigh, or the buttock. Figure-of-eight Bandage of the Knee. Roller Two and a Half Inches in Width, Five Yards in Length. Application.—The initial extremity of the roller is placed upon the thigh three inches above the patella and secured by two or three circular turns; then conduct the bandage over the outer condyle of the femur across the popliteal space to the inner border of the tibia and around FIGURE-OF-EIGHT BANDAGE OF KNEE. 77 the anterior surface below the tubercle and head of the fibula, and make one circular turn ; the roller should then be carried obliquely across the popliteal space to the inner condyle of the femur, crossing the previous turn; then carry it around the front of the thigh to the outer condyle ; repeat these turns, ascending toward the knee from the leg and descending from the thigh toward the knee, and finish the bandage by a circular turn over the patella. (Fig. 66.) Fig. 66. Figure-of-eight bandage of the knee. Use.—This bandage is employed to hold dressings to the knee-joint either anteriorly or posteriorly. These figure-of-eight turns are often employed in covering the knee in applying the spiral reversed bandage of the lower extremity when it is desired that the patient be allowed to bend the knee. Figure-of-eight Bandage of Both Knees. Roller Two and a Half Inches in Width, Seven Yards in Length. Application.—Place the knees of the patient together with a compress between them ; then place the initial ex- 78 REGIONAL BANDAGES. tremitv of the roller upon one thigh, about three inches above the patella, and secure it by one or two circular turns around both thighs; then conduct the roller from the outer condyle of the femur obliquely across the pop- liteal spaces of both legs to the head of the fibula on the opposite side, making a circular turn around both legs; Fig. 67. Figure-of-eight bandage of both knees. pass the roller from the head of the fibula on the opposite side across the popliteal space to the external condyle opposite the point of starting. Repeat these turns, descending from the thighs and ascending from the legs, until the knees are covered, and finish the bandage by carrying a turn of the bandage at right angles to the previous turns between the thighs and the legs. r(Fig. 67.) Use.—This bandage is employed to secure fixation of the limbs after operation upon the perineum, and may also be employed to obtain temporary fixation of the limbs in transporting cases of fracture of the neck of the femur, and after the reduction of dislocations of the head of the femur. SPICA BANDAGE OF THE FOOT. 79 Spica Bandage of the Foot. Roller Two and. a Half Inches in Width, Five Yards in Length. Application.—Fix the initial extremity of the roller upon the ankle and secure it by two circular turns; then carry the bandage obliquely over the dorsum of the foot to the metatarso-phalaugeal articulation and make a circular turn around the foot at this point; then continue it upward over the metatarsus by making two or three spiral reversed turns; next carry the bandage parallel with the inner or outer margin of the sole of the foot, according to whether it is applied to the right or left foot, directly across the posterior surface of the heel; thence along the opposite Fig. 68. Spica bandage of the foot. border of the foot and over the dorsum, crossing the original turn in the median line of the foot. This com- pletes the first spica turn. These spica turns are repeated, gradually ascending by allowing each turn to cover in three-fourths of the preceding turn, until the foot is covered in with the exception of the posterior portion of the sole of the heel. (Fig. 68.) (are should be taken to 80 REGIONAL BANDAGES. see that the turns cross each other in the median line of the foot, and that they are kept parallel to each other throughout their course. Use.—This bandage will be found very useful when it is desired to make firm compression upon the foot or to retain dressings to it; it is especially useful in the treatment of sprains of the ankle or anterior tarsus. Bandage of Foot Covering the Heel (American). Roller Two and a Half Lnches in Width, Seven Yards in Length. Applicatiox.—The initial extremity of the roller is placed upon the leg just above the malleoli and fixed by two circular turns around the leg; the bandage is then carried obliquely across the dorsum of the foot to the metatarso-phalangeal articulation, at which point a circular Fig. 69. Bandage of foot covering the heel. turn is made; two or three spiral or spiral reversed turns are then made ascending the foot; the roller is next carried directly over the point of the heel and continued back to the dorsum of the foot; thence beneath the instep around one side of the heel and up over the instep; from this bandage of foot not covering heel. 81 point it is carried beneath the instep around the other side of the heel and up in front of the ankle, from which point it may be continued up the leg. (Fig. 69.) Use.—This bandage is employed to cover in the foot and retain dressings to the foot and heel. Bandage of Foot not Covering the Heel (French). Roller Two and a Half Inches in Width, Seven Yards in Length. Application.—Fix the initial extremity of the roller upon the leg just above the malleoli and secure it by two circular turns around the leg; the bandage is then carried Fig. 70. Bandage of foot not covering the heel. obliquely across the dorsum of the foot to the metatarso- phalangeal articulation and at this point a circular turn around the foot is made. The roller is now carried up the foot, covering it in with two or three spiral reversed turns, and at this point a figure-of-eight turn is made around the ankle and instep ; this should be repeated once, which will cover in the foot with the exception of the heel; the ban- dage may then be continued up the leg with spiral reversed turns. (Fig. 70.) 82 regional bandages. Use. —This bandage may be employed to secure dress- ings to the foot and is the one generally used to cover the foot in applying the spiral reversed bandage of the lower extremity. Spiral Reversed Bandage of the Lower Extremity. Roller Two and a Half Lnches in Width, Seven Yards in Length. Application.—The initial extremity of the roller is placed upon the leg just above the malleoli and secured by two circular turns, then carried obliquely over the foot to the metatarso-phalangeal articulation and here a circular turn is made around the foot; the foot is next covered in with two or three spiral reversed turns and two figure-of- eight turns of the ankle and instep, and just above the ankle one or two circular or spiral turns are made around the leg, and as the bandage is carried up the leg, as it increases in diameter, spiral reversed turns are made until Fig. 71. Spiral reversed bandage of the lower extremity. it approaches the knee ; at this point, if the limb is to be kept straight, the spiral reversed turns may be continued over this region and up upon the thigh. If the knee is to be bent, figure-of-eight turns may be applied until the knee is covered, and then the thigh may be covered with spiral reversed turns. (Fig. 71.) To cover in the thigh figure-of-eight bandage of the leg. 83 as well as the leg, two bandages of the dimensions before given will be required, (are should be taken to keep the reverses in a line and not to make them over the spine of the tibia, as they may thus become painful to the patient. Use.—This is one of the most frequently employed of the roller bandages; it is used to apply pressure to the lower extremity, to retain dressings, and to secure splints in the treatment of fractures and dislocations. Figure-of-eight Bandage of the Leg. Roller Two and a Half Lnches in Width, Seven Yards in Length. Application.—This bandage differs from the spiral reversed bandage of the lower extremity only in the fact Fig. 72. Figure-of-eight bandage of the leg. that when the swell of the calf is reached, figure-of-eight turns are made around the leg instead of spiral reversed turns. In applying the roller, when the calf of the leg is 84 special bandages. reached, the bandage is carried obliquely around the leg and brought in front of the leg and made to cross the starting-turn in the median line; these turns are repeated until the calf of the leg has been covered in, and the ban- dage is finished with one or two circular turns just below the knee. (Fig. 72.) Use.—This bandage holds its place more firmly than the ordinary spiral reversed bandage of the leg, and may be employed in the treatment of ulcers of the leg in con- junction with strapping, where it is desirable to change the dressings at infrequent intervals and to allow the patient to walk about during the course of treatment. SPECIAL BANDAGES. Spiral Reversed Bandage of the Penis. Roller Three-quarters of an Inch in Width, Thirty Inches in Length. Fig. 73. Spiral reversed bandage of the penis. recurrent bandage of stump. 85 Application.—Fix the initial extremity of the roller by two circular turns around the penis close to the pubis; then carry the bandage obliquely down to the corona glandis; from this point ascend the body of the penis bv spiral reversed turns to the pubis and finish the bandage by two figure-of-eight turns around the neck of the scrotum and root of the penis ; split the end of the bandage so as to form two tails and secure it by tying these around the root of the penis. (Fig. 73.) Recurrent Bandage of Stump. Roller Two and a Half Inches in Width, Five to Seven Yards in Length. Application.—Place the initial extremity of the roller upon the anterior or posterior surfaee."of the limb a few inches above the extremity of the stump, and carry the Fig. 74. Recurrent bandage of stump. bandage to the end of the stump, and then conduct it upward or downward on the limb, as the case may be, to a point directly opposite the point of starting; then bring 5 86 SPECIAL bandages. the bandage back over the face of the stump to the point of starting and continue these recurrent turns, each turu overlapping two-thirds of the previous one, until the face of the stump is covered; then reverse the bandage and secure the recurrent turns at their points of origin by two or three circular turns. The roller should next be carried obliquely down to the end of the stump and a circular turn should be made around this, and the bandage should next be carried up the limb by spiral or spiral reversed turns beyond the point at which the recurrent turns termi- nated, and secured by one or two circular turns. (Fig. 74.) In applying this bandage in very short stumps resulting from amputations at or near the shoulder or hip-joints, after making the recurrent and spiral turns, it will be found necessary to carry the bandage, in the case of the shoulder, across the chest to the opposite axilla and back, and apply several of these turns; so in case of the hip amputations it will be found best to finish the bandage with a few turns about the pelvis. Bandage for Securing the Haxds and Feet in the Lithotomy Position. Roller Two and a Half Lnches in Width, Three Yards in Length. Application.—The hand of the patient should be brought down and made to grasp the outer side of the foot; the initial extremity of the roller is fixed by two circular turns around the wrist and ankle, and the bandage is then passed around the foot and hand, and these turns are alternated with turns around the wrist and ankle, until the hand and foot are firmly secured. The same procedure is adopted with the hand and foot of the opposite side. (Fig. 75.) Use.—This bandage is useful in securing the hands and feet while the patient is put in the lithotomy position for that operation, or for perineal section. liebreich's eye bandage. Fig. 75. 87 Bandage for securing hands and feet for lithotomy. Liebreich's Eye Bandage. This bandage consists of a strip of flannel two and a half inches in width and from six to ten inches in length, Fig. 76. Liebreich's eye bandage. 88 special bandages. to the extremities of which are sewed tapes. It may be applied transversely so as to cover both eyes, or obliquely so as to cover one eve only, and is secured by the tapes carried around the head and tied over the forehead. (Fig. 76.) Use.—This bandage is used to hold compresses or dress- ings to the eve or eyes, and the elasticity of the flannel permits of its being applied so as to make a variable amount of pressure. Bandage of Scultetus. Fig. 77. Bandage of Scultetus. This is a compound bandage, consisting of a number of pieces of muslin, and may be prepared from a two and a flannel bandage. 89 half or three-inch roller by cutting off strips long enough to encircle the part about one and one-third times. These strips are placed under the part in such a manner that the first piece shall be overlapped by the second, the second by the third, and so on from below upward; the pieces are then brought around the limb, and the extremities of the last piece are secured by pins. (Fig. 77.) This bandage was formerly much employed in the treatment of com- pound fractures to secure dressings to the wound, and possessed the advantage that when a single strip became soiled it could be removed without disturbing the whole dressing, the new strip to be introduced being pinned to the extremity of the soiled piece to be removed, and then being drawn through by its removal. This bandage will often be found convenient in applying dressings to cases of excision of the joints, where as little disturbance of the parts as possible is important in dressing the wounds. When the strips arc attached to each other by a thread passed through each strip in the centre, the bandage is known as Pott's bandage. This bandage is applied and secured in the same manner, but it possesses no advantages over the bandage of Scultetus. Flannel Bandage. These bandages are prepared from flannel which is cut into strips from two to four inches in width and from five to seven yards in length. These strips arc formed into rollers either by hand or by means of the bandage winder. Flannel bandages by reason of the elasticity which they possess can be applied without reverses and are used to make a moderate amount of clastic pressure. They are often employed in applying dressings to the head, espe- cially after operations upon the eyv^, and are generally applied as a primary roller before the application of the plaster-of-Paris dressings, and may also be used in sub- acute joint affections, both to protect the parts and make a moderate amount of elastic pressure. 90 special bandages. The Rubber Bandage. This bandage is made from a strip of rubber sheeting, from one inch to four inches in width and from three to five yards in length, which, for convenience of application, is rolled into a cylinder. Its use was introduced to the profession by Dr. Martin, of Boston, and it will be found a useful form of dressing where it is considered desirable to apply elastic pressure to a part. (Fig. 78.) It may be employed in the treatment of varicose veins of the legs, in chronic ulcers of those parts where pressure Fig. 78. Martin's rubber bandage. is an important element in the treatment, and may be used as a substitute for strapping to secure this object. Its application has also been recommended in the treatment of swelled testicle in that stage of the affection in which pressure is indicated. Application.—For application to the leg a rubber ban- dage two and a half inches in width and three yards in length is required. The initial extremity of the roller is fixed upon the foot near the toes and secured by a circular turn; the foot is then covered in by spiral turns overlapping each other about two-thirds, and a figure-of-eight turn is made from the ankle to the instep, and the bandage is then carried up the limb to the knee with spiral turns, where it is secured by two tapes sewed to the terminal extremity of the ban- HARDENING BANDAGES. 91 dagc, which arc passed around the leg and tied. The bandage need not be reversed, as its elasticity allows it to conform to the shape of the limb. Care should be taken not to apply the turns with too much firmness; the bandage should be stretched very slightly; if this precau- tion is not taken, it soon becomes uncomfortable to the patient. A patient using one of these bandages will soon learn to apply it himself, making just the requisite amount of* tension to secure its holding its place and to insure a comfortable amount of pressure upon the part. A well- fitting stocking may be placed upon the limb before the bandage is applied, or it may be applied directly to the skin. The bandage should be removed at night when the patient goes to bed and hung up to dry, as its inner sur- face becomes moist from the secretions from the skin; it should be reapplied as soon as the patient rises in the morning. In using it in the treatment of ulcers of the leg no oint- ments should be applied to the ulcer, as oily dressings soon destrov the rubber; dressings may be made to the ulcer by means of dry powders, such as oxide of zinc, iodoform, or aristol, before the bandage is applied. In the treatment of swelled testicle the bandage is ap- plied to the testicle by means of recurrent turns not too firmly made, and secured in place by spiral turns, until the whole surface of the organ is covered in; the end of the bandage is secured with tapes tied around the root of the scrotum. The same precaution to apply the bandage so as to make only moderate pressure should here also be observed. Fixed Dressings or Hardening Bandages. For the application of these dressings a variety of sub- stances are used which are incorporated in the meshes of some fabric, such as crinoline or cheese-cloth, or painted over its surface to give fixity or solidity to the bandage. The materials most commonly used in the preparation 92 SPECIAL bandages. of fixed dressings are plaster-of-Paris, starch, silicate of sodium or potassium, paraffine, or a mixtur of chalk and gum or of oxide of zinc and glue. The Plaster-of-Paris Bandage. The plaster-of-Paris used for the application of surgical dressings should be of the same quality as that which the dental surgeons employ in taking casts for teeth—that is, the extra-calcined variety. If moist or of inferior quality, it will not set rapidly or firmly, and will fail to give suffi- cient fixation to the dressing. The plaster-of-Paris dressing may be applied in several ways, either by covering the part to be enclosed with some loose fabric, and rubbing the moist plaster into it, alter- nating the layers of the fabric with layers of moist plaster, or it may be applied by means of a roller which has been prepared with plaster-of-Paris and is moistened and ap- plied to the part. To apply a plaster-of-Paris dressing according to the first method, the part to be enclosed—the leg, for instance —should first be covered by a neatly applied flannel ban- dage or a muslin bandage, which has been shrunken by being washed; new muslin is not satisfactory as a primary application to a limb in applying a plaster-of-Paris dress- ing, as the moisture from the plaster wets it and causes it to shrink, so that it may exert injurious pressure after the bandage becomes dry. The limb having been covered by the bandage, and any bony prominences such as the malleoli having been padded with small wads of cotton to prevent undue pressure upon them, the part is next covered by a layer of turns of a crinoline bandage or by strips of cheese-cloth or any other loose material. A small quantity of plaster-of-Paris is next mixed with water until it has the consistence of thick cream, when it is smeared evenly over the whole surface of the previously applied bandage. Another laver of the bandage or of strips is next applied, and the plaster is smeared over this in the same manner, and so alternate PLASTER-OF-PARIS BANDAGE. 93 layers of plaster-of-Paris and bandage are applied until a casing of the desired thickness is obtained. If the plaster- of-Paris of the quality previously described be used, it will set or become hard in a few minutes. The most convenient method of applying the plaster-of- Paris dressing is that employed by Prof. Say re, which con- sists in the use of bandages which have been previously prepared with plaster-of-Paris; these are moistened and applied while moist to the part to be encased. Preparation of the Plaster-of-Paris Bandage. These bandages are prepared by taking cheese-cloth, mosquito-netting, or crinoline, which latter is by far the best fabric, and cutting or tearing it into strips two and a half to three inches in width and five yards in length. These are laid on a table, and plaster-of-Paris of the quality before mentioned is dusted over them and rubbed into the meshes of the fabric; the material when impreg- nated with plaster is loosely rolled into a cylinder, and these bandages when prepared should be placed in air-tight jars or tin cans until required. Bandages thus prepared, which have been exposed to the air or have been kept for a long time, are not apt to set well when applied; but if such bandages arc placed in a hot oven and baked for half an hour before being used, they will be found to set as satisfactorily as those freshly prepared. These bandages may be prepared by a machine made for this purpose, but I do not think that they are apt to have the plaster as evenly distributed through them, and there- fore are not as satisfactory, as those prepared by hand. Application of the Plaster-of-Paris Bandage. Before applying this dressing, the part to be encased— the leg, for instance—should be covered by a flannel roller, the bony prominences being protected by pads of cotton, or a closely fitting stocking may be applied to the part. 5* 94 SPECIAL BANDAGES. The bandage should be dipped in warm water and kept covered by water for a few moments; it may be squeezed with the hand, and as soon as bubbles of air cease to escape it is a sign that it is thoroughly soaked and is ready for application. On removing it from the water the excess of water should be squeezed out by the hand and the bandage should then be evenly applied to the limb with just enough firmness to make it fit the part nicely, and as few reverses as possible should be made. A sufficient number of ban- dages are applied to make a dressing as firm as may be required; three rollers of the above dimensions are usually quite ample for a dressing for the leg, and when the last roller has been applied some dry plaster should be moist- ened with water until it has the consistence of thick cream, and it should be rubbed evenly over the surface of the bandage to give it a finish (Fig. 79). If a good quality Fig. 79. Leg encased in plaster-of-Paris dressing. of plaster has been used, the bandage should be quite firm in from ten to fifteen minutes, but the patient should not for a few hours be allowed to put any Avcight upon the bandage. An equally firm bandage may be applied with the use of a less number of bandages, if the surgeon rubs over the surface of each layer of bandage applied a little moist PLASTER-OF-PARIS DRESSING. 95 plaster, then applying another layer and repeating the same procedure; finishing the dressing by an external coating of moist plaster, as above described. In applying these dressings a fewer number of bandages will be required if narrow strips of tin, zinc, or binder's board are incorporated in the layers of the bandage, which also increase the strength of the dressing. Interrupted Plaster-of-Paris Dressing. This form of plaster-of-Paris dressing is applied by first placing a short iron rod under the extremity some distance above and below the point at which the dressing is to be interrupted; this is fixed by a few turns of the plaster bandage above and below the portion of the limb which is to be left exposed; stout wire is next bent into loops, the Fig. 80. Interrupted plaster-of-Paris dressing. (Stimson.) extremities of which are incorporated in the subsequent turns of the plaster bandage; three loops thus placed in addition to the posterior iron bar will usually make the dressing sufficiently firm (Fig. SO). A number of turns of the bandage are applied to firmly fix the loops, and the limb is held in the desired position until the plaster has set. 96 SPECIAL BANDAGES. Application of the Plaster-of-Paris Jacket. The patient's body should be covered with a soft, closely fitting woven shirt without arms, but with shoulder-straps to hold it in position, or an ordinary woven undershirt may be employed ; one or two folded towels, or a pad of Fig. 81. Suspensory apparatus. cotton folded in a towel, are next placed over the abdomen between the shirt and the skin—this is called, by Prof. Havre, the dinner pad, and is intended to leave space for the distention of the abdomen after eating. Small pads of raw cotton may also be placed over the anterior iliac spines, and, in the case of females, a pad of cotton PLASTER-OF-PARIS JACKET. 97 wrapped in a handkerchief may be placed over each mammary gland. The patient should next be suspended by the apparatus consisting of a collar and arm-pieces attached to a cross- bar^ Fig. SI), which is attached by a cord and pulley to a Fig. 82. Patient suspended for application of plaster jacket." tripod. If this apparatus is not at hand, a very satis- factory substitute may be made by folding two towels into cravats and tying together the ends, so as to make two loops, one of which is placed in each axilla; a bar of wood two and a half feet in length is next taken and the loops are secured to the vnds of this bv stout cords or 98 SPECIAL BANDAGES. handkerchiefs; a Barton's bandage is next applied to the head, and a strip of bandage is passed under the turns which cross the vertex and is secured to the middle of the cross-bar. The bar is next suspended by a cord passed through a pulley or ring which may be attached to the sill of a door if the ordinary tripod cannot be obtained. The patient should be slowly raised by the apparatus until the toes only are in contact with the floor, and the extension should not be carried to the point which makes it uncomfortable to the patient. (Fig. 82.) The shirt should be drawn downward over the hips by an assistant and held in place until a few turns of the bandage have been applied. The plaster bandage having been soaked and squeezed, a turn should be made around the body above the pelvis, and it should then be carried downward below the iliac spines, and from this point should be made to ascend gradually by spiral turns until it reaches the axillary line. The turns should be applied smoothly and not too tightly. After one or two layers of turns have been applied, the surgeon may rub some moist plaster upon their surface if he desires to use fewer bandages. These turns are repeated until a bandage of the desired thickness is applied, and the surface of the dressing may be finished by rubbing it over with moistened plaster. This jacket for a child will generally require the use of four bandages of the dimen- sions given ; for an adult, six to eight bandages. The patient should be kept suspended until the bandage has set, usually from ten to fifteen minutes, and then should be carefully lifted so as not to bend the spine, aud placed upon his back upon a mattress, until the dressing becomes perfectly hardened. The dinner pad, and mammary pads, if they have been used, should next be removed. In ap- plying this dressing, strips of zinc or tin may be placed between the layers of bandage if it is desired to give more strength to the dressing. THE BAVARIAN DRESSING. 99 Application of the Jury-mast by Means of p l a ster-of-p aris. In disease of the spine involving the cervical or upper doi-sal region the ordinary plaster-of-Paris jacket is not satisfactory, and in such cases the "jury-mast" is em- ployed in connection with the plaster jacket. In applying the " jurv-niast " the same steps are taken in the prepara- tion of the patient as in applying the plaster-of-Paris jacket, with the exception of extension, which need not be used. After three or four layers of the plaster bandage have been applied to the body, an apparatus made of two bars of metal having two perforated strips of zinc attached to them a few inches apart, which [tartly encircle the body, is applied and held in position by turns of the plaster bandage. The per- pendicular bars have at their upper part a slot, into which the lower end (Fig. 83) of the "jury- mast " fits, and is secured by a screw ; to the upper part of this is attached a movable cross-bar, to which arc fastened the straps of the collar from which the head is suspended. The Bavarian Dressing. To apply this dressing, which is sometimes employed in the treatment of fractures, take two pieces of Canton flannel the length of the part to be enclosed, and more than wide enough to Oil- Head-support and jury-mast. velope its circumference. In ap- plying it to the leg these pieces should be cut so as to ' correspond to the outline of the leg and posterior portion of the foot. 100 SPECIAL BANDAGES. These pieces should be placed one over the other and sewed together in the middle line, the seam corresponding to the back of the leg. The leg and foot arc then placed upon this, and the inner layer of flannel is brought up in front of the leg and over the dorsum of the foot and made fast with pins. (Fig. 84.) Plaster-of-Paris is next mixed with water and made into a paste, which is rubbed thickly and evenly over the flannel next to the limb until a suffi- cient thickness is obtained; the outer layer of flannel is then brought up about the leg and moulded to its surface bv the hands. A loosely applied roller may now be used to hold the dressings in place until the plaster has set. Fig. 84. Bavarian dressing. When it is necessary to inspect the parts, the turns of the roller are cut, and upon separating the layers of flannel the two halves can be turned aside, the seam at the back acting as a hinge. Upon reapplying the splints to the leg they may be retained in position by a toller or by one or two strips of bandage. Moulded Plaster Splints. It is sometimes found difficult to apply the ordinary plaster dressings to parts irregular in their shape, and at the same time to have a splint which can be removed with ease. To accomplish this purpose moulded splints of plaster may be made by cutting a paper pattern of the part to be covered in, and then cutting pieces of crinoline to conform to this pattern; eight or ten pieces will usually form a splint of sufficient thickness. One of these pieces TRAPPING PLASTER BANDAGES. 101 of crinoline is laid upon a table and dry plaster is rubbed into its meshes ; another is laid upon this and plaster is applied to it in the same way, and so on until all the pieces have been placed in position, one over the other, with plaster rubbed well into the meshes. The dressing is then folded up and dipped into water, squeezed out, and moulded to the part and held in position, until it sets, bv the turns of a bandage. The edges should overlap slightly, and in applying it a strip of waxed paper may be placed under the overlapping edge to prevent its adhesion to the dress- ing below, and thus facilitate its removal. Splints pre- pared in this way can be removed with ease, and are often of service in cases where it is desirable to inspect the parts frequently; I have employed with advantage such splints in making fixation of the hip-joint in cases of coxalgia, and also for the same purpose in affections of other joints. The splints upon being reapplied are secured by a few strips of bandage, or by a roller bandage. Trapping Plaster Bandages. In applying the plaster-of-Paris dressing to a part where there is a wound which is covered bv the plaster bandage. Fig. 85. Plaster-of-Paris bandage trapped. (Esmarch.) it is well to make some provision whereby the plaster dressing over the site of the wound may be cut away, 102 special bandages. making a trap or window through which the wound may be inspected or dressed, if necessary. (Fig. 85.) To accomplish this, before applying the plaster bandage, a compress of lint or gauze should be placed over the wound, which, when the dressing is completed, forms a projection on its surface, indicating the position of the wound, and also allows the surgeon to cut away the dressing without injuring the skin below. These traps may be cut out after the bandage has partially set, or after it has become hard. In applying the plaster-of-Paris dressing in cases of com- pound fracture and after osteotomy, I always make pro- vision for trapping of the bandage if it should become necessary, although in the vast majority of cases it does not have to be done. Removing Plaster-of-Paris from the Hands. One objection to the use of plaster-of-Paris dressings is the difficulty of removing it from the hands of the surgeon, and the harsh condition in which the skin of the hands is left after its removal. If, however, the hands are washed in a solution of carbonate of sodium—a tablespoonful to a basin of water—the plaster will be readily removed and the skin will be left in a soft and comfortable condition. Removing the Plaster-of-Paris Bandage. The removal of the plaster bandage is sometimes a matter of difficulty, particularly if it has to be removed before the parts below it are consolidated, as it may dis- arrange them and cause the patient pain if it is not accomplished without much force. When the bandage is applied to get a cast of the part, a strip of sheet-lead one inch in width is first placed over the flannel bandage, and is allowed to project at each end beyond the dressing ; the plaster can then be readily cut through upon this strip with a knife without injury to the parts below. uses of plaster-of-paris dressings. 103 It may also be removed by means of a saw devised for this purpose (Fig. 86), or by strong cutting shears of Fig. 86. Hunter's saw for removing plaster bandages. various kinds (Fig. 87); or a line may be painted over the dressing with hydrochloric acid or vinegar, which softens the plaster so that it can readily be cut through with a knife. Dr. William B. Hopkins has devised a vertebrated metal chain which is applied to the part before the plaster is applied and removed when the bandage has Fig. 87. Shears for cutting plaster bandages. set, leaving a hollow longitudinal ridge which can be cut through or divided with a rasp. The use of the saw or shears is, I think, most satisfactory in removing these dressings ; the only caution to be exercised is to use them carefully, as the final layers of the bandage are divided, to avoid wounding the skin. Usfs of Plaster-of-Paris Dressings. These dressings are employed to secure fixation, as pri- mary or secondary dressings in the treatment of fractures, and for a like purpose in injuries and diseases of the joints. They arc also largely used in the treatment of diseases and deformities of the spinal column, and will also be found most satisfactory applications after osteotomy and 104 special bandages. tenotomy, to secure immobility and hold the parts in their corrected positions ; when employed in dressing cases after tenotomy, they are generally used for a few weeks until the proper mechanical apparatus is applied. The Starched Bandage. To apply this bandage starch is first mixed with cold water until a thick, creamy mixture results; to this is added boiling water until a clear mucilaginous liquid is produced ; if too thin it can be made thicker by heating it upon a stove. The part to be dressed is first covered with a flannel roller, and over this a few layers of a cheese-cloth or crinoline bandage, which has been shrunken, are ap- plied ; the starch is then smeared or rubbed with the hand evenly into the meshes of the material, and the part is again covered with a layer of turns of the bandage, and the starch is again applied ; this manipulation is continued until a dressing of the desired thickness is produced. Strips of pasteboard may be applied between the layers of the bandage to give additional strength to the dressing, if desired. It requires from twenty-four to thirty-six hours for the starched bandage to become dry and thoroughly set, and it may be removed in the same way in which the plaster- of-Paris dressing is removed. Use.—Before the introduction of the plaster-of-Paris dressing it was formerly much employed in the treatment of fractures and in injuries of the joints. It may be used in such cases, but possesses no advantage over the former dressing and has the disadvantage of setting much less promptly. Gum and Chalk Bandage. In applying this dressing equal parts of powdered gum arabic and precipitated chalk are mixed with boiling water until a mass of the consistence of cream results. This is applied to the cheese-doth or crinoline bandage in the same THE PARAFFIN BANDAGE. 105 manner as is the starch in the application of the starched bandage; it has the advantage over the latter dressing of setting more promptly, five or six hours only being required for it to become hard. It may be employed for the same purposes as the starched or plaster-of-Paris bandage. Silicate of Potassium or Sodium Bandage. In applying this bandage after a flannel roller and several layers of a cheese-cloth or crinoline bandage have been applied to the part, the surface of the latter is coated with silicate of sodium or potassium applied by means of a brush, then a second layer of bandage is applied and treated in the same manner, and this manipulation is con- tinued until a bandage of the desired thickness is produced. It requires twenty-four hours for this dressing to become firm. In removing the silicate bandage it may be first softened by soaking it in warm water, and then it can be readily cut with scissors. In applying either the starched bandage or the silicate of potassium bandage care should be taken to use cheese- cloth or crinoline which has been shrunken by being moistened and allowed to dry before being employed; otherwise dangerous compression of the part mav occur if the bandage has been firmly applied and shrinks after its application. The Paraffin Bandage. Paraffin, which melts at from 105° to 120° F., is used in the application of this bandage. The limb being covered by a flannel roller, a vessel containing paraffin is placed in a basin of boiling water. As the roller, which may be either of flannel, cheese-cloth, or crinoline, is unwound it is passed through the melted paraffin and applied to the part, and the turns are repeated until a dressing of sufficient thickness results, and the surface may be brushed over with melted paraffin. This dressing sets very rapidly, being quite firm in from five to ten minutes. 106 SPECIAL bandages. It possesses the advantage of the other fixed dressings in that it does not absorb discharges and become offensive, and for this reason it was formerly recommended in the treatment of compound fractures. Glue or Glue and Oxide of Zinc Bandage. Glue or glue combined with oxide of zinc has been em- ployed in the preparation of fixed dressings, but possesses no advantages over those previously mentioned. Fig. 88. Raw-hide or Leather Splints or Dressings. In moulding raw-hide or leather splints it is necessary, first, to apply a plaster-of-Paris bandage to the part to which the raw-hide splint is to be fitted; as soon as the plaster has set it is removed, and a solid plas- ter cast is next made by pouring liquid plaster-of-Paris into this mould. When this has become dry a piece of raw-hide, which has been soaked for a time in warm water, is moulded to the cast and held firmly in contact with it bv a bandage until it has become per- fectly dry. It is then removed, Fig. 89. Leather jacket with jury- mast. Leather splint for cervical caries. (Owen.) porous felt splints. 107 and its surface is covered with several coats of shellac, to prevent its absorbing moisture from the skin when ap- plied, and changing its shape. Eye-lets or hooks are fast- ened to the edges of the splint, through which strings are passed to secure the splint in place. Made in this manner raw-hide splints fit the part very accurately, and constitute a very satisfactory dressing for cases of joint-disease, and in the form of leather jackets are often employed in the treatment of disease of the spine in place of the plaster-of-Paris jacket. (Fig. 88.) In the treatment of high dorsal or cervical caries a leather splint in two sections, which rests upon the shoulders and supports the head, is often used with u-ood results. (Fig. 89.) Binder's Board or Pasteboard Splints. This material, which can be obtained in sheets of dif- ferent thickness, is frequently employed for the manu- facture of splints. In moulding these'splints a portion of the board of the requisite size and thickness is dipped in boiling water for a short time, and when it has become softened it is removed and allowed to cool; a thick lavcr of cotton batting is next applied over it, and it is then moulded to the part and held firmly in place by the turns of a roller bandage; in a few hours it becomes drv and hard. This material, from its cheapness and the ease with which it is obtained, is frequently employed to mould splints for the treatment of fractures, especially in chil- dren, and for the fixation of joints in the treatment of acute and chronic joint affections. A moulded pasteboard splint is also often employed to fix the ends of the bones after the excision of a joint. Porous Felt Splints. This material is also employed for the manufacture of splints, and is applied by dipping the material in hot water 108 hatter's felt splints. and then moulding it to the part; as it dries is becomes hard. Hatter's Felt Splints. Hatter's felt is also frequently employed for the manu- facture of splints or dressings. It is softened by dipping it in boiling water or heating it in the flame of an alcohol lamp, and when soft and pliable it is moulded to the part, and as it cools it again becomes hard. These splint are employed for the same purposes as those made of plaster-of-Paris, leather, or pasteboard. PART II. MINOR SURGERY. Theory of Asepsis and Antisepsis in Wound Treatment. The term Asepsis, applied to wounds, implies that the wound is free from those vegetable parasites or micro- organisms whose presence sets up fermentative changes, accompanied by suppuration and constitutional disturb- ance. Antisepsis, on the other hand, has reference to the means employed to bring about the destruction of micro-organisms which may be present in the wound or upon the instru- ments, dressings, or hands of the surgeon, and which, if not destroyed or rendered inert, will set up fermentative changes in the wound. It lias long been a well-recognized fact that albuminoid substances, such as dead animal tissue, blood, or blood- serum, will, when exposed to moisture, warmth, and the presence of certain living organisms or fungi, bacteria and micrococci, develop putrefactive changes; and if these changes take place in the living body there result certain constitutional disturbances known as symptomatic, inflam- matory, or septic fever. It was also recognized that these putrefactive changes in albuminoid substances could be avoided by their exposure to heat, cold, or by drying—any of these conditions being sufficient to destrov or arrest the development of the micro- cocci. The micro-organisms which set up fermentative and putrefactive changes in animal tissues exist in great 6 110 MINOR SURGERY. variety, but those which are of most interest to the surgeon belong to the cocci and bacilli. Rosenbach's investigations have shown that the most common cause of suppuration in living human tissue is a minute globular micrococcus, to which the name staphylo- coccus pyogenes aureus has been given. This coccus is found in almost all varieties of acute suppuration. Another form of coccus which may exist alone or in connection with the previously mentioned fungus is the staphylococcus pyogenes albus. Both of these varieties of cocci, from the agminated arrangement of the single coccus, are known as grape cocci, and have the peculiarity of causing well-localized foci of inflammation. The streptococcus pyogenes, a pus-generating chain coccus, which extends rapidly along the lymph spaces and lym- phatics, and by rapid infiltration of the tissues causes spreading gangrene, is also of especial interest to the surgeon. Decomposition in tissues, accompanied by the presence of foul odors, is said always to be due to the action of rod- like bodies called bacilli or bacteria, such as the bacillus pyogenes foetidus and bacillus pyocyaneus. In wounds the result of accident or made by the sur- geon, we have present conditions most favorable for the entrance and development of these organisms, such as the serum and blood, and the dead or partially devitalized cells of the various tissues which are exposed. We have present also warmth and moisture, and in the air coming in contact with the wound we have vast quantities of dust laden with spores, which under these favoring conditions develop into the organisms before mentioned, which rapidly set up fermentative processes known as decomposition. The products of this decomposition, carried into the circulation by the lymphatics and veins, set up local changes in the shape of inflammation and at the same time give rise to systemic disturbances which we recognize as septic fever. Modern wound treatment aims at the prevention of decomposition and suppuration, and accomplishes this ANTISEPTIC AGENTS. Ill purpose by having the wound kept aseptic, by perfect cleanliness of the region of the wound, the hands and instruments of the surgeon, and by not exposing the wound to an atmosphere which contains dust; as the latter con- dition is difficult to obtain we secure the destruction of the micro-organisms which may be present by heat, as seen in the use of the actual cautery or by chemical sterilization, which is accomplished by the use of germicides. Surgical Cleanliness. Surgical cleanliness may be obtained by following either the aseptic or the antisejitic method; the latter was first introduced, and produced a revolution in surgical practice ; but at the present time, recognizing that evil results have arisen from the use of antiseptics, and that equally good results may be obtained without bringing antiseptic sub- stances directly in contact with wounds, the weight of surgical opinion is decidedly in favor of the aseptic method. In the asfptio method the sterilization of the field of operation, the hands of the surgeon and his assistants, the instruments, ligatures, sponges, and sutures, is accomplished by heat or by the use of chemical germicides, and after this relying upon the completeness of the sterilization, no anti- septic substances are brought into contact with the wound, the solutions and dressings employed being only those which have been sterilized by moist or dry heat. In the antiseptic .method the same means and ma- terials are employed to sterilize the field of operation, the hands of the surgeon and his assistants, the instruments, sponges, ligatures, etc., but in addition the wound is irri- gated constantly with germicidal solutions during the operation, and it is afterward covered with dressings impregnated with germicidal substances. Antiseptic Agents Employed. A great variety of agents possessing more or less germi- cidal properties have been at different times employed in 112 MINOR SURGERY. the practice of aseptic or antiseptic surgery ; those most employed at the present time are heat, bichloride of mercury, carbolic acid, iodoform, beta-naphthol, chloride of zinc*, peroxide of hydrogen, creolin, permanganate of potassium, pyoktanin and boric acid, the double cyanide of mercury and zinc, and aristol. Heat. The most reliable and universally available agent for the destruction of pyogenic organisms is heat, either dry or moist; many forms of bacteria are rendered inert at a temperature of 140° F., and none can withstand the appli- cation of moist heat at a temperature of 212° F. continued for a short time. As moist heat is the most efficient sterilizer, it should be preferred, and can always be made use of for this purpose by boiling the instruments and dressings for a few minutes, and if for any reason it is thought advisable to employ dry heat as a sterilizer, this mav be made use of by baking the instruments or dress- ings in a hot oven. The same results, of course, may be obtained by the use of one of the various dry or moist sterilizers. Bichloride of Mercury. This is employed as an antiseptic in watery solution, varying in strength from 1 : 500 to 1 : 10,000. The solution 1 : 500 to 1 : 1000 is used only for the irrigation and disinfection of the hands and skin ; for the irrigation of wounds, a solution of 1 : 2000 is generally employed. In using the bichloride solution in operations upon children, I am in the habit of using a solution of 1 in 4()()0, and I find that it produces less irritation of the skin and is equally efficient as a germicide. Where con- tinuous irrigation is kept up or where it is employed in large cavities, a still weaker solution, 1 : 5000 to 1 :10,000, should be employed. In using these solutions the surgeon should watch the patient carefully for symptoms of poisoning due to the BICHLORIDE OF MERCURY. 113 absorption of the bichloride of mercury; the symptoms denoting this are vomiting, fetid breath, salivation, in- flammation of the gums, diarrluea, blood-stained stools, and bleeding from the mouth and nose. In preparing the solutions of bichloride of mercury for use, it will be found convenient to have a concentrated solution of the salt in alcohol, one part of the bichloride of mercury to ten parts of alcohol; this can be kept in a well-stoppered bottle, and to this should be added one tea- spoon ful of common salt, which prevents the disintegration of the mercuric compound. One teaspoonful of this solution added to one quart of water makes a 1 : 1500 solution. A ten per cent, bichloride solution may be made as follows : Bichloride of mercury . . .2 parts. Sodium chloride ...... 1 part. Dilute acetic acid . . . . . . 1 " Water........16 parts. By adding water in an appropriate quantity, 1 :1000 or 1 : 2000 solu- tion can be made. Or the solution may be prepared with tartaric acid in the proportion of five parts of the acid to one part of the bichloride of mercury, the following formula being em- ployed : Hydrarg. chlor corrosiv. ..... grs. xv. Ac tartaric........grs. lxxv. Aquae dest. ....... Oij Pellets containing a definite amount of bichloride of mercury compounded with a few grains of common salt or muriate of ammonia, which, when dissolved in a definite quantity of water, make a solution of 1 : 1000 or 1 : 2000, will also be found very convenient for the preparation of solutions. These bichloride or sublimate solutions are also em- ployed to sterilize the gauze and cotton which are largely employed in antiseptic dressings. 114 MINOR SURGERY. Carbolic Acid. This drug is employed in solutions of 1 : 20 or 1 : 40. The stronger solution, 1 : 20, is usually employed to sterilize the instruments, the latter being allowed to remain in this solution for thirty minutes before being used. As a carbolic solution of this strength benumbs and cracks the skin of the hands of the operator, it should be diluted just before the instruments are required, In- adding an equal quantity of water, making it a 1 : 40 solution. The 1 :40 solution is used for the irrigation of wounds and the washing of sponges. Carbolic acid is also em- ployed in the preparation of gauze. A ready method of making a 5 per cent, carbolic solution is to add one table- spoonful of carbolic acid to one quart of water. In using carbolic acid solutions continuously the surgeon should be on the watch for the symptoms of poisoning, which will show itself by dark-colored urine, headache, dizziness, vomiting, and in severe cases bloody diarrhoea, hemoglobinuria, and death from collapse. Carbolic acid solutions should be used with great caution in young children, as they seem to be more susceptible than adults to the constitutional effects of this drug. I have seen the use of quite dilute solutions produce the characteristic symptoms of poisoning in such patients. Iodoform. Iodoform has been shown by experimental research to possess little germicidal action, but in spite of this fact clinical experience has proved that it possesses powerful antiseptic properties, due not to the destruction of germs, but to its undergoing a decomposition in their presence, and thus rendering the ptomaines which have resulted from the germ-growth inert. Iodoform may be rendered absolutely sterile by washing it in a 1 : 1000 bichloride solution, which destroys all micro-organ isms ; it should then be dried, and kept for use in closely-stoppered bottles. CHLORIDE OF ZINC. 115 Iodoform is very extensively employed as an application to wounds; it is especially useful as a dressing to infected wounds, and to tubercular or syphilitic ulcers. It is also employed in the preparation of iodoform gauze, and may be combined with collodion to form iodoform collodion, which is a useful dressing in superficial wounds: Iodoform ..... grs. xlviij. Collodion.....gj. An ethereal solution of iodoform (iodoform grs. xv, ether .V)) is also used as an application to chronic ulcers. An emulsion of iodoform in glycerin (iodoform 5j, glycerin 5x) is much employed at the present time as an injection in the treatment of chronic or tubercular abscesses. Elderly persons are more prone to the toxic action of iodoform than young persons. These symptoms are mani- fested by sleeplessness, debility, headache, delirium, and death may result from meningitis or cardiac depression. Beta-na pi thiol. Beta-naphthol, in a 1 : 2500 solution, is employed for much the same purposes as the bichloride of mercury solu- tion ; it is not, however, so powerful a germicide. It is employed in irrigating large cavities because it is not a poisonous agent, but is especially useful as a bath for instruments, as it does not corrode them, as does the sub- limate solution. It also possesses the advantage over a carbolic acid solution of not irritating; the skin of the surgeon's hands. Chloride of Zinc. Chloride of ziilc, in a solution of 30 to 40 grains to water f^j, is a very powerful antiseptic AVhen employed upon raw surfaces it produces marked blanching of the tissues; it is especially useful in wounds which arc infected or which have been exposed to infection. I have found it 116 MINOR SURGERY. by all means the best application to the poisoned wounds which are received in dissecting dead bodies and in oper- ating. In such cases the whole cavity or surface of the wound should be washed with a 30-grain solution of the chloride of zinc, and then the wound should be dressed with a bichloride dressing. Sulpho-carbolate of Zinc. This drug has been found to possess more decided anti- septic properties than the chloride of zinc, and is much less irritating. It may be used in the same strength and for the same purposes as the former drug. Peroxide of Hvdrogen. This drug is employed in what is known as a 15-volume solution, which may be diluted from 10 per cent, upward or used in full strength. It is employed in the steriliza- tion of sinuses or suppurating cavities, such, for instance, as often result from diseases of or operations upon bone. It seems to have a direct action upon pus generation bv destroying the micro-organisms of pus. It is injected into sinuses and cavities by means of a syringe, or may be applied to open wounds in the form of a spray ; its activity is shown by the escape of bubbles of air, and it should be used as long as these continue to ('scape. Kreolin or Creolin. This substance is obtained from English coal bv drv distillation, and has been found to possess powerful germi- cidal properties; it is non-irritating and practically non- toxic. It is insoluble in water, but forms an emulsion with it which possesses marked germicidal properties. It is employed for the same purposes as carbolic acid, and has the advantage over the latter drug that it is not irri- tating to the skin, and is almost devoid of toxic properties. It is used in an emulsion, in strength from two.to five permanganate of potassium. 117 per cent., and is employed in the irrigation of large wounds or cavities of the body, and has been most favorably rec- ommended in gynecological practice. As a bath for instruments, to render them sterile during operations, it is useful, but the opacity of the emulsion makes it difficult to find the instruments and interferes with its efficiency. Boric Acid. This drug has not very marked antiseptic qualities, but is unirritating even in saturated solutions. It is frequently employed in a 5 to 30 per cent, solution to cleanse and dis- infect mucous surfaces and large cavities. It is often em- ployed to wash out the bladder before the operation for the removal of calculi or growths from that organ. In the dressing of superficial wounds, or in wounds in which the bichloride or carbolic; acid dressings produce irri- tation, an ointment of boric acid, made by taking boric acid 1 part, vaseline 5 parts, will be found very satisfactory. BORO-SA LIC V LIC L( )T I( )N. This lotion is prepared by adding 2 parts of salicylic acid and 12 parts of boric acid to 1000 parts of hot water. This forms a very bland solution, which can be used where there is danger in using bichloride or carbolic solutions— as, for instance, in the bladder or peritoneal cavity. Permanganate of Potassium. This drug, owing to its rapid absorption of oxygen, acts as an antiseptic, and is often employed for the disinfection of foul wounds and ulcers. It is also employed in solution for washing the operator's hands, and for the washing of sponges. It is practically non-irritating, and may be used in quite concentrated solutions, but is usually employed in the following solution : Permanganate of potash oj, water f5j. One fluid drachm of this solution to a pint of water makes a 1 :1000 solution. 6* 118 MINOR SURGERY. Pyoktanin. Methyl-violet, known in commerce under the name of pyoktanin, has been recommended as a drug possessing marked antiseptic powers. It is said to prevent suppura- tion by destroying the organisms which are active in its production, which are said to have an affinity for and are killed by aniline colors. It has been claimed that it sterilizes the pus of suppurating wounds and ulcers, and it is recommended as an injection in the treatment of large suppurating cavities for this purpose, as it is practically non-poisonous. It is employed in a solution of a strength of 1 :1000 or 1 :2000, and for the sterilization of surgical instruments a 1 : 10,000 solution may be employed. When employed as a means of irrigating wounds, it should be used until the tissues are of a deep-blue color. Kcccnt investigations have shown that it is, as a germicide, much less reliable than bichloride of mercury. Aristol. Aristol, which is a compound of iodine and thymol, pos- sesses germicidal properties and has been introduced as a substitute for iodoform. It has the advantage over iodo- form of not being poisonous and is also without disagree- able odor. It may be employed for the same purposes as iodoform, and it seems to be particularly useful as a dress- ing to chronic and specific ulcers. Iodol. This drug possesses antiseptic properties and is employed for much the same purposes as iodoform and aristol, and has much less odor than the former; it is soluble in alcohol, ether, and oil, and may be-employed in solution or used as a dry powder. It is used for the same purposes as iodoform, and is DOUBLE CYANIDE OF MERCURY AND ZINC. 119 much employed as a local application in inflammatory and ulcerated conditions of the mucous membrane of the nose and throat. Double Cyanide of Mercury and Zinc. Cyanide of potassium, cyanide of mercury, and sulphate of zinc are mixed together in solution, in quantities pro- portioned to the atomic weights of 2 KCy, HgCy2 and ZnS04 -f- 7II20 ; the cyanide of potassium and cyanide of mercury being dissolved together in one and a half ounces of water for every 100 grains of potassium cyanide, are added to the sulphate of zinc dissolved in three times that amount of water. The precipitate is collected and washed in two successive portions of water equal in quantity to that used for the solutions, that is six ounces of water for every 100 grains of the potassium cyanide, to free the precipitate from the irritating salts associated with it in its formation. The precipitate being well washed, is next mixed with distilled water containing one part of hema- toxylin for every 100 parts of the cyanide salt; this, when it precipitates the cyanide salt, changes its color to a pale bluish tint. Ammonia is next added in such a proportion to the mixture that one fluidrachm of the ammoniacal liquid shall correspond with one grain of hematoxylin, and the ammoniacal mixture is allowed to stand for three or four hours, when it is filtered and the dyed salt is drained and dried at a moderate heat, is next levigated, and may then be kept for any length of time for use. When employed for charging gauze it is mixed with a 1 : 4000 bichloride solution in the proportion of four pints of the solution to 100 grains of the salt. 120 MINOR SURGERY. Preparation of Materials Used in Aseptic Surgery and Dressings. Sponges. Sponges cannot be sterilized by boiling, which destroys them, so they have to be prepared by washing and by treat- ment with germicidal solutions; they are prepared as follows : Sponges, while dry, should be beaten to free them from calcareous matter, then placed in a 15 per cent, solution of hydrochloric acid for thirty minutes to dissolve any lime which may remain in them ; they should then be removed from this solution and washed, and should next be well washed with green or castile soap and warm water for a few minutes and then thoroughly rinsed and placed in a 1 :1000 bichloride solution or in a 5 per cent, carbolic solution in closely covered jars until required for use. Or, after beating the sponges to remove any sandy mat- ter, they may be placed for twenty-four hours in a solution of hydrochloric acid—hydrochloric acid §iv, water four pints—then removed and washed until free from acid, then steeped for half an hour in a solution of permanganate of potassium, ISO grains to six pints of water. Next wash them and place them in the following solution : hypo- sulphite of sodium, 5x ; hydrochloric acid, f 5v; water, f§lxviij ; and allow them to remain in this solution for four hours; remove them from this and place them in running water for six hours ; they should then be placed in jars and covered either by a 5 per cent, carbolic acid solution or a 1 : 1000 bichloride solution. The carbolic acid solution is better for keeping the sponges than the sublimate solution, as it does not decompose. They may be prepared also by beating and washing them, and then soaking them for twelve hours in a solu- tion of chlorinated soda—chlorinated soda 1 part, water 5 parts. They are then removed and well rinsed and placed in a 5 per cent, carbolic solution, or they may be placed in a moderately warm oven until thoroughly dry, and SILKWORM-GUT. 121 then placed in air-tight jars, if it is desired to keep them dry. It is better to use a cheaper grade of sponges, and to use them only once, but if the same sponges are to be used again, they should be well washed in a solution of carbonate of soda, 1 ounce to the quart, and then placed in a 1 :1000 bichloride solution. Gauze Pledgets or Pads. Pads or pledgets of sterilized or sublimated gauze may be used in the place of sponges during operations, and in preparing the gauze pads, a piece of gauze composed of from sixteen to twenty layers is cut into pads of the desired size, and the layers in each pad are quilted together bv a few stitches, and the edges should be loosely whipped with a thread to prevent the edges from fraying. The gauze pledgets are prepared by cutting a piece of gauze composed of from twelve to sixteen layers in pieces six inches square, the four angles of these pieces are then brought together and tied by a thread or are secured together bv a few stitches. The pads or pledgets are usually employed in a moist condition and before being used should be sterilized bv being placed in a 1 : 2000 bichloride solution or by boiling, and any excess of moisture should be squeezed from them before being brought in contact with the wound. Silk. Silk for sutures or ligatures, either the plaited silk or the Chinese twisted silk, should be sterilized by boiling for thirty minutes in a 5 per cent, solution of carbolic acid or water, then placed in stoppered bottles and covered with a 5 per cent, solution of carbolic acid or with absolute alcohol. Silkworm-get. Silkworm-gut is an excellent material for sutures, and % is much easier to thread than the silk or catgut. It may 122 MINOR SURGERY. be kept dry in glass jars, or preserved in alcohol, and should be placed in a 5 per cent, carbolic solution for a few minutes before being used, as this renders it more supple. Catgut Ligatures or Sutures. In preparing catgut for ligatures or sutures, the ordinary catgut of the shops should be washed with castile soap and water, and then should be placed in ether and allowed to remain for four or five hours, and upon being removed should be placed in 95 per cent, alcohol in a tightly-stop- pered bottle. Before being used it should be soaked for a few minutes in a 1 : 20 carbolic solution. Juniper Catgut. Catgut, varying in size from No. 0, which is very fine, to No. 4, which is quite thick, is placed in oil of juniper berries for one week, and is then transferred to absolute alcohol, in which it should be kept until required for use. No. 1 catgut is the size usually employed for ligatures and sutures. Alcohol is the best material in which to preserve the catgut, as it keeps it firm, and does not interfere with its flexibility, while both carbolic acid and bichloride solu- tions render it brittle and weak. Chromic Acid Catgut. The catgut is first washed in alcohol and placed in 1 quart of a 5 per cent, solution of carbolic acid, containing 30 grains of bichromate of potassium, and is allowed to remain for forty-eight hours. This immersion should be longer when large-sized varieties of catgut are used ; but for the sizes of catgut which are ordinarily used, this time of immersion will prepare the gut to resist the action of the living tissues for a week or more. Catgut thus pre- 0 pared may be dried and placed in closely stoppered jars, or may be kept in alcohol. drainage-tubes. 123 ( atgut may also be prepared by soaking it in alcohol for a short time, and then placing it in the following solution for forty-eight hours: Chromic acid, 1 grain; carbolic acid, 200 grains; alcohol, 2 drachms; water, 2\ ounces. It is then removed and placed in glass jars for use. IJefore being used it should be soaked for thirty minutes in a 5 per cent, carbolic acid solution, or in a 1 : 1000 bichloride solution. The chromic acid catgut is by far the best variety of gut to use for sutures and for the ligation of the larger vessels in their continuity. Drainage-tubes. Fig. 90. Rubber drainage-tube. The drainage-tubes usually employed are prepared from rubber tubing of different sizes perforated at short inter- vals ; the black rubber tubes are softer and more pliable than the red or white rubber tubes, and should be pre- V 124 MINOR SURGERY. ferred. (Fig. 90.) Drainage-tubes are also made of glass (Fig. 91), which are almost exclusively used in abdominal surgery, and also of decalcified bone. Drainage-tubes Fig. 91. Glass drainage-tube. should be kept in a 5 per cent, solution of carbolic acid, or, if kept dry, they should be well washed and placed iu a carbolic or bichloride solution for thirty minutes before being used. Horse-hair and Catgut for Drainage. Cutgut as ordinarily prepared for ligatures may be used to secure drainage in small and superficial wounds; a number of strands of catgut are placed in the bottom of the wound, and the end or ends are allowed to project from one or both extremities of the wound. Horsehair may be employed for the same purpose, a number of strands of the hair being placed in the wound in the same manner. Before being used it should be well washed with soap and water and then soaked in a 5 per cent, carbolic solution or 1 : 1000 bichloride solution for thirty minutes. Protective. Protective is employed to prevent the wound from being irritated by the antiseptic substances with which the gauze is impregnated or by its irregular surface. Various materials arc employed as protectives, the prin- cipal requirement being that it is some tissue which can be readily rendered aseptic, and does not absorb any irri- tating materials from the dressings. RUBBER TISSUE. 125 The protective first employed by Mr. Lister, which is still generally employed, is prepared by coating oiled silk with copal varnish, and when this is dry a mixture of 1 part of dextrine, 2 parts of powdered starch, and 16 parts of a 1 : 20 carbolic acid solution is brushed over its surface. Rubber tissue may be employed very satisfactorily as a substitute for this protective. Before applying the protective to the wound, it is dipped into a solution of bichloride of mercury or carbolic acid. Mackintosh. This consists of cotton cloth, with a thin layer of India- rubber spread on one side. It is employed in antiseptic dressings as a layer of dressing outside of the gauze, and should be applied with the rubber surface toward the wound, to prevent the entrance of air and to allow the serum from the wound to permeate the gauze and not soak directly through the dressings. The mackintosh (doth is not at the present time as much employed as formerly, unless the moist method of dressing is adopted. Rubber Dam. This is thin, pure rubber tissue, and as it has no cloth surface like mackintosh, it is cleaned and sterilized with greater facility. It is used in applying the moist method of dressing to cover the gauze dressings, and is attached to the drainage-tube in abdominal wounds to shut off the opening of the drainage-tube from the abdominal wound. Before being used it should be washed with soap and water, rinsed, and then placed in a bichloride or carbolic solution for a short time. Rubrer Tissue. This consists of a very thin sheet of India-rubber with glazed surfaces, which can be obtained from the rubber manufacturers; it is employed for the same purposes as 126 MINOR SURGERY. the mackintosh, is much less expensive, and, as previously stated, may be used instead of protective for covering the wound. Parchment Paper. This consists of a very tough paper material which can be soaked in a watery solution of corrosive sublimate or carbolic acid without becoming so much softened as to tear upon handling. It is prepared by the manufacturers of surgical dressings, and is employed for the same pur- poses as mackintosh. Gauze Dressings. The most convenient and cheapest material for wound- dressing is a sheer material known in the trade as cheese or tobacco cloth. By reason of having a very open mesh it absorbs well either the materials with which it is pre- pared or the discharges from the wound when applied as a dressing. It can be readily obtained anywhere, is inex- pensive, and is soft and pliable, so that it is a comfortable form of dressing to the patient. The gauze is impreg- nated with different materials to render it antiseptic, and its preparation is a matter of little difficulty. Preparation of Gauze Dressing. Bichloride of Mercury or Corrosive Sublimate Ga uze. In preparing bichloride or corrosive sublimate gauze, thirty yards of cheese-cloth are placed in a wash-kettle, and covered with water, to which is added two pounds of washing soda or a pint of lye, and boiled for an hour; the soda or lye is added to remove any oily matters which the cheese-cloth contains, and thus make it more absorbent. The gauze is next removed from the water and washed in clear water, and passed through a clothes-wringer, and CYANIDE OF MERCURY AND ZINC GAUZE. 127 then immersed in a 1 : 1000 bichloride of mercury solu- tion for twenty-four hours. It is then dried and cut into pieces several yards in length, and packed in closely cov- ered glass jars or tin boxes and put away for use. Or it may be preserved as moist gauze by packing it in air-tight jars. If gauze has been prepared for some time, it is well to soak it for a short time in a 1 : 1000 bichloride of mer- cury solution before using it. In using the sublimate gauze on delicate skins there will sometimes result a dermatitis which is known as mercurial eczema; this is particularly apt to occur if the gauze is moistened or covered with rubber tissue or mackintosh. If this condition develops, the parts covered by the gauze should be rubbed over with boric acid ointment or vase- line before it is reapplied, or another variety of dressing may have to be substituted, such as the iodoform or car- bolized gauze. Iodoform Gauze. Iodoform gauze may be prepared by sprinkling cheese- cloth, which has been boiled in soda solution, with pow- dered iodoform and rubbing it wcdl into its meshes; it should then be dried and packed in glass jars for use. It may also be prepared by rubbing an emulsion of iodoform, made by adding 3 drachms of iodoform to 6 ounces of castile soap-suds, into 1tt<>n. This material is prepared from ordinary cotton, which is boiled with a strong alkali to remove the oily matter which it contains. When so prepared it absorbs liquids freely, and by reason of its great absorbing capacity it is largely employed in surgical dressings. A small mass of absorbent cotton wrapped upon the end of a probe or stick is now generally employed to make applications to wounds, and has taken the place of the sponge or brush which was formerly employed for this purpose. From its cheapness, after one application it can be thrown away and a new piece can be used, and thus the danger of carrying infec- tion from one wound to another by the applicator is abol- ished. It is largely employed in gynecological practice for making applications to the female genital organs. It is impregnated with various antiseptic substances, 146 minor surgery. such as the bichloride of mercury, carbolic add, boric acid, and salicylic acid, and when thus treated, forms the bichloride, carbolized, borated,^ and salicylated cotton so much employed in antiseptic dressings. Jute. This substance is made from the fibre of the Corchorus capsularis, which, on account of the character of its fibre, possesses both elasticity and absorbing qualities; it has been employed for much the same purposes as oakum and cotton, such as the padding of splints, and is also used as an external absorbing dressing. Wood AVool. Wood wool made from wood pulp, such as is employed in the manufacture of paper, is also furnished in the shape of lint, sponges, and pacts, and may be used for the same purposes as the ordinary surgical lint. Oiled Silk or Muslin. These materials are employed as an external cover for moist dressings to prevent rapid evaporation from the dressings ; they form excellent materials for this purpose, but as they are quite expensive their use is limited. Waxed or Paraffin Paper. This dressing is prepared by passing sheets of tissue- paper through melted wax or paraffin, and then allowing them to dry for a few minutes. Paper thus treated forms an excellent and cheap substitute for oiled silk or muslin, and may be employed for the same purpose for which the latter materials are used. Rubber Tissue. This material, which is prepared by rubber manufac- turers, consists of rubber run out into very thin sheets; TAMPON. 147 it has a glazed surface, is very pliable and strong at the same time, and forms a cheap and satisfactory substitute for oiled silk, and is employed for the same purposes. In the moist method of antiseptic dressing it may be used in place of the mackintosh, and indeed I prefer it to the latter in this method of dressing. Par< hment Paper. This paper is prepared so as to render it water-proof; it is employed in surgical dressings for the same purposes as oiled silk and rubber tissue. (■-( auterv. A very convenient and efficient means of using the ther- mo-cautery is the apparatus of Paquelin, which utilizes the property of heated platinum-sponge to become incandescent when exposed to the action of the vapor of benzole or rhigolene. (Fig. 108.) The cautery is prepared for use Paquelin's cautery. by attaching the gum tube to the receiver containing ben- zole and heating the platinum knife or button, which is also attached to the benzole receiver by a rubber tube, in the flame of the alcohol lamp for a few moments, and then passing the vapor of benzole through the platinum- sponge, which is enclosed in the knife or button, by com- pressing the rubber bulb. The points may be brought to SCARIFICATION. 173 a high degree of heat, or may be brought only to a dull- red heat. This form of cautery may be employed for the same pur- poses as that previously mentioned; its great advantage consists in the ease Avith which it can be prepared for use. The knives heated to a dull-red heat will be found of great service in operating upon vascular tumors, where the use of an ordinary knife would be accompanied by profuse or even dangerous hemorrhage. Wounds made by the actual cautery are aseptic wounds, and when dusted with iodoform will generally heal promptly under the scab without suppuration. Bloodletting. This procedure is often resorted-to to obtain both the local and the general effects following the withdrawal of blood from the circulation. Local depletion is accom- plished by means of some one of the following pro- cedures: scarification, puncfuration, cupping and leeching, and general depletion is effected by means of venesection or arteriotomy. Scarification. Scarification is performed by making small and not too deep incisions into an inflamed or congested part with a sharp-pointed bistoury; the incisions should be in parallel lines and should be made to correspond to the long axis of the part, and care should be taken in making them to avoid wounding superficial veins and nerves. Incisions thus made relieve tension by allowing blood and serum to escape from the engorged capillaries of the infiltrated tissue of the part. Warm fomentations applied over the incisions will increase and keep up the flow of blood and serum. Scarification is employed with advantage in in- flammatory conditions of the skin and subcutaneous cellular tissue and in acute inflammatory swelling or (edema of the mucous membrane; for instance, of the conjunctiva, and 174 MINOR SURGERY. in acute inflammation of the tonsils, tongue, and epiglottis it is an especially valuable procedure. A modification of scarification known as deep incisions is practised in urinary infiltration to establish drainage and relieve the tissues of the contained urine and to prevent sloughing; in threatened gangrene and phlegmonous erysipelas the same procedure is adopted to relieve tension by permitting of the escape of blood and serum, and its employment is often followed by most satisfactory results. PUNCTURATION. This procedure consists in making punctures, which should not extend deeper than the subcutaneous tissue, into inflamed tissues with the point of a sharp-pointed bistoury; it is an operation similar in character to that just described, its object being to relieve tension and bring about depletion. It is employed in cases similar to those in which scarification is indicated, and is resorted to in cases of diffuse areolar inflammation or erysipelas. Cupping. Cupping is a convenient method of employing local depletion by inviting the blood from the deeper parts to the surface of the skin. Cupping is accomplished by the use of wet or dry cups. When the former are used, no blood is abstracted and the derivative action only is ob- tained ; when wet cups are employed there is an actual abstraction of blood or local depletion as well as the derivative action. Dry Cupping. Dry cups as ordinarily applied consist of small cup- shaped glasses, which have a valve and stop-cock at their summit; these are placed upon the skin and an air-pump is attached, and as the air is exhausted in the cup the con- gested integument is seen to bulge into the cavity of the cupping. 175 Fig. 109. cup. When the exhaustion is complete the stop-cock is turned and the air-pump is removed, the cup being allowed to remain in position for a few minutes, and is then removed by turning the stop-cock and allowing the air again to enter the cup. This procedure is repeated until a sufficient number of cups have been applied. (Fig. 109.) In cases of emergency, when the ordinary cupping-glasses and air-pump cannot be ob- tained, a very satisfactory substitute may be obtained by taking a wineglass and burning in it a little roll of paper, or a small piece of lint or paper wet with alcohol, and before the flame is extinguished rapidly inverting it upon the skin, or the air may be exhausted by the introduction, for a moment or two, of the flame of a spirit-lamp into the cup. Applied in this manner cups will draw as Avell as when the more complicated apparatus is used, and when thev are removed it is only necessary to press the finger on the skin (dose to the edge of the CuPPiDs- ~ ~ fiflftSS £LHQ cup until air enters the cup, when it will fall air-pump. off. Although dry cups do not remove blood there is often an escape of blood from the capillaries into the skin and cellular tissue, as evidenced by the ecchymosis which frequently remains at the seat of the cup-marks for some days. Dry cups, as previously stated, are employed for their derivative action in cases in which depletion is not indi- cated. Wet Cupping. When the abstraction of blood as well as the derivative action is desired wet cups are resorted to, and here it is necessary to have a scarificator as well as the cups and air- pump. (Fig. 110.) Before applying wet cups the skin should be Mashed carefully with a carbolic solution, and the scarificator should also be dipped in a carbolic solution. A cup is 176 MINOR SURGERY. first applied to produce superficial congestion of the skin; this is removed and the scarificator is applied, and the skin is cut by springing the blades, and the cups are immedi- ately applied and exhausted, and they are kept in place as long as blood continues to flow. When the vacuum is exhausted and blood ceases to flow, they should be removed and emptied, and can be reapplied if it is de- sirable to remove more blood. A sharp-pointed bistoury which has been sterilized may be employed to make a few incisions into the skin instead of the scarificator, and the improvised cups may be employed scarificator. if the ordinary cupping apparatus cannot be obtained. After the removal of wet cups the skin should be washed carefully with a bichloride or carbolic solution, and an antiseptic dressing should be placed over the wounds and held in place by a roller bandage. Leeching. In the abstraction of blood by leeching two varieties of leeches are used—the American leech, which draws about a tcaspoonful of blood, and the Swedish leech, which draws three or four teaspoonfuls. Before applying leeches the skin should be carefully washed, and the leech should be placed upon the part from which the blood is to be drawn, and confined to this place by inverting a tumbler or glass jar over him ; if he does not bite or take hold, a little milk or blood should be smeared upon the surface, which will generally secure the desired result. As soon as the leech has ceased to draw blood he is apt to let go his hold and fall off; if, however, it is desired to remove leeches, they may be made to let go their hold by sprinkling them with a little salt. After the removal of leeches bleeding from the bites may be en- LEECHING. 177 couraged if desirable by the application of warm fomenta- tion. Leech-bites should be washed with a bichloride or carbolic solution, and a compress of bichloride or iodoform gauze should be placed over them and secured by a bandage. It sometimes happens that free bleeding continues from the leech-bite after the removal of the leeches ; in this event, if a compress does not control the hemorrhage, the bleeding-point should be touched with a stick of nitrate of silver or with the point of a steel knitting-needle heated to a dull-red heat, and if this fails to control the bleeding a delicate harelip pin should be passed through the skin under the bite and a twisted suture should be thrown around this; the wound should then be washed and dressed as previously described. fig. in. In applying leeches in or near mucous cavities, care should be taken to see that they do not escape into the cavities and pass out of reach. Leeches should not be em- ployed directly over inflamed tissue, but should be applied to parts surrounding it; they should not be allowed to take hold directly over a superficial artery, vein, or nerve, and should never be applied to a part where there is delicate skin and a large amount of loose cellular tissue, as in the eyelid or scrotum, as unsightly ccchymoscs will result, which will persist for some time. Leeches should not be used a second time. Mechanical Leech. The mechanical leech is an apparatus which has been constructed to take the place of the leech ; it consists of a scarificator, cup, and exhausting syringe or air-pump. (Fig. 111.) In using this apparatus, after the scarificator has been used the piston of the exhausting instrument should be drawn out slowly, which secures a better flow of blood than if a sudden vacuum is made. 178 MINOR surgery. The mechanical leech may be employed when the natural leech cannot be obtained, but possesses no advantages over the latter, and is apt to get out of order if not in constant use. ArENESECTION. Venesection, as its name implies, consists in the division of a vein, and it is the ordinary operation by which general depletion or bleeding is accomplished. Venesection at the bend of the elbow is the operation which is now usually resorted to for general bloodletting; the vein selected is the median cephalic, which is further from the line of the brachial artery than the median basilic vein. (Fig. 112.) Fig. 112. Venesection. (Heath.) To perform venesection the surgeon requires a bistoury or lancet—the spring lancet was formerly much used, but it is not employed at the present time—several bandages, a small antiseptic dressing, and a basin to receive the blood. The patient's arm should be carefully cleansed, washed over with a bichloride solution, and a few turns of a roller bandage should be placed around the middle of the arm, being applied tightly enough to obstruct the venous circu- lation and make the veins below become prominent, but not to obstruct the arterial circulation. The patient at the same time should be instructed to grasp a stick or a roller bandage and work his finger upon it. The surgeon should next assure himself that there is no abnormal artery be- VENESECTION. 179 neath the skin, and having selected the vein, the median cephalic by preference, he then steadies the vein with his thumb and passes the point of the bistoury or lancet be- neath it and cuts quickly outward, making a free skin opening. The blood usually escapes freely, and the amount withdrawn is regulated by the condition of the pulse and the appearance of the patient. For this reason it is better to have the patient sitting up or semi-reclining when venesection is performed, as the surgeon can judge better as to the constitutional effects of the loss of blood while the patient is in this position. When a sufficient quantity of blood has been removed, the thumb is placed over the wounded vein and the bandage is removed from the arm above. The wound is next washed with a bichloride solution, and a compress of antiseptic gauze is applied over the wound and held in position by a bandage, which should be so applied as to envelop the limb from the fingers to the axilla. The dressing need not be disturbed for five or six days, at which time the wound is usually found to be healed. Wounds of the brachial artery have occurred in opening the vein at the bend of the elbow, but if care is taken this accident should not take place. Venesection may be practised on the external jugular vein when, from excess of fat or in the case of children, the veins at the bend of the elbow cannot be easily found. The vein is rendered prominent by placing the thumb or a pad over the vein at the outer edge of the sterno-cleido-mastoid muscle just above the clavicle. The vein is next opened over this muscle by an incision parallel to its fibres. After a sufficient quantity of blood has escaped, the wound is washed with an antiseptic solution and closed by a com- press of antiseptic gauze held in position by a bandage carried around the neck. Bleeding from this vein has been advocated in cases of apoplexy and cerebral inflammation, but it is questionable whether any advantage is gained by opening the external jugular vein over the vein at the bend of the' elbow. The internal saphena vein is also sometimes selected for 180 MINOR SURGERY. venesection, and here care should be taken not to wound the accompanying nerve which lies directly behind the vein. Arteriotomy. This operation is now scarcely ever performed, but if done the vessel generally selected is the anterior branch of the temporal artery. The position of the vessel is fixed bv the finger and thumb, and it is opened by a transverse in- cision with a bistoury. After a sufficient quantity of blood has escaped the wound is inspected, and if the vessel is not completely divided, its division is completed and the ends of the vessel should be secured with ligatures, and the wound should be washed out with an antiseptic solution and a gauze compress should next be applied and held in position by a firmly applied bandage. Transfusion of Blood. This operation may be employed to introduce a certain quantity of blood into the circulation of a patient who has suffered from profuse hemorrhage. There are two methods by which transfusion may be effected : the direct, by which the blood is conveyed directly and without exposure to the air from the bloodvessel of one person to that of another, and the indirect, in which the blood is first drawn from one person and is then injected into the vein of another, being first deprived of its fibrin before being injected. Direct Transfusion of Blood. This is best accomplished by using Aveling's apparatus, which consists of a rubber tube, about eighteen inches in length, with a small bulb in the centre, having metallic extremities provided with stop-cocks, and two bevel-pointed metallic canulse to be used to connect the tube with the bloodvessels. In performing the operation of direct trans- fusion the bulb and tube are first placed in a shallow basin containing warm normal saline solution (0.7 per cent.), and TRANSFUSION OF BLOOD. 181 the bulb and tube are filled with this solution to displace anv air which they contain. The person supplying the blood places his arm near the arm of the patient, and the operator exposes a prominent vein on the patient's arm at the bend of the elbow and opens it, and inserts into it one of the canulaj filled with saline solution, with the point directed toward the body, and at the same time an assistant should introduce the other canula into a vein at the bend of the elbow of the party who supplies the blood. Fig. 113. Apparatus for the direct transfusion of blood. The canuhe are held in position by assistants, and the tube is quickly connected with them, the stop-cocks being closed before it is taken out of the saline solution, to pre- vent the entrance of air; then upon opening the stop-cocks a direct communication is established between the circula- tion of the patient and the donor. (Fig. 113.) The in- troduction of the contents of the bulb into the vein of the patient is effected by the operator slowly compressing the bulb with one hand, while he keeps the tube closed on the side of the donor with the finger and thumb of the other hand. By relaxing the pressure on the tube on the donor's 182 minor surgery. side of the bulb and closing it on the patient's side, blood will flow from the donor's vein into the bulb as it slowly expands, and when filled the communication with the patient's circulation is again made, and the manipulation is repeated until a sufficient quantity of blood has been intro- duced as indicated by the condition of the patient's pulse. The quantity of blood or saline solution introduced can be calculated by remembering that at each emptying of the bulb two drachms of fluicl are introduced into the cir- culation. When a sufficient quantity has been introduced the canulse are removed and the wounds are dressed as ordinary venesection wounds. Indirect Transfusion of Blood. Indirect transfusion of blood is accomplished by with- drawing from a vein of the donor by venesection about ten ounces of blood, which is received in a (dean glass or porcc- FlG. 114. Apparatus for the indirect transfusion of blood. lain vessel, which is placed in water at a temperature of 110°. The blood thus kept warm is next defibrinated by whipping it with a bundle of broom straws or a wire brush, and after being filtered through a fine linen (doth or wire strainer, it is injected by means of an ordinary svringe transfusion of blood. 183 attached to a canula which has previously been inserted into a vein of the patient ; care should be taken that no air is introduced with the blood. When a sufficient quantity of blood has been introduced, the canula is re- moved and the wound is dressed in the usual manner. The success of this operation largely depends upon the expedition with which it is performed; to prevent the coagulation of the blood not more than two minutes should be allowed to intervene between the reception of the blood in the syringe and its introduction into the patient's vein. Various forms of apparatus have been devised for the operation of indirect transfusion of blood, and of these one of the best is that devised bv Dr. J. (I. Allen and modified by the late Dr. C. T. Hunter. (Fig. 114.) Arterial Transfusion. This procedure, which consists in injecting defibrinated venous blood into an artery, is occasionally practised. An artery, usually the radial at the wrist or the posterior tibial behind the inner malleolus, is exposed and secured by a ligature; it is then opened on the distal side of the ligature and the point of a canula or the nozzle of a syringe is introduced, directed toward the distal extremity of the limb, and blood, which has been previously defibrinated, is slowly injected. When a sufficient quantity has been introduced the canula is removed, and the division of the artery is completed and its extremities are secured by liga- tures, and the wound is (dosed and dressed. A uto-transfusion. This procedure is recommended in cases of excessive hemorrhage to support a moribund patient until other means of resuscitation can be adopted. It consists in the application of rubber bandages or of muslin bandages to the extremities for the purpose of forcing the blood toward the vascular and nervous centres. 184 MINOR SURGERY. Intra-venous Injection of Saline Solution. It has been proved by experiments and by clinical experience that human blood is not more efficacious in supplying volume to and restoring a rapidly failing circu- lation than normal salt solution, and as the latter can be obtained with much more ease than blood, its use has largely superseded the latter. The saline solution which is found most satisfactory to employ for this purpose is known as normal saline solution (0.7 per cent.). Fig. 115. The solution should be prepared with water which has been boiled to sterilize it, and should be of a temperature of about 100° when used. A vein of the patient, at the elbow, should be exposed and should have placed under it, about one-half inch apart, two catgut ligatures; the distal ligature is then tied and an opening is made into the vein between the ligatures; a canula is next inserted into the opening into the vein, and is secured in position by tying the proximal ligature. The artificial respiration. 185 canula is first filled with the saline solution, and is then connected with a funnel by means of a rubber tube (Fig. 115), which is filled with saline solution to displace the air, and upon raising the funnel above the part the solu- tion enters the vein ; care should be taken to see that the funnel is kept well supplied with solution until a sufficient quantity has been introduced. The quantity introduced is regulated by the condition of the patient's pulse. Saline solution may also be introduced by means of a svringe when the apparatus described cannot be obtained. Ixtra-vexofs Injection of Milk. The infra-venous injection of cow's or goat's milk has also been employed as a substitute for transfusion of blood in patients who have suffered from excessive hemorrhage or from diseases which greatly deteriorate the quality of the blood, such as pernicious anaemia, typhoid fever, and in carbolic acid poisoning. In making one of these injec- tions the milk should be fresh and should be warmed and strained through a fine wire or linen strainer, and it should be introduced by means of a canula inserted into a vein and secured in position by a ligature; to this canula is attached the rubber tubing and funnel, such as is employed in the intra-venous injection of saline solution. The funnel and tube are next filled with milk prepared as above described, and it is made to enter the vein of the patient by turning the stop-cock and raising the funnel above the patient's body. This injection has been em- ployed in the class of cases mentioned above with appar- ently beneficial results. Artificial Inspiration. This procedure is resorted to in cases of threatened death from apinea consequent upon drowning, profound anesthetization or the inhalation of irrespirable gases, or any cause which cheeks or interferes with the function of breathing. Before resorting to artificial respiration care 186 MINOR SURGERY. snould be taken to see that nothing is present in the mouth or air-passages which will obstruct the entrance of air into the lungs, such as mucus, foreign bodies or liquids, and also that all tight clothing, interfering with the free ex- pansion of the chest walls should be removed from the chest. When artificial respiration is resorted to the operator should persevere with it for some time, even when no apparent spontaneous respiratory movements are excited; for resuscitation has been accomplished in seemingly hopeless cases by patient perseverance with the manipu- lations. When the first natural respiratory movement is detected the operator should not cease making artificial respiration, but should continue these movements in such a way as to coincide with the spontaneous inspiratory and expiratory movements until the breathing has assumed its regular character. The temperature of the body should also be restored by frictions to the surface of the body by the hands or by rough towels and hot-water bottles, and warm coverings should be applied for the same object. Mouth-to-Mouth Inflation. This method of artificial respiration has been resorted to in eases of great emergency, especially in very young children. The operator draws the tongue forward, closes the nostrils, and applies his mouth directly to the mouth of the patient, and by a deep expiratory effort endeavors to force air into the chest; when this is accomplished the air can be expelled from the lungs by pressure upon the walls of the chest, and the procedure should be repeated about sixteen times in a minute. The same object may be accomplished by passing a flexible catheter into the trachea through the mouth, or by passing an intubation-tube, to the upper part of which a rubber tube is attached, into the larynx ; this can be passed with the fingers without difficulty, and the lungs can then be inflated by the oper- ARTIFICIAL RESPIRATION. 187 ator blowing into the catheter or tube, or by attaching to it a pair of bellows. Inflation of the lungs through the nostrils has been em- ployed bv Dr. Richardson, of London, who has devised a pocket-bellows for this object. The apparatus consists of two elastic bulbs, to which two rubber tubes are attached, which terminate in a single tube. In using this bellows the terminal tube is introduced into one nostril, the other nostril and mouth being closed ; air is forced into the lungs bv compressing one bulb, and withdrawn by com- pressing the other bulb. (Fig. 116.) Richardson's bellows for artificial respiration. This bellows may also be attached to a catheter or in- tubation-tube passed into the larynx, which would prevent the possibility of air escaping into the (esophagus, a com- plication which is liable to occur in mouth-to-moutli infla- tion or inflation through the nose. Direct Method of Artificial Respiration [Howard's). This method of artificial respiration is at the present time considered the most efficacious, and is the one adopted by the United States Life-saving Service, and although the rules given are for the resuscitation of cases of apparent drowning, the same procedures may be adopted in cases of apinea arising from other causes. The rules laid down by Dr. Howard are as follows : Rule I.—"To expel water from the stomach and lungs, strip the patient to the waist, and if the jaws are clenched 188 MINOR SURGERY. separate them and keep them apart by placing between the teeth a cork or a small piece of wood. Place the patient face downward, the pit of the stomach being raised above the level of the mouth by a large roll of clothing placed beneath it. (Fig. 117.) Throw your weight forcibly two or three times upon the patient's back over the roll of clothing so as to press all fluids in the stomach out of the mouth." Fig. 117. First manipulation in Howard's method. The first rule applies only to cases of drowning, and in using Howard's method in apnoea from other causes it is to be omitted. Rule II—u To perform artificial respiration, quickly turn the patient upon his back, placing the roll of clothing beneath it so as to make the breast-bone the highest point of the body. Kneel beside or astride of the patient's hips. Grasp the front part of the chest on either side of the pit of the stomach, resting the fingers along the spaces between the short ribs. Brace your elbows against your sides, and steadily grasping and pressing forward and upward throw your whole weight upon the chest, gradually increasing the pressure while you count one—two—three. Then suddenly let go with a final push which springs you back ARTIFICIAL RESPIRATION. 189 to vour first position. (Fig. 118.) Rest erect upon your knees while you count one—two; then make pressure again as before, repeating the entire motions at first about four or five times a minute, gradually increasing to about ten or twelve times. Use the same regularity as in blowing bellows and as seen in the natural breathing which you are imitating. If another person is present let him with one Fig. 118. Direct method of artificial respiration. hand, by means of a dry piece of linen, hold the tip of the tongue out of one corner of the mouth, and with the other band grasp both wrists and pin them to the ground above the patient's head." This method may be employed in cases of still-birth, or in young children, the operator holding the chest of the child in his left hand and compressing it with the right hand. Sylvester's Method of Artificial Respiration. In employing this method of artificial respiration the patient should be placed on his back upon a firm flat sur- face; a cushion of clothing is placed under the shoulders, and the head should be dropped lower than the body by tilting the surface on which he is laid. The mouth being 9* 190 MINOR SURGERY. Fig. 119. Sylvester's method—Inspiration. (Esmaech.) Fig. 120. Sylvester's method—Expiration. (Esmarch.) ARTIFICIAL RESPIRATION. 191 cleared of mucus or foreign substances, the tongue is drawn forward and secured to the chin by a piece of tape tied around it and the lower jaw, or may be pulled out of the mouth and held by an assistant. The operator, stand- ing at the patient's head, grasps the arms at the elbows and carries them first outward and then upward until the hands are brought together above the head; they should be kept in this position for two seconds, after which time they are brought slowly back to the sides of the thorax and pressed against it for two seconds. These movements are repeated fifteen times in a minute until the breathing is restored, or until it is evident that the case is a hopeless one. Marshall Hall's Ready Method of Artificial Respiration. In this method the mouth should first be freed from mucus or foreign bodies, and the patient is turned upon his face with one wrist under his forehead, and a roll of clothing is placed beneath his chest. By turning the body briskly on the side and a little beyond, and then on the fiice, alternately, respiration is imitated. As the body is brought in the prone position, compression is to be made upon the posterior aspect of the chest. These manipula- tions should be made fifteen times in a minute. In using any of these methods of artificial respiration the operator should persevere with them for an hour at least before abandoning the case as a hopeless one. In cases where the apnoea is due to the presence of a foreign body in the larynx or trachea, it is evident that no efforts at respiration can be successful until the air- passages are freed from the occluding body, and in such cases tracheotomy should be performed before artificial respiration is attempted ; the tracheal wound should be held open by retractors, which in a case of emergency can be made from bent hairpins, or by a tracheotomy-tube if one be at hand. Forced Respiration. Phis is that method of artificial respiration by which air is forcibly passed into the lungs. This procedure is 192 MINOR SURGERY. strongly advocated by Dr. George E. Fell, who has de- vised an apparatus by which it may be satisfactorily ac- complished. Prof. H. C. Wood has also made use of forced respiration in the resuscitation of animals with an apparatus somewhat similar to that devised by Dr. Fdl with good results, but has never applied it practically in the case of the human subject. Wood's apparatus consists of a pair of bellows, a few feet of rubber tubing and a face mask of rubber, and one or two intubation-tubes ; the mask or intubation-tube is attached to one end of the rub- ber tube and the bellows to the other end of the tube. The mask is applied over the mouth, or if this is not used the intubation-tube is introduced into the larynx, and air is forced into the lungs by working the bellows. He also advises that in the tubing a double metal tube be intro- duced, with the openings so placed that their size can be so regulated by turning the outer tube, that the operator can allow7 any excess of air thrown by the bellows to escape. The apparatus of Fell, which he has used in a number of cases with good results, consists of a tracheotomy-tube, a tube connected with the air-control valve, which is attached to an air-warming apparatus, which in turn is connected with a bellows by another tube. By means of this apparatus air is forced into the lungs and allowed to escape when the lungs have been expanded by the elas- ticity of the lung tissue and the chest Malls. Forced respiration will prove of value in cases of nar- cotic poisoning and other accidents in which death is pro- duced by paralysis of the respiratory centres. Dr. Fell has reported a number of cases of narcotic poisoning in which he has used his apparatus with the most satisfactory results. Aspiration. This procedure is adopted to remove fluid from a closed cavity without the admission of air, and the instrument which is employed to accomplish this object is known as an aspirator. The two forms of aspirator most generally employed are those of Dieulafoy and Potain. (Fig. 12L) ASPIRATION. 193 Tot a in's aspirator consists of a glass bottle, into the stopper of which is introduced a metallic tube, which is connected with two rubber tubes, one of which is con- nected with an exhausting pump, and the other with a delicate canula carrying a fine trocar; the apparatus is provided with stop-cocks to prevent the admission of air. In using this aspirator the bottle is exhausted of air bv using the air-pump; the canula enclosing the trocar is Fig. 121. Aspirator. next pushed through the tissues into the cavity containing the fluid to be removed; the trocar is next removed, and upon opening the stop-cock the fluid is forced out of the cavity by atmospheric pressure and passes into the bottle or receiver. If the fluid contains masses of lymph or (dots which block the canula, interrupting the flow of fluid, a stylet is passed through the canula to free it of the ob- struction. To diminish the pain produced in introducing the trocar and canula, the skin at the point to be punctured may be rendered less sensitive by holding in contact with it for a few minutes a piece of ice wrapped in a towel, or a towel 194 MINOR SURGERY. containing broken ice and salt. Care should also be taken to see that the trocar and canula are perfectly clean; to accomplish this it should be carefully washed and placed in boiling water or a 5 per cent, carbolic solution before being used. In introducing the trocar and canula the operator should be careful to avoid injuring any important veins, arteries, or nerves. After removing the canula the small puncture should be dressed with a compress of antiseptic or iodoform gauze held in place by a bandage or adhesive straps. The aspirator is frequently employed in cases of hydro- thorax, empyema and ascites, to evacuate the contents of cold abscesses in diseases of the hip and spine, and*to remove the contents of a distended bladder until a more radical operation can be performed. It is also a valuable instrument for diagnostic purposes, being frequently used to ascertain the character of the contents of deep-seated tumors containing fluid. The Stomach-tube. This consists of a tube about twenty-eight inches in length and three-eighths of an inch in diameter, which is introduced while the patient is in the sitting posture, the head being thrown backward so as to bring the mouth and gullet as nearly as possible in the same line. The tube being warmed and oiled, the surgeon standing in front of the patient passes it directly back to the pharynx, at the same time introducing the index finger of the left hand to guide its point over the epiglottis; it is then passed gently downward into the stomach. If any obstruction is met with in its passage it should be withdrawn a little way and then pushed gently downward; all manipulations should be made without much force to prevent perforation of the wall of the oesophagus. The introduction of the stomach-tube mav be required for the evacuation of poisons from the stomach, or to wash out the cavity of this viseus, and it may also be used to THE STOMACH-PUMP. 195 introduce liquid nourishment into the stomachs of patients who are unable or unwilling to swallow food. In the recently introduced method of treating disorders of the stomach and intestines by washing them out, lavage, the introduction of a stomach-tube is required; the tube here employed is from twenty-four to thirty inches in length (Fig. 122), and the fluid is introduced by means of a funnel attached to its free extremity, or it may be attached to a stomach-pump. In introducing liquid nourishment a syringe or funnel is fitted to the exposed end of the tube which has been passed into the stomach; the syringe or funnel having been filled with milk or beef-tea or broth, the contents are injected gently or allowed to run into the stomach. Fig. 122. In cases of poisoning, where it is desirable to withdraw the contents of the stomach and to wash out the organ, a stomach-tube and syringe may be employed ; several svringefuls of warm water are first thrown into the stomach and then withdrawn by suction, but in such cases the use of the stomach-pump will be found more satisfactory. The Stomach-pump. This consists of a brass syringe, the nozzle of which is connected with two tubes, one at the end, the other at the side. The passage through the nozzle is regulated by a valve controlled by a lever. The nozzle of the pump is attached to the stomach-tube, and the end of the lateral tube is placed in a pan of warm water. By raising the piston and opening the valve, water may be drawn from the basin, and by closing the valve and depressing the piston it is passed through the stomach-tube into the stomach ; when a sufficient quantity has been injected in this manner, by reversing the action of the valve the fluid is drawn out of 6906 196 MINOR SURGERY. the stomach and discharged through the lateral tube into a basin. This manipulation is continued until the water returns clear and the stomach has been completely washed out. A less complicated instrument will often serve as well as that just described (Fig. 12.3). Fig. 123. Stomach-pump. (Esophageal Bougie.—This instrument—which may be passed through the (esophagus into the stomach for the purposes of diagnosis, or for the purpose of dilating stric- tures of the o'sophagus—is passed in exactly the same manner as the stomach-tube, and, as in the case of the latter instrument, it should be introduced without the use of much force, as perforations of the oesophagus have followed the forcible introduction of such bougies. Vaccination. This is a minor surgical procedure which every physi- cian is called upon to perform. The surface may be pre- pared for the reception of the lymph by abrading the surface of the skin at one or two points with a dull lancet, or by making several superficial incisions with a knife, or by scratching the surface of the skin with the ivory-point charged with lymph, in lines with crossing lines, cross- VACCINATION. 197 scratch., until a little serum exudes. It is not advisable to draw blood, which washes away the lymph, and for this reason I prefer the abraded surface made by the dull knife or the ivory-point. The lvmph used may be the humanized or the bovine. The humanized lymph may be the viscid fluid taken from the vaccine vesicle on the eighth or ninth day, or the dried scab which separates when the wound is about healed ; if the latter is used, a small portion of it is rubbed up with water until it forms a mixture of creamy consistence ; this is rubbed into the abraded surface or the punctures. In using humanized lymph care should be taken to see that it is procured from a healthy subject. Bovine lymph or virus, which is now most generally em- ployed, is taken from the vaccine vesicles upon the udders and teats of heifers; ivory-points or quills are dipped into this lymph and allowed to dry, and in using them they are dipped in water for a moment, to moisten the lvmph, before being applied to the abraded surface. The ivory- point is one of the most convenient means of vaccinating, as the surface may be abraded with it before the lymph is applied. It has recently been advised that antiseptic precautions be exercised in performing vaccination, and although all of the details cannot be carried out, I have found that the exercise of care as regards cleanliness of the surface has been followed by much fewer inflammatory complications in vaccination wounds. In an institution in which I vaccinate yearly a lar^e number of cases, since I have adopted the following precautions I have had fewer bad arms. The surface to be abraded, usually the left arm below the deltoid, is first washed with soap and water, and then with a 1 : 2000 bichloride solution. Two points of this surface, an inch apart, are then abraded by using a knife which has been washed or dipped in boiling water, or by using the ivory-point which has been dipped in water which has been boiled and cooled down. When the surface has been pre- pared in the manner described, the moistened virus is 198 MINOR SURGERY. rubbed upon it and allowed to dry. Vaccination upon the leg, which is practised by some physicians to prevent the scar from showing, I think is not to be recommended, and I never practise it in this situation, as it is more diffi- cult to keep this part at rest, and I have seen some very severe cases of cellulitis and phlebitis follow leg vaccina- tion. Hypodermic Injections. The svringc used to make hypodermic injections is pro- vided with a perforated needle, wdiich is passed into the cellular tissue. (Fig. 124.) Care should be taken to see that the instrument and needle are perfectly clean before Fig. 124. Hypodermic syringe and needles. being used; if a metallic syringe is employed it should be rendered aseptic by soaking it for a few minutes in boiling water or in a five per cent, carbolic solution. Hypodermic injections are generally made into parts in which the cellular tissue is abundant, and great care should be observed to avoid introducing the needle into a huge vein or artery, as by neglect of % this precaution serious symptoms have resulted, from the drug being thrown rapidly into the circulation instead of being slowdy ab- sorbed from the subcutaneous cellular tissue ; the injury of superficial nerves should also be avoided. Care should also be taken to see that the solutions employed are hypodermic injections. 199 sterilized if possible, and freshly made solutions should be preferred. An unclean syringe or a solution which has not been sterilized may give rise to a troublesome abscess at the site of the injection. To avoid using solutions for hypodermic use which un- dergo change from being kept, it will be found convenient to use the compressed pellets which are prepared by the manufacturing chemists, the alkaloids being compressed with a little sulphate of sodium, which increases their solubility, the solution being prepared with boiled water just before being used. The portions of the body usually selected for hypodermic injection are the outer surface of the thighs or arms and the anterior surface of the forearm. In making a hypo- dermic injection the syringe is charged and the needle is Fig. 125. Method of giving a hypodermic injection. fastened to the nozzle of the syringe; the skin is next pinched up and the needle is quickly thrust through this into the cellular tissue ; the syringe is then emptied by pressing down the piston, and when the cylinder is empty the needle is withdrawn ; the small puncture in the skin resulting seldom bleeds and usually heals without diffi- culty. (Fig. 125.) In persons who have suffered from profuse hemorrhage, where transfusion of blood is not considered advisable, large injections of normal salt solu- tion may be introduced into the cellular tissue by means of hypodermic injections, or the needle may be introduced into the cellular tissue and connected by a piece of rubber tubing with an irrigator containing normal salt solution 200 minor surgery. held above the part, and the solution gradually finds its way into the subcutaneous cellular tissue. A large quan- tity of fluid may be introduced in this way. Exploring Needle. This consists of a fine-grooved needle fitted into a handle (Fig. 126), which is introduced into tumors or swellings Fig. 126. Exploring needle. to ascertain the nature of their contents, and its use is often of service for purposes of diagnosis. The exploring trocar (Fig 127) is employed for the same purpose, or the needle Fig. 127. (h_________ Exploring trocar. of the hypodermic syringe or a fine needle attadied to an aspirator may be used for a like purpose. When either the exploring needle or trocar is employed care should he taken to sec that it is rendered perfectly aseptic before being used; otherwise its employment is not without danger, for I have seen the introduction of an exploring needle into an effusion in a joint for diagnostic purposes followed by suppuration and destruction of the joint, which subsequently necessitated its excision. SxrN-ORAFTINO. This is a minor surgical procedure which may be em- ployed to hasten cicatrization where large granulating surfaces are exposed, such as result from extensive opera- tions and from burns. SKIN-GRAFTING. 201 The operation consists in applying shavings of the epi- dermis or of the epidermis and cutis together, to the granu- lating surface and holding them in contact with it for a few davs; the grafts often seem to disappear, but at the end of a few days, if the part is closely inspected, bluish- white points will be seen to occupy the positions at which the grafts were applied, which become converted into iso- lated cicatrices from which the healing process rapidly extends. To have a successful result following the use of skin-grafts the surface of the ulcer should be healthy, and its surface and the surrounding skin should be rendered aseptic, and the grafts should be applied at a number of points. The surface from which the grafts are to be taken should also be rendered aseptic, and the skin is removed by scis- sors made for this purpose (Fig. 1'2H), or by raising the Fig. 128. Scissors for skin-grafting. epidermis with a needle or with forceps and cutting out a small portion of it with a sharp scalpel. The graft is next applied to the granulating surface with its raw sur- face in contact with the granulations ; after a sufficient number of grafts have been applied, a piece of sterilized protective is laid over them and is held in place by means of a few strips of isinglass plaster. An ordinary antisep- tic or sterilized gauze dressing is next applied, and the dressing is not disturbed for a week or ten days, at which time, if the grafts have taken, isolated cicatrices at the points w here the grafts were applied will be found to exist. 202 MINOR SURGERY. Thiersch's Method.—In skin-grafting, according to this method, the surface of the ulcer is rendered aseptic, and all antiseptics arc washed away with sterilized salt solu- tion. The surface of the ulcer is next curetted to remove soft granulations, and it is then irrigated and covered with protective and a compress is applied to control all bleeding. Shavings of skin are then removed from a surface which has been rendered aseptic by means of a razor or section knife. Eadi graft should be as long and broad as possi- ble, and when cut it should be floated from the section knife by a stream of salt solution and placed upon the prepared surface of the ulcer and gently pressed into place. After a sufficient number of grafts have been applied, strips of protective are laid over the surface of the grafts, and over these is placed a compress moistened with salt solution and covered by protective, and a few layers of sterilized cotton are next applied over this, and the dress- ing is held in position by a bandage. The dressings need not be removed for a week or ten days, and a second dressing should be applied in the same manner until the grafts have become thoroughly vitalized. The skin of the belly or back of frogs, or the hairless skin of young animals may be used in the place of human skin. Bone-grafting. This procedure is resorted to to replace portions of bone which have been separated, to fill up cavities in bone, or to restore the continuity of the long bones. The bone to be introduced should be rendered thoroughly aseptic, and should be placed in a sterilized salt solution at a temperature of 100°-105° F.; it may be inserted in one piece or broken into fragments and laid over the surface. When it is desired to restore the continuity of one of the long bones, after the surfaces of the bone have been exposed and rendered aseptic, a bone is removed from a freshly killed animal, is rendered aseptic, and is fitted into the gap or is split into strips and packed into the cavity. electrolysis. 203 Bone-grafting may also be very satisfactorily accom- plished by means of Senn's decalcified bone plates or cliips, which will be found useful in filling up the cavities result- ing from the operation of trephining or for extensive re- movals of bone in the operations for necrosis or caries. In such cases, after the cavity has been sterilized, it is dusted with iodoform and is then packed with bone chips; iodoform is next dusted over them and a piece of protec- tive is placed upon them and a compress of iodoform gauze and bichloride cotton is next applied, and the dressing is held in position by a bandage. When bone plates are employed they are cut to fit the cavitv, and provision should be made for drainage. Preparation of Decalcified Bone Chips or Plates.—Take the compact tissue of the fresh tibia or femur of an ox, remove the periosteum and medullary tissue, and split in pieces one-half an inch in width, and place them in a 15 per cent, watery solution of hydrochloric acid, allowing them to remain in this for three weeks, changing the solution daily. At the end of this time they should be removed and washed and cut in thin strips or plates, and washed in a weak solution of caustic potash, and then placed for fortv-eight hours in a 1 : 1000 bichloride solution. After this they may be kept in a solution of iodoform in ether, or in 1 : .100 solution of bichloride in alcohol until required for use;; before being used they are soaked in a 1 :200() bichloride solution. Muscle-grafting and nerve-grajling arc also occasionally resorted to to supply deficiencies in muscles or nerves ; here fresh muscle or nerve tissue is employed to fill up the gap. Electrolysis. Electrolysis, or the chemical decomposition induced by electricity, is employed in surgery to destroy morbid prod- ucts, tumors, or exudations. For this procedure a galvanic or continuous-current battery is required, which is pro- vided with electrodes and needles of suitable shapes. In applying electrolysis to a tumor, for instance, the needle 204 MINOR SURGERY. connected with one of the poles of the battery is inserted into the tumor and the other rheophore is applied to the surface of the body, or two fine needles, carefully insulated nearly to their extremities, are connected with both poles of the battery by conducting cords; these are introduced into the tumor and a weak current is allowed to pass, and its strength is gradually increased as the operation ad- vances; the current is passed for fifteen or twenty minutes, and the procedure is repeated at intervals of several days, until some decided change occurs in the tumor. Electrolysis has been applied with success in the treat- ment of aneurism inaccessible to other operative procedures, in malignant growths, in ngevi, goitres, cysts, hydatids, and is at the present time the most satisfactory method of re- moving superfluous hairs from those portions of the body in which their presence causes disfigurement. Gal VA NO-CAUTERY. Galvano-cautery batteries are constructed with plates of large size, placed closely together, so that the internal re- sistance is reduced and a current is quickly obtained which will keep a metallic electrode at a white heat. The advan- tage" in the use of this form of cautery is that the electrode Fig. 129. Electrodes for galvano-cautery. can be introduced into the various cavities of the body while cold and quickly heated to the desired temperature. The electrodes are made of various shapes and sizes, ac- cording to the object desired (Fig. 129). Galvano-cautery is applied for the same purposes as the actual cautery, but, as previously stated, its use is more convenient in the MASSAGE. 205 various cavities of the body, its action can be more easily localized, and by its use hemorrhage is avoided. It is fre- quently employed to destroy morbid growths in the nasal passages, the throat, vagina, or uterus, and also may be employed in the treatment of superficial external growths; in using it for the removal of growths from the mucous membrane its application may be rendered practically painless by previously thoroughly cocainizing the parts. Faradization. Idle application of electricity in this form is often em- ployed in surgical affections; in cases of wasting of the muscles following fractures or sprains, in some forms of club-foot, and in lateral curvature of the spine the judi- cious use of the fa radio current will often be found to be followed by the most satisfactory results. The current is applied in such a manner as to bring about contraction of the affected or wasted muscles, and thus improve their nutrition. Maskaoe. Massage consists in a variety of manipulations, such as pinching up the integuments and muscles, and rolling them between the thumb and fingers, in stroking or rubbing the surface with the palm of the hand from the periphery toward the centre, to empty the distended veins and lym- phatics; rubbing the parts circularly with the extremities of the fingers and thumb or the palm of the hand, or kneading of the parts is another method of practising massage. .Massage may also be practised by tapping the surface of the affected part with more less force with the tips of the fingers held in a row, or with the ulnar border of the hand or with the palm of the hand. Before apply- ing massage to an affected part, if there be a heavy growth of hair, it should be carefully shaved off; otherwise the manipulation may give the patient pain, and irritation of the hair follicles resulting in abscesses will be apt to occur. 10 206 MINOR surgery. The part should also be rubbed over with olive oil, vase- line, or cocoa-butter before and during the manipulations. Massage is often employed with advantage in the treat- ment of sprains and strains in their subacute and chronic stages, and it will be found of great service in the later treatment of fractures involving the joints or their vicinity, in regaining the motion of the parts as well as in improv- ing the nutrition of the muscles which have become wasted from disuse. Passive Motion. This manipulation consists in alternately flexing and extending or rotating the limb to imitate the normal joint movement. The motions should be carefully practised, and in cases of fracture they should not be undertaken until there is quite firm union at the scat of fracture, or if for any reason passive motion is made use of before this time the fragments should be firmly supported while it is being employed. Other forms of massage, such as stroking and kneading, may be employed in conjunction with pas- sive motion in the treatment of the troublesome stiffness of joints resulting from fractures, dislocations, and sprains; passive motion applied in this manner will often restore the function of a stiff joint more satisfactorily and with less pain to the patient than the forcible manipulations of the joint which are practised under an anesthetic. The Clinical Thermometer. For clinical observations two thermometer scales are in general use, the Centigrade and Fahrenheit; the latter is the one commonly employed in America and England. This scale has a limited range above and below the normal bodily temperature, which is 9Sf° Fahrenheit or 36° Centigrade. Thermometers are now made with a convex surface, which serves to magnify the column of mercury, and thus enables the observer without difficulty to note the position of the index. (Fig. 130.) The temperature of the body may be taken in the mouth. THE RECTAL TUBE. 207 axilla, vagina, or rectum; the two former positions are those generally employed. When taken in the axilla care should be exercised to see that no clothing is interposed between the skin and the instrument, and when the mouth is used for therniometrie observations the patient should be instructed to keep his lips tightly closed and breathe through his nose. The thermometer should be kept in place for from three to five minutes. Fig. 130. Clinical thermometer. Surface thermometers arc sometimes employed, the in- struments for this purpose having bulbs of a discoid shape, or are drawn out in the form of a spiral or coil. (Fig. 131.) In using this form of thermometer to determine Fig. 131. Surface thermometer. the amount of variation of the surface temperature, the temperature of corresponding parts of the body on the opposite side and the general temperature of the body should be taken at the same time. The Rectal Trio:. The introduction of the rectal tube is best accomplished by placing the patient upon his left side, and the surgeon should introduce his index finger well oiled into the rectum and guide the tube upon this through the anus, and by gentle pressure it is gradually passed iuto the rectum; if a stricture exists- in the rectum within reach of the finger, the latter should be used to guide the tube through the opening in this; if the tube becomes caught in a transverse 208 MINOR SURGERY. fold of the mucous membrane, and becomes doubled upon itself, it should be withdrawn and a fresh attempt should be made to pass it; in passing a rectal tube all manipula- tions should be made with extreme gentleness, as it has been shown that its passage is not without danger, perfora- tions of the intestine having followed its use in some eases. In cases of stricture of the rectum high up, the operator has to depend upon the sense of resistance experienced in passing the tube, and in such cases the manipulations should be most carefully made. When the rectal tube is employed to introduce fluids into the large intestine, the fluids may be introduced by means of a syringe, or by pouring them into a funnel attached to the free end of the tube, or by attaching the tube to a fountain syringe, thus allowing the liquid to pass slowly into the intestine. The rectal tube is often employed with good results in relieving the intestine of excessive flatus, and in intro- ducing water or oil into the intestine in cases of intestinal obstruction, and in those cases where the obstruction re- sults from intussusception or fecal accumulations its use will often prove most satisfactory. Rectal Bougies. These instruments are made of the same material as the English flexible catheter, and are of various sizes. They should first be oiled, and carefully introduced in the same manner as the rectal tube. They are generally employed in cases of stricture of the rectum, and they should be used with great care to avoid perforating the wall of the rec- tum. A very satisfactory substitute for a rectal. bougie is a tallow candle, one end of which is melted or rubbed down to a conical shape. Enemata. These may be administered by means of the ordinary syringe, or by means of a gravity or fountain syringe; the precautions which should be observed are to introduce the ANESTHETICS. 209 nozzle of the syringe gently and in the right direction, as perforation of the lower portion of the rectum has taken place from the careless and forcible introduction of the nozzle of the enema-syringe; the fluid should also be in- jected slowly, as by so doing there is less resistance and less tendency for the patient to pass the fluid before the desired quantity has been introduced. The enema most commonly employed to empty the lower bowel is made by adding a tablespoonful of sweet oil and two teaspoonfuls of spirits of turpentine to one or two pints of warm water in which a little castile soap has been dissolved; warm water and sweet oil are also frequently used for the same purpose. Glycerin Enema.—One or two teaspoonfuls of glycerin injected into the rectum, or a suppository made of gly- cerin, will often be found an efficient substitute for the larger enemata of water. Nutritious Enemata. When it is found necessary to resort to feeding by the rectum, the substances employed should be injected into the rectum by means of a syringe, and care should be taken to see that the quantity is not too large, and that it is of such a nature as not to cause any irritation of the walls of the rectum, or it will not be retained ; two ounces in the case of an adult is generally a sufficient quantity to inject at one time. Peptonized milk or beef juice, or the yelk of an egg beaten up with milk, are often employed, and any unirri- tating drugs may be mixed with the enema and adminis- tered at the same time. Anaesthetics. The substances which arc employed at the present time to produce cither local or general anaesthesia are ice, co- caine, rhigolene, nitrous oxide, chloroform, and ether. 210 MINOR SURGERY. Local An.esthesia. Cold. Local aiucsthcsia may be produced by the application of cold, either by a piece of ice or a mixture of ice and salt held in contact with the part for one or two minutes, or by directing a spray of rhigolenc upon the surface of the part whose sensibility is to be obtunded. (Fig. 132.) Fig. 132. Application of rhigolene spray. Chloride of Ethyl is also used to produce local anaesthesia, and is conveniently furnished in glass tubes, one end of which is drawn out into a fine point and hermetically sealed. AVdien used the end of the tube is broken off and a fine jet of ethyl is projected up the surface, the warmth of the hand being sufficient to force the fluid from the tube. This form of local aiuesthcsia is made use of in minor surgical procedures, such as aspiration, the opening of ab- scesses, and the removal of superficial tumors. Rapid Respiration. Rapidly repeated deep inspirations kept up for a few minutes will produce insensibility to pain, but sensibility to contact is not obliterated. This form of aiucsthcsia may be made use of in slight operations, such as the open- ing of abscesses. LOCAL ANAESTHESIA. 211 Cocaine. Local aiuesthesia produced by the employment of an aqueous solution of the hydrochlorate of cocaine, in strength from 2 to 12 per cent., is often made use of in minor sur- gical procedures, wdiere the mucous membrane is to be operated upon or growths removed from it. Analgesia is produced by brushing the surface over with the solution of cocaine, or by applying a compress of absorbent cotton saturated with the solution to the part for a few minutes ; in mucous cavities the latter method of application will be found most eovoniont. In using a solution of cocaine to produce aiuesthesia in operations upon the eye a 2 or 4 per cent, solution is dropped into the eye, and the application is repeated until the analgesia is complete. In applying cocaine to the urethra a 4 to 10 per cent. solution is injected into the urethra, and is allowed to re- main for two or three minutes; more than one or two grains should not be injected at one time. When it is desired to produce local anaesthesia of the skin or deeper tissues the application of the solution of cocaine to the surface is not satisfactory, and it should in such cases be injected hypodermically into the deeper layers of the skin and into the cellular tissue of the parts to be operated upon ; to avoid multiple puncture the needle is not completely withdrawn from the wound, but its di- rection is changed and the solution is thrown into different portions of the tissues. It is well in situations w here it can be accomplished, to cut off the circulation from the part to be operated upon by placing around it a rubber strap or tube, which prevents its rapid absorption into the general blood current. It is well not to inject more than one grain of the drug in this way, for fatal results have followed the injection of larger quantities; this is espe- cially the case in using cocaine in the urethra and rectum, and in these situations groat caution should be exercised in its use. Some persons also have an idiosyncrasy for cocaine, and children seem more susceptible to its constitutional effects 212 MINOR SURGERY. than adults. I have ^een several cases in children in w hieh marked symptoms of cocaine poisoning resulted from the application of a 4 per cent, solution to the nasal mucous membrane. In minor surgical operations, such as amputations of the finger, circumcision, opening of abscesses, and removal of superficial tumors, cocaine-anaesthesia may be employed with advantage, but its utility is most marked in opera- tions upon the eye and those upon the mucous membranes of the nose, throat, rectum, vagina, and urethra. Applied to the surface of an ulcer for a few minutes, which is to be cauterized, it will render the operation almost painless to the patient. Nitrous Oxide Gas. This gas is administered for the purpose of producing aiuesthesia, and the apparatus best suited for its adminis- tration consists of a cvlinder of metal in which the gas is compressed ; this is attached to a rubber bag which has a mouthpiece fastened to it; this is provided with a double valve, which prevents the expired air from passing back into the bag. The mouthpiece is adjusted over the mouth, and after removing any false teeth, or foreign bodies, from the mouth, the patient is instructed to take deep, full breaths, and in from one-half to one minute the face be- comes congested and dusky, and the breathing becomes stertorous, indicating that the patient is fully under the influence of the gas. The anaesthesia from nitrous oxide cannot be prolonged for more than a few minutes, so that it can only be employed in operations which take a short time for their performance, such as the extraction of teeth, opening of abscesses, and reduction of dislocations or frac- tures. In England nitrous oxide is frequently used to produce anaesthesia, and when this result is accomplished the anaesthesia is kept up by the administration of ether by the employment of a special apparatus devised for this purpose. Nitrous oxide gas is most commonly employed in dental surgery to produce aiuesthesia for the removal of teeth, but is also occasionally employed in minor surgical ANESTHESIA. 213 operations; but from the fact that the apparatus for its administration is a bulky one, its use is not as convenient as ether or chloroform, and in this country it is not much employed in general surgery. Ethei;. Sulphuric ether is one of the most widely employed substances in surgery to produce aiuesthesia; it is probably the safest of all amesthctics, and for this reason should be given the preference over all others. A patient should be prepared for the administration of ether by not allowing him to have any solid food for at least six hours before its inhalation ; he should be in the recumbent posture, and any garments about the chest or neck should be loosened so that the respiratory movements are not interfered with. The surgeon should also see that any false teeth or foreign bodies wdiidi may be present in the mouth arc removed before the administration of the drug is begun. As the vapor of ether often causes irrita- tion of the mucous membrane of the lips and nasal pas- sages, it is well to anoint these parts with a little vaseline or cold-cream before administering the ether. It should also be borne in mind that the vapor of ether is very inflammable, and that it is heavier than the air, so that lights brought near the patient while being etherized should be held at a higher level than the ether can or inhaler. For the administration of ether a towel folded into a cone or one of the various ether inhalers may be employed. The best of these is Allis's inhaler (Fig. 133), which con- sists of a metallic framework covered with leather, which carries a number of folds of a roller bandage, giving a large surface for the rapid evaporation of the drug. If* a towed folded into a cone is used, a few layers of stiff paper interposed between the outer layers of the towel a\ ill keep the cone in shape and will prevent the evaporation of the ether from its external surface. In debilitated patients or those wdio arc weak from the 10* 214 MINOR SURGERY. loss of blood the administration of half an ounce to an ounce of whiskey from fifteen to thirty minutes before the anaesthetic is given is often advisable. Fig. 133. Allis's ether inhaler. In administering ether, half an ounce of ether is poured over the inner surface of the towel or inhaler and it is brought near the mouth of the patient, and he is requested to take deep breaths or to blow the ether away, and as soon as he has become accustomed to the irritating qualities of the ether vapor, the cone or inhaler is held firmly over the mouth and nose, and the vapor is administered in as concentrated a form as possible ; if the respiration and circulation are good there is no disadvantage in pushing the ether. When the conjunctiva is insensible to the touch of the finger, and the muscular relaxation is complete, and the breathing tends to become stertorous, the stage of com- plete anaesthesia has been reached, and the ether should be withdrawn for a time or should be given only in such quantities as suffice to keep the patient in this condition. The first effect from the inhalation of ether is to produce acceleration of the pulse and respiration; the mucous mem- brane of the air-passages is irritated and coughing often occurs; there is also in this stage a disposition to muscular movements, and it is frequently necessary to restrain the ANESTHESIA. 215 patient; the brain is also excited and the patient is apt to cry out. These symptoms call for a continuance of the administration of the ether and not for its withdrawal. Succeeding this stage, if the ether is pushed, profound aiuesthesia takes place, as is evidenced by loss of conscious- ness, relaxation of the muscular system, moistened skin, loss of the special senses, contracted pupils, and slowr and deep respiration tending to become stertorous. I nder the name of first insensibility from ether there exists early in the course of the administration of ether a primary aiuesthesia, which lasts for a minute or so, and which may be taken advantage of to perforin such minor surgical operations as the opening of an abscess or the reduction of a dislocation or the drawing of a tooth. The recovery from this condition is usually very prompt, and it is not followed by nausea and the after-effects which attend the prolonged administration of ether. During the administration of ether, particularly in the early stage, the patient may stop breathing, the face at the same time becoming oyanosed; this condition calls for the withdrawal of the ether, and if a deep inspiration does not quickly follow, pressure should be made upon the front of the chest, and when this is relaxed a deep inspiration usually takes place and no further difficulty is experienced. If the patient has eaten solid food shortly before the etherization, vomiting is apt to occur; when this takes place the ether inhaler should be removed and the head should be turned to one side, or the patient should be rolled upon his side, the mouth being kept open to facilitate the escape of the vomited matters. The breathing also sometimes becomes obstructed by the accumulation of mucus in the fauces ; this should be removed by small sponges securely fastened to sponge-holders. When the anaesthesia is profound it sometimes happens that the muscular relaxation is so complete that the tongue falls backward and the glottis is (dosed, the face becomes cyanosed and the pulse frequent and irregular, and death is threatened from asphyxia; in this event the head should be extended and the lower jaw should be pressed forward bv 216 MINOR SURGERY. the fingers placed beneath the ramus of the inferior maxil- lary bone. (Fig. 134.) This manipulation is usually suffi- cient to re-establish the respiratory movements, but if so fortunate a result does not take place artificial respiration should be practised—Sylvester's or Howard's methods being given the preference — the patient's head being placed upon a lower level than the body, the tongue brought forward, and the fauces being cleared of mucus, The res juratory action should also be stimulated by the use of electricity—one sponge-electrode being placed over the sternum, the other being applied to the epigastrium during an inspiratory effort. Fig. 134. Pushing the lower jaw forward. ( Esmarch. , If artificial respiration is not satisfactorily applied in tins way, forced respiration applied bv means of a mask with tube and bellows attached (Fell's apparatus, see page 192), or an intubation-tube with a rubber tube attached. which is connected with a bellows, may be slipped into the larynx, and air may thus be directly forced into the lungs. or the trachea should be opened. Tracheotomy is especially to be recommended if the asphyxia has resulted from blood or vomited matters having 'entered the larvnx. After ANAESTHESIA. 217 opening the trachea and introducing a tracheal canula, a rubber tube and bellows is connected with this and respir- atory movements are simulated by forcing air directly into the trachea. The hypodermic injection of strychnia, atropia, or digi- talis is also recommended, and the intravenous injection of ammonia is said to have been followed by good results. Efforts at resuscitation in these cases should be per- severed in for at least half an hour, as apparently hopeless cases have been saved by persistent use of these means. The person intrusted with the administration of the amesthetic should watch the patient closely and should not have his attention diverted by the operation ; he should carefully watch the pulse, respiration, and the color of the patient's face, and be ready to withdraw the ether upon the development of any symptom of danger, and to meet such symptoms, should they arise, by the use of some of the means previously mentioned. The administration of ether vapor by the rectum was a few years ago employed in many cases, and although aiues- thesia was quickly produced, dangerous symptoms some- times followed its employment, so that this method of administration has been abandoned. Vomiting after the administration of ether is very com- mon, and if it persists after a few hours it may be relieved by the administration of the fourth of a grain of cocaine with crushed ice, repeated two or three times, or by the use of crushed ice with champagne or brandy, and in some cases the swallowing of a few mouth fills of very warm water will relieve this condition. An amesthetic should never be given to a woman without the presence of a third person, as in some cases these agents give rise to erotic dreams, and it may be diffi- cult to disabuse the patient's mind of the idea that an assault has been committed unless the evidence of eye- witnesses at the time of the anesthetization can be brought forward to prove that such was not the case. 218 MINOR SURGERY. Chloroform. A patient is prepared for the administration of chloroform as in the case of ether, the same precautions being taken as regards the removal of false teeth or foreign bodies from the mouth, and to see that the clothing about the chest and neck does not restrict the circulation or respiratory move- ments. Chloroform is certainly a much more dangerous anaesthetic than ether, and although it is widely used in the British Islands and upon the Continent, it is not used in this country except in certain districts—as in the southern and southwestern districts of the United States, and here its use is followed by fewer fatalities than in the northern districts, so that it is possible that its use is safer in warm climates. Clinical experience has demonstrated the fact that chloroform can be used in aged and very voung subjects and in puerperal patients with comparative safety ; it is also to be preferred to ether in patients suffer- ing from emphysema of the lungs, bronchitis, and vascular degeneration of the kidneys. It is also employed instead of ether in operations upon the mouth when the actual cautery is employed, on account of its less inflammable character. Chloroform is administered by pouring a drachm of the drug upon a folded towel, which is first held a few inches from the mouth and nose and gradually brought nearer, but is not allowed to come in contact with the face, as from its local irritating action it will blister the surface; the anaesthetizer should remember that one of the dangers in the administration of chloroform is the risk of too great concentration of its vapor, so that he should see that a sufficient admixture of atmospheric air takes place. Pro- found anesthesia is evidenced by insensibility of the con- junctiva to the touch, by complete muscular relaxation, and by the absence of reflexes; the pupils in chloroform- anesthesia are usually contracted. Various inhalers have been devised to regulate the amount of chloroform admin- istered and to secure the proper admixture of atmospheric air, and the best of these is probably Mr. Clover's ANESTHESIA. 219 apparatus. (Fig- 13o.) This consists of a bag holding S000 cubic inches of air connected with a face-piece by a flexible tube. The bag is charged by means of a bellows (Fig. 13o, 1) measuring 100 cubic inches; and the air is passed through a box warmed with hot water, into which is introduced at each filling of the bellows as much chlo- roform as is required for 1000 cubic inches of air. This is done with a syringe (Fig. 13"), 2) ; the amount of chloroform required is usually from 30 to 40 minims. Fig. 135. clover's chloroform apparatus. (Ekichsen.) When the bag is full the tube is removed from the evaporator and the mouthpiece (Fig. 135, 3) is fitted to it. Additional air may be admitted by regulating the size of the opening in the mouthpiece ; the patient, however, cannot receive a larger proportion of chloroform than the air in the bag is charged with. Death from the administration of chloroform results from cardiac syncope or from respiratory arrest, and the dangerous symptoms develop so rapidly that the greatest promptness is required to meet them. The person ad- ministering chloroform should constantly watch both the pulse and the respiration, and should not for a moment 220 MINOR SURGERY. have his attention diverted from the patient; great vigilance is here, if possible, more important than during the administration of ether. AY hen dangerous symptoms arise they are to be treated by lowering the patient's head, and if respiratory arrest has occurred the same means to bring about respiratory action should be employed as for a similar condition during ether narcosis. Cardiac syncope is treated by the use of electricity, the electrodes with a rapidly interrupted current being swept over the chest; hypodermics of digi- talis and strychnia and atropia may be employed to stimulate the heart and respiration, and as in ether narcosis the efforts should not be desisted from for some time, as by the persistent employment of these means apparently hope- less cases have been resuscitated. The A. C. E. Mixture. This mixture, which consists of 3 parts of chloroform, 1 part of ether, and 1 part of alcohol, has been employed by some surgeons in the place of ether or chloroform, with the idea that the dangers of chloroform are diminished by its combination with ether and alcohol. Clinical ex- perience, however, has not proved this view to be correct, and I see no advantage in the use of this combination over that of ether or chloroform. If administered with as much care as chloroform, its administration is accompanied with the same safety. It should be administered upon a towel iu the same manner as chloroform, and the patient should be watched as carefully during its inhalation as during the administration of the latter drug, and complications occur- ring should be treated in the same manner as those arising during the use of chloroform. Trusses. A truss for the palliative treatment of hernia is a me- chanical contrivance with one or more pads and a strap; these are held in position by a spring to which they are TRUSSES. 221 attached, which holds the pad in contact with the skin over the hernial ring. Thcv are applied in all cases of reducible hernia, and arc used in the treatment of hernia at all ages ; in infants and voung children the continued use of a properly fitting truss is often followed by a radical cure of the hernia. Trusses are made with steel or rubber springs and with pads of wood, rubber, celluloid, or horsehair, covered with chamois, and their shape and the pressure which they should exert varies with the variety of hernia for which they arc applied. A firm compress applied over the inguinal canal or crural ring, secured in position by a firmly applied spiea-of-the- groin bandage, forms a very satisfactory temporary means of preventing the descent of a hernia. A properly fitting truss should be worn without discom- fort to the patient—that is, should not make too much pressure upon the skin at the points where the pads are applied—and should absolutely prevent the descent of the hernia. In testing the adequacy of a truss, after appli- cation, to prevent the escape of the hernia, the patient should be instructed to separate his legs, bend forward over the back of a chair, and cough or strain deeply ; if this docs not bring the hernia down, its control of the rup- ture may be considered satisfactory. Trusses should be applied after the complete reduction of the hernia, while the patient is in the recumbent pos- ture. When first applied the truss should be worn both during the night and day, and if the skin becomes tender at the points of pressure it should be sponged with alcohol and alum, then dried and dusted with powdered starch or lycopodium. Patients at first sometimes complain of dis- comfort in wearing a truss, but they soon become accus- tomed to its presence. After a truss has been worn for some time its use at night, while the patient is in bed, may be dispensed with, but the patient should not remove it until he is in bed in the recumbent posture, and he should reapply it before he rises in the morning. In children it is better to have the truss worn continuously, and if it is 222 MINOR surgery. removed for bathing the nurse should be instructed to place her finger over the ring to prevent the descent of the hernia until"the truss is reapplied. In applying trusses to male children care should be taken not to make pressure upon an undescended testicle. Trusses for Inguinal Hernia. In measuring a patient for this form of truss the cir- cumference of the body midway between the crest of the ilium and the great trochanter should be taken, and the distance from the symphysis pubis to the anterior superior spinous process of the ilium may also be given, as half of Fig. 136. Truss for inguinal hernia. this distance corresponds to the position of the internal abdominal ring. In reducible inguinal hernia the truss- pressure should be exerted upon the inguinal canal and directly backward. To control this variety of hernia a single-spring truss (Fig. 136) may be employed, or the use Fig. 137. Hood's truss. of a truss having a double spring with flat pads on eacn side of the spine attached to the springs, and a smaller pad over the inguinal canal on the unaffected side, with a TRUSSES FOR UMBILICAL HERNIA. 223 full pad on the side of the hernia will often be found most satisfactory. This, wdiich is known as Hood's truss, is one wdiich will be found a very satisfactory instrument both in inguinal and femoral hernia. (Fig. 137.) Trusses for Femoral Hernia. In measuring a patient for this variety of truss, the cir- cumference of the body midway between the crest of the ilium and the great trochanter should be taken; the dis- tance of the saphenous opening from the symphysis pubis, as well as from the anterior iliac spine, should also be taken. In reducible femoral hernia the truss-pressure should be directed backward against the femoral canal, and the pad should be large enough to make pressure upon the adjacent tissues through which the hernia passes, as well as upon the relaxed tissues covering the femoral canal. As in inguinal hernia, either a single or a double spring truss may be employed (Fig. 138). In applying a truss for femoral hernia, care should be taken to see that the pad does not rest upon the pubis, and thus remove the pressure from the crural ring and adja- cent tissues and prevent the proper control of the hernia. Trusses for Umbilical Hernia. In measuring a patient for this variety of truss, the cir- cumference of the body over the umbilicus should be taken. Hood's truss for femoral hernia. Truss for umbilical hernia. In reducible umbilical hernia the truss-pressure should be directed backward, and the pad should bear rather on the tendinous margins of the ring than on the hernial 224 MINOR SURGERY. opening. A truss for this variety of hernia should have a flat or slightly convex pad, which is held in position over the umbilical ring by means of springs having counter- pads on either side of the spine attached to their extremi- ties ; these are fastened together by a strap (Fig. 139). A simple and satisfactory truss for umbilical hernia in infants consists of a penny covered by adhesive plaster, held over the umbilical ring by one or two strips of adhe- sive plaster about two inches in width, which should he applied so as to cover in about the anterior two-thirds of the body. A penny, or a small, flat compress of linen, will be found much more satisfactory than the conical rubber or cork pad which is often recommended. Trusses for Irreducible Hernia. The application of a truss to this variety of hernia secures the hernia from injury and prevents the further protrusion of the hernia; such trusses are secured in the same way as those for reducible hernia, but the pads are made concave or cup-shaped, or may have an air-cushion attached to the pad. Use of Catheters and Bougies. ( atheters are hollow tubes, made either of metal, India- rubber, or other flexible substances. Metallic catheters are made of silver, or, if constructed of other metals, they should be plated with silver or nickel, to give them a smooth, bright surface wdiich can easily be kept perfectly (dean ; and their shape should conform to that of the normal urethra (Fig. 140). The shape of the metallic catheter is sometimes changed to meet certain indications ; for instance the metallic catheter for use in cases of enlarged prostate is longer and has a larger curve than the ordinary instrument (Fig. 141). The metallic female catheter is shorter and has a much smaller curve than the instrument used for the male urethra. USE OF CATHETERS AND BOUGIES. 225 Flexible Catheters.—The most commonly used variety of flexible catheter is that known as the English catheter, which is made of linen and shellac, and is provided with Fig. 140. Fig. 141. Metallic catheter. Prostatic'catheter. a stylet; it can be moulded into any shape desired by dip- ping it into hot water, which renders it very flexible, and, after moulding it to the proper curve, this can be fixed by immersing it in cold water, wdiich hardens it again. The French flexible catheters arc made of India-rubber, 226 MINOR SURGERY. or a combination of this material with other substances. These instruments arc conical toward their extremities, and terminate in an olive-shaped point; they are provided Fig. 142. French flexible catheters. with one or two smoothly finished eyes near their vesical extremities (Fig. 142.) Another form of flexible catheter, known as the elbow- catheter or Mercier's catheter (Fig. 143), has an angle or Fig. 143. Mercier's elbowed catheter. elbow near its vesical extremity ; this is often found a satis- factory instrument to use in eases of enlarged prostate. A Fig. 144. Soft rubber catheter. variety of flexible catheter made of soft India-rubber is also sometimes employed. (Fig. 144.) INTRODUCTION OF A CATHETER. 227 Catheters and bougies are made according to a certain scale. The Fnglish scale runs from 1 to 12 ; the American from 1 to 20; and the French from 1 to 30. Bougies and Sounds. Bougies arc flexible instruments wdiich correspond in size and shape to the English and French catheters, and besides these is the acorn-pointed bougie (Fig. 14o) and the filiform bougie, which is made of whalebone or of the Fig. 145. Bulbous or acorn-pointed bougies. same materia] as the ordinary French bougie and catheter. These instruments arc of very small size and can often be passed through strictures wdiich will admit no other form of instrument. (Fig. 14(>.) Hounds.—These are solid instruments usually made of steel with a smooth surface and plated with nickel; they correspond in size and have the same curve as the metallic catheter; the handle is flattened to allow the operator to grasp them firmly ; they are employed in the treatment of strictures by dilatation. (Fig. 147.) The sound used in dilating strictures of the meatus is straight and is shorter than the sound employed in the treatment of urethral strictures. (Fig. 148.)' Introduction of a Catheter. The passing of a catheter is a minor surgical procedure which every practitioner is at times called upon to employ, and its passage through a healthy urethra is a matter of little difficulty. For the introduction of a catheter the patient may be in the standing, sitting, or recumbent posture, and the latter is the best in most cases; he should 228 MINOR SURGERY. rest squarely on his back and have the thighs a little flexed and separated. Before passing a metallic catheter the surgeon should sec that it is perfectly clean, and after warming and oiling Fro. 146. Fig. 147. Fig. 148. [/ Filiform bougies. Steel sound. Sound for dilating meatus. it he stands upon the left side of the patient and grasps the penis with the left hand, and turns it over the pubis and introduces the beak of the catheter into the meatus, and gently passes it along the urethra until its point passe* INTRODUCTION OF A CATHETER. 229 beneath the symphysis pubis ; at this point the handle is elevated and gently depressed between the thighs, and the beak will pass into the bladder. (Fig. 149.) Fig. 149. Introduction of catheter. (Voillemiek.) When the prostatic region is reached difficulty is some- times experienced in passing the catheter; this may be overcome bv introducing the finger into the rectum and guiding the catheter through this, or if the prostate is found much enlarged the catheter should be withdrawn, and a prostatic catheter (Fig. 141) should be substituted for it. The same manipulation is made use *of in passing metallic sounds. 11 230 MINOR SURGERY. Flexible catheters and bougies arc passed by grasping the penis and holding it in such a position that it is at a right angle to the axis of the body, and the catheter or bougie is passed into the meatus and carried through the urethra into the bladder by gently pushing the instrument downward. In this variety of catheter, which has no curve, the sur- geon has no means of guiding the point of the instrument, and if an obstruction is met he should withdraw the instru- ment slightly and make another attempt; all manipulations should be extremely gentle. The same manipulations are employed in passing bougies through the urethra. Passing the Female Catheter. This should be introduced without exposure of the patient, she being in bed with the thighs slightly flexed and separated from each other. The surgeon introduces Fig. 150. Method of holding female catheter. the forefinger of the left hand between the nymphse, bring- ing it from behind forward until he touches the space between the entrance of the vagina and the orifice of the urethra; the catheter is then introduced with the right hand held as shown in Fig. 150, and guided by the left forefinger is passed through the orifice of the urethra into the bladder. TYING MALE CATHETER IN BLADDER. 231 Fig. 151. Tvi.no Male Catheter in the Bladder. When it is desirable to retain a catheter for some time in the male bladder, it is necessary to secure it to prevent its slipping out. Either a metallic or flexible catheter may be employed, but, as a rule, the flexible instrument is to be preferred; there are several methods of securing it in the bladder. By one method two narrow strips of tape, or two or three strong silk ligatures arc attached to the rings at the end of a metallic catheter, or are securely fastened around the end of the flexible instrument; these are next brought backward, one on each side of the penis, and the skin is drawn forward and a strap of adhesive plaster half an inch in width is passed over the strings or tapes and carried three or four times around the body of the penis just behind the position of the glans penis. If the skin has been brought well forward before the straps have been applied, the ligatures arc tightened as it slips back, and the catheter has not too much play (Fig. 151). Another method consists in ligature around the catheter just in advance of the meatus; the two ends arc next brought backward and tied in a knot behind the corona glandis ; the ends are then carried around behind the corona and tied on one side of the fhenum ; the foreskin is slipped forward and covers the ligatures. A catheter may also be secured in the bladder by tying the ends of the silk ligatures, which aie attached to the instrument in advance of the meatus, to tufts of pubic hair. A simpler method of securing the catheter is to perforate the free end wdth a needle armed with a double ligature of silk or hemp; the needle being removed, two loops are made of the proper length, and these are passed through :*. Tying in catheter. (Bryant.) fastening a strong sil 232 MINOR SURGERY. the ends of a T-bandage, which is secured around the waist, the tails being brought up on either side of the scrotum and secured to the body of the bandage passing around the waist. In the female bladder, when it is desirable to keep the bladder empty, the self-retaining catheter is usually em- ployed, which consists of a catheter with a bulb at its vesical extremity, or an ordinary catheter w ith silk loops and a T-bandage may be employed in the same manner as in securing a male catheter. The Endoscope. This instrument is employed to explore the internal cavities of the body. When used to obtain a view of the Fig. 152. Endoscope of Desormeaux. washing out the bladder. 233 urethra, it consists of a straight conical metallic tube for the urethra, and for the bladder one which is somewhat curved like a vesical sound; there is also an eye-piece, an illuminating apparatus, and an arrangement of mirrors by which a strong light can be thrown upon whatever touches the end of the tube (Fig. 152). By the use of this instru- ment the urethra and inner surface of the bladder can be examined by the eye. A view of the urethra may also be obtained by the use of the urethroscope, which consists of a straight metal tube provided with a rounded obturator of hard rubber which projects somewhat beyond the end of the tube. The in- strument is introduced into the urethra until the bladder is reached, when it is slightly withdrawn and the obturator is removed and a strong light is thrown into the tube from a head mirror or from an electric lamp, and as the tube is withdrawn various portions of the urethra are exposed to the view of the surgeon. A modification of this instrument, known as the cysto- scope, is also employed to obtain a view of the cavity of the bladder. Washing out the Bladder. This procedure may be required in the treatment of cystitis, and it is accomplished by passing a flexible catheter with a large eye into the bladder, or a double Fig. 153. Rubber bag with stopcock, for washing out the bladder. catheter may be employed. A syringe, or better a rubber bulb holding about a pint, having a nozzle and stopcock (Fig. 153), is filled with warm water, or with any medi- cated solution wdiich is desired, and it is then attached to the free end of the catheter and the contents are gently 234 MINOR SURGERY. injected into the bladder; care should be taken that the bladder is not too much distended. AY hen the desired amount of fluid has been injected, it is allowed to run out of the catheter, and the procedure may be repeated until the solution comes away perfectly (dear. Care should be taken to see that the bladder is perfectly emptied of the solution, and in cases of paralysis of the bladder gentle pressure should be made upon the abdomen over the pubis to accomplish this object. Solutions of boric acid, permanganate of potassium, and weak solutions of carbolic acid and of nitrate of silver are often employed in washing out the bladder in cases of chronic cystitis. Fig. 154. Urethral Injections. In the treatment of urethral inflammations the injection of medicated solutious is generally made use of, and as these injections are usually made by the patient himself, he should be shown or instructed how to em- ploy them. A rubber syringe having a conical nozzle and holding about two or three drachms is the best instrument to employ for this pur- pose. (Fig. 154) The syringe having been filled with the solution, and the patient sitting upon the edge of a hard chair, with the thighs separated, grasps the syringe between the thumb and middle finger of the right hand, the tip of the index finger resting upon the end of the piston, and inserts its conical end from a quarter to half an inch within the meatus, which is held open by the thumb and finger of the left hand, and after its introduction it should be drawn tightly around it, the pressure being made shape of laterally so as to narrow the aperture instead nozzle of ()f broadening it, as is the case when the com- urethral p ' . ,. . syringe. pression is in an antero-postenor direction. After the fluid has been thrown into the urethra in this manner the syringe is removed, and the patient is instructed to hold the lips of the meatus together for one or two minutes to prevent the escape of the fluid. SUTURES. 235 Sutures. A variety of materials are employed for sutures, such as silk, catgut, silver or iron wire, silkworm-gut, and horse- hair; the material most frequently employed at the present time is either catgut, silk, or silkworm-gut, although some surgeons still prefer silver wire. Catgut is practically the only substance employed as a suture which is absorbable; the other varieties of suture require removal after their application, although some sutures, such as the silk, when employed in subcutaneous wounds may be cut short, as they are apt to become encysted and produce no trouble. It matters little what variety of material be employed for suture if the surgeon is careful to see that it is rendered thoroughly aseptic before being brought in contact with the wound. Sutures of Relaxation are those wdiidi are entered and brought out at some distance from the edges of the wound, and are employed to prevent dangerous tension upon the sutures wdiich (dose skin wounds. This form of suture is employed by the use of the quilled, button, or plate suture. Sutures of Coaptation.—These arc superficial sutures applied closely together and include only the skin; they are employed to secure accurate apposition of the cutaneous surface of wounds. Sutures of Approximation are those wdiich arc applied deeply into the tissues to secure approximation of the deep portions of a wound ; this object is accomplished by the use of the quilled, button, or plate suture. Secondary Sutures.—These sutures are applied when the surfaces of the wound are covered by granulations, when the primary sutures have failed to secure apposition of the edges of the wound, or in cases of secondary hemorrhage where the opening of the wound has been necessitated to turn out the blood-clot and secure the bleeding vessel, or in plastic operations wdiere the primary sutures have failed to secure adhesions of the edges of the flaps. They are also employed with advantage in cases in which it is neces- 236 MINOR SURGERY. sarv to pack a wound with antiseptic gauze, or to allow hemostatic forceps to remain clamped upon bleeding tissues iu a wound at the time of operation. The sutures should in such a case be introduced and loosely tied at this time, and when the packing or forceps are removed at the end of two or three days the sutures are tightened so as to secure apposition of the edges of the wound. SlIiGKAL XEEDI.ES. Needles for surgical use are of different sizes and shapes (Fig. 155); straight needles are the ones most commonlv Fig. 155. Surgical needles. employed, but curved needles will be found most con- venient for the introduction of sutures in wounds of certain Fig. 156. Mounted needle. locations. Tubular needles are often employed in intro- ducing sutures in wounds in which the use of an ordinary SECURING SUTURES AND LIGATURES. 237 needle is difficult: for instance, in the operation for cleft palate, and for the introduction of sutures in deep wounds, a mounted needle will often be found very useful (Fig. 15(1). Needles should be sharp and clean and should be rendered thoroughly aseptic before being used. A needle- holder is often required for the satisfactory introduction of needles in wounds of certain localities (Fig. 157); if Fig. 157. Needle-holder this is not at hand the needle may be held by a pair of dressing forceps or a pair of haemostatic forceps. Method of Secukinu Sutures and Ligatures. Metallic sutures are usually secured by twisting the ends together or by passing the ends through a perforated shot and clamping the shot with a shot-compressor, wdiidi securely fixes them. Sutures and ligatures of catgut, silk, silkworm-gut or horsehair are secured by tying, and several different knots are employed to secure them. Reef or Flat Knot. Fig. 15s. Reef or flat knot. 11* 238 MINOR SURGERY. This is one of the best forms of knot to use in securing sutures or ligatures, and it is made by passing one end of the thread over and around the other end, and the knot thus formed is tightened ; the ends of the thread are next carried toward eadi other and the same end is again car- ried over and around the other, and when the loop is drawn tight we have formed the reef or flat knot (Fig. 158). Surgeon's Knot. This knot is formed by carrying one end of the thread twice around the other end (Fig. 159); and after tighten- Fig. 159. Surgeon's knot. ing this loop the same end is carried over and around the other end as in the case of the final knot of the reef or flat Fig. 160. Surgeon's knot and reef knot combined. knot. The surgeon's knot and reef knot combined is one of the best methods of securing sutures or ligatures of catgut or silk, as the first knot is not apt to relax before the second knot is applied. (Fig. 160.) SECURING SUTURES AND LIGATURES. 239 Granny Knot. This method of tying the ligature or suture should not be employed, as the resulting knot is not as secure as the reef knot and is apt to relax; it differs from the latter in the fact that one end of the thread having been carried Fig. 161. Granny knot. across and around the other end, the knot is completed bv carrying the same end under and around the other end of the thread (Fig. IbT). The Staffordshire knot, wdiich is much used to secure the pedicle in the removal of the ovaries or ovarian tumors, is Fig. 162. Staffordshire knot. applied as follows : A handled-needle armed with a stout silk ligature is passed through the pedicle, and then with- drawn so as to leave a loop on the distal side; this loop is drawn over the ovary or tumor and one of the free ends is passed through it so that one end is above while the other end is below the retracted loop. (Fig. 1<>2.) The ends are then seized and drawn through the pedicle; at the 240 MINOR SURGERY. same time the thumb and forefinger arc pressed against it, until sufficient constriction is made, and the ends are finally secured by tying as in the securing of an ordinary ligature. Varieties of Suture. The Interrupted Suture. This variety of suture is the one most usually employed in the apposition of wounds, consisting of a number of single stitches, each of wdiich is entirely independent of those on either side. In applying this suture the surgeon holds the edge of the wound with the fingers or forceps and thrusts the needle, previously threaded, through the skin three or four lines from the edges of the wound. He Fig. 163. The interrupted suture. then passes the needle from wdthin outward through the tissues of the opposite flap at the same distance from the edge of the wound. (Fig. 103.) Each stitch is secured as soon as it is passed—by tying if a silk, catgut or silk- worm-gut suture be used, or by twisting if a silver-wire suture is employed. A suture may be used with a needle threaded on each end, and in this case both needles arc passed from within outward. The sutures may be secured VARIETIES OF SUTURE. 241 as soon as applied or they may be left unsecured until a sufficient number have been introduced and then they may be secured by tying or twisting. Care should be taken to see that they make no tension on the edges of the wound and that they are so introduced as to make the best possi- ble apposition of the parts. In extensive and deep wounds it may be found necessary to introduce both dee]) and superficial sutures, the former bringing about apposition of the muscles and deep fascia, the superficial layer bringing together the superficial fascia and skin. The deep or buried sutures are often employed to unite fascia, muscles or tendons, and the best material for this variety of suture is either catgut or silk. Continued or Glover's Suture. Phis variety of suture is applied in the same manner as the interrupted suture, but the stitches arc not cut apart Fig. 164. Continued or glover's sutury ; method of securing. 242 MINOR SURGERY. and tied; it is made with silk or catgut, and is secured by drawing it double through the last stitch and using the free end to make a knot with the double portion attached to the needle. (Fig. 104.) This suture is generally em- ployed in intestinal sutures, but may also be employed in bringing about apposition of the edges of wounds in tissues of loose structure. The Twisted or Hare-lip Suture. This is a very useful form of suture where great accu- racy and firmness of apposition of the edges of the wound arc desired. It is applied by thrusting pins or needles Fig. 165. Fig. 166. Twisted or hare-lip suture. India-rubber suture. through both lips of the wound, the edges being kept in contact over the wound by figure-of-eight turns with silk or wire. (Fig. 105.) The ends of the pins should be cut off by pin-cutters after the sutures are applied, or should be protected by pieces of cork or plaster to prevent them from injuring the skin of the patient and causing him pain. The twisted or hare-lip suture is frequently employed in plastic operations about the face and in other parts of the body, where accurate apposition of the flaps is desired. The India-rubber Suture. This is applied by first passing the pins or needles through the edges of the flaps, and instead of the twisted figure-of-eight suture of silk, delicate rings of India-rubber are employed. (Fig. 100.) VARIETIES OF SUTURE. 243 The Quilt Suture. This variety of suture is made with silk or catgut, and is employed in wounds to effect very close approximation Fig. 167. The quilt suture. of the parts and to prevent bagging; it is often employed in connection with the continued suture, and is applied as shown in Fig. 107. The Quilled Suture. In making use of this suture a needle armed with a double thread of wire or silk is passed through the tissues as in applying the interrupted suture, but at a greater dis- tance from the edges of the wound. Into the loops on one side of the wound is inserted a quill or piece of a flexible catheter or bougie, and on the opposite side the free ends of the sutures are tied around a similar object after being 244 MINOR SURGERY. tightened. (Fig. 108.) This form of suture makes deep and equable pressure along the whole line of the wound. Fig. 168. Fig. 169. The quilled suture. (Smith.) In applying this suture it may be found well in some cases to introduce a few superficial interrupted sutures along the line of the wound to secure accurate approximation of the skin. This form of suture was formerly much employed in cases of deep wounds to secure accurate apposition of the deep portions of the wound, but recently the introduction of buried catgut sutures has supplanted the use of this variety of suture. Button or Plate Suture. This suture is applied by passing a needle armed with a double thread as in the case of the quilled suture, the ends of the suture being passed through the eyes of a button or through perforations in a lead plate before being threaded in the eye of the needle. After the suture pre- pared in this way has been passed through both sides of the wound, the needle is removed and the free ends of the suture are passed through the eyes of a Button suture. (Smith.) VARIETIES OF SUTURE. 245 button or the perforations in a lead plate on the opposite side of the wound, and are tightened and secured. (Fig. lO'.i.) This form of suture may be employed in deep wounds to accomplish the same purpose as the quilled suture, and allows the cutaneous margins of the wound to remain free from compression, and here, as in the case of the quilled suture, a fewT interrupted sutures may be introduced between the button or plate sutures to secure accurate apposition of the skin surfaces if desired. Tongue- and-groove Suture. This variety of suture, devised by the late Dr. Joseph I'aneoast, consists in slipping the margin of the flap which has been bevelled into a groove, made by dissecting up the mar- gin of the skin surrounding the raw surface which is to be covered. In applying this su- ture the wire or thread used has a needle applied on each end, and after passing the su- Tongue-and-groovesuture. hires so as to secure the flaps the free ends arc secured over a pad of adhesive plaster or a disc of lead or a button. (Fig. 170.) Shotted Sutures. This suture receives its name not from any special method of application, but solely from the way in wdiich it is secured ; any of the previously mentioned varieties of sutures may be employed. The material used in applying this suture may be catgut, silver wire, silkworm-gut, silk,or horsehair, and after the suture has been passed the needle is removed, and the ends are passed through a perforated shot; the ends are then drawn upon to bring the edges of the wound in contact, and the shot is pressed down to the skin and clamped by means of a shot-compressor. The suture is then cut off* flush with the surface of the shot. 246 MINOR SURGERY. This method of securing sutures is especially useful in closing wounds in the mucous cavities, such as the vagina, rectum, and mouth, where the knot or twist of the wire might cause irritation of the surface or pain to the patient; it is also a useful method of securing sutures in plastic operations ; it also facilitates the removal of the sutures, as the shot is not apt to be obscured by the swollen tissues and is easily seized by forceps when the loop is divided. Removal of Sutures. Where sutures are buried in the tissues or used to ap- proximate parts in cavities wdiich are subsequently (dosed, such material should be used for sutures as will be absorbed in a few days, or will become encysted and remain harmless in the tissues—such as catgut, silkworm-gut, or silk—and it is needless to state that sutures used with this end in view should be rendered perfectly aseptic before being employed. Catgut sutures, w hen well prepared and used for sutures in external wounds, usually undergo absorption in from ten to fifteen days; the loop buried in the tissues is absorbed and the knot may be removed from the surface with forceps or comes off with the dressings. The other substances, such as silk, silkworm-gut, silver wire, and horsehair, are removed by cutting one side of the loop and making traction upon the knot of the suture with forceps, or in the case of the wdre suture, after dividing the loop and straightening out one end of it, the wire should be withdrawn in a curved direction. Sutures wdiich are not causing any irritation should be allowed to remain in position until the wound is solidly healed. The time usually required for their retention in cases of aseptic wounds is from eight to twelve days. Lembert's Sidure. Lembert's suture is used in wounds of the viscera covered by the peritoneum, with the object of bringing in VARIETIES OF SUTURE. 247 contact the peritoneal surfaces. This form of suture is usually employed in (dosing wounds of the intestine or stomach. (Fig. 171.) A needle armed with a fine catgut or silk thread is passed, and it is better to employ a round needle, such as the ordinary sewing-needle, in preference to the bayonet- pointed needle, as there results by its use less bleeding from the punctures. The needle is first carried through Fig. 171. Lembert's suture. (Bryant.) Fig. 172. Lembert's suture, a, serous; b, muscular; and c, mucous coat. (Smith.) the peritoneal and muscular coats of the intestine a short distance from the wound, and it is then carried across the wound and passed through the same portions of the intestine a short distance from the edge of the wound on i . . . the opposite side, and when the suture is tightened the peritoneal surfaces of the intestine are inverted and brought into contact with each other (Fig. 172); the inter- 248 MINOR SURGERY. rupted or continued suture may be employed in making this form of suture. Gelys Suture. In applying this form of suture in intestinal wounds a ligature armed with a fine needle at each end is employed, Fig. 173. Gely's suture. and the punctures should be about five millimetres apart; the method of applying the suture is shown in Fig. 173. Bouisson's Suture. This method of suturing intestinal wounds, wdiich is more complicated than either of the previously mentioned methods and possesses no advantage over them, is applied by passing a delicate pin in and out along each side of the wound as shown in Fig. 174, and drawing them together laterally by ligatures passed through the intervals, one end of cadi ligature being cut short and the other end being brought out at the lower angle of the external wound; a thread is also tied under the head of each pin and brought out at the upper angle of the wound, and at VARIETIES OF SUTURE. 249 the end of three or four days the pins arc removed bv means of the threads attached to them, and at the same time the sutures, having been freed by the removal of the pins, are withdrawn. Fig. 174. Bouisson's suture. Czerny Suture. This suture is applied in intestinal wounds by passing the needle armed with a catgut or silk thread through the serous membrane on one side of the wound of the intestine and out at the wound surface so as not to include the mucous membrane ; the needle is then passed through the wound surface on the opposite side, avoiding the mucous membrane, and brought out through the serous membrane a short distance from the edge of the wound. By this suture the lips of the wound are approximated. For additional security in preventing the escape of the contents of the intestine and to secure approximation of the serous surfaces a few Lcmbert sutures should be introduced. Jobert's Suture. Fig. 175. Jobert's suture. 250 MINOR SURGERY. This suture which was employed in transverse wounds of the intestine which completely or incompletely divided the gut, is introduced after turning the lower end of the bowel in upon itself. When the division of the gut was incomplete he employed only one suture, when complete two; the ends of the sutures were brought out of the external wound. (Fig. 175.) By this method of suture the two serous surfaces are brought into contact. Sutures Employed in Intestinal Anastomosis. When it is desired to form a permanent orifice between two portions of the gut, the ends of the gut are closed and Fig. 176. Method of applying Senn's decalcified bone plates. (Geeig Smith.) an opening is made in each portion of the gut, and the walls of the gut surrounding the openings are ludd in contact with each other by sutures attached to perforated plates of VARIETIES OF SUTURE. 251 decalcified bone; this is the method devised by Senn. The manner of using the bone plates and sutures is shown in Figs. 170 and 177. To accomplish the same purpose rubber rings or perforated plates of rubber have been em- ployed, also rings made from catgut, to which the sutures are attached, are applied in the same manner as Senn's plates. In using the rubber rings or plates it is well to divide them at one or two points and unite them by catgut sutures which will soften and be dissolved in a few days and allow the ring or plate to change its shape and facilitate its passage through the bowels ; if catgut rings are employed these will be softened and dissolved in a short time so as to be passed without difficulty. Fig. 177. Diagram showing position of bone plates in intestinal anastomosis after resection of the bowel. (Roberts.) At the present time many surgeons iii performing in- testinal anastomosis dispense with the use of bone plates or rings and make use of Abbe's long incision, in which after closing the two ends of the gut, the two portions are laid alongside of each other and two rows of continuous Lembert's sutures are applied, a quarter of an inch apart and an inch longer than the proposed cut. The bowel is then opened for four inches a fourth of an inch from the sutures, both rows being to one side of the cut; the op- posite portion of the bowel is then opened in the same 252 MINOR SURGERY. manner, and the adjacent edges of the bowel are united by a continuous suture. The two free cut edges are then hemmed to secure any bleeding that may be present, after wdiich the serous surfaces on the opposite sides of the opening are approximated and secured by two rows of continuous Lembert's sutures. Intestinal anastomosis may be employed instead of Jobert's suture or the circular suture in wounds com- pletely dividing the intestine and after resection of the gut for the removal of growths or for stricture. Sutures Employed in Gastrostomy. In this operation, when the wall of the stomach has been exposed, two hare-lip pins should be thrust through the integument and tissues near the edge of the wound and then through the peritoneal and muscular coats of the stomach, to bring the surface of the stomach in contact with the peritoneum covering the inner surface of the abdominal wralls in the region of the wound; a fewr sutures of silk may also be introduced to secure the wall of the stomach to the edges of the wound. The opening of the stomach is postponed for four or five days if possible, until the adhesion between its Avails and the abdominal parictes is secure, and at this time the sutures and the pins are removed. When immediate opening of the stomach is required for any reason, after the wall of the stomach has been exposed two silver-wire sutures are passed through the peritoneal and muscular coats of the stomach by means of a needle; these sutures should be placed transversely to the external abdominal wound and serve to draw the wall of the stomach in contact with the inner margins of the abdom- inal incision. A long silk suture is next passed through the outer coats of the stomach so that the loops project upon the external surface of the organ (a). A needle, having a hook near its extremity (c), is passed through the abdom- inal wall and engages the loop and draws it to the surface VARIETIES OF SUTURES. 253 of the abdomen near the edge of the abdominal wound ; the same manipulation is repeated until all of the loops have been brought to the surface. (Fig. 178.) A piece of rubber tube is carried around the external wound and slipped through the loops wdiich project upon the surface of the abdomen (c), and by drawing the loops Fig. 178. Sutures for immediate gastrostomy. (Robekts.) tight over the rubber tube and tying the ends of the suture the stomach wall is secured in contact with the inner mar- gins of the abdominal -wound, and it may be safely opened after being thus fixed. In the operation of gastrotomy, wdiere the stomach has been exposed and opened and the foreign body removed, or its cavity has been explored, or its orifices dilated as the case may be, the wound in the wall of the stomach is closed with Lembert's sutures, silk or catgut being the material employed for sutures. The abdominal wound is next closed with deep sutures wdiich include the parietal peritoneum. 12 254 MINOR SURGERY. Ligatures Used in the Treatment of Vascular Growths. Various forms of ligature arc used for the strangulation of vascular growths; the material used for ligatures is usually strong silk or hemp thread, catgut, or silver wire. The Single Ligature with Pin. This is applied by first inserting a hare-lip pin through the skin near the edge of the growth, passing it under the growth and bringing its point out through the skin at a point opposite the point of entry ; a strong silk or hemp ligature, which has been well waxed, is passed under the ends of the pin surrounding the base of the tumor and is drawn tight enough to strangulate the growth, and is secured by two knots (Fig. 179). If the growth is of considerable size it is better before applying this ligature to introduce a second pin at right angles to the first one, and then secure the ligature under the pins. In applying these forms of ligatures to healthy skin, the patient is saved much pain, and the separation of the mass is hastened, by cutting a groove in the skin with a sharp Fig. 179. Vascular tumor strangulated with pin and ligature. (Roberts.) knife at the point where the ligature is to be applied; the ligature when tied is buried in the groove thus made. Double Ligature in Vascular Growths. This ligature is applied by passing a needle or a needle with a handle, armed with a double ligature, through the LIGATURES USED IN VASCULAR GROWTHS 255 skin near the growth, and then passing it under the tumor and bringing it out through the skin at a point directly opposite the point of insertion; the ligature is then divided Fig. 180. Method of applying double ligature. (Roberts.) and the needle removed and the tumor is strangulated by tving firmly the corresponding ends of the ligature on each side of the tumor, each ligature strangulating one-half of the growth (Fig. ISO). Fig. 181. Method of applying double ligature and pin. (Bryant.) The double ligature may also be applied by first passing a pin under the growth and then passing a needle armed with a double thread under flic tumor at right angles to the pin, and after removing the needle the ends of the 256 MINOR SURGERY. ligature are tied and the tumor is strangulated in two sections. (Fig. 181.) Quadruple Ligature. In applying this ligature two needles carrying a double ligature are passed under the growth at right angles to each other, or if the handled needles be used they may be first passed in this manner, and then threaded with double Fig. 182. Method of applying quadruple ligature. (Liston.) ligatures, which are carried under the growth as they are withdrawn. The needles being removed, the surgeon ties two ends of the ligature together and repeats this pro- cedure until the growth has been strangulated in four sections. (Fig. IS2.) LIGATURES USED IN VASCULAR GROWTHS. 257 Subcutaneous Ligature. This is applied by introducing a needle armed with a ligature through the skin near the growth, and carrying it through the subcutaneous tissues around the growth for a short distance, then bringing it out through the skin. The needle is again introduced through the same puncture, and is again brought out through the skin at some distance from the tirst point of exit, and is next introduced through this puncture and brought out at a more distant point. In this way the growth is completely encircled by a subcuta- neous ligature, which is finally brought out at the point of entrance ; the tumor is strangulated by firmly tying together the ends of the ligature. (Fig. ISo.) Fig. 183. Method of applying subcutaneous ligature. (Holmes.) If a needle armed with a double ligature is first passed under the growth the ligature is divided, and by passing each end of the divided ligature subcutaneously around the growth it may be strangulated subcutaneously in two sections. 258 MINOR SURGERY. Erichsen's Ligature. This ligature is employed to strangulate tumors of irregular shape in a number of sections. A strong silk Fig. 1S4. Method of applying Erichsen's ligature. (Erichsen.) or hemp ligature three yards in length, one-half of which is stained black, is carried by a needle as a double ligature Fig. 185. Erichsen's ligature applied. under the growth at various points so as to leave a scries of loops about nine inches long on each side of the tumor (Fig. 184); the black loops being cut on one side, the TREATMENT OF HEMORRHAGE. 259 white on the other, the ends are then firmly tied so as to strangulate the growth in sections. (Fig ISo.) Klastic Lkjatures. Ligatures made of India-rubber varying from half a line to several lines in thickness are often made use of in surgery. They may be employed to strangulate growths such as moles or mevi, or in the treatment of fistuhe, and are especially useful in the treatment of those cases of (istula-in-ano in which the internal opening into the bowel is situated high up, as the division of such fistuhe bv this means is accomplished without hemorrhage and with less risk than by the employment of the knife. In applying elastic ligatures in such eases the ligature, after being- passed through the fistula by means of a probe, is carried out through the internal opening ; the anus is next well stretched, and the elastic ligature is then firmly tied with two or three knots ; the greater the tension made before the ligature is tied the more rapidly will it cut its way out. The smaller sizes of rubber drainage-tubes may be sub- stituted for the solid rubber ligatures. Treatment of Hemorrhage. The surgeon may be called upon to treat the following varieties of hemorrhage : arterial, venous, or capillary ; and these again are classified according to the time of their occurrence, as—primary, that is, bleeding wdiich occurs at the time the wound is inflicted; intermediary or consecutive, that which occurs within twenty-four or forty-eight hours after the reception of the injury, wdiich generally takes place during the period of reaction; and secondary, wdiich takes place after forty-eight hours, and may occur at any time subsequent to this period until the wound is healed. The treatment of hemorrhage is either constitutional or heal. The constitutional treatment of hemorrhage consists in keeping the patient in the recumbent posture and avoiding 260 MINOR SURGERY. any sudden elevation of the head or arms which might induce fatal syncope. Opium is a valuable remedy and should be freely used. Ergot, gallic acid, acetate of lead and tincture of iron may also be employed, and stimulants and food should be carefully administered, and in extreme cases auto-transfusion or transfusion of blood or normal salt solution, as described on page 180, may be resorted to. In the local treatment of hemorrhage various measures may be adopted wdiich may be either temporary or perma- nent in their action. Temporary Control of Arterial Hemorrhage. This may be effected by pressure applied directly to the bleeding vessel in the wound or by pressure applied indi- rectly to the main artery between the point of its injury and the centre of the circulation, and this pressure may be made by the fingers, digital compression, by compresses, or by means of tourniquets. Digital Compression. This constitutes one of the most valuable means em- ployed in the temporary control of hemorrhage; the finger is pressed directly upon the bleeding vessel in the wound or is used to make pressure upon the artery from which the bleeding arises at some point between the wound and the centre of the circulation. (Fig. 186.) Control of hemorrhage by digital pressure can only be maintained for a few minutes, for the fingers of the surgeon or assistant soon become tired, so that it is only employed until means are adopted for the permanent control of the bleeding. Digital compression of the radial and ulnar arteries is frequently resorted to for the control of hemorrhage during amputations of the fingers, also of the axillary and femoral arteries in amputations at the shoulder- and hip-joints. It is also used to control hemorrhage from wounds either the result of accident, or those made by the knife CONTROL OF ARTERIAL HEMORRHAGE 261 of the surgeon, in which case the finger is placed directly upon the divided vessel, or is employed to hold a sponge or compress firmly in the wound. Fig. 186. Digital compression of the femoral artery. Compresses. By the use of compresses placed directly in the wound or applied to the vessel betw een the wound and the centre of the circulation, the temporary control of hemorrhage may be very satisfactorily accomplished. Where it is possible, the compress which is applied in the wound should be made of antiseptic gauze, thereby diminishing the chances of wound-infection. The compress should be held in position by a bandage firmly applied and is generally employed only as a tem- porarv expedient until a more permanent means of con- trolling the bleeding is adopted. Tourniquets. These instruments, which are employed for the tem- porary control of hemorrhage from wounds, are of many different kinds. 12* 262 MINOR SURGERY. Petit's tourniquet, which is the best for ordinary use, consists of two metal plates connected by a strong linen or silk strap, with a buckle—the distance between the plates being regulated by a screw. (Fig. 187.) In applying this tourniquet a compress or roller bandage is placed directly over the artery to be compressed and may be held in posi- tion by a few turns of the roller bandage. The lower plate Fig. 187. Petit's tourniquet. of the tourniquet is placed directly over this pad and the strap is tightly secured around the limb to keep the instru- ment in place. The screw is then turned so as to separate the plates and tighten the strap, thus forcing the compress or pad upon the artery controlling its circulation. This instrument is very generally employed for the control of hemorrhage in wounds of the extremities, and is especially useful in amputation of these parts, being placed over the main artery some distance above the seat of operation. CONTROL OF ARTERIAL HEMORRHAGE. 263 Fig. 188. The Spanish Windlass. An improvised tourniquet, known as the Spanish windlass, may be employed in cases of emergency ; it is prepared by folding a handkerchief or piece of muslin into a cravat and placing a compress or smooth pebble on the body of the cravat; this is placed over the artery to be controlled, and the ends of the handkerchief are tied loosely around the limb; a short stick is passed through this loop, and by twisting the stick the loop is tightened and the compress is forced down upon the artery (Fig. 188). Many other forms of tourni- quet have been devised which have the pad and counter-pad arranged to make pressure upon the vessel desired, such as Lister's aorta compressor (Fig. 189),which is employed in the treatment of aneurism of the iliac vessels, and for the control of hemorrhage in amputation at the hip-joint. Iloey's clamp (Fig. 190) and Signorini's tourniquet (Fig. 191) arc constructed upon the same principle, and are frequently em- ployed to control the circulation in the femoral artery in cases of operations on the thigh and leg, and in the treatment of femoral or popliteal aneurism. The elastic tube, or strap of Esmarch's apparatus (Fig. 192) may also be employed for the temporary control of arterial hemorrhage, being applied above the wound, and if this is not at hand, any strong rubber cord, or a piece of large-sized drainage-tube may be used as a substitute. In hemorrhage from wounds of the hands and feet, especially in children, and in controlling hemorrhage from wounds The Spanish windlass. 264 MINOR SURGERY. of the penis, a piece of drainage-tube, firmly applied above the wound, may be employed wdth advantage. This tube Fig. 189. Lister's aorta compressor. Fig. 190. Fig. 191. Hoey's clamp. Signorini's tourniquet. or strap, although generally employed to control hemor- rhage from vessels of the extremities, may be used to control the femoral artery as it crosses the brim of the CONTROL OF ARTERIAL HEMORRHAGE. 265 pelvis, by placing a compress over the artery in this posi- tion, and then applying the elastic band to secure it with a figure-of-eight turn, passing it under the thigh, crossing over the pad, and then carrying the ends around the pelvis, and securing them. Fig. 192. Elastic strap of Esmarch's apparatus. To make pressure on the axillary artery, a compress should be placed in the axilla, and the middle of the tube is placed over this to hold it in position ; the ends of the tube are then carried over the shoulder and crossed, and then carried to the opposite axilla and seemed. In amputation at the shoulder-joint, to make pressure upon the subclavian artery, wdiich is difficult to compress by an ordinary tourniquet, the handle of a large key well padded may be used ; it is firmly pressed against the vessel above the clavicle, and held by an assistant, and will prove a very satisfactory means of controlling the circulation in this vessel. Haemostatic Forceps. The temporary control of arterial hemorrhage by the use of haemostatic forceps is now very generally employed in surgical operations, and their use has done much to diminish the shock following operations from the loss of blood. The hemostatic forceps in general use is self- retaining; it is (damped upon the bleeding vessel, and is allowed to remain until the operation is completed, when the vessel is secured permanently by the application of a 266 MINOR SURGERY. ligature, and the forceps is removed. The use of these forceps Avill be found very satisfactory in controlling hemorrhage during the removal of tumors and in cases of amputation, and for the temporary control of bleeding during the operation of tracheotomy they will be found most efficient, as also in abdominal operations, in which their utility was first demonstrated. (Fig. 193.) Fsmarch's Bandage and Tube. This apparatus, wdiich is applied to the limbs to render them bloodless during operations, consists of a rubber bandage two and a half fig. 193. inches in width and three or four yards in length, and a rubber tube two yards in length, to one end of which is attached a chain and to the other a hook, or better a rubber strap, one inch in width and one and a half yards in length with a hook and chain. The bandage is applied to the extremity of the limb and is carried up the limb to a point some distance above the seat of proposed operation; the bandage is applied firmly, each turn overlapping one- fourth of the preceding one, and w hen the last turn has been made the rubber tube or strap is wound firmly around the limb and secured by fastening the hook into one of the links of the chain. (Fig. 194.) After securing the tube or strap the rubber bandage is removed from the limb and if the tube Hreinostatic forceps. esmarch's bandage and tube. 267 has been firmly enough applied the limb wdll be found to be blanched, and should be free from blood during the operation. ('arc should be taken not to apply the tube or strap too tightly in poorly developed limbs, or on parts of the limb where large nerve trunks approach the surface, as they may be subjected to an amount of pressure which will interfere w ith their functions subsequently. I have know ledge of one case of this nature in which permanent Fig. 194. Esmarch's bandage and tube applied. paralysis of the limb followed the use of Ksmarch's apparatus; tin; tube should be applied with just enough firmness to control the circulation. As the strap, when firmly applied, completely cuts off the circulation of parts below, it should be applied for as short a time as possible, as gangrene has resulted from its prolonged use. After the removal of the tube there is generally quite free capillary hemorrhage, due to paralysis of vasomotor nerves from pressure, but this in a short time stops. This apparatus is of the greatest service in controlling hemor- rhage at the time of operation, and in amputations and removal of vascular tumors from the limbs will be found most satisfactory. In operations upon bone, either oste- otomy or seijiiestrotomy, it is especially useful, as it allows the surgeon to have a view of the parts unobscured bv hemorrhage. I have found its use most satisfactory in operations for the removal of foreign bodies, such as needles imbedded in the hands or feet or extremities, 268 MINOR surgery. Permanent Control of Arterial Hemorrhage. To secure this end the surgeon may resort to the use of position, cold, heat, styptics, pressure, cauterization, liga- tion, torsion, or acupressure. Position. In arterial hemorrhage from w ounds of the extremities elevation of the part will be found to materially diminish the amount of hemorrhage; in hemorrhage from wounds of the arteries of the hand, forearm, foot, or leg, forcible flexion of the forearm on the arm or of the leg on the thigh will be found useful in diminishing the force of the blood-current. Cold. The application of cold by means of a stream of cold water or an ice-bag or pieces of ice will often be found an efficient means of controlling hemorrhage from vessels of small calibre ; it is especially applicable to hemorrhage from wounds of the vessels of the mouth, nostrils, vagina, or rectum. Hot Water. Hot water will be found a very efficient means of con- trolling hemorrhage from small vessels, and it may be used in the form of a hot antiseptic solution. It is of especial value in capillar}' or parenchymatous hemorrhage and is employed in the form of a douche or by means of sponges dipped in the hot solution and packed into the wound. Injection of hot water is a most satisfactory method of controlling uterine hemorrhage. Styptics. These agents arc sometimes employed to control capil- lary bleeding or hemorrhage from small vessels, and although their use is often satisfactory as regards the control of the bleeding, they have the disadvantage of control of arterial hemorrhage. 269 interfering with the primary union in wounds, and since the value of asepsis in wound treatment has been demon- strated they are now very seldom employed. The most valuable styptics which are used are alcohol, alum, oil of turpentine, perchloride of iron, and persulphate of iron or Monsel's solution, acetic acid, and vinegar. Pressure. For the permanent control of arterial hemorrhage pressure may be applied directly to the bleeding-point or surface by means of a compress of antiseptic gauze or by strips of gauze packed firmly into the cavity from whose surface the bleeding arises. Compresses are used with the best results wdiere the proximity of a bone gives a firm substance upon which the vessel may be compressed, as is the case in the vessels of the seal}). Pressure applied by means of packing with strips of gauze will be found most efficient in controlling hemorrhage from cavities such as the nose, vagina, or rectum, and in the cavities resulting from the removal of necrosed or carious bone. Pressure may be indirectly applied by flexing the proximal joint over a compress or by firm bandaging of the limb. In controlling bleeding from a divided artery in a bony cavity, such as the inferior dental, a piece of catgut liga- ture may be forced into the canal, and will control the bleeding in a most satisfactory manner. The troublesome hemorrhage sometimes occurring after the removal of a tooth may be controlled by packing the alveolar cavity with a strip of gauze, or by introducing a wedge-shaped piece of cork and holding it in plate by fastening the jaws together by means of a bandage. Cauterization. The use of cauterization by means of a hot iron is a satisfactory method of arresting hemorrhage. Care should be taken to have the iron only of a dull-red or black heat, as the result desired is not the destruction of the tissues, 270 MINOR surgery. Fig. 195. but the coagulating effect of heat upon them. The form of cautery iron employed Avill depend upon the position of the vessel. Paquelin's cautery is also a satisfactory appa- ratus to use for the control of hemor- rhage. Control of arterial bleeding by cauterization is often resorted to in operations upon the jaws and in the removal of tumors from the mouth or pharynx or of the tonsils; it is also frequently employed to control hemorrhage in operations upon the uterus and the rectum, and also that resulting from the removal of ab- dominal tumors, where the applica- tion of a ligature is difficult and often impossible. Torsion. Ilewson's torsion forceps. This method of controlling arterial hemorrhage consists in seizing the end of the artery, drawing it slightly out of its sheath and twisting it; it may be accomplished with a single pair of forceps or by two pairs of forceps. In the latter method the vessel is held by one pair of forceps and is twisted by the second pair. Torsion of arteries in accidental wounds is quite common, and in many cases controls the hemorrhage until surgical aid is rendered. I have seen the femoral artery in Scarpa's triangle completely controlled in this manner in the case of an avulsion of the thigh from railway injury. In vessels of moderate size it mav CONTROL OF ARTERIAL HEMORRHAGE. 271 be practised with one pair of forceps, and the ordinary double-spring artery forceps (Fig. 196) will be found satisfactory for such cases. In larger arteries two forceps Fig. 196. Double-spring artery forceps. should be employed, or some of the numerous forms of torsion forceps wdiich have been devised for this purpose. (Fig. 1<)5.) Ligation. The use of the ligature is by far the most generally em- ployed method of controlling arterial hemorrhage. The materials used for ligature are silk, hemp thread, catgut, horsehair, iron or silver wire. Catgut or silk is the mate- rial generally employed. The vessel is seized with a pair of artery forceps or a tenaculum (Fig. 197) and drawn out Fig. 197. of its sheath, and a ligature of prepared catgut is thrown around it and secured by a surgeon's knot, or by a reef knot and a surgeon's knot combined, and when firmly tied the ends are cut short in the wound. Silk; ligatures which have been rendered aseptic are applied in the same manner, and the ends may be cut short in the wound. When ligatures are applied to vessels in their continuity they may be threaded into an eyed probe or aneurism needle (Fig. 198) and carried around the vessel and se- cured. A convenient method of applying a ligature to a bleeding-point in a deep wound or to a vessel in tissues which are of such a nature as not to permit of the isola- 272 MINOR SURGERY. tion of the vessel, is to use a curved needle threaded with a catgut ligature, which is passed deeply into the tissues Fig. 198. Aneurism needle armed with ligature. near the vessel and brought out on the opposite side; the ligature thus placed is then firmly tied, and the ends are cut short in the wound. (Fig. 199.) Fig. 199. Artery occluded by suture. (Esmarch ) Acupressure In this method of controlling arterial hemorrhage a needle or pin is used which is thrust through the tissues in such a way as to compress the artery. There are a number of methods of using the needle or pin, and a few of these will be described. ACUPRESSURE. 273 First Method of Acupressure. In this method the surgeon places a finger of his left hand upon the mouth of the bleeding vessel and with his right hand introduces the needle from the cutaneous sur- face and passes it through the thickness of the flap till its point projects for a couple of lines or so from the surface of Fig. 200. Fig. 201. Acupressure—rirst method : raw Acupressure—first method; cutaneous surface. (Eeichsen.) surface. (Erichsen.) the wound a little to the right side of the tube of the vessel. By forcibly inclining the head of the needle toward his right he brings the projecting portion of its point firmly down on the site of the vessel, and after seeing that it oc- cludes the artery he makes it re-enter the flesh as near as possible to the left side of the wound and pushes the needle through the flesh till its point comes out again at the cuta- neous surface. (Figs. 200 and 201.) Second Method of Acupressure. A straight needle threaded with a short piece of iron or silver wire, for the purpose of afterward retracting and removing it, is passed down through the soft parts a little to one side of the vessel ; its point is then raised up and passed over the artery and is then turned down again and thrust into the soft tissues on the other side of the vessel. (Fig. 202.) 274 MINOR SURGERY. Third Method of Acupressure. In this method the point of the needle is passed into the tissues a few lines to one side of the vessel, then passed under it and afterward pushed on, so that the point again emerges a few lines beyond the vessel. A loop of wire is next passed over the point of the needle, and then after Fig. 202. Fig. 203. Acupressure—second method. (Erichsen.) Acupressure—third method. (Erichsen.) being carried over the vessel and passed around the oppo- site end of the needle it is drawn sufficiently tight to close the vessel, and the ends of the wire are secured by making a twdst around the stem of the needle. (Fig. 20.'].) Fourth Method of Acupressure. This method is identical with the third, except that a long pin is used in place of the needle, the head of the pin remaining outside the wound. Fifth Method of Acupressure. Fig. 204. Acupressure—fifth method. (Erichsen.) TREATMENT OF VENOUS HEMORRHAGE. 275 This method consists in passing a pin or needle through the soft tissues (dose to the artery, and by giving the pin a quarter or half rotation twisting the vessel upon itself, fixing the pin by thrusting its point deeply into the tis- sues beyond. (Fig. 204.) Sixth Method of Acupressure. This method consists in applying the pin as in the fourth method, but differs from it in crossing the ends of the wire behind the pin so as to embrace the mouth of the vessel between them. Seventh Method of Acupressure. This method consists in passing a long needle or pin through the cutaneous surface deeply into the soft parts at some distance from the vessel, making it emerge near the vessel, bridging over the vessel and then thrusting it down into the soft parts on the other side of the vessel and making its point emerge again from the integument. Treatment of Venous Hemorrhage. Bleeding from small veins often stops spontaneously unless there is sonic pressure upon the wounded veins upon the cardiac side of the wound. It is, however, very satisfactorily controlled by position or by the application of a compress and bandage, or by the use of a ligature; if the divided vein he a large one it is well to secure both ends of the vein by ligatures. The free bleeding arising from ruptured varicose veins of the leg is easily controlled by the application of a compress and bandage, while hem- orrhage from the larger veins, such as the jugular, should he controlled by the application of ligatures as in the case d' wounded arteries. The application of the lateral liga- ture to small wounds of veins of large size, such as the femoral, or to wounds of venous sinuses, has been recom- mended, and employed with good results, Avhich consists 276 minor surgery. in pinching up the wall of the vein so as to include the orifice of the wound and throwing a delicate ligature around it. The use of the actual cautery may also be required for the control of xenons hemorrhage in positions in which its arrest by pressure or the ligature is not feasible. Treatment of Capillary Hemorrhage. Capillary or parenchymatous hemorrhage is usually arrested spontaneously by the exposure of the injured surface of the wound to the air, but it is often so profuse that its arrest becomes a matter of importance. To con- trol this form of bleeding, pressure may be applied to the bleeding surface for a short time, and if this fails to arrest it, sponging the surface with dilute alcohol will sometimes prove satisfactory; but the best application to arrest hem- orrhage of this nature is hot water, which may be used in the form of a hot bichloride solution. Acetic acid and vinegar are also sometimes employed for the same purpose. In cases where the means mentioned above fail to control the bleeding, it may be necessary to pack the wound with strips of antiseptic gauze ; this dressing is most service- able when the hemorrhage comes from cavities such as result from the removal of tumors or excisions of joints, and for the control of bleeding following the removal of necrosed or carious bone, packing the cavity resulting is the method very generally employed. To control hem- orrhage from the mucous cavities, such as the nose, rec- turn, and vagina, this method of treatment is frequently resorted to. Treatment of Secondary Hemorrhage. Secondary hemorrhage following the use of the ligature or other means of controlling bleeding is, since the adop- tion of the antiseptic method of wound-treatment, a much less frequent complication of wounds. The treatment of this complication is both constitutional and local; the con- treatment of secondary hemorrhage. 277 stitutional treatment consists in the use of those remedies which were mentioned as serviceable in primary hemor- rhage, and the drugs upon which the most reliance is to be placed are opium and ergot. The local treatment of this form of hemorrhage consists in the use of the various means of controlling hemorrhage which have been mentioned before, such as tin; ligature, hot water, pressure, or the actual cautery. If possible, it is well to secure the vessel from wdiich the bleeding arises in the wound ; if for any reason this cannot be done, the main artery should be ligated above the wound if the hemorrhage be arterial. Rules for Ligating Wounded Arteries. The following rules for the application of ligatures to wounded arteries are laid down by Ashhurst : 1. In cases of primary hemorrhage, no operation should be performed upon an artery, unless it is at the moment actually bleeding. The exception to this rule is in the cases where the vessel is seen to pulsate in the wound or where the wound involves the region of a large artery and the patient has to be transported or may be in a position not to receive surgical aid subsequently if needed ; under these circumstances, the vessel should be tied or the wound should be explored to ascertain the fact that no important vessel has been injured. 2. In applying a ligature to a wounded artery, the sur- geon should cut down directly upon it at the point from which it bloods and secure it in the wound. This rule holds good for both primary and secondary hemorrhage. •\. Two ligatures should be applied, one to each end of the artery if it be completely divided, and one on each side of the wound if the latter has not completely severed the coats of the artery. This procedure is adopted for the reason that the arterial anastomosis is so free that the proximal ligature will not always, even temporarily, arrest the bleeding; and if it does accomplish this object at the 13 278 minor surgery. time, after the collateral circulation is established, bleeding is apt to occur from the distal extremity of the divided vessel. If the coats of the artery are not completely sev- ered their division should be completed, either before or after the application of the proximal and distal ligatures, thereby favoring the contraction and retraction of the ends of the divided vessel. Control of Hemorrhage from Special Parts. Epistaxis or hemorrhage from the nose may be so pro- fuse as to require surgical interference. To control this form of hemorrhage the application of iced compresses to the surface of the nose may first be made use of, and if this fails to control the bleeding, the surgeon or the patient should grasp the cartilaginous portion of the nose with his thumb and forefinger in such a manner as to keep the nos- trils tightly closed, wdiich will prevent the passage of air through the nose and thus permit clots to form, arresting the flow of blood. If these simple means fail to arrest the bleeding the nasal cavity or cavities may be packed with strips of antiseptic gauze introduced into the anterior nares, and pushed backward by a director or probe; this will often be found a perfectly satisfactory means of arresting the bleeding. This method may be supplemented by a plug of antiseptic cotton introduced into the posterior nares with the. fingers. The use of a rubber tampon, con- sisting of a rubber bag, introduced into the nares in an empty state and afterward inflated, has also been recom- mended for the control of this variety of hemorrhage. Another method of controlling hemorrhage from the nose consists in introducing a small piece of sponge, tied to a strong silk ligature, into the anterior nares and push- ing it back along the floor of the nose to the posterior nares; a small piece of sponge about the size of a mar- ble with a hole in the centre is threaded on the ligature and pushed back until it comes in contact w ith the first piece of sponge introduced, and thus by introducing a number of pieces of sponge in this wav the nasal cavity control of hemorrhage. 279 may be completely filled up and the bleeding is arrested. (are should be taken to see that the sponge has been ren- dered aseptic before being introduced, and the nasal cavity should also be washed out with an antiseptic solution before its introduction. The sponges may be allowed to remain in place for twenty-four to forty-eight hours. (Fig. 205.) Fig. 205. Plugging the nares from the front. (Roberts.) Plugging the nares by means of Bellocq's canula is also employed to arrest hemorrhage from the nasal cavities; the canula, armed with a strong ligature, is passed along the floor of the nose until it reaches the pharynx,, when the spring being protruded, the ligature is seized and brought out of the mouth and secured to a plug of lint or antiseptic gauze of the required size, and upon withdrawing the in- strument the plug is brought into position in the posterior nares and the end of the ligature is allowed to protrude 280 MINOR SURGERY. from the mouth to facilitate its removal. (Fig. 20(i.) An ordinary flexible catheter may be employed in place of Bellocq's canula for the introduction of the ligature. Fig. 206. Plugging the nares with Bellocq's canula. (Fergusson.) Hemorrhage from the Urethra. In hemorrhage from the urethra, if profuse, the blood will trickle from the meatus, or if efforts at micturition are made the first gush of urine will contain blood, but afterward will be clear, and the last urine will contain a few drops of pure blood. This variety of bleeding, if it proceeds from the anterior portion of the urethra, may be controlled by the introduc- tion of a catheter and the application of a bandage around the penis, carefully applied so as to make only moderate pressure. If the bleeding conies from the posterior portion of the urethra, it will often be controlled by the application of cold or pressure to the perineum, or by the introduction of CONTROL OF HEMORRHAGE. 281 a cold steel bougie, or by the injection of a solution of tannic acid. Hemorrhage from the Bladder. In this variety of hemorrhage the first portion of the urine mav be blood-stained and the last portion will con- tain more blood and clots as the organ contracts, which distinguishes it from hemorrhage from the kidneys, in which the admixture of blood with the urine renders it of a smoky color or dark-red if the bleeding is profuse. To control bleeding from the bladder a catheter should be introdiued and the urine and clots withdrawn; the bladder should next be washed out w ith a warm or cold boric acid solution, or in severe cases weak astringent solu- tions, such as tannic acid or alum, may be employed. The application of ice to the perineum and supra-pubic regions may also be employed with advantage. Hemorrhage from the Rectum. This varietv of bleeding may be controlled by the injec- tion of cold or astringent enemata. If the bleeding be profuse a speculum should be introduced, and when the source of the bleeding has been discovered the actual cau- tery or a ligature should be applied. If this is not feasible the rectum may be plugged with strips of antiseptic gauze, or a piece of a rubber catheter of large calibre may be wrapped with gauze and introdiued into the rectum, the end of the catheter being allowed to protrude; by using this tube flatus can escape, and if the bleeding is not con- trolled blood will escape through the tube, preventing the risk of concealed hemorrhage. If the bleeding arises from hemorrhoids or polypus of the rectum the operative treat- ment of these conditions should be undertaken to perma- nently control the bleeding. 282 MINOR SURGERY. Opening and Dressing of Abscesses. Acute abscesses, as a rule, should be opened by incision, and this is best done with a*straight, narrow, sharp-pointed bistourv ; the incision should be deep enough to freely expose the cavity of the abscess, and should be so planned as to be parallel with and not across important structures, and it should also be made at as dependent a portion as possible. Abscesses of the limbs are opened by a longi- tudinal incision, and those in the region of the anus and breast bv an incision radiating from the anus or nipple. In deep-seated abscesses in the region of important structures the method of opening suggested by Mr. Hilton may be employed with advantage; it consists in making a small incision through the skin and cellular tissue; a director is next pushed through the tissues into the abscess cavity, which will be shown to have been reached by the escape of a little pus along the director; a dressing forceps with the blades closed is now pushed along the director into the abscess cavity, and when this has been accom- plished the director is withdrawn and the forceps arc removed with the blades expanded so as to dilate the wound and allowr the pus to escape. The cavity of the abscess being emptied of pus, it should be irrigated with a stream of carbolic acid solution 1 :40, or bichloride solution, and if the cavity is not very large or deep no drainage-tube need be introduced, and a small piece of protective may be placed between the lips of the wound to prevent their adhesion ; but if, on the other hand, the cavity is extensive and deeply situated, a rubber drainage-tube or a strip of iodoform gauze should be introduced to the bottom of the cavity to secure free drainage and fixed at the surface of the skin by a safety- pin. A piece of protective which has been dipped in bichloride solution is next placed over the wound, and over this is laid a gauze dressing, consisting of a number of layers, which has been moistened in carbolic or bi- chloride solution ; this is covered by a number of layers OPENING and dressing OF ABSCESSES. 283 id'drv gauze which is in turn covered by a piece of rubber tissue. The latter may be omitted, and over this is placed a few layers of bichloride cotton and the dressing is finally secured by a roller bandage. The dressing is removed at the end of two or three days, the cavity being washed out with one of the antiseptic solutions previously mentioned ; the drainage-tube may be shortened or removed, and the dressings are reapplied as at the primary dressing. Under this method of treatment acute abscesses usually heal more promptly and with less suppuration than under the older methods of treatment in wdiich poultices were ap- plied. Chronic or cold abscesses, which occur chiefly in con- nection with diseases of the bones or joints or of the lymphatic system, and are generally tubercular in their origin, may be opened in various ways, the time at wdiich this should be done depending upon the size and situation of the abscesses and the amount of constitutional and local disturbance which the patients experience from their presence. A cold abscess may be evacuated by means of the aspi- rator ; the pus being withdrawn as far as possible, the puncture is sealed with a small piece of gauze covered with iodoform collodion Pcaccumulation of the pus often takes place and the aspiration has to be repeated a number of times. The greatest difficulty in the successful removal of the contents of cold abscesses by means of aspiration is the presence of masses of lymph in the pus which occlude the canula and often prevent the complete emptying of the cavity. These abscesses may also be evacuated by making a puncture through the skin and overlying tissues with a narrow bistoury, the surface having been previously thor- oughly washed with soap and water and with a carbolic or bichloride solution ; a director is next pushed through this small wound into the cavity of the abscess and the pus is allowed to escape by stretching the wound by the director; when the cavity is emptied of pus it is washed out with a carbolic or bichloride solution introduced into 284 MINOR SURGERY. it by pushing the nozzle of a syringe into the cavity, and this is allowed to escape in the same way as the pus pre- viously did, and when the irrigating solution has all escaped the cavity may be injected with an emulsion com- posed of iodoform one part, glycerin ten parts ; after this has been introduced the small wound is closed by a com- press of antiseptic gauze ludd in place by a compress of bichloride cotton and a bandage or by strips of adhesive plaster. The injection of the iodoform emulsion need not be repeated as long as iodoform continues to be excreted with the urine. Cold abscesses are also treated by making a free incision into the abscess cavity with full antiseptic precautions, and after the escape of the purulent matter the walls of the abscess should be thoroughly scraped with a curette, and after the cavity has been freely washed out with a carbolic or bichloride solution large drainage-tubes are introduced and an antiseptic dressing is applied to the wound. The dressings are removed as soon as they become soaked, and the drainage-tubes are shortened or removed as the discharge diminishes and the cavitv contracts. In evacuating chronic abscesses by means of the aspi- rator or by a small puncture, there is absence of shock and the loss of blood is insignificant, so that these pro- cedures should generally be first employed, and the more radical operation of incision and curetting of the cavity of the abscess, which is accompanied with a certain amount of shock and hemorrhage, should be reserved for those cases in which the less severe operations have failed to be followed by a satisfactory result. Diffused suppuration is treated by numerous punctures or incisions, which allow the purulent matter to escape, and where sloughs are present free incisions may be re- quired to give exit to the necrosed tissues; the introduction of drainage-tubes may also be required. The wounds and the cavities, as far as possible, should be washed out with a carbolic or bichloride solution and an antiseptic gauze dressing should be applied. Sinuses resulting from abscesses, if superficial, should be laid open freely and their surfaces should be scraped DRESSING OF WOUNDS. 285 with a curette and they should then be lightly packed with strips of bichloride or iodoform gauze and should be covered bv an antiseptic dressing. If they are too deep to be treated by incision their healing may be facilitated bv the injection of stimulating solutions introduced by means of a syringe; the employment of solutions of chloride of zinc, nitrate of silver, ^ul sulphate of copper varying in strength from five to twenty grains to the ounce of water will often prove satisfactory. Dkkssixo of WorxDs. Incised wounds present the conditions favorable for prompt healing, and they should first be carefully irrigated with an antiseptic solution to remove any blood-clots or foreign bodies, and after any hemorrhage wdiich is present is controlled by the use of ligatures, if the wound be an extensive or deej) one, provision should be made for drain- age bv introducing a drainage-tube or a few strands of prepared catgut to the bottom of the wound, allowing the extremity to project from the most dependent portion of the wound. In superficial incised wounds, after the hem- orrhage has been controlled, it is not usually found neces- sary to make any provision for drainage. If the wound be a deep one, involving the muscles and deep fascia, buried sutures of catgut should be applied to approximate the muscles and fascia, and if important nerves or tendons have been divided their ends should be brought into appo- sition bv sutures of catgut or sterilized silk; the superficial portions of the wound should next be brought together by the introduction of a number of interrupted sutures, catgut, silkworm-gut, silver wire or silk being employed for this purpose; the accurate apposition of the edges of wounds of this variety is secured by the introduction of a number of sutures placed closely together. After a wound of this variety has been closed the sub- sequent dressing is accomplished by dusting the surface of the wound with iodoform or aristol, and a piece of pro- tective a little larger than the wound, which has been 13* 286 MINOR SURGERY. dipped in a 1 :40 carbolic solution, is placed over it; over this is placed a pad of antiseptic gauze, composed of ten or twelve layers, which has been soaked in a 1 :40 carbolic solution or a 1 : 2000 bichloride solution, and over this is laid a pad of dry antiseptic gauze of the same thickness, overlapping the wet gauze by a few inches in all directions; a few layers of bichloride cotton are next applied over the gauze dressings and the w hole dressing is secured in posi- tion by the application of an antiseptic gauze bandage. Under this form of dressing prompt healing of incised wounds is the rule, and the wound need not be re-dressed for a week or ten days unless some indications exist for the change of dressing at an earlier period. Dry or moist sterilized dressings may also be employed. At the time of the first dressing the catgut drain or the drainage-tube is usually removed and if the adhesion of the edges of the wound is firm the sutures may also be removed. An antiseptic dressing is usually next applied and allowed to remain in position for a few days longer. Lacerated wounds present edges which are torn and not sharply cut, and the vitality of the injured parts is often so seriously impaired that prompt union in this variety of wounds is not, as a rule, to be looked for. "Wounds of this nature should first be irrigated with an antiseptic solution, as in the ease of incised wounds, and blood-clots and for- eign bodies should be removed. If the wounds be deep, drainage-tubes should be introduced; on the other hand, if they be superficial or if the edges are not closely approx- imated, provision for drainage may be omitted. The torn or irregular edges of the wound should next be brought into apposition at a few points, by the introduction of a few catgut or silkworm-gut sutures, applied not very closely together; and if the edges are discolored and their vitality seems markedly impaired, it is better not to use sutures, but rest satisfied by bringing them as nearly as possible in contact by the use of a few strips of isinglass plaster moistened with a bichloride solution. If the edges of the wound are so much crushed as to have their vitality destroyed, they may be trimmed away Math scissors until DRESSING OF WOUNDS. 287 a surliicc possessing fair vitality is secured. The evil results arising from the introduction of sutures into this variety of wounds with the idea of closely approximating their ed^e^ are so common, that the surgeon wdio dispenses with the use of sutures entirely errs upon the safe side. Idle use of many sutures in wounds of this nature often causes marked tension in the wound, wdiich is frequently followed by impairment of the vitality of the injured tis- sues and sloughing results. The wound should next be dressed antisepticallv, and if it runs a favorable course it need not be re-dressed for a week or ten days; the time required for the repair of a wound of this nature is longer than that for an incised wound, and more frequent dressing may be required. In lacerated Avounds of the extremities continuous irri- gation of the wound by a warm bichloride or carbolic; solution, applied as described (page lo9), is often followed by the most satisfactory results; wounds produced bv machinery and railway accidents, in which the vitality of the tissues is much impaired, are particularly favorable cases for this method of treatment, and here the same cau- tion should be exercised as regards the introduction of sutures. Contused Wounds.—This variety of wounds possesses many characteristics in common with lacerated wounds; the edges are bruised and the injury of the subcutaneous tissue is often more extensive than the size of the external wound would lead one to suspect. They are dressed in the same manner as lacerated wounds, and the same objec- tion here exists to the use of sutures as in the latter class of injuries. Punctured Wounds.—These wounds are inflicted by sharp-pointed instruments, and it often happens that a portion of the vulncrating body remains in the wound, as is frequently the case in wounds produced by needles; and another complication in this variety of wound is the injury of vessels, giving rise to concealed hemorrhage, or of nerves resulting in neuritis. Simple punctured wounds should be carefully washed with an antiseptic solution and covered 288 MINOR SURGERY. by an antiseptic gauze dressing, and if no complication exists their healing is usually very rapid. When, however, a foreign body remains in the wound, as it often happens in punctured wounds produced by needles and pins, the punctured wound should be con- verted into an incised wound, and the body should be searched for and removed if possible, and in doing this in the case of wounds of the extremities the operation is much facilitated by the employment of Esmarch's bandage and strap. After the removal of the foreign body the wound is treated as an incised wound, and an antiseptic dressing should be applied. When concealed hemorrhage occurs after a punctured wound, the Avound should be laid open and the bleeding vessel searched for and ligatured if possi- ble, and the Avound should afterward be dressed as an incised wound. Poisoned Wounds.—These wounds are caused by the absorption, by means of a cut or abrasion in the skin, of fluids from a dead body in making dissections or post- mortem examinations or in operating upon living subjects, and often result in serious consequences. Such wounds, as soon as possible after their reception, should be care- fully Avashed out with a solution of bichloride of mercury, 1 : 2000, or a 30-grain solution of chloride of zinc, and then dressed Avith an antiseptic dressing. If, hoAvever, this precaution is not taken or the wound has escaped notice, and in a feAV hours becomes inflamed and painful, and evidences of lymphatic involvement show themselves, the.wound should be opened and its surface should he thoroughly w ashed out Avith a .'>0-grain solution of chlo- ride of zinc, and finally w ith a 1 : 2000 bichloride solution, and it should then be dressed with an antiseptic gauze dressing. Under this method of dressing the poisoned wound is often converted into a healthy one, even after the lymphatic involvement is Avell marked, and it usually heals promptly Avithout further constitutional disturbance. Gunshot Wounds.—These wounds are produced by small shot, balls, or fragments of shells, and are of the nature of contused and lacerated Avounds, and the vulnerating body DRESSING OF WOUNDS. 289 as well as portions of the clothing are often imbedded in the tissues. In dressing these wounds any foreign bodies, if they can be located, should be removed, and in the search for and removal of balls from the extremities the application of the Fsiiiarch bandage and strap Avill be found most useful. The wound should next be thoroughly Avashed out Avith ] : 2<)00 bichloride solution, and an antiseptic dressing ap- plied as in the case of other contused and lacerated avouikIs. Powder burns resulting from the explosion of poAvder, in addition to the burning and laceration of the tissues, are accompanied by the introduction of grains of unburnt powder into the skin, which, if not removed, leaATe perma- nent points of pigmentation. These wounds should first be washed with an antiseptic solution, and upon the face, to avoid unsightly pigmentation of the skin, care should be taken to pick out the small masses of powder with a needle or the sharp point of a tenotomy knife. The sur- face should then be dressed Avith antiseptic gauze or with lint spread Avith an ointment of boric acid or an ointment of aristol, consisting of half a drachm or a drachm of aristol to an ounce of vaseline, this dressing being covered by a few layers of bichloride or borated cotton, held in place by a roller bandage. Contusions or bruises differ from contused wounds in the fact that the skin is not broken, though in spite of this fact there may exist very extensi\e laceration of the sub- cutaneous tissues, accompanied by more or less extra\asa- tion of blood from the injured vessel. When not severe enough to require operative treatment, they should be dressed by applying over them several layers of lint satu- rated with lead-Avater and laudanum, and over this dress- ing is placed a layer of Avaxed paper or rubber tissue, and the dressing is secured by a roller bandage. A solution which I find most satisfactory in the dress- ing of contusions is as follows : Ammonii chloridi ...... grs. xx. iLtU.....alf3J; Aquae. ...... q. s. ad f ^ j. 290 MINOR SURGERY. Several layers of lint saturated Avith this solution are laid over the contused tissues, and are covered with waxed paper, oiled silk, or rubber tissue. Extensive collections of blood following contusions often remain in the tissues for some time, but usually are ab- sorbed. If this result does not follow , or an abscess forms, the blood or pus should be removed by aspiration or by incision w ith full antiseptic precautions. Burns and Scalds. The dressings employed in the treatment of burns and scalds are similar, as the injury to the tissues is practically the same in both classes of injuries. Superficial burns or scalds, in Avhicli the effect of the heat has only extended to the superficial layer of the skin, may be treated by the application of lint saturated with a solution of carbonate of sodium, a drachm to an ounce of water; this dressing rapidly relieves the pain, and is a satisfactory application in this variety of burns and scalds. In cases in Avhicli the effects of heat have extended to the deeper tissues, the affected surface may be dressed Avith carron oil, which is prepared by rubbing together lime-Avater and linseed oil until a thick creamy paste results ; lint is saturated Avith this mixture and laid over the surface of the burn or scald. The dressing is a comfortable one to the patient, but soon becomes offensive, and for this reason requires frequent reneAval. The disadvantage met a\ ith in the antiseptic method of dressing burns and scalds is the fact that the raw surface presented offers the most favorable conditions for the ab- sorption of the antiseptic substances employed in the dress- ings, and for this reason the use of bichloride of mercury, carbolic acid, and iodoform is not to be recommended in burns or scalds involving a large extent of surface, on account of the toxic symptoms which may result from their employment. A recent burn or scald, by reason of the heat employed in its production, is practically an aseptic Avound, and it BEDSORES. 291 may be dressed by covering it with boric acid ointment, and placing over this a number of layers of borated or salicylated cotton, and holding the dressings in position by a roller bandage. If, however, a full antiseptic dressing is employed, the injured surface should first be irrigated with a 1 : 60 car- bolic or 1 : 4000 bichloride solution and then covered with protective or rubber tissue which has been sterilized, and over this a dressing of carbolized or bichloride gauze and bichloride cotton should be applied. Aristol, as a substitute for iodoform, mav be employed in the dressing of burns or scalds, being either dusted over the surface or used in the form of an ointment, and over this application should be placed a few layers of borated or salicylated cotton. When blebs are present upon the surface of the burn or scald, they should be opened to allow the serum to escape. If suppuration occurs or the tissues become necrosed bv reason of the severity of the injury, the surface of the burn may be washed w ith a 1 : 60 carbolic solution or 1 : 4000 bichloride solution and the same dressing should then be applied. The ulcers resulting from the separation of the dead tissues should be touched with a solution of nitrate of silver, four grains to the ounce of water, and dressed with lint spread with ointment of boric acid or aristol. In the dressing of extensive burns or scalds of the neck, face, and region of the joints, the possibility of serious deformity from contraction of the tissues in healing should not be lost sight of, and position, splints and bandages should be employed to prevent, as far as possible, this complication. Bedsores. These sores usually occur over the sacrum or hips in patients who are confined to bed for a considerable time, as the result of a long-continued pressure, or in those cases wdiere the vital powers are depressed by adynamic diseases, and are also a frequent and troublesome complication in 292 minor surgery. spinal injuries. Their formation may be prevented in many cases by the use of air-cushions or of a water mat- tress, and by keeping the parts exposed to pressure scrupu- lously clean and frequently bathing them Avith stimulating lotions, such as alcohol, olive oil and alcohol equal parts, or soap liniment. The parts should also be protected from pressure by the application of adhesive plaster, or, still better, soap plaster spread upon chamois. When a bed- sore has actually formed, and in many cases its formation is very rapid and the slough will be found to involve a large surface of the skin over the sacrum, and to extend down to the bone, Ave have present a very serious compli- cation, and one which requires most careful treatment. The dressing of a bedsore before the separation of the slough consists in relieving the part from pressure by the use of an air-cushion placed under the buttocks, and the application of a fermenting poultice until the slough has separated. When the slough has become detached the ulcer remaining should be well Avashed with a carbolic or bichloride solution and the granulations should be touched with a 5-grain solution of nitrate of silver; and resin cerate, iodoform, aristol, or boric acid ointment, spread upon lint, should be applied to the surface of the ulcer, and a piece of soap plaster a little larger than the ulcer should be placed over this dressing and held in place by broad strips of adhesive plaster. This dressing should be renewed every day or every other day, and means should be adopted to protect the parts from further pressure, and the constitutional condition of the patient should be im- proved by the administration of a nutritious diet, tonics, and stimulants. The application of the galvanic current has been employed with good results to promote the heal- ing of the ulcer in obstinate cases. Sprains. Sprains of joints from twists or other external violence resulting in the stretching or laceration of the ligaments are injuries which require careful dressing. SPRAINS. 293 Sprains may be first treated by the application of cold- or hot-water dressings for a few hours, or by the application of lead-water and laudanum, the joint being kept at rest by the use of a splint or by confining the patient in the recumbent posture in the case of sprains of the joints of the lower extremities. After a few days' use of the lead-water and laudanum dressing the swelling usually subsides and the joint mav be fixed by the application of a moulded soap-plaster splint or felt splint held in place by a firmly applied roller band- age, which should be worn for a week or ten days; in ordinary cases after this time the splint may be removed and the patient should be encouraged to use the joint. In eases of severe sprains, on the other hand, the pain and swelling persist for some time, and here the fixation of the joint by a soap plaster, or better by a plaster-of-Paris bandage, Avill be found useful for a few weeks. If upon the removal of this dressing the parts are still painful and swollen, the swollen tissues should be painted with tincture of iodine ; or the method of applying tincture of iodine recommended by Mr. Jordan, that is, the applica- tion of the iodine in a broad band around and not over the swollen tissues, may be employed. The joint should next be surrounded by a piece of lint spread with an ointment composed of equal parts of ointment of mercury and ointment of belladonna, and a moulded soap-plaster splint being fitted to the joint, it is held in place by a firmly applied bandage. This will be found a most satis- factory dressing in the treatment of sprains after they have passed their acute stage. The dressing is removed at intervals of three or four days, the joint is sponged off with alcohol, and a similar dressing is reapplied ; and this method of dressing may have to be continued for some weeks, but the results obtained by its continuous use are often most satisfactory. An ointment of iehthvol one part to lanolin throe parts may also be used in the same manner as the ointment of belladonna and mercury with good re- sults in the treatment of these injuries. The employment 294 MINOR SURGERY. of pressure in the treatment of sprains, by means of strap- ping, is also sometimes advantageous. In the chronic stage of a sprain, after all dressings have been removed, the methodical use of massage is often most beneficial; and after the parts have been thoroughly manipulated a flannel bandage should be applied which, by its elasticity, gives a certain amount of support to the parts. Sprain-fracture.—Under this name Mr. Callender has described an injury which consists in the separation of a ligament or tendon from its point of insertion, with the detachment of a thin shell of bone; this injury is apt to occur about the ankle-, knee, elbow-, and wrist-joints, and the treatment is the same as that of an ordinary fracture in the same locality. This injury is probably much more common. than is generally supposed in connection with sprains of the joints, and is, I think, in many cases the cause of the tardy restoration of the function of sprained joints, this injury being overlooked and the injury simply being treated as a sprain, and the patient being encouraged to use the part before the union of the bone has been accomplished. Strains of muscles and fascia varying in severity from simple stretching of the fibres to absolute rupture are treated by putting the parts at rest and by the application of pressure by means of adhesive straps or of a bandage ; in strains of the muscles and fascia of the back the use of broad strips of adhesive plaster, applied as in cases of fracture of the ribs, will be found most satisfactory, and in the treatment of the latter stages of the injury the employ- ment of massage will often be followed by good results. Tracheotomy. This operation consists in dividing the tissues over the trachea in the median line of the neck, and after the trachea has been exposed it is opened by dividing two or three of the tracheal rings. TRACHEOTOMY. 295 The operation of tracheotomy may be required to relieve the dvspncea dependent upon membranous or diphtheritic laryngitis, growths in the larynx or trachea, growths ex- ternal to these organs causing pressure upon them, cedenia of the mucous membrane of the larynx or trachea from inflammation from burns or scalds, or from the inhalation of irritating gases or the swallowing of corrosive liquids. The operation may also be required for the removal of foreign bodies from the larynx, trachea, or from the bronchi, as wedl as for the relief of the dyspnoea due to their presence, and it is also required in cases of fracture or laceration of the larynx or trachea, and occasionally in cases of spasm of the glottis, and in cases of glossitis, to overcome the mechanical obstruction which prevents the entrance of air into the air-passages. The case with which the operation is performed varies much in different cases ; it is, as a rule, a much simpler operation in adults than in children. In the latter sub- jects the shortness of the neck, the relatively greater size of the thyroid gland and the possible presence of the thymus body, the great vascularity of the parts, and the abundance of adipose tissue, render the trachea difficult to expose and open. Under certain circumstances the operation may be per- formed with very few instruments ; but if the surgeon has the choice he will find it convenient to have' at hand two small scalpels, one short grooved director, a tenaculum, two Fig. 207. Author's tracheotomy director. aneurism needles which may be used as retractors, one pair of artery forceps, hemostatic forceps, two pairs of dissect- ing forceps, a pair of scissors, a sharp-pointed tenotome, a pair of tracheal forceps, a tracheal dilator, tracheotomy 296 MINOR SURGERY. tubes, tapes, ligatures, sponges, a flexible catheter, and feathers. The director should be short; the ordinary grooved director is too long to use with satisfaction in oper- ating upon the short necks of children ; so that I have had made a shorter and somewhat broader one, Avhicli has a bevelled extremity which alloAVS it to be passed with ease between the different layers of the tissue. (Fig. 207.) Hemostatic forceps are also of great use in controlling hemorrhage during the operation in case of the divison of vessels which bleed freely, when the operator from the urgency of the case does not think it justifiable to ligature them at the time of their division. They may also be employed under similar circumstances to damp the isthmus of the thyroid gland on either side of the trachea when it becomes necessary to-divide it to expose the trachea. A sharp-pointed tenotome is the instrument I prefer to employ in opening the trachea, as its sharp point enables it to be easily thrust into the trachea, and its short cutting surface and the narrowness of the blade obscure as little as possible the line of incision and thus enable the opera- tor to see exactly Avhere he is cutting. Fig. 208. Fig. 209. Golding-Bird's tracheal dilator. Trousseau's tracheal dilator. Tracheal dilators of various kinds are employed, but the most satisfactory tracheal dilator which I have employed is that of Golding-Bird (Fig. 208), which is a self-retain- ing instrument; the blades are slipped through the tracheal incision and are then expanded by turning the screw to which thev are attached. TRACHEOTOMY. 297 Trosseau's tracheal dilator, the blades of which are introduced through the incision in the trachea and are expanded by bringing together the handles, is also a satis- factory instrument (Fig. 209), but is not as useful as the tracheal dilator previously mentioned, as it has to be retained in position by the hand. Tracheal dilators may be improvised from bent hairpins or pieces of wire, Avhicli will often serve a useful purpose Avhere ordinary dilators cannot be obtained. It is also well to have at hand a number of pliable feathers to be used in cdeaning the trachea or larynx of mucus or membrane after it has been opened, and by their use this object can be accomplished Avith little risk of injury to the mucous membrane. Tracheal forceps, which are constructed with a double spring and curved blades are also useful in removing mem- brane or foreign bodies from the larynx above the wound or from the trachea below the tracheal incision. (Fig. 210.) Fig. 210. Tracheal forceps. Tracheotomy-tubes of various shapes are made of silver, aluminium, hard and soft rubber, but the tube wdiich I think is the most satisfactory for general use is a silver quarter-circle tube with a movable collar (Fig. 211), and provided with a fenestrated guide. (Fig. 212.) A good tracheotomy-tube is one which inflicts the least possible injury upon the mucous membrane of the trachea, and to insure this object the part of the tube within the trachea should lie exactly in its axis and its free extremity should be capable of as little movement as possible. The trache- otomy-tube is held in position after being introduced by 298 MINOR SURGERY. means of tapes attached to the shield of the tube and tied around the neck. Fig. 211. Fig. 212. Silver tracheotomy-tube. Silver tracheotomy-tube with fenestrated guide. Position of Patient for Tracheotomy. The best position in Avhich to place the patient for this operation is that Avhicli brings the neck into the greatest prominence, and this can best be obtained by laying the patient upon his back upon a firm table and placing under the shoulders a round cushion; or an empty wine-bottle, or a roller-pin wrapped in towels Avill answer the same purpose. If an amesthetic is not used the arms should be held by an assistant, which is better than securing them by a binder fastened around the chest, which restricts respi rate >ry movements. Use of an Anaesthetic in Tracheotomy. As a rule, I think it is better not to administer an ames- thetic in performing this operation, as little pain is expe- rienced, in cases in which the dyspnoea is well marked, after the incision in the skin has been made, and I have seen the dyspnoea which was Avell marked before the use of the amesthetic suddenly become so alarming that OPERATION OF TRACHEOTOMY. 299 the trachea had to be opened before it was thoroughly ex- posed, which is a procedure always attended with risk. So strong is my conviction that the risks of the operation are much increased by the employment of an amesthetic that in later years I have abandoned its use. Operation of Tracheotomy. The trachea may be opened above the isthmus of the thyroid gland or below it, and these operations constitute respectively the high and low operations. ddic high operation is generally selected, because at this point the trachea is more superficial and is more easily exposed, whereas in the low operation the trachea is more difficult to expose by reason of its relatively greater depth, the large size and number of the veins, and its proximity to the large arterial trunks. Fig. 213. Position of patient for tracheotomy. The patient being placed in position, and the best posi- tion is secured by placing a firm pad under the shoulders (Fig. 21.')), or the head may be dropped over the edge of the table, the object being to secure a free exposure of the neck and to render the trachea as superficial as possible. 300 MINOR SURGERY. The operator stands at the head of the patient; this position I prefer, as it is easier from this point to keep the incisions exactly in the median line of the neck. The operator next makes himself familiar with the landmarks of the neck ; locating the position of the cricoid cartilage, he makes an incision through the skin in the median line of the neck from one and a half to two inches in length, the position of the cricoid cartilage being the middle point. There is no disadvantage in making a longer incision if a freer exposure of the parts is required. Having divided the skin, the operator will often see a large vein lying in the superficial fascia—the superficial anterior jugular ; this should be displaced, and the fascia divdded upon the director. The surgeon should keep his incisions strictly in the median line of the neck, for this is the line of safety; and he should be careful, as the Avound increases in depth, not to make the incisions too short, so that it becomes funnel- shaped. When the deep fascia is exposed it should be picked up and divided upon the director^ and any large veins in the line of the wound should be carefully displaced, or, if this is impossible, they should be ligateel on each side and then divided between the ligatures. The operator now looks for the intermuscular space between the sterno-hyoid and the sterno-thyroid muscles, Avhicli can generally be found without difficulty, and the muscles are noAV separated in this line with the handle of the knife or with the director, and the isthmus of the thy- roid gland will be exposed. The muscles should now be held aside by retractors placed on either side. A caution here as to the use of retractors may not be out of place: the operator should place them himself and allow the assistants to hold them. I once almost lost a case in which I had the trachea exposed, and while I turned aside to pick up a knife with which to open it, my assist- ant, in replacing a retractor which had slipped, included the movable trachea in the grasp of the retractor, pulling it to one side and completely shutting off respiration; when OPERATION OF TRACHEOTOMY. 301 I attempted to find the trachea to open it I could only feel the anterior surface of the vertebra' at the bottom of the wound, and it was only when I appreciated what had occurred, and lifted the retractor, allowing the trachea to spring back into its normal position, that I was able to open it. Mr. Durham and Mr. Marsh mention somewhat similar eases in which the trachea and vessels were held aside with retractors by assistants until the surgeon had exposed the cervical vertebrae. The operator should carefully explore the wound with the finger, to locate exactly the position of the trachea, and to ascertain, if possible, the presence of any anoma- lous arteries. The isthmus of the thyroid gland being exposed, Avhicli generally occupies a position over the first three tracheal rings; this is usually surrounded by a plexus of veins which should be displaced Avith the director, or, if this is impossible, they should be ligated on each side and divided between the ligatures. The thyroid isthmus is next displaced upward or downward, according as the surgeon desires to open the trachea beloAV or above this bociv. This is often done without difficulty, especially its upward displacement; but when there is difficulty iu dis- placing it downward, a procedure recommended by Bose may be employed, which consists in making a transverse incision across the cricoid cartilage to divide the layer of fascia by wdiich the isthmus is bound down ; a director is then passed into this incision, and the isthmus is gently depressed without difficulty. Having displaced the isthmus of the thyroid gland upward or downward, the trachea, yellowish-white in appearance, covered by the tracheal fascia, should be ex- posed ; this fascia should next be thoroughly broken iip with the director or handle of the knife so as to bare the trachea, and in doing this the operator can feel it crepitate under the finger from the suction of air draAvn in with inspiration. Having arrived at this stage of the opera- tion the operator should examine the wound to see that it is free from hemorrhage and he should also replace the 14 302 MINOR SURGERY. retractors so as to expose as large a portion as possible of the trachea, for, be the case ever so urgent, he now feels assured that he can open the trachea in a moment if the breathing should cease. The trachea is now fixed with a tenaculum, introduced into it a little to one side of the median line; an incision is made into it with a narrow knife from below upward, from one-half to three-fourths of an inch in length (Fig. 214), care being taken to Fig. 214. Opening the trachea. (Liston ) see that this incision is in the median line, for if the trachea be opened by a lateral incision the wound does not heal so promptly and the tracheotomy-tube does not fit well, and its lower extremity may cause injury to the mucous membrane of the trachea. If the Avound be a deep one, after fixing the trachea with the tenaculum the operator may lift it slightly from its bed, thereby bringing it more prominently into vdew and making it more super- ficial in the wound, thus facilitating its opening. As soon as the incision is made into the trachea there is a gush of air from the wound in the trachea, mixed with blood or membrane; this should be wiped aAvay Avith a sponge and a tracheal dilator should next be introduced and the trachea should be cleared of membrane, if it is present in OPERATION OF TRACHEOTOMY. 303 the region of the wound, with a feather or with forceps. The tracheotomy-tube is next introduced and is secured in position by tapes tied around the neck. I f respiration has ceased artificial respiration should be resorted to or the use of a tube attached to a bellows, or Fell's apparatus, and these efforts should be continued for at least fifteen minutes, for I have seen resuscitation take place in patients who were apparently dead by a persistent employment of artificial respiration. The care of the tracheotomy tube is a matter of some importance after its introduction; the inner tube should be removed at short intervals, Avashed and replaced, and if the operation has been done for an inflammatory condition of the larynx or trachea a moistened feather should occa- sionally be passed through the tube into the trachea to with- draw any mucus or membrane which is present. In cases of croup after tracheotomy the use of a sprav of steam or of a spray composed of Carbonate of soda.....3j to 3 ijss. (ilvcerin.......f'Jij- WiU'r.......fjvj. applied by means of a steam atomizer, the sprav beino' directed over the opening of the tube, w ill be found most satisfactory in softening the discharges and thus facilitating their expulsion through the tube. The tracheotomy-tube is usually allowed to remain in the trachea from five to ten days ; its permanent removal is indicated as soon as the patient is aide to breathe through the larynx with the wound in the trachea closed; its use may be required for a longer time, but as soon as the in- dication for its presence has disappeared the sooner it is removed the better, for its presence sometimes sets up a troublesome tracheitis. After its removal the wound rapidly dimishes in size, the healing taking place bv gran- ulation and contraction. Difficulty is occasionally met with in the permanent removal of tracheotomy-tubes ; for the causes and treatment of this complication the reader is referred to special works upon tracheotomy. 304 MINOR SURGERY. Where the operation of tracheotomy is done for the re- moval of foreign bodies from the air-passages, the steps of the operation are the same, but after the removal of the foreign body the treatment of the wound is somewhat dif- ferent. If the foreign body has remained in the trachea only for a short time the wound in the soft parts may be closed by means of sutures or may be allowed to remain open, being covered by a piece of moistened gauze, and the use of the steam spray is here also beneficial for a few days. If, hoAvever, the body has remained in the larynx, trachea, or one of the bronchi for some time, and has set up a certain amount of inflammatory trouble, it is better to introduce a tracheotomy-tube and alloAV it to remain for a feAV days. If it is found impossible to locate or remove the foreign body at the time of operation, a tracheotomy-tube should be introduced and allowed to remain until the foreign body is expelled through the tube or removed subsequently by means of forceps. Laryngotomy. In this operation an opening is made into the air-passages through the crieo-thyroid membrane. It is a simple opera- tion, and one which is practically free from risk, and can therefore be performed much more rapidly and safely in urgent cases than tracheotomy. In this operation the same objection exists to the use of an anaesthetic as in tracheotomy, and therefore it should be dispensed with. The patient being placed in the recum- bent posture, Avith the shoulders slightly elevated and the head throAvn back to make the neck as prominent as possi- ble, the surgeon feels for the prominence of the thyroid cartilage, and steadying the larynx between the finger and thumb of the left hand, he makes an incision in the median line over the centre of the thyroid cartilage and extending downward for an inch or an inch and a half. The skin and superficial fascia being divided, the fascia between the sterno-hyoid muscles and the areolar tissue is exposed and divided, and the crico-thyroid membrane is exposed. The LARYNGO-TRACHEOTOMY. 305 knife is then passed transversely through the membrane into the larynx, care being taken that both that membrane and the mucous membrane which covers its inner surface arc divided at the same time. As soon as the knife enters the cavity of the larynx blood and mucus will be forcibly expelled. The wound should be carefully enlarged and a tube in- troduced, which differs from the ordinary tracheotomy-tube in being slightly flattened; this is secured in position by tapes tied around the neck as in the case of the ordinary tracheal tube. The only bleeding which is likely to occur is from the crico-thyroid arteries or veins, and if these cannot be avoided, and are divided in the operation, they should be temporarily secured by haemostatic forceps or ligatured, and if the case is not extremely urgent, all bleeding should be arrested before the crico-thyroid mem- brane is incised. The after-treatment of cases of laryngotomy is similar to that of eases of tracheotomy ; the same attention is required in the care of the tube and in the general management of the patient. Laryngo-tracheotomy. This operation consists in making an incision into the air-passages by dividing one or two of the upper rings of the trachea, the crico-tracheal membrane, the cricoid cartilage, and the crico-thyroid membrane. This opera- tion is employed in cases where, from the age of the patient, the crico-thyroid space is too small to admit of a sufficient opening, or in those in which, for any reason, the surgeon does not deem it advisable to attempt to open the trachea lower down. The incision in the skin and superficial fascia of the neck is made in the same manner as in the operation of laryngotomy, but is carried a little further downward. It may be necessary to displace the isthmus of the thyroid gland downward to expose the upper portion of the trachea, and when the trachea is exposed the incision should be made through this and the cricoid cartilage from below upward. 306 MINOR SURGERY. This operation is more often performed in the high operation of tracheotomy than is generally supposed. A tracheotomy-tube is introduced through the wound and secured by tapes tied around the neck, and the care of the tube should be similar to that in cases of tracheotomy. Intubation of the Larynx. This procedure, at the present time, is widely employed as a substitute for tracheotomy in the treatment of the dyspnoea clue to inflammatory affections of the larynx or trachea, or stenosis of the larynx; it consists in the intro- Fig. 215. Mouth-gag. duction of a metallic tube into the larynx, which is allowed to remain in place for a few days. The operation has been recently reintroduced to the profession by Dr. O'Dwyer, of Fig. 216. Intubation-tube and introductor. New York, who has devised a set of ingenious instruments for the purpose of laryngeal intubation. The instruments required are a mouth-gag (Fig. 215), INTUBATION OF THE LARYNX. 307 with which the jaws are separated and held open ; an in- strument for the introduction of the tube, which is fastened to the obturator which fills the cavity of the tube (Fig. Fig. 217. Intubation-tube extractor. 1 — 2Ki), and an instrument for extracting the tube after it lias lieen placed in the larynx. (Fig. 217.) The tubes are of metal and have a collar Avhicli rests upon the false cords and bulge fig. 218. slightly toward their middle and again taper toward their lower extremity ; at the collar of the tube there is a perfora- tion through which a strand of silk is passed wdiich is made into a loop ; this is used to allow the operator to remove the tube if on its introduction it is found to have passed into the (esophagus instead of the larynx, and also is used to remove the tube if it becomes occluded with mem- brane while in the larynx. The intuba- tion set now in common use is provided with a scale and six tubes ranging in size from such as arc suited for a child of one year or less up to the age of twelve or fourteen years. (Fig. 218.) In performing the operation of intuba- tion of the larynx the child is placed upon the lap of the nurse or assistant, wrapped in a blanket, and the arms are secured by the nurse holding the elbows so as not to interfere with the respiratory movements. Scale of intubation- tubes. 308 MINOR SURGERY. The patient's head is next secured by an assistant, and the position of the head, neck and body, should be as if he were hung from the top of the head, and this position should be firmly maintained during the insertion of the tube. The mouth-gag is next inserted upon the left side and the blades dilated so as to open the jaws widely, and as the gag is self-retaining this position is easily main- tained. The jaws being thus held open, the operator, sitting on a chair facing the patient (Fig. 219), next in- FlG. 219. troduces the index-finger of the left hand, protected by a strip of adhesive plaster, into the mouth and passes it over the tongue until he feels the epiglottis; the introducing instrument to which the tube is attadied is held in the right hand, and this is now introduced into the mouth, first seeing INTUBATION OF THE LARYNX. 309 that the silken loop is free ,and it is swept over the tongue and passed down until it touches the epiglottis; this is hooked up by the index finger of the left hand and the tube is passed into the larynx ; the index finger of the left hand is then transferred to the edge of the tube, and by drawing upon the trigger of the instrument with the index finger of the right hand the obturator is detached, and the instru- ment is withdrawn, and before removing the finger it is well to place it upon the head of the tube and to sink it well into the larynx. As soon as the obturator is removed there is usually a violent expiratory effort which is accom- panied by a gush of mucus, muco-purulent matter or mem- brane from the tube, and after this escapes the breathing is usually satisfactorily established. If the operator has passed the tube into the (esophagus and has detached it from the introducing instrument, no improvement in the respiration takes place ; it should then be withdrawn by the silk loop and attached to the obturator and another attempt should be made to introduce it into the larynx. The mistake which inexperienced operators make in at- tempting to introduce the tube is in not hugging the pos- terior surface of the tongue closely, so that they pass the tube over the epiglottis into the (esophagus. The silken loop may be brought out at one side of the mouth and fastened around the ear or fastened to the side of the face by strips of adhesive plaster for a few hours, so that by drawing upon it the nurse or attendant is able to withdraw the tube instantly if it should become ob- structed with membrane ; or, if it is coughed up, by this means it may be withdrawn from the oesophagus if it has not been expelled from the mouth. Some operators keep the loop attached to the tube during the time it is retained in the larynx, others prefer to remove it after several hours and remove the tube by means of the extracting instrument when required. The tube is removed at the end of the second or third day, and if the child is able to breathe comfortably for an hour or two it is not reintro- duced ; if, however, the dyspnoea returns it is reintroduced and allowed to remain one or two days longer; several 14* 310 MINOR SURGERY. attempts may have to be made before the tube is perma- nently removed, but it is usually dispensed Avith from the third to the eighth day. The most serious complication Avhich is apt to occur during the introduction of the intubation-tube is the de- tachment and pushing of a mass of membrane in front of the tube into the trachea; if this is too large to be expelled Fig. 220. Feeding a case of intubation of the larynx. through the tube the breathing is suddenly arrested, and the tube should be removed, and if the mass of membrane does not escape upon the expiratory efforts of the patient the trachea should be rapidly opened as the only means of re-establishing the respiratory function. So much do I dread this accident, wdiich has occurred in a few cases, INTUBATION OF THE LARYNX. 311 that I never introduce the intubation-tube without having at hand the necessary instruments to do a tracheotomy if it should be suddenly required, and if possible obtain the consent of the parents or friends to perform tracheotomy if it should be indicated. One of the greatest troubles after intubation of the larynx is the satisfactory feeding of the patient; liquids as a rule are not swallowed well, a portion of them escaping into the tube, causing coughing and difficulty in breathing. The diet I usually order is of semi-solids, such as corn- starch, soft-boiled eggs, and mush ; and if these are not well swallowed it may be necessary to resort to nutritious enemata or the use of a stomach-tube to introduce food. Some patients swallow liquids and semi-solids quite well if the head is dropped a little lower than the body during the act of deglutition. (Fig. 220.) PART III. FRACTURES. In the folloAving article the author has endeavored to confine himself simply to a description of the varieties of fracture and to their dressing and treatment, and he has tried as far as possible to avoid the multiplication of dress- ings, being satisfied to describe a few of the methods of dressing most frequently employed. He has also avoided the description of complicated splints and dressings, by the use of which in certain fractures most excellent results are obtained, but has preferred to recommend the employ- ment of simple splints and dressings, which can be obtained by physicians practising in districts remote from large cities, where the services of an instrument-maker cannot be obtained to construct special apparatus for the treat- ment of these injuries. Varieties of Fractures. A complete fracture is one in Avhicli the line of separa- tion completely traverses the bone, involving the entire thickness of the bone. An incomplete fracture is one in which there is only a partial separation of the bone-fibres (Fig. 221), under which name are included partial or ugreen-stick' fracture, in which some of the bone-fibres have given way, while the remaining fibres have been bent by the force and have not been broken. (Fig. 222.) Fissured, punctured, in- VARIETIES OF FRACTURE. 313 dented, and perforating fractures are also included in the class of incomplete fractures. (Fig. 223.) A simple or closed fracture is a fracture in which there are but two fragments, and the seat of injury in the bone Fig. 221. Fig. 222. Fig. 223. Incomplete fracture Partial or green-stick Fissured fracture of of femur. fracture of radius. humerus. (Gurlt.) docs not communicate Avith the external air by a wound in the soft parts. Compound or open fractures are fractures in which the scat of injury in the bones communicates with the external air by a wound in the soft parts. Comminuted fractures are those in wdiich there are more than two fragments, the lines of fracture intercommuni- cating with each other. (Fig. 224.) 314 FRACTURES. A multiple fracture is one in which a bone is the seat of two or more distinct fractures at different points, the lines of fracture not necessarily communicating with each other. Complicated fractures are such as are accompanied In- some serious injury of the parts in the region of the frac- ture—as, for instance, the laceration of important blood- vessels 0r nerves, contusion or laceration of the muscles, or dislocation of a neighboring joint. Fig. 224. FlG. 226. Comminuted fracture of patella. Fig. 225. Impacted fracture. Transverse fracture of femur. (Gorlt.) Impacted fractures are those in which one fragment is driven into and fixed in the other, the impaction taking place at the time of fracture, or being caused by a force sub- sequently applied. (Fig. 225.) DIRECTION OF FRACTURE. 315 Direction of Fracture. A transverse fracture is one in which the general line of division of the bone is at right angles with the long axis of the bone. (Fig. -'26.) Transverse fractures of the long bones are rarely met with, the Hue of fracture usually being more or less oblique. Fig. 227. Fig. 228. Oblique fracture of humerus. Longitudinal fracture of tibia. (Stimson.) (STIMSON.) An oblique fracture is one in which the line of separa- tion is oblique to the long axis of the bone. This is one of the most common directions of the line of fracture. (Fig. 227.) A longitudinal fracture is one in which the line of sepa- 316 FRACTURES. ration runs in the general direction of the long axis of the bone. (Fig. 228.) This form of fracture is rare, but is sometimes met with in the long bones as the result of gun- shot injury. Epiphyseal fracture or separation occurs before complete ossification has taken place betAveen epiphysis and diaph- ysis, and is rarely seen after the twentieth year of life; the direction of the epiphyseal separation is transverse. (Fig. 229.) Fig. 229. Epiphyseal fracture of head of humerus. (Moore.) The deformity or displacement in fractures is either angular, transverse, longitudinal, or rotary. Repair of Fractures. The process of repair in cases of fracture is concisely stated by Ashhurst as follows : " The traumatic irritation propagated from the broken bone causes SAvelling of the periosteum, active proliferation, and formation of a sheath EXAMINATION OF CASES OF FRACTURE. 317 of new bone around the seat of fracture ; this is the ensheathing or ring callus of surgical writers. At the same time, the medulla feels the effect of the irritation, becomes hardened, and partially ossified; this constitutes the interior or pin callus. Lastly, the osseous tissue itself undergoes cell-proliferation, and union of the fragments takes place—mutatis mutandis—precisely by the same pro- cess that we have already studied in considering wounds of the soft tissues. The new material which is thus developed between the fragments themselves, constitutes what Dupuy- tren called the intermediate, permanent, or definitive callus, in contradistinction to the ensheathing and interior forms of callus, which are temporary or provisional." Examination of Cases of Fracture. In examining a case of fracture to locate the nature and seat of fracture, the clothing should be removed from the part with as little disturbance as possible, and it is better, in most cases, to cut or rip the clothing, rather than to attempt to remove it in the ordinary manner. The surgeon should first inspect the injured part, and, where possible, compare it with its fellow, as in the case of injuries of the extremities; much valuable information is also derived from the patient or his friends as to the manner in which the injury was produced. The part should next be care- fully examined by the surgeon ; if it be one of the ex- tremities which is injured, it should be gently lifted, firm extension being made at the same time, the surgeon by his touch and by gentle movements seeking to locate the seat of fracture; and he may, by his manipulation, at the same time develop crepitus. All manipulations should be made with care, and with the greatest gentleness, not only to save the patient from pain, but also to prevent the soft parts in the region of the fracture from being injured by the rough or sharp fragments of the bone. Hough handling of fractures may increase the muscular spasm by the irritation caused by 318 FRACTURES. the sharp fragments of the bones, and may also result in the injury of important vessels and nerves, and indeed a simple fracture may be converted into a compound one by forcible and injudicious manipulations. The sooner the examination is made after the fracture has occurred the better, for at this time there is less swell- ing in the region of the injury, and the surgeon can locate the bony prominences with much more ease, and can often discover the exact seat of the fracture with the least amount of manipulation of the parts. AVhen a case of suspected fracture is not subjected to examination for several days after the reception of the injury, the parts in the region of the supposed fracture are often so much swollen that it is impossible to accurately locate its seat, and in such a case it is often necessary to wait until the swelling has subsided before the position of the fracture can be satisfactorily fixed, the case being treated in the meantime as one of fracture. Anaesthetics may be employed to relieve the patient from pain and to obliterate muscular spasm in the examination of fractures, and their employment is often of the greatest service in the diagnosis of obscure or complicated frac- tures, especially those in the neighborhood of joints; but the surgeon should remember that all manipulations should be made with the same gentleness as when the examination is conducted without anaesthesia, for there is the same risk of injury to the surrounding structures by the fragments; this precaution is often neglected when an amesthetic has been given, the surgeon often being inclined to handle the parts more roughly than he"otherw ise would ; such practice cannot be too severely condemned. Provisional Dressings in Cases of Fracture. It generally happens that fractures occur at localities more or less distant from the point where the treatment of the fracture is to be conducted, and the transportation of the patient and the temporary dressing of the fracture are, therefore, matters of the first importance. In frae- provisional dressings. 319 Fig. 230. tares of the upper extremities, if the fracture be simple, the clothing need not be removed, and the arm should be bound to the side by some article of clothing, or supported in a sling made from handkerchiefs or the clothing, and the patient can usually walk or ride for a short distance without much injury to the parts in the region of the fracture or inconvenience to himself. 'When the bones of the lower extremities or the trunk are the parts involved, the transportation of the patient is a matter of more difficulty. When the bones of the trunk arc involved, the part should be surrounded by a binder firmly pinned or tied, made from the clothing or from towels, or sheets or other strong materials which are at hand. When the bones of the lower extremity are involved, if the fracture be a simple one, the clothing need not be removed, and the motion of the frag- ments should be prevented by applying to the sides of the limb, extending above and be- low the seat of fracture, strips of wood, shingles, pasteboard, bundle's of straw, strips of bark taken from trees, or bundles of twigs, these being held in place by handkerchiefs or strips torn from the clothing. Umbrellas or canes, or broomsticks (Fig. 2o0), applied in the same man- ner, may be employed, the object of any of these dressings being to secure temporary fixation of the fragments of bone during the transportation of the patient. If the fragments are not fixed in some way, but are allowed to move about during the transportation of the Provisional dressing for fracture of the leg. (Esmarch.) 320 FRACTURES. patient, much damage may result to the soft parts sur- rounding the fractured bones, and simple fractures may become compound ones by the bones being forced through the skin, the discomfort of the patient at the same time being much increased. Having applied any dressing to bring about fixation of the fragmenis, the patient should next be placed upon a broad board or settee; if a mattress cannot be obtained, the fractured limb should be laid upon a mass of clothing, or upon some straw, and he should be placed in a wagon or carried to the point where the subsequent treatment of the fracture is to be conducted. Reduction or Setting of Fractures. This should be effected as soon as possible after the occurrence of the injury and as soon as the surgeon is prepared to apply the dressings to keep the parts in their proper position ; reduction at an early period is less painful to the patient and is accomplished with more ease to the surgeon than at a later period, when marked swelling and inflammation are present at the seat of fracture. It con- sists in bringing the fragments by manipulation as nearly as possible in their normal position, and it is accomplished by extension and manipulation with the hands, care being taken to use as little force as possible to attain the object. Very little force is often required if the surgeon places the part in such a position as to relax the muscles which produce the displacement; when this is accomplished the fragments can usually be pressed into position by the fingers without the application of any considerable force. When the reduction of a fracture has been accomplished the fragments are retained in position by the application of various splints or dressings which serve to prevent their displacement. materials and appliances used. 321 Materials and Appliances Used in the Dressing of Fractures. Fracture Bed. Many ingenious forms of beds have been devised for the use of patients suffering from fractures of the bones of the trunk and lower extremities, but a simple bedstead provided with a firm hair mattress having a perforation near its centre, into which is fitted a firm pad, and pro- vided with a pan which slides in a framework beneath a corresponding opening in the bedstead, will prove a useful appliance. The mattress is covered by a sheet perforated to correspond to the opening in the mattress, and when the pad is removed the evacuations of the patient are passed into the pan. In fractures of the trunk or loAver extremities it will be found more convenient in handling the patient to use a single bed not over thirty-two or thirty-six inches in width, and it is not essential that the mattress be perfor- ated, as a bed-pan can usually be slipped under the patient; the mattress should be a firm one stuffed with hair. The use of an ordinary tin pie-plate covered with a piece of old muslin to receive the fecal evacuations may be substi- tuted for the bed-pan and will be found in many cases more satisfactory, especially in the case of children suffer- ing from fracture of the lower extremity. Splints. After the reduction or setting of the fragments in cases of fracture they are usually retained in position until union occurs by the use of splints held in position bv means of bandages or strips of muslin. Splints may be made of wood, or of tin, lead, copper or wire which pos- sess the requisite amount of firmness and permit of their being moulded to the part, which latter may be found useful in certain cases. 322 fractures. Wooden splints.—The simplest and best splints are made from wood—white pine, willow or poplar being the best material to employ for their construction, being sufficiently strong to give fixation to the parts and at the same time being light. Splints made from smooth white pine, willow or poplar boards from one-eighth to one-half an inch in thickness may be employed in the form of straight or angular splints, and their preparation is a matter of little difficulty. Wooden splints before being applied to the part should be well padded Avith cotton, avooI, oakum, or hair, and where lateral Avooden splints are employed in the treat- ment of fractures of the loAver extremity it is usual to place bandages or junk-bags between the limb and the splint. The carved wooden splints a\diich are sold by the instrument-makers are not to be recommended, as a rule, for unless the surgeon has a large number to select from it is rare that a splint can be obtained to accurately fit any individual case. Binder s board or pasteboard, is an excellent material from which to construct splints; it is first soaked in boil- ing Avater and when sufficiently soft is padded with cotton or a layer of lint and moulded to the part, and secured in position by a bandage; as it becomes dry it hardens and retains the shape into which it avus moulded. Undressed leather is also an excellent material from which to construct splints; it is applied by first soaking it in boiling water, and after padding it with cotton or lint it is moulded to the part and retained in position by a bandage. Felt made from avooI saturated with gum shellac, pressed into sheets, is also a good material from which to con- struct splints. This material is prepared for application to the surface by heating it before a fire until it becomes pliable, or by dipping it into boiling water. Gutta-percha splints made from sheets of this material, in thickness from TXg to \ of an inch, may often be em- ployed Avith advantage; it is prepared for use by immers- ing it in hot water, when it becomes soft and can be materials and appliances used. 323 moulded to the surface. Care should be taken that it is not allowed to become too soft by too long immersion to permit of its being conveniently handled. Paper splints made from layers of manilla paper stiffened with starch constitute a very fair substitute for some of the varieties of splints previously mentioned. Rlaster-of-Paris, starch, chalk and gum, silicate of potas- sium or sodium may be employed for the construction of splints, either movable or immovable, in the treatment of fractures; their method of preparation and application is described (p. 92 etseq.); the plaster-of-Paris dressing is the one which is most generally used at the present time. Fracture-box.—This is a form of splint used in the treatment of fractures of the lower extremity, and con- sists of a piece of board eighteen to twenty inches in length, with a foot-board firmly secured at its lower Fig. 231. Fracture-box with movable sides. extremity; the sides are secured by hinges which alloAV them to be raised or lowered (Fig. 231). A fracture-box of greater length is required for the treatment of fractures about the knee-joint. Bran, Sand, or Junk Bags. Those are constructed by taking a piece of unbleached muslin five feet in length and fourteen and half inches in width, doubling it and securing the free margins except at the mouth by stitches so as to form a bag; the bag is then inverted so that the edges of the seams are brought in the inner surface of the bag. The bags are next filled with dry sand, bran, or hair, or with straw, and the mouth of the bag is closed by stitches or by being tied with a 99999999 324 FRACTURES. string. Bran bags Avith splints or sand bags are fre- quently employed in the treatment of fractures of the femur. Bandages made of muslin are used to retain splints in the treatment of fractures, and are also sometimes applied directly to the injured part before the application of splints to control muscular spasm and limit the amount of swell- ing; Avhen a bandage is so used it is knoAvn as a, primary roller. The use of the primary roller is sometimes of the greatest service in the dressing of fractures; but its use in inexperienced hands has often been followed by such un- fortunate results in the early treatment of fracture, or in cases which are not under constant observation, that I think it is a safe rule of practice to discard entirely the use of the primary roller. Compresses made from a number of folds of lint, or cotton or oakum, are often employed to retain fragments in position or to make localized pressure upon certain points in the treatment of fractures. The compresses are held in position by strips of adhesive plaster, by a few turns of a roller bandage, or by the splints. Compresses are sometimes employed to protect bony prominences of the skeleton from the pressure of the splints; but this purpose is often better effected by the use of small pieces of soap plaster spread on chamois fitted over the promi- nent points. Fig. 232. Rack for supporting bed-clothes in fracture of the lower extremity. A rack or cradle, made of wire or wooden hoops, is often employed to support the weight of the bed-clothes in the treatment of fracture of the lower extremity (Fig. 232). FRACTURE OF THE NASAL BONES. 325 Use of Evaporating Lotions in Cases of Fracture. The employment of evaporating lotions such as dead- water and laudanum, or muriate ammonia and laudanum, to the skin in the region of fractures is highly recom- mended by many surgeons, especially in fractures involv- ing or situated near joints. It is here employed to relieve' pain, to limit inflammatory swelling, and to hasten the absorption of the blood and serum at the seat of fracture. Many surgeons, on the other hand, think that their use causes irritation of the skin and delays the process of repair in the union of the fracture, and so strongly con- demn their employment. I personally have never seen any bad results arising from their use, and have generally employed them in fractures near or involving the joints, but I do not consider their employment absolutely essen- tial, and when I use them 1 only do so for two or three days. In cases of fracture accompanied with much pain and swelling, when the surgeon docs not wish to use any of the lotions before named, an ointment of ichthyol one part, lanoline three parts, spread on lint and wrapped around the limb, will often prove a satisfactory dressing, or a layer of cotton may be simply wrapped around the part before the application of the splints. Dressing of Special Fractures. Fracture of the Nasal Bones. Fractures of the nasal bones are often accompanied with fractures involving the septum, the nasal process of the maxillary bone, and the nasal spine of the frontal bone. The treatment consists in replacing the fragments, if displacement exists, by manipulation with the fingers over the seat of fracture and by pressure made from within the nostrils by a probe or a steel director. When the displace- ment is once corrected it is not apt to recur, and in the 15 326 FRACTURES. majority of cases no dressing is required. Before resort- ing to anv manipulation within the nasal cavities the mucous membrane should be thoroughly cocainized to render the operation painless to the patient. When there is depression of the fragments or displacement of the septum, after correcting the deformity by raising the de- pressed fragment or bending the septum into place by a director, the parts may be held in position by packing the nasal cavity firmly with a strip of antiseptic gauze. In lateral displacements of the nasal bones from frac- ture, after reducing the displacement, a small compress held over the fragment by strips of adhesive plaster will be the only dressing required. Fig. 233. Mason's dressing for fractures of nasal bones. Mason transfixes the nose, after reduction of the frag- ments, with a stout needle, and steadies the pieces with a strip of plaster crossing the bridge of the nose and fastened to the ends of the needle. The needle is kept in position FRACTURES OF THE UPPER MAXILLA. 327 for eight or ten days (Fig. 233). Roberts, in cases in which there is a displacement of the cartilaginous portion of the nose, after reducing the deformity, holds the parts in position by transfixing them with steel pins. I'rofuse hemorrhage sometimes occurs after fracture of the nasal bones and may require plugging of the nares to control it. Fractures of the nasal bones are usually firmly united in from ten to twelve days, and dressings may be dispensed with after this time. Fractures of the Malar Done and Zygoma. These fractures are usually the result of direct force; the displacement is upward or backward, and when the zygomatic arch is broken the fragments from pressure upon the masseter muscle or on the tendon of the temporal muscle may interfere with the movement of the lower jaw in mastication This displacement is corrected by cutting down upon the fragment and elevating it or by passing a tenaculum into the fragment and raising it. Outward displacements may be corrected by pressure and the application of a compress. The dressing of these fractures after the correction of the deformity, consists in the application of a compress of lint over the seat of frac- ture, held in position by strips of adhesive plaster or a bandage. There is little tendency to recurrence of the deformity after it has been corrected, and union at the seat of fracture is usually firm at the end of three weeks. Fractures of the Upper Maxilla. These fractures may involve the body, the nasal processes or the alveolar processes. The displacement should be corrected and if any teeth have been displaced they should be replaced ; if there is comminution of the alveolus the teeth in the separate fragments may be fastened together by fine wire to fix the fragments and hold them in place; and the teeth of the lower jaw should be brought up in 74 328 FRACTURES. contact with those of the upper jaAV, and the jaws should be secured together by the application of a Barton's or a (Jibson's bandage (Fig. 23d). Inter-dental splints, made of cork with grooves to fit the teeth, or of gutta-percha, fig. 234. Dressing for fracture of the upper jaw. are also employed in the dressing of these fractures. The patient should not be allowed to move the jaw in mastica- tion, and should be nourished by liquid and semi-solid food which can be taken without removing any teeth to give' space for its introduction. The bandage should be removed every second or third day, and after the face and neck have been sponged off w ith alcohol it should be reapplied. These fractures are usually firmly united at the end of four or five weeks, and dressings may be dispensed Avith at this time. Fractures of the Lower Maxilla. The loAver jaAV may be broken at or near the symphysis, the most usual seat of fracture being near the mental fora- men ; it is often broken at two places at once, and the frac- tures are in many cases rendered compound by laceration FRACTURES OF THE LOWER MAXILLA. 329 Fig. 235. Dressing for fracture of the lower jaw. of the mucous membrane, or the injury mav consist in a separation of a portion of the alveolar process of the bone Ine dressing of a fracture of the lower jaw, after reduc- ing the displacement and replaciug any loosened or Fig. 236. Four-tailed bandage applied for fracture of the lower jaw. (Hamilton. 330 FRACTURES. detached teeth, consists in applying a pad of lint under the chin and bringing the jaw up against the upper jaw and holding the compress in place and securing the jaws firmly in contact by applying a Barton (Fig. 23o), modified Barton or Gibson's bandage. The bandage should be re- moved and reapplied at the end of the second or third day, and at like intervals during the course of treatment. The patient should be fed upon a liquid or semi-solid diet, not being allowed to chew any solid food until the union at the seat of fracture has become firm. .V very satisfactory temporary dressing for fracture of the lower jaw consists in the application of a four-tailed sling. (Fig. 236.) Fig. 237. Shape of splint before being fitted to chin. (Roberts.) Fig. 238. Some surgeons prefer to use an external splint moulded from pasteboard or gutta-percha fitted to the chin in the dressing of this fracture, this being padded with cotton and held in place by a Barton or Gibson bandage. (Fig. 23X.) Where there is much difficulty in keeping the frag- ments in position the wiring together of the teeth may be employed, or the fragments may be perforated with a drill and held in place by a strong silver-wire suture; inter-dental splints of metal or gutta-percha are also sometimes used for this pur- pose. During the course of the treatment in fracture of the jaws the mouth often becomes very offensive from the fermentation of the saliva and Splint moulded to fit chin. (Roberts.) FRACTURES OF THE LARYNX OR TRACHEA. 331 discharges, and it is well to use frequently a mouth- wash of chlorate of potash, tincture of myrrh, glycerin, and water. The dressings for fracture of the lower jaw are usually applied for four or six weeks, the union usually being quite firm at the end of this time. Fracture of the Hvoid Bo.nh. In fracture of the hvoid bone, if displacement exists, its reduction is facilitated by pressure made with the finger in the pharynx. The treatment consists in enforced quiet and the use of opium if cough is a prominent symptom, and the inflam- matory symptoms may require the employment of active local treatment. A dressing may sometimes be employed with advantage, consisting of a splint of pasteboard or leather moulded to the anterior portion of the neck. Fractures of the Larvxx or Trachea. In fractures of the larynx or trachea where there is little displacement and dvspncea is not marked, the parts should be supported by the application of compresses of lint held in place by strips of adhesive plaster. If, on the other hand, the respiration is embarrassed or there is free expec- toration of blood, tracheotomy should be performed, and if the injury be seated in the larynx the displacement of the fragments may be overcome by manipulation with the finger or a director through the tracheal Avound, or the larynx may be packed with a strip of antiseptic gauze to control hemorrhage or hold the fragments in position, the patient in the meantime breathing through a tracheotomy- tube secured in the tracheal wound ; the packing should he removed in a few days, the tracheotomy-tube being permanently removed as soon as the patient can breathe comfortably through the larynx with the tracheal wound closed. In fractures of the trachea the opening into the trachea should be below or at the seat of injury. 332 fractures. Fractures of the Trunk. Fractures of the Ribs. Fig. 239. Fractures of the ribs are more frequent than fractures of anv other bones of the trunk; the ribs most commonly broken are those from the fourth to the tenth ; the most common seat of fracture is near the junction of the costal cartilages or at the angle. The dressing of fractures of the ribs is best accomplished by envel- oping the side of the chest on which the rib or ribs are broken with broad straps of adhesive plaster. The adhesive straps should be two and a half inches in width and long enough to extend from the spine to the middle of the sternum. The straps are warmed and the first strap is firmly applied a short distance below the seat of fracture, extending from the spine to the mid-sternal line ; a number of as- cending straps are applied in this way, each strap overlapping the preceding one by about one-third of its width, until half the chest is covered in. (Fig. 239.) This dressing usu- ally gives the patient much comfort, and the straps need not be reneAved until they become slightly loosened, usu- ally at the end of a week or ten days; they should then be renewed in the same manner. The dressings for fractures of the ribs are usually dis- pensed with at the end of three or four weeks, as repair of the fracture is generally well advanced by this time. A satisfactory temporary dressing for fractures of the ribs consists in surrounding the chest by a broad binder of stout linen or muslin ; indeed, some surgeons prefer to employ this dressing during the course of treatment, but as a rule I think it is not as good a dressing as the adhe- Adhesive plaster dressing or fracture of the ribs. (Ham- ilton.) fractures of the sternum. 333 sive plaster dressing, as the former confines the movements of both sides of the chest. Fractures of the Costal Cartilages. These fractures often take place at the junction of the cartilages with the ribs or in the body of the cartilages, and the union of the fracture usually takes place by the production of a mass of bone at the seat of fracture. The dressing for fractures of the costal cartilages consists in the application of strips of adhesive' plaster applied in the same manner as for fracture of the ribs, and the dressing should be retained for about the same time. Fractures of the Sternum. Fractures of the sternum are rare injuries, but diastasis of the bones of the sternum is a more common accident. The dressing for either variety of injury is the same, and Fig. 240. Adhesive plaster dressing for fracture of the sternum. consists in the application of a compress over the seat of fracture held in place by a broad bandage, or, better, by strips of adhesive plaster (Fig. 240), applied so as to cover and fix the anterior portion of the chest, covering the entire length of the sternum. This dressing should be 15* 331 FRACTURES. retained for at least four weeks, being renewed if it be- comes loose at the end of a week or ten days. Fractures of the Pelvis. These fractures are often serious injuries from implica- tion of the pelvic viscera. The reduction of the displace- ment should be first accomplished as far as possible by external manipulation, together with internal manipula- tion by the fingers introduced into the rectum, or into the vagina in the female. The patient should be placed upon a firm bed on his back, with the knees slightly flexed over a pillow, and the parts should be kept at rest by surround- ing the pelvis with broad straps of adhesive plaster or a stout muslin binder, or by a firmly applied padded pelvic belt. The hip-joints should be kept at rest by the applica- tion of pasteboard splints or by sand-bags. The dressings should be retained for a period of at least six weeks. When these fractures are complicated by injury of the pelvic viscera various operative' procedures may be re- quired, which will compel the surgeon to modify the method of dressing. Fractures of the Sacrum and Coccyx. The dressing of fractures of the sacrum, after effecting reduction of the fragments as far as possible by pressure from Avithin the rectum, consists in the application of broad adhesive straps around the pelvis, and the patient should be kept at rest in bed. When the coccyx only is fractured, after reduction of the displacement the patient should lie confined to bed and the bowels should be kept at rest by the use of opium by suppository. The patient should be kept at rest for three or four weeks, and, in ease of fracture of the sacrum, the dressings should be retained for this time. FRACTURES OF THE VERTEBRAE. 335 Fractures of the A^ertebr.e. Fractures of the vertebne are always most serious in- juries, not only from the injuries of the bones themselves, but also from the damage to the spinal cord, membranes, and nerves, which often accompanies them. In transporting, or turning in bed, a patient suffering from fracture of the vertebras, great care should be exer- cised, for rough or sudden motions might cause a displace- ment of the fragments which might, by injury of, or pressure upon, the spinal cord, rapidly prove fatal. In the treatment of fractures of the spine, if the de- formity is marked, efforts should be made to reduce it by extension and counter-extension, and the result may be successful, especially if the fracture be associated with a dislocation of the vertebra1. In some cases the use of permanent extension by means of weights attached to the legs, shoulders, and chest by adhesive plaster and bandages has been successful in reducing the deformity. The patient should be placed upon his back upon a bed with a hair mattress, or better, if it can be obtained, a water-bed, which consists of a rubber mattress filled with water, which distributes the weight of the patient's body evenly over the surface. Whatever form of bed be used, the greatest care should be exercised to keep the patient absolutely clean, and the parts of the body or limbs which are exposed to pressure should be frequently bathed with alcohol or soap liniment; and to distribute the pressure, small pads should be placed under the parts and changed at intervals. These precautions are necessary to prevent, if possible, the formation of extensive bedsores, which are a frequent and troublesome complication of these injuries. The bowels should be carefully watched, and, if con- stipation is present, it should be relieved by the use of enemata; and, as it is not desirable to lift the patient to slip a bed-pan under him, the discharges can be received in a fiat tin plate pushed under the thighs and buttocks, or on pads of oakum or old muslin. 336 FRACTURES. The care of the bladder is also a matter of the greatest importance; the retention which at first exists should be relieved by the use of a flexible catheter introduced with great gentleness, and when incontinence supervenes the catheter should also be used at intervals; the employment of a soft instrument, if used with care, is not apt to produce any injury to the urethra or bladder. The employment of a plaster-of-Paris jacket has been followed, in some cases, by good results, and it may be applied early in the case, or it may be used after the patient has been kept in the recumbent posture for some weeks ; by its use it is often possible to get the patient out of bed and allow him to sit in a chair. In fractures involving the cervical vertebne, care should be exercised in lifting or moving the head, and it is often of advantage in these cases to apply short sand-bags to the sides of the neck and head, to give additional fixation to the parts while the patient is in the recumbent posture, or, if he is allowed to get out of bed, to apply a moulded leather or pasteboard splint to the neck, shoulders, and back of the head for the same purpose. Trephining of the spine in cases of fracture of the verte- brae, to remedy the displacement and relieve the cord from pressure, has been recommended and employed in some cases, and although the operation under strict antiseptic methods is not attended with much risk, the results ob- tained iij) to the present time scarcely seem to warrant its performance. The course of treatment in cases of fractures of the ver- tebrae, if the patient does not succumb to the injury in a few days or weeks, often extends over many months, and recovery is often more or less incomplete as regards the function of the parts below the seat of fracture. Fractures of the Skull. The treatment of fractures of the skull, whether simple or compound, depends largely upon the nature of the in- jury and the condition of the cranial contents. In simple FRACTURES OF THE CLAVICLE. 337 fractures unaccompanied with cerebral symptoms no special dressing is required, but in compound fractures where loose fragments are present, these should be re- moved; and if there is no depression of the fragments, and if no cerebral symptoms are present, the wound should be drained and closed and dressed antiseptically, the dressings being held in place by a recurrent bandage of the head. The patient should be put to bed, and the use of an ice- cap to the head is often of service. The diet should be restricted and calomel and opium and bromide of potassium should be administered ; it is well to keep the patient for a few weeks in a quiet and darkened room. Where cere- bral symptoms are present, either in simple or compound fractures, and trephining is resorted to, the dressing of the wound is similar, and the same general treatment should he adopted. In all cases of fracture of the skull, whether subjected to operative treatment or not, it is well to keep the patient at rest in bed for three or four weeks, and he should be cautioned to avoid excesses and should not resume active work for some months. Fractures of the Upper Extremity. Fractures of the Clavicle. Fractures of the clavicle may be complete or incomplete, and in the latter variety of injury the deformity is not usually very marked. The indications for treatment in complete fractures of the clavicle are to relax the sterno- cleido-mastoid muscle, to prevent the weight of the arm on the injured side from dragging down the outer fragment of the clavicle, and by fixing the scapula, to carry the attached external fragment outward and forward. A large number of dressings have been devised and used to accom- plish these objects. The treatment of fractures of the clavicle by position is accomplished by placing the patient in bed on his back upon a firm mattress with a Ioav pillow 338 FRACTURES. under his head, and the arm on the side of injury should be fastened to the side of the chest by a few circular turns of a bandage passing around the arm and chest; the de- formity is usually very satisfactorily reduced upon the patient assuming this position, and after three weeks' rest in this position the union is generally sufficiently firm to allow the patient to get out of bed and be about with the arm bound to the side or carried in a sling or with a Velpeau bandage applied without any recurrence of the deformity. A satisfactory temporary dressing for fractures of the clavicle consists in the application of a four-tailed bandage; the bandage is made from a piece of muslin two yards in Fig. 241. Four-tailed bandage for fracture of clavicle. (Stimson.) length and fourteen inches in width ; a hole is cut in its centre about four inches from its margin, to receive the point of the elbow; the bandage is then split into four tails in the line of the hole and to within six inches of it; the body of the bandage should be applied so that the point of the elbow rests in the hole, and a folded towel being placed in the axilla, the lower tails should be car- ried, one anteriorly, the other posteriorly, diagonally across the chest and back to the neck on the side opposite the FRACTURES OF THE CLAVICLE. 339 seat of fracture and secured ; the remaining tails are next carried around the lower part of the chest and secured so ;is to fix the arm to the side of the body. (Fig. 241.) In some cases the deformity is corrected by the applica- tion of a posterior figure-of-eight bandage, the forearm on the side of injury being carried in a sling. (Fig. 242.) fig. 242. Posterior figure-of-eight dressing for fracture of the clavicle. (Hamilton.) Say re's dressing for fracture of the clavicle consists of two strips of adhesive plaster three and a half inches wide and two yards in length. The first strip is looped around the arm just below the axillary margin, and is pinned or sewed with the loop sufficiently open not to constrict the arm. The arm is then drawn downward and backward until the clavicular portion of the pectoralis major muscle is put sufficiently upon the stretch to overcome the action of the sterno-cleido-inastoid muscle, and in this way draws the sternal fragment of the clavicle down to its place. The strip of plaster is then carried completely around the body and pinned or stitched to itself on the back. (Fig. 243.) The second strip is next applied, commencing upon the front of the shoulder of the sound side; thence it is car- 340 FRACTURES. ried over the top of the shoulder diagonally across the back, under the elbow, diagonally across the front of the chest to the point of starting, where it is secured bv pinning or sewing. A slit is made in this strip to receive the point of the elboAV. Before the elbow is secured by the plaster it should be pressed Avell forward and inward. (Fig. 244.) Fig. 243. Fig. 244. Sayre's dressing for fracture of the Sayre's dressing for fracture of the clavicle. First strip applied. clavicle. Second strip applied. Velpeau's dressing may also be used in the treatment of fractures of the clavicle. (Fig. 24o.) A compress may also be secured by the vertical turns of this bandage over the seat of fracture if needed. The application of the bandage is described (p. 59). In any form of dressing in wdiich the arm is held against the side of the chest, it is well to apply a folded towel or piece of lint betAveen the arm and chest to prevent the surfaces from becoming excoriated. FRACTURES OF THE CLAVICLE. 341 A modified form of the Velpeau die-sing for fracture A soft towel or piece Fig. 245. Velpeau's dressing for fracture of the clavicle. of the clavicle i- applied as follow nf lint i- placed against the side of the body and over the front id'the chest, and held in position bv a -trip id* adhesive planter; the arm i- next placed in the Veljieau position, a good-sized pad of lint is next applied over the s,apula, and this i^ held in place by a broad strip of adhesive plaster two and a half inches in width and one and a half vards in length ; this strip is continued downward and forward so as to pa-- over the point of the elbow, and is carried diagonally across the chest to the shoulder of the opposite side and is secured, a slit being cut in it to receive the pint of the elbow; a-compress of lint is next placed over the sat of fracture and held in place by a strip of ad- hesive plaster ; an additional strip of plaster is next car- ried from the spine around the arm and chest and secured on the opposite side of the chest; circular turns of a roller Iwndage are then passed around the chest, including the arm, from below upward until the arm is securely fixed to the body, and the dressing is finished by making one or two turns of the third roller of Desault. (Fig. 24<>.) Or the turns of the third roller of Desault may be applied first, and the dressing may be finished by circular turns d a roller passing around the arm and chest, extending from the elbow to the shoulder. In the treatment of fractures of the clavicle in children the Velpeau or modified Velpeau dressing will be found to be the most satisfactory dressing to employ, and as these patients are particularly apt to disarrange their dressings it is well to render the dressing additionally secure by applying a few broad strips of adhesive plaster over the 342 FRACTURES. turns of the roller bandage, the strips following the turns of the bandage. The removal of dressings and their reapplication will depend upon the comfort of the patient and the manner in which they keep their position. As a rule in fractures of the clavicle the dressings are removed at the end of the second or third day, the parts are inspected, and the skin is sponged off with dilute alcohol or whiskey ; the dress- ings are then reapplied, and if they arc comfortable and Fig. 246. Modified Velpeau dressing for fracture of the right clavicle. the parts are in good position, the dressings are made at less frequent intervals until union is completed at the seat of fracture. Union is cases of fracture of the clavicle is generally quite firm at the end of four or five weeks, and at this time the dressings may be removed, and the patient should carry the arm of the affected side in a sling for several weeks, and should not undertake any work requiring forcible movements of the arm until eight or ten weeks have elapsed from the receipt of the injury. FRACTURES OF THE SCAPULA. 343 The time required for union in fractures of the clavicle in children is somewhat shorter; the dressings mav be removed at the end of three weeks. Fractures of the Scapula. Fractures of the scapula may involve the body, neck, acromion or coracoid process of the bone. Fractures of this bone are quite rare. Fracture of the Body of the Scajnda. In dressing this fracture, if deformity is present, it is reduced by manipulation, and compresses of lint are placed above and below the seat of fracture and held in place by adhesive strips; the arm is next fixed to the side of the body by spiral turns of a roller bandage passing around the arm and chest, and the forearm is supported in a sling. Fracture of the Neck, Acromion or Coracoid Process of the Scapula. Fig. 247. Velpeau dressing for fracture of the scapula. 344 FRACTURES. These fractures may be dressed by placing a pad of lint or a folded towel in the axilla and binding the arm to the body by spiral turns of a roller bandage passing around the arm and chest and supporting the forearm in a sling. Or these fractures of the scapula may be dressed by first placing a pad of lint or a folded towel in the axilla and then securing the arm in the Velpeau position by the application of a Velpeau's bandage (Fig. 247.) In fractures of the acromion or coracoid processes the union is usually fibrous. In the treatment of fractures of the scapula the dressing should be retained for about four weeks. Fractures of the Humerus. Fractures of the humerus may involve the upper ex- tremity, the shaft or the lower extremity of the bone. Fractures of the Upper Extremity of the Humerus include fractures of the head and anatomical neck of the bone, fractures through the tuberosities, fractures through the surgical neck of the humerus, and epiphyseal fracture or disjunction of the upper epiphysis of the fig. 248. humerus. The most satisfactory dressing for all frac- tures of the humerus above the upper third of the bone is applied as follows: A pri- mary roller should be evenly applied from the tip of the fingers to the seat of the fracture, the arm being flexed at the elbow before the bandage is carried above this point, to prevent the dangerous constriction which might result if the bandage were applied with the arm in the straight posi- tion, and it were afterward flexed at the elbow. A folded towel or a thin pad of Moulded splint for lint should next be placed in the axilla and shoulder and arm. over the outer surface of the chest, to fur- nish a firm basis of support for the humerus and also to prevent excoriation from the contact of the skin surfaces. A splint of pasteboard, felt or leather (Fig. FRACTURES OF THE HUMERUS. 345 24*) is next moulded to the shoulder and arm; this should be long enough to extend some distance below the seat of fracture and wide enough to cover in about one-half of the circumference of the arm, and is padded with cotton and fitted to the shoulder and arm. The splint and arm are next secured to the side of the body by spiral turns of a roller bandage including the arm and chest in its turns and applied from the elbow to the top of the shoulder. The forearm is carried in a narrow sling suspended from the neck (Fig. 24!»). This dressing should be removed at the end of fig. 249. Dressing for fracture of the upper extremity of the humerus. twenty-four or forty-eight hours, and after the parts have been inspected and sponged over with alcohol, the dress- ings should be reapplied in the same manner, and if the patient is comfortable they need not be disturbed again for three or four days, subsequent dressings being made at the same intervals. Union in fractures of the upper extremity of the humerus, except in intra-capsular fract- ure, in which bony union is the exception, is usually quite firm at the end of five or six weeks, and the dressings can be dispensed with at this time. 346 FRACTURES. Fractures of the Shaft of the Humerus. The dressing consists in the application of a primary roller from the tips of the fingers to the seat of fracture; a short well-padded wooden splint extending from the axilla to a point a little above the internal condyle is next placed on the inner surface of the arm and against the chest; a moulded pasteboard or felt splint, fitted to the shoulder and outer side of the arm and extending a short distance below the seat of fracture, is padded with cotton and applied to the shoulder and arm. The splints are held in position by the turns of a bandage, and the arm is secured to the body by spiral turns of a roller bandage carried around the chest and arm, and the forearm is carried in a sling suspended from the neck. The dressing is much the same as that for fracture of the upper part of the humerus, with the addition of the short internal splint. Fractures of the shaft of the humerus may also be dressed by first applying a primary roller and then plac- ing the forearm and arm upon a Avell-padded internal angular splint. (Fig. 2o0.) Care should be taken to see Fig. 250. Internal angular splints. that the end of the splint extends only to the axilla and does not press upon the brachial vein. A pasteboard or felt moulded splint is next applied to the shoulder and outer side of the arm, which should be long enough to FRACTURES OF THE HUMERUS. 347 extend below the scat of fracture. The splints are held in position by turns of a roller bandage beginning at the fingers and carried up to the shoulder, and finished with a few spica-of-the-shoulder turns. (Fig. 251.) The arm is supported by a sling applied at the wrist, and sometimes tor additional security the arm is secured to the side of the body by spiral turns of a bandage carried around the arm and chest. The after-treatment of these fractures as re- Fig. 251. Dressing for fracture of the shaft of the humerus with internal angular splint and external splint of binder's board. gards the removal and renewal of the dressings is the same as m cases of fracture of the upper portion of the humerus. In fractures of the shaft of the humerus the dressings should be retained for five or six weeks. Fractures of the Lower Extremity of the Humerus. These include fractures at the base of the condyles, splitting fractures between the condyles or those of the internal or external condyle, and epiphysial fracture or disjunction of the lower epiphysis of the humerus. 348 FRACTURES. In dressing fractures of the lower extremity of the humerus, if a primary roller is employed it should be carried up onby to the elbow; the displacement is reduced by extension and manipulation, and before applying any Fig. 252. Anterior angular splint. splint it is well in many cases to apply over the region of the fracture several folds of lint saturated with lead-water and laudanum, and to cover this dressing with waxed paper or rubber tissue to diminish as far as possible the Fig. 253. Dressing for fracture of the lower extremity of the humerus with anterior langular splint. swelling, which is very marked after these injuries. The use of this lotion may be omitted, and a layer of cotton may be placed around the joint in its place. An anterior angular splint (Fig. 252) well padded with cotton or oakum is next applied and held in position by the turns of a roller bandage applied from the fingers to the upper portion of the splint. (Fig. 253.) These fractures may FRACTURES OF THE HUMERUS. 349 also be dressed with a well-padded internal angular splint, this splint being substituted by an anterior angular splint at the end often days or two weeks. These fractures may also be dressed by placing the arm in a posterior angular trough (Fig. 254) made of paste- hoard or leather. Some surgeons prefer to dress fractures of the condyles of the humerus with the arm in the ex- tended position upon a straight an- terior splint, or with short, narrow pasteboard splints applied around the joint, as favoring more accurate coaptation of the fragments. If this position is employed a straight wooden splint is applied to the anterior surface of the arm and forearm, or moulded splints of . ' , . iin Posterior angular trough. pasteboard mav be used, and after the union is moderately firm, at the end of two weeks, the elbow should be flexed and kept in this position during the remaining time of the treatment. When fractures of the lower extremity of the humerus involve the elbow-joint a certain amount of impairment of joint-motion is apt to occur either from ankylosis or from displacement of the fragments wdiich in many cases it is impossible to completely reduce, so that flexion and exten- sion of the joint is restricted. Bearing these facts in mind, it is well to make passive motion in these cases as early as the second or third week. It is well to explain to the patient or his friends that impairment of joint-motion may result in these fractures in spite of the greatest skill and care in the treatment. In a case of fracture in the region of the condyles of the humerus the dressings should be removed in twenty-four hours and it should be re-dressed in the same manner, and if the swelling does not increase and the dressing is comfortable to the patient it should afterward be dressed at less frequent intervals; the union is generally quite firm at the end of four weeks and the splint may be removed at this time. Fractures of the condyles of the humerus are very common in children, and 16 350 FRACTURES. epiphyseal disjunctions of the lower epiphysis of the humerus are also met with ; the dressing of these injuries in this class of patients is similar to that described for fractures of the condyles of the humerus. Fractures of the Olecranon Process of the Ulna. Fractures of the olecranon may consist in simply a separation of the cortical layer of bone over the summit of the process to which the triceps is principally attached, or the line of fracture may pass through the sigmoid fossa. Fractures of the olecranon are dressed with the arm slightly flexed at the elbow, or with it completely extended; Fig. 255. Adhesive strap applied to draw fragment downward. the former position is possibly a little less irksome to the patient. The separation of the fragment by the action of the triceps muscle is usually not very marked; but, if the displacement is marked, it may in a measure be over- come by the use of a compress above' the fragment, over which figure-of-eight strips of adhesive plaster are fastened to draw it down into position (Fig. 255). The ends of the strap are then attached to a well-padded straight splint which should be long enough to extend from the upper third of the arm to the ends of the fingers, which is secured in position by the turns of a roller carried from fractures of the olecranon. 351 the fingers to the upper extremity of the splint with figure- of-eight turns at the elbow to reinforce the action of the -trips of plaster. Tliis fracture may also be dressed by first applying a primary roller up to the elbow, and then placing the arm upon a well-padded anterior obtuse-angled splint, or a straight splint with a good-sized pad of lint or oakum litstened at a point corresponding to the position of the flexure of the elbow. When cither 'of these splints is Fig. 256. Fracture of olecranon dressed in the extended position. placed upon the arm a position of moderate flexion is obtained. A compress of lint is next placed above the fragment, if there is displacement, and one or two narrow strips of adhesive plaster are fastened over this and passed obliquely downward and attached to the splint on either side. The splint is then securely fastened to the arm by the turns of a roller bandage applied from the fingers to the upper end of the splint. (Fig. 25(5.) The dressings in a case of fracture of the olecranon should be removed at the end of twenty-four or thirty-six hours, or sooner if there is evidence of swelling of the tissues in the region of the fracture, and they should be reapplied in the same manner. If the dressing is com- fortable to the patient, and there is no evidence of swelling, the subsequent dressings should be made at less frequent intervals; the dressings arc usually retained in this frac- ture for five or six weeks. Passive motion should not be made until this time, as ficxion of the elbow tends to separate the fragments, unless union has taken place. The 352 fractures. repair of a fracture of the olecranon is, in most cases, by fibrous union, but in a few instances bony union has been found to have taken place. Fractures of the Coronoid Process of the Ulna. Fractures of the coronoid process are rarely met with, and their dressing is accomplished by placing the arm in a flexed position and applying a well-padded internal right-angled splint, or a posterior right-angled splint, and securing it to the arm by the turns of a roller bandage. A moulded pasteboard or leather gutter may be substituted for the angular splints. The dressings should be changed at intervals, and after their removal at the end of three or four weeks, passive motion should be practised. Fractures or the Head and Neck of the Radius. These fractures are also quite rare, and, when met with, should be dressed, after reducing the fragments by manipu- lation, by flexing the elboAV and keeping it in this position by the application of a well-padded anterior right-angled splint, the splint being firmly secured in position by the turns of a roller bandage applied from the tips of the fingers to the upper end of the splint. The splint should be changed at intervals, and should not be permanently removed for four weeks, at which time passive motion, consisting in flexion and extension at the elboAV and pronation and supination of the forearm, should be made. (Fig. 253.) An internal angular splint applied to the inner surface of the forearm and arm may also be used in the treatment of these fractures. (Fig. 251.) Fractures of Both Bones of the Forearm. These fractures are often met Avith as the result of direct or indirect violence, and after reducing the displacement, Avhicli is always marked when both bones are broken, and fractures of both bones of forearm. 353 is not so marked when one bone only is broken, by making extension from the hand and by manipulation; the forearm is placed in the supine position or in a position between pronation and supination. The supine position is, as a rule, to be preferred in any fracture of the radius, as the upper fragment is supinated by the action of the biceps and supinator brevis muscles, and, therefore, unless the lower fragment be placed in the supine position union w ith rotary deformity will almost inevitably ensue. Two straight wooden spliuts, well padded, a little wider than the forearm, are employed. The anterior splint Fig. 257. Dressing for fracture of both bones of the forearm. should be long enough to extend from the elbow to the lips of the fingers, and the posterior splint should extend from the elbow to the wrist. A primary roller should never be applied to the forearm in dressing these fractures, as its application diminishes the interosseous space and its use has been followed by gangrene of the hand and forearm. In applying the anterior splint to the palmar surface of the forearm and hand care should be taken to see that the upper end of the splint docs not press upon the brachial artery and vein at the elbow when the forearm is flexed ; the posterior splint is next applied from the elbow to the wrist and the splints are held in position by the turns of a bandage carried from the fingers to the elbow. (Fio-. 257.) 354 FRACTURES. Iii dressing this fracture a posterior splint equal in length to the anterior splint may be used in place of the short posterior splint extending from the elbow to the wrist. In fracture either of the shaft of the radius or of the ulna alone, the deformity is usually not so marked as when both bones are broken at the same time, the unbroken bone acting as a splint; the dressing for these fractures is the same as for fracture of both bones of the forearm. The dressing should be removed in twenty-four or thirty- six hours, and after inspecting the parts and sponging them with dilute alcohol the splints should be replaced in the same manner and secured, and the dressings should be removed and renewed at intervals of two or three days for two weeks at least, and after this time the dressings should be made at less frequent intervals. The time required for union in these fractures is usually five or six weeks, and the splints should be retained for this time. Fractures of the forearm should be seen by the surgeon frequently for the first two weeks of the treatment, for it is in these fractures that the most unfortunate results have occurred from neglect of this precaution. In children incomplete or green stick fractures of the bones of the forearm are very common ; their dressing, after reducing the deformity, which consists in bending the bones back into place, Avhicli often converts the in- complete fracture into a complete one, is accomplished in the same manner as described above. In these patients there is a great tendency to displace the splints or rather to draw the forearm out of the splints, and to prevent this I often employ an anterior angular splint, in place of the straight anterior splint, the upper portion of which, being fastened to the arm, prevents the child from dragging the arm out of the dressings. Fractures of the Lower End of the Badius. The most common fracture of the radius is one situated from one-half of an inch to one and one-half inches above the lower articular surface of the bone, the line of fracture fractures of lower end of radius. 355 being more or less transverse, although it may in some cases be slightly oblique; the characteristic deformity in this fracture is represented in Fig. 25S. Fig. 258. Fracture of the radius near its lower extremity. The most important point in the treatment of this frac- ture is to effect complete reduction before the application of any splint; this is clone by making extension from the hand, and at the same time, by extending and flexing the Fig. 259. Position of compresses in Colles's fracture. wrist and by manipulation, the deformity can usually be completely reduced. The arm should then be brought into the position of supination, and a firm compress of lint is next placed over the lower end of the upper fragment on the palmar surface of the forearm ; a second compress is then placed over the upper end of the lower fragment (Fig. 25!)), and a Avell-padded Bond splint (Fig. 260) is 356 FRACTURES. Fig. 260. Bond's splint. applied to the palmar surface of the arm and held in place by the turns of a roller bandage. (Fig. 261.) Fig. 261. Dressing for fracture of the lower end of the radius. Many surgeons treat this fracture Avith the hand in a position betAveen pronation and supination, the thumb Fig. 262. Substitute for Bond's splint. pointing upward. A substitute for Bond's splint may be prepared by fastening a roller bandage obliquely upon FRACTURES OF THE CARPAL BONES. 357 a straight wooden splint as suggested by Dr. Hays. (Fig 262.) Two straight splints with compresses are also employed in the treatment of this fracture, and a vast number of splints have been devised ; among these may be mentioned those of Gordon, Coover, and the metal splint of the late Dr. R. J. Levis. The most important point in the treat- ment of this fracture is the complete reduction of the deformity at the first dressing, and if this has been satis- factorily done almost any splint may be used with a good result, and indeed some surgeons use no splint, applying only a compress over the palmar fragment, held in place by a strip of plaster, the arm being carried in a sling. The after-treatment of these fractures consists in remov- ing the splint and compresses after twenty-four or thirtv- six hours and in sponging the surface of the skin with dilute alcohol, and the compresses and splint should then he reapplied in the same manner; the fracture should be dressed every second or third day for the first two weeks, and after this time it should be dressed at less frequent intervals. Union is usually quite firm at the end of four weeks, and the splint should be dispensed with at this time. A certain amount of stiffness of the wrist and fingers is apt to follow this fracture, which is usually soon overcome by passive motion and physiological use of the parts. In children epiphyseal separations or fractures of the lower epiphysis of the radius are often met with, and their treatment is similar to that described above; a Bond splint with compresses or two straight splints with compresses being the most satisfactory dressing to employ in this injury, the dressings being retained for three weeks. Fractuhes of the Carpal Boxes. These fractures are usually compound or open fractures, and are so frequently associated with extensive laceration <>f the arm and hand that operative measures have to be resorted to; but if such is not the case they are dressed, 16* 358 FRACTURES. when compound, with an antiseptic dressing, and the hand and forearm are supported upon a well-padded palmar splint held in place by a roller bandage; more or less im- pairment in the motion of the wrist is apt to follow these fractures. In simple fractures of the carpal bones the use of an evaporating lotion for a fewy days, in connection with the splint just mentioned, will he found useful. The dressings should be retained for three or four weeks, and after their removal passive motion should be employed to overcome as far as possible the joint-stiffness resulting. Fractures of the Metacarpal Bones. These fractures are often met with as the result of direct or indirect force applied to the metacarpal bones. The Fig. 263. Agnew's splint for fracture of the metacarpal bones. Fig. 264. Dressing for fracture of the metacarpal bones. treatment of fractures of the metacarpal bonesjconsists in first reducing the deformity, which is usually an angular one, the projection of the angle being toward the back of fractures of the phalanges. 359 the hand ; this is reduced by pressure with the fingers, and the hand and forearm should then be placed upon a palmar splint (Fig. 263) with a pad of oakum or cotton under the palm ; a compress of lint is next placed over the scat of fracture, and the hand and forearm are bound to the splint by the turns of a roller bandage. (Fig. 264.) At the end of three weeks union at the seat of fracture is usually cpiite firm, and the splint should be dispensed with at this time. FliACTURES OF THE PlIALANOES. The treatment of fractures of the phalanges consists in reducing the displacement by extension and manipulation, and in placing the finger in a moulded gutta-percha or pasteboard splint (Fig. 265), and securing the splint in Fig. 265. Gutta-percha splint for fracture of phalanx. (Hamilton.) position by the turns of a roller bandage. "When the proximal phalanx is fractured a narrow, padded, wooden splint extending from the end of the finger to the wrist should be applied upon the palmar surface of finger and hand, and a short dorsal splint should also be used; if there is a tendency to lateral displacement short lateral splints should also be employed, and the splints should be held in place by strips of plaster or by a roller bandage. (Fig. 266.) Union in fractures of the phalanges is usually quite firm 360 FRACTURES. at the end of three weeks, and the splints can be dispensed with at that time. Fig. 266. Dressing for fracture of phalanx with anterior and posterior splints. Fractures of the Lower Extremity. Fractures of the Femur. Fractures of the upper extremity of the femur are those involving the neck, great trochanter, and upper end of the shaft of the bone. In dressing fractures of the upper extremity of the femur the patient should be placed in bed upon a firm mattress, and an extension apparatus made from adhesive plaster should be applied to the leg, extending as far as the knee- joint. The extension apparatus is constructed by taking a piece of adhesive plaster two and half inches in width and long enough to extend from the outer side of the knee to four inches below the sole of the foot, and from this point back to the inner side of the knee; in the centre of this strip is placed a block of wood, two and a half inches wide and four inches in length, with a perforation in its centre; the block and the inner surface of the strip on each side are next faced with a similar strip of adhesive plaster to a point about an inch above each malleolus ; a few straps are next wound around the wooden block to FRACTURES OF THE FEMUR. 361 fix the previously applied straps; the strip of plaster is next warmed and applied to the sides of the leg and held in position by three strips of adhesive plaster carried around the leg at intervals (Fig. 2(57), and the plaster is made additionally secure by the application of a roller bandage applied to the foot and leg and carried up to the knee. Through the perforation in the block or stirrup is fastened a cord wdiich passes over a pulley attached to the bed, and to this cord is attached the extending weight. The extension apparatus being applied, lateral support is given to the leg and thigh by sand-bags applied on either side; the outer sand-bag should extend from the foot to the Fig. 267. Adhesive plaster extension apparatus applied to limb. (Ashhurst.) axilla, and the inner one from the foot to the groin. A weight of five or ten pounds is attached to the extending cord, and the lower feet of the bed should be raised on blocks a few inches high to prevent the patient from slip- ping down in bed ; a pad of oakum or cotton should also be placed under the tendo A chillis to relieve the heel from pressure. This dressing is kept in place for from four to six weeks, and if union has occurred the patient is kept in bed for a few weeks longer and is then allowed to be about using crutches. In the majority of cases of fracture of the neck of the femur fibrous union only takes place, and after employing the dressing before described for six 362 FRACTURES. weeks the patient is allowed to get up and go about on crutches. It often happens that the subjects in whom these fractures occur are old and feeble, and if it is found that restraint in bed Avith the dressings here described is not well borne, under such circumstances they should be discarded and the patient should be allowed to sit up in bed Avith the limb resting on a pilloAV, or in a chair, the treatment of the local condition having to be disregarded, attention beiug given to the patient's constitutional con- dition. The application of a plaster-of-Paris bandage to the leg, thigh, and pelvis is also sometimes made use of in the Fig. 268. Plaster-of-Paris bandage applied to thigh. (Hamilton.) treatment of fractures of the upper extremity of the femur; extension should be made from the foot while the bandage is being applied. (Fig. 268.) In fractures of the neck of the femur and of the upper part of the shaft of the bone the anterior wire splint of Prof. X. R. Smith is sometimes used with advantage; the limb being swung from the splint the patient is able to move in bed without causing him pain or disturbing the fragments. (Fig. 269.) In fractures in the upper portion of the femur where there FRACTURES OF THE FEMUR. 363 is marked tilting forward of the upper fragment Prof. Agnew employed extension made from the thigh and Fig. 269. Smith's anterior splint for fracture of the femur. placed the limb upon a double inclined plane, maintaining this position during the treatment of the case. (Fig. 270.) Fig. 270. 'I'^illlllillllMill^lllllillHIIIDIIillll:!!!!!!'/^- "Ilf.'ll Dressing of fracture of the femur with extension upon an inclined plane. (Agnew ) With the same object in view, in place of the double in- clined plane a double inclined fracture-box may be em- 864 FRACTURES. ployed, extension being made from the thigh by means of adhesive plaster strips applied above the knee, to which a weight is attached. (F"ig. 271.) Fig. 271. Double inclined fracture-box. Fractures of the Shaft of the Femur. In the treatment of fractures of the shaft of the femur the dressings are applied to diminish as far as possible the shortening and to prevent angular or rotary displacement of the fragments. In dressing these fractures the patient should be placed upon a fracture-bed or an ordinary bed with a firm hair mattress; an extension apparatus of ad- hesive plaster is applied and extension is made by a weight attached to this as previously described. Lateral support is given to the limb by the application of two wooden splints—the outer or long one extending from the axilla to the foot, the inner or short one extending from the groin to the foot. The splints at their upper extremity should be about six inches in width and at their lower extremity about three and a half inches. The splints are wrapped in a splint cloth which extends from the foot to the groin, and after this has been placed under the limb the splints are fixed in their proper positions, the short one to the inner side, the long one to the outer side of the limb. Between the limb and the splints are interposed bran- bags ; the outer bag should be long enough to extend from the axilla to the foot, the inner one from the groin to the foot. The splints and bran-bags are held in place by five or six strips of bandage passing under the limb and body and around the splints and bran-bags at intervals. The heel is saved from pressure by placing a wad of oakum or FRACTURES OF THE FEMUR. 365 cotton under the tendo Achillis, and after the splints have been brought into place the strips of bandage are firmly tied to secure them and a weight of ten or twelve pounds is attached to the extending cord. The foot of the bed is raised to prevent the patient from slipping downward and to allow the weight of the body to act as a counter-extend- ing force. After the application of the dressings the thigh should be slightly abducted. During the after-treatment of these fractures the surgeon should see that the splints and bran-bags are kept firmly in place and that the foot does not roll outward ; this is accomplished by untying Fig. 272. Dressing for fracture of the shaft of the femur with lateral splints and bran-bags (Ashhurst.) the strips and readjusting the bags and then bringing up the splints and securing them in position by fastening the strips. (Fig. 272.) The extension apparatus usually dees not require renewal during the course of treatment. The extension and splints are kept in place for four or six weeks and at this time union at the seat of fracture is usually quite firm, so that they may be removed, and the fracture is then supported by moulded pasteboard splints or by the application of a plaster-of-Paris splint for several weeks longer, and at the end of eight weeks it is safe to allow the patient to be up and around on crutches. Many surgeons, in fracture of the shaft of the femur, prefer to use" a long external sand-bag and a shorter in- 366 FRACTURES. ternal one in place of the corresponding long and short splints and bran-bags, and, if care is observed to see that the sand-bags are kept accurately in contact with the limb and body, excellent results may be obtained by this form of dressing. After considerable experience with both methods of furnishing lateral support in the dressing of fractures of the shaft of the femur, I am well satisfied that angular deformity is less likely to result where the splints and bran-bags are employed. The plaster-of-Paris dressing, including the foot, leg, thigh, and pelvis, is employed by some surgeons in the early treatment of fracture of the shaft of the femur, the limb being kept well extended until the plaster has thor- oughly set. The double inclined plane and the anterior angular wire splint are also sometimes employed in the dressing of fractures of the shaft of the femur. Fractures of the Shaft of the Femur in Children. The treatment of these fractures in young children by extension by a weight and pulley and lateral splints is often unsatisfactory on account of the difficulty in keeping the patient quiet upon his back, and from the soiling of the dressings by the feces and the urine. In children two years of age and over I have' never found much trouble in employing extension and lateral support by splints and bran-bags or sand-bags, and in these cases I make addi- tional fixation at the seat of fracture, and guard against displacement of the fragments by the child sitting up in bed when not watched, by carefully moulding external and internal pasteboard or felt splints to the thigh, and holding them in place by the turns of a bandage. I have employed this form of dressing even in children under two years of age with the most satisfactory results. In cases of fracture of the femur in children from a few months to a year or eighteen months of age, in whom it is difficult to obtain quietude, or Avho have to be moved to give, them nourishment if they are taking the breast, the dressing which I have found most satisfactory consists in FRACTURES OF THE FEMUR. 367 Fig. 273. first applying a roller bandage from the foot to the groin, and then moulding to the outer half of the foot, leg, thigh, and also to half of the pelvis, a pasteboard or felt splint which is well padded with cotton, and held in position by the turns of a bandage carried from the foot to the pelvis and finished with circular turns about the pelvis. The splint should be so moulded as to include a little more than one-half of the circumference of the thigh and leg. If this splint becomes soiled it is easily replaced by a fresh one, and its removal and renewal is much easier than that of the plaster-of-Paris splint which is recom- mended by some surgeons in these cases. In young children fractures of the femur are often incomplete or green-stick fractures; and, even when com- plete, the shortening is usually not marked, as the line of fracture is apt to be transverse, the periosteum often not being completely ruptured, which tends to hold the fragments in position. In green-stick fractures the deform- ity should be reduced by manipulation, even if it is necessary to convert the incomplete fracture into a complete one to accomplish this object. Mr. Prvant recommends that fract- ures of the femur in young children be treated in the vertical position; the injured limb, together with the sound one, is flexed at a right angle to the pelvis and fixed with a light splint, and attached to a cradle or bar above the bed. (Fig. 273.) If the plaster-of-Paris dressing is used, the limb should be first enveloped from the foot to the pelvis with a flan- nel bandage, and extension should be made while the plaster-of-Paris bandage is being applied and should be kept up until the bandage has become fixed. The plaster bandage should extend from the toes to the pelvis, and it is well to fix the Fracture of the fe- mur treated by vertical extension. (Bryant.) 368 FRACTURES. hip-joint by carrying several turns of the bandage about the pelvis. To prevent the splint from absorbing the discharges and becoming offensive, the upper portion of it may be coated w ith shellac. The time required for union in fractures of the femur in children is about three weeks, and the dressings may be removed at this time, but the child should not be allowed to use the limb for several weeks after this period. Fractures of the Lower End of the Femur. The fractures met with in this portion of the femur are supra-condyloid fractures, or those in which one condyle is separated, or comminuted fractures in which both con- dyles are separated; epiphyseal disjunctions of the lower end of the femur, met with in young subjects, may also be classed with fractures at this portion of the bone. The dressing of supra-condyloid fractures, if there is shortening, should be similar to thai employed in fractures of the shaft of the femur, consisting in the application of an extension apparatus, and bran-bags and splints or sand- bags to give lateral support; if, however, there is no marked shortening the dressing employed should be the same as that applied in fractures involving one or both condyles or epiphyseal separations. The dressing employed in fracture of one or both con- dyles or in epiphyseal disjunction of the lower end of the femur consists in placing the limb in a long fracture-box extending from the foot to the upper third of the thigh, the box being well padded with a soft pillow, or a well- padded posterior splint, or a moulded pasteboard or felt gutter may be employed; if either of these dressings is employed, the splint or gutter should be long enough to extend from the lower part of the leg to the middle of the thigh. If there is much effusion into the joint or soft parts, lead-water and laudanum should be applied over the region of the injury for some days, until the swelling has subsided. At the end of two weeks it is well to place the FRACTURES OF THE PATELLA. 369 limb ill a plaster-of-Paris dressing, extending from the foot to the middle of the thigh. This dressing should be retained for four weeks, and at the end of this time the dressing should be removed, and if the union is suffi- ciently firm to allow the patient to go about on crutches, a fresh plaster-of-Paris splint should be applied extending from the middle of the leg to the middle of the thigh, or lateral splints of pasteboard may be substituted for the plaster dressing. A certain amount of permanent impairment of the joint motion is apt to follow fractures involving one condyle or both condyles of the femur. Fractures of the Patella. The dressing of fractures of the patella consists, first, in the application of a roller bandage from the toes to the upper part of the leg; a well-padded posterior wooden splint long enough to extend from the middle of the leg- to the middle of the thigh, or an Agnew splint, which is Fig. 274. Agnew's splint for fracture of the patella. provided with pegs for the attachment of strips of adhe- sive plaster (Fig. 274) is next placed under the limb. A small compress of lint is next placed above the upper fragment, and a similar compress is placed below the lower fragment; a strip of adhesive plaster one and a half inches in width and twenty-four inches in length has its middle portion applied over the compress, and its ends are then brought oblicpidy downward and fastened to the splint, 370 FRACTURES. or to the pegs if Agnew's splint be used; this may be re- inforced by a second or third strip. The object of these strips is to bring the upper fragment down in contact with the lower fragment. A strip of plaster with the ends passing in the opposite direction is next placed over the lower compress, and the ends are fastened to the splint or pegs; this strip serves only to steady the lower fragment, as it cannot be drawn upward to meet the upper fragment by reason of the mextensibility of its ligamentous attach- ment. (Fig. 275.) If the Agnew splint is employed the strips of plaster may be tightened by turning the pegs to which they are fastened without removing the splint. Fig. 275. Agnew's splint applied. The splint is next firmly fixed in contact Avith the limb by the turns of a roller bandage extending from the loAver to the upper end of the splint. The limb should next be placed upon an inclined plane or in a long fracture-box with its foot elevated to relax the quadriceps femoris muscle. This dressing should be removed and reapplied in a few clays, as the dressings become loose as the swelling about the seat of injury subsides, and after this disappears the dressings require renewal at less frequent intervals and usually at the end of three weeks the splint may be re- moved and a plaster-of-Paris bandage may be applied extending from the middle of the leg to the middle of the thigh. At the end of six weeks the patient may be allowed to walk upon the limb, the knee-joint being fixed with a plaster-of-Paris or pasteboard splint. FRACTURE OF THE BONES OF THE LEG. 371 It is well, after the removal of the splints, for the patient to wear for some months a laced muslin knee- supporter, which gives some support to the knee-joint. The union in fractures of the patella is usually fibrous, although in rare eases bony union has occurred. A great variety of splints have been devised and used in the treatment of fractures of the patella, the main object of which is to fix the knee-joint and bring the fragments as nearly as possible in apposition. Malgaigne's hooks or Lewis's modification of the same are employed by some surgeons to secure close apposition of the fragments. The method of treatment in fractures of the patella, which con- sists in exposing the fragments by an incision and drilling and suturing them with catgut or silver wire sutures, is also employed at the present time, the strictest antiseptic precautions being taken to prevent infection of the wound. In oases of rupture of the fibrous union after fracture of the patella, which is not an uncommon accident, the treat- ment of the case should be the same as that for a recent fracture of the patella. Fracture of the Boxes of the Leg. In fractures of both bones of the leg the displacement is usually very marked ; when one bone only is broken, the sound bone, acting as a splint, prevents much deformity, Fig. 276. Fracture-box with movable sides. except in case of fracture at the lower end of the fibula, when the foot inclines to the injured side. The dressing for fractures of both hemes of the leg or for fracture of the tibia or fibula alone, except in cases 372 FRACTURES. wdiere the lower portion of the fibula is the seat of injury, is best accomplished by the use of a fracture-box. (Fig. 276.) The displacement being overcome as far as possible by extension and manipulation, the leg is placed in a fracture-box, which is prepared for the reception of the limb bv having the sides let down and having a soft pillow laid in it; the foot is next secured to the footboard by a loop of bandage passed around the foot, the ends being tied after passing through the slots in the footboard; a pad of oakum or cotton is placed under the tendo Achillis Fig. 277. Application of the fracture-box. to relieve the heel from pressure, and a similar pad is placed between the sole of the foot and the footboard. (Fig. 277.) The sides of the box are then brought up and secured by two or three strips of bandage tied around the box. In using a fracture-box in the treatment of fractures of the bones of the leg the surgeon should see that the foot is kept well down to the footboard and is at a right angle with the leg, that there is no eversion of the knee and that the pillow is full enough to make equable pressure upon the leg when the sides of the box are secured, and that the heel is not subjected to undue pressure—the use of a pad of oakum or cotton under the tendo Achillis being em- ployed to prevent this complication. Where there is a tendency to tilting upward of the lower end of the upper FRACTURE OF THE BONES OF THE LEG. 373 ♦ fragment the lower fragment can be brought in line with this by raising the foot by a mass of oakum or cotton placed under the tendo Achillis and heel, and so overcom- ing the deformity. In some eases division of the tendo Achillis may be required before this deformity can be corrected. The subsequent dressings of the eases are conducted by letting down the sides of the box and correcting any dis- placement, if present, by adjusting the limb and pads in their proper position, and again bringing up the sides of Fig. 278. Plaster bandage applied to fracture of the leg. the box and securing them. At the end of two or three weeks the fracture-box may be removed and a plaster-of- Paris dressing may be applied to the limb, which will allow the patient more freedom of movement in bed, or permit of his sitting up without disturbing the fragments (Fig. 27X). Inion in fractures of the bones of the leg is usually quite firm in six weeks, but the patient should not be allowed to put his weight upon the limb in walking for at least eight weeks. 17 374 FRACTURES. If the patient is restless, and finds his position with the fracture-box resting upou the bed irksome, the fracture- box mav be swung from a frame fastened over the bed (Fig. 279). The application of a plaster-of-Paris dressing as a primary dressing—the ordinary plaster-of-Paris bandage or the Bavarian dressings being applied—in fractures of the bones of the leg, is adopted by some surgeons, and, if employed, the case should be under constant supervision for a few days, so that the dressing can be removed if a dangerous amount of swelling takes place. Moulded splints of felt or pasteboard are also sometimes applied in the treatment of these cases. (Fig. 280.) Fig. 279. Fracture-box suspended. (Agnew.) FRACTURE OF THE BONES OF THE LEG. 375 In patients suffering with delirium tremens, or in maniacal patients, the use of a fracture-box in the treat- ment of fractures of the bones of the leg is often not satisfactory on account of the difficulty in restraining the movements of the patient, and the consequent displace- ment of the fragments. In such cases it is well to apply Fig. 280. Moulded binder's board splints for fracture of the leg. a few strips of bincler's-board, well padded with cotton, to the limb, extending above and below the seat of the fracture, holding them in place by a few turns of a roller, and then to wrap the limb and foot in a soft pillow and hold this in place by the turns of a roller banclage applied with moderate firmness. This dressing allows the patient to move the limb without serious disturbance of the frag- 376 FRACTURES. nients, and, after the patient recovers from his attack, the leg may be placed in the fracture-box, or in a plaster-of- Paris dressing. In fractures of the bones of the leg in young children the same difficulty is often experienced in keeping them quiet, and for this reason a fracture-box cannot be used with satisfaction. In dressing these cases, two lateral splints of pasteboard, moulded to the foot and leg and well padded w ith cotton, may often be employed with the best results. The splints should not be a\ ide enough to meet on the anterior or posterior surface of the leg or foot. The splints, after being carefully adjusted, are held in place by the turns of a roller bandage; and, after these splints haAe been applied for two Aveeks, and all swelling has subsided at the seat of fracture, a plaster-of-Paris bandage may be substituted for them, which should be worn for three Aveeks; at the expiration of this time union is usually firm enough to dispense with all dressings. Fractures of the Fibula. In fractures of the fibula, with the exception of that fracture occurring at the lower end of the bone, the de- formity is not marked, and they are usually dressed with a fracture-box applied as in the dressing of fractures of both bones of the leg, and at the end of two weeks a plaster-of-Paris dressing should be applied, and the patient may be allowed to get out of bed and move about on crutches. The union in a fracture of the fibula is usually quite firm at the end of five weeks, and all dressings may be dispensed with at that time. Fracture of the Lower End of the Fibula. This fracture usually occurs in the lower fifth of the bone and is often associated with a laceration of the in- ternal lateral ligament of the ankle-joint or a sprain-frac- ture of the internal malleolus, and is usually accompanied fractures of the fibula. 377 by marked cversion of the foot. This fracture is com- monly known as Pott's fracture. In this fracture after reducing the displacement by ex- tension and manipulation, the limb should be placed in a fracture-box provdded with a soft pilloAV, the foot should be secured to the footboard, and a pad of oakum or cotton should be placed under the tendo Achillis; before bring- ing up the sides of the box and securing them two firm compresses of lint or oakum should be placed in contact with the leg, one just above the inner malleolus, the other just below the outer malleolus. The sides of the box are next brought up and secured, and by the pressure of these compresses the foot is brought into an inverted position and the deformity is corrected. The after-dressing of this fracture consists in letting down the sides of the box, and in inspecting the parts to see that the foot is kept in the proper position, and care should be taken to see that undue pressure is not made upon the skin by the compresses, which might result in ulceration; this may be avoided by sponging the skin with alcohol and changing the positions of the compresses slightly at each dressing. At the expiration of ten days the fracture-box and compresses may be removed and the limb may be put up in a plaster-of-Paris dressing including the foot and leg up to the knee. The patient may then be allowed to go about on crutches and at the end of five weeks all dressings may be dispensed with. A certain amount of stiffness and even permanent impairment in the motion of the ankle-joint often results from these fractures. This fracture is also dressed by means of Dupuytrcn's splint, which consists of a straight wooden splint long enough to extend from the condyles of the femur to the end of the toes ; this splint is provided with padding, the thickest part of which, several inches in thickness, should rest upon the skin just above the inner malleolus when the splint is applied to the inner side of the leg. The splint is applied to the inner surface of the leg with the thickest part of the pad resting upon the skin just above the inner malleolus, and is secured in position 378 FRACTURES. by the turns of a roller applied over the foot and at the upper part of the leg. (Fig. 281.) After using this dress- ing for a few days if the displacement is satisfactorily corrected the splint may be removed and the leg may be placed in a fracture-box or in a plaster-of-Paris dressing. Fig. 281. Dupuytren's splint applied. This splint, when applied with sufficient firmness to correct the displacement, is not, as a rule, a comfortable dressing to the patient, so that in practice the use of the fracture-box and compresses will be found a more com- fortable dressing and one equally satisfactory in correcting the deformity. Fractures of the Bones of the Foot. Fractures of the Tarsal Boxes. The calcaneum and astragalus are the tarsal bones most frequently fractured. The dressing of fractures of the calcaneum after reducing the displacement, which is not usually marked unless the posterior portion of the bone is involved, by manipulation, consists in placing the leg and foot in a fracture-box, and care should be taken to see that the foot is kept at a right angle to the leg. When the fracture involves the posterior portion of the bone and there is displacement by the action of the muscles inserted into the fragment, the leg should be flexed upon the thigh and the foot should be extended ; this position may be maintained by applying a well-padded curved splint to the anterior portion of the leg and foot and FRACTURES OF THE METATARSAL BONES. 379 securing it in position by a bandage, or the same result mav be obtained by applying a band or padded collar around the thigh, which is made fast by a cord or strap to the heel of a slipper applied to the foot. (Fig. 282.) Fig. 282. Apparatus for fracture of posterior portion of the calcaneum. (Hamilton.) Fractures of the astragalus, after reducing any deformity which is present by extension and manipulation, are dressed by placing the foot and leg in a fracture-box, care being taken to see that the foot is kept at a right angle to the leg. This precaution is important, as ankylosis not infrequently occurs after this fracture, and if the foot is in the proper position it is much more useful to the patient. As soon as the swelling, which is usually very marked after fracture of the calcaneum or astragalus, subsides, the foot and leg should be put up in a plaster-of-Paris band- age. The amount of tension and the inability to reduce the displacement in cases of fracture of the astragalus may be indications for excision of the fractured bone. The time required for union in fractures of the tarsal bones is from five to six weeks. Fractures of the Metatarsal Boxes. These fractures arc dressed by placing the foot upon a well-padded plantar splint, and using compresses to hold the fragments in place if there is much displacement, the 380 FRACTURES. splint and compresses being held in position by a bandage; or they may be treated by placing the foot and leg in a fracture-box, the foot-board of the box acting as a plantar splint; the plaster-of-Paris dressing may also be used in these cases. The time required for union in fractures of the metatarsal bones is from three to four weeks. Fractures of the Phalanges of the Toes. These fractures are often compound and attended xvith so much laceration of the soft parts that immediate ampu- tation is required; when, however, the fractures are sim- ple, or in compound fractures where amputation is not required, the dressing consists in applying a plantar splint of Avood or binder's board, extending beyond the toes and securing it in position by the turns of a roller bandage. When a single toe only is broken a moulded splint of gutta-percha or binder's-board may be applied, and a por- tion of the splint should extend some distance upon the sole of the foot, to fix the proximal joint and also to give it a firm point of fixation ; the moulded splint should be held in position by a narrow roller bandage or by strips of adhesive plaster. The time required for union in frac- tures of the phalanges of the toes is about three weeks. Dressing of Compound or Open Fractures. In the dressing of compound or open fractures the same dressings and splints which are generally used in the treatment of simple or closed fractures may be employed ; the wound in the soft parts requires a special dressing and this should be so arranged as to secure free drainage and promote its prompt healing. In some cases of compound fracture the treatment of the injuries of the soft parts de- mands attention first, and in such cases the injury to the bones is for a time disregarded, care being taken to see that the fragments are kept quiet so as to jnevent further damage to the soft parts until the wound is in such a condition that the proper manipulation to reduce the dis- dressing of compound fractures. 381 placement and fix the fragments by splints and suitable dressings can be undertaken without interfering with the repair of the wound. In the dressing of compound or open fractures the skin surrounding the wound should be first carefully cleansed and the wound should next be thoroughly irrigated with a 1 : 2000 bichloride solution or a 1 :40 carbolic solution, and any foreign bodies or loose fragments of bone should be removed, and if there is hemorrhage it should be con- trolled by securing the bleeding vessels with ligatures. The reduction of the displacement should next be accom- plished by making extension and by manipulation (Fig. 2S3); if the fragments project from the wound, before this Fig. 283. Method of reducing a compound fracture. (Hamilton.) can be satisfactorily accomplished it may be necessary to enlarge the wound, and to resect one or both ends of the fractured bones, and in some cases it may be necessary to drill the ends of the fragments and introduce a strong- wire or catgut suture, or a metallic nail or screw, to hold them in their proper positions. After reduction of the displacement the wound should again be thoroughly irri- gated with the antiseptic solution, and after making pro- vision for drainage by the introduction of a drainage-tube or tubes, counter-openings being made to secure free drain- age if necessary, the dressings should be applied, 17* 382 FRACTURES. The wound, if a small one, need not be closed with sutures; but if extensive, a few catgut, silk, or silkworm- gut sutures may be applied to bring the edges of the wound into apposition, care being taken to avoid making undue tension ; if the soft parts have been much lacerated or con- tused, it is better to introduce no sutures. A final irriga- tion of the wound through the drainage-tube is next made, and the wound is covered by a piece of protective, and the ordinary gauze dressing should be applied, and covered by a number of layers of bichloride cotton, the whole dressing being held in position by a gauze bandage applied with moderate firmness. The reduction of the fragments and the dressing of the wound havdng been accomplished as has been described, the splints and dressings appropriate for a similar fracture, if it were a simple or closed one, are next applied. If the surgeon has been able to render the wound aseptic, and has applied an antiseptic dressing, the compound fracture is often soon converted into a simple one, by the prompt healing of the wound, and the patient may exhibit no more constitutional disturbance than he would have with a similar simple or closed fracture. The re-dressing of a compound fracture dressed in this way need not be made for a week or ten days, unless there is a rise in the patient's temperature or the dressings become soaked with dis- charges from the wound, or they become uncomfortable to the patient by reason of swelling of the soft parts in the region of the wound. When the re-dressing of the frac- ture becomes necessary, the dressings are removed, and the drainage-tubes may be removed if no longer needed; the wound being re-dressed with an antiseptic dressing, the splints are reapplied, and, after the wound is healed, the subsequent dressing of the fracture should be the same as that of a simple fracture. The time required for union in a compound fracture is usually much longer than in a corresponding simple fracture. Many ingenious splints have been devised for the dress- ing of special compound fractures, but these Avere princi- pally used before the introduction of the antiseptic method DRESSING OF COMPOUND FRACTURES. 383 of wound-treatment, and as the treatment of these cases has been much simplified by its use, they possess no special advantage over the ordinary splints and dressings used in simple fractures. The plaster-of-Paris dressing may be used as a primary dressing in compound fractures; the displacement being reduced and the wound being dressed with an antiseptic gauze dressing, a plaster-of-Paris bandage is applied to the part so as to firmly fix the fragments ; the joints on either side of the fracture should be fixed by the banclage, and the parts should be held in position until the plaster has set firmly. After the plaster has become firm, a fenestrum Fig. 284. Fenestrated plaster dressing for compound fracture of the leg. (Stimson ) should be made over the position of the wound, so that it can be inspected or dressed through this when necessary. The ends of a piece of stout wire, bent into a semicircle, may be incorporated in the turns of the plaster bandage above and below the position of the fenestrum, to give it additional strength after the removal of a portion of the bandage to make the fenestrum. (Fig. 2S4.) If the plaster-of-Paris dressing is applied as a primary dressing in compound fractures the case should be care- fully watched for a few days, and if much swelling occurs at the scat of fracture its removal and renewal is indicated ; profuse discharge of serum mav also soak the dressings 384 FRACTURES. and bandage so that its renewal is necessitated. Some surgeons, therefore, prefer to defer the application of the plaster-of-Paris dressing in compound fractures for a few- weeks until the swelling has diminished and the wound is nearly or quite healed; the wound being covered with an antiseptic dressing the plaster bandage is applied and a fenestrum is made over the position of the wound if required. Binder's-board or felt splints may also be employed in the dressing of compound fractures, being moulded to the parts after an antiseptic dressing has been applied to the wound, and held in position by the turns of a roller bandage. The principal advantage in the use of these splints is the ease with which they can be removed and reapplied if frequent dressings of the fracture are necessary for any reason. They may be used during the course of treat- ment, or, after a few weeks Avhen the swelling has dimin- ished at the seat of fracture and the wound is well advanced toAvard repair, they may be discarded and a plaster-of- Paris dressing substituted. In compound fractures of the bones of the leg, after reducing the displacement and applying an antiseptic dressing to the Avound, I usually apply moulded binder's-board splints to either side of the leg, including the foot, and place the leg in a fracture-box for additional security, and after a feAv weeks I discard the binder's-board splints and apply a plaster-of-Paris dressing. Bran dressing for compound fractures was formerly a popular dressing in this city, especially for compound fractures of the leg and thigh. It was applied by placing a piece of muslin or rubber cloth over the bottom and sides of a fracture-box, and upon this was placed a layer of bran; the fractured leg wras next placed in the box upon the layer of bran, the foot was then fastened to the footboard and the sides of the box were brought up and secured; bran was next poured into the box and firmly packed around and over the limb. The bran absorbed the discharges which escaped from the wound, and at the sub- DRESSING OF COMPOUND FRACTURES. 385 sequent dressings the soiled bran was renewed without disturbing the limb and fresh bran was packed about the limb. Sawdust which has been saturated Avith a solution of bichloride of mercury and dried may be used in the same manner as bran in the dressing of compound fractures, and the former, Avhicli has been rendered antiseptic, has decided advantages over the bran dressing. Continuous irrigation of compound fractures bv a warm antiseptic solution either of bichloride of mercury 1 :400() or of carbolic acid 1 :60 in cases in which so much contu- sion or laceration of the soft parts exists that the applica- tion of the ordinary dressings would be attended with the risk of gangrene, will be found a most satisfactory method of treatment. This dressing is applied by supporting the injured extremity upon a splint laid on a pillow covered by a rubber cloth, and a can or jar with a nozzle contain- ing the solution is placed over the part and the irrigation is accomplished by allowing the fluid to run continuously over the wound; this irrigation maybe kept up for day's or weeks, and when the vitality of the parts is assured an antiseptic dressing with the ordinary splints or a plaster- of-Paris banclage may be applied. A method of dressing compound fractures which has recently been introduced, consists in rendering the skin in the region of the wound aseptic and removing anv foreign bodies from the wound, then rendering it as far as possible aseptic; iodoform is then dusted thickly over the wound at intervals and, mixing Avith the blood and scrum from the wound, is allowed to dry, forming an antiseptic scab, the wound being exposed to the air, and the fragments are retained in position by splints or by a fracture-box. PART IV. DISLOCATIONS. A dislocation is the displacement of the articular sur- faces of bones which enter into the formation of a joint. Dislocations may be complete, partial, simple, compound, and complicated, and they are also known as recent and old dislocations, the latter terms being used not entirely with reference to the length of time the displacement of the articular surfaces of the bones has existed. A complete dislocation is one in which no portions of the articular surfaces of the bones remain in contact with each other. A partial dislocation is one in which portions of the articular surfaces of the bones still remain in contact with each other. A simple dislocation is one in which there exists dis- placement in the relation of the articular surfaces of the bones ay ith little injury to the soft parts adjacent to the joint, and the displaced ends of the bones do not com- municate with the air by a wound in the soft parts. A compound dislocation is one in which there exists dis- placement of the articular surfaces of the bones which coniniunicate with the air through a wound in the soft parts. A complicated dislocation is one in which in addition to the displacement of the articular surfaces of the bones, there exists a fracture, or a laceration of important blood- vessels, nerves, or muscles in proximity to the dislocation. treatment of dislocations. 387 A recent dislocation is one in which the displacement of the articulating surfaces of the bones has existed for such a period that time has not been afforded for inflammatory changes to have taken place in the articular surfaces of the bones or in the adjacent tissues, which would seriously interfere with their reduction. An old dislocation is one in which the displacement of the articulating surfaces of the bones has existed for some time, and in this variety of dislocation the displaced bones often form firm adhesions to the surrounding tissues. Treatment of Dislocations. The first indication in the treatment of dislocations is to return the displaced articular surfaces of the bones to their normal position and to retain them in this position by the use of suitable dressings. The return of the articular sur- faces of the bones to their normal position or the reduction of the dislocation, is accomplished by manipulation, exten- sion, and counter-extension. The reduction of dislocations should be attempted as soon as possible after they have occurred. The principal obstacles to the reduction ot dislocations are muscular resistance and the anatomical peculiarities of the joints. The former is best overcome by the use of an amesthetic given to the point where complete muscular relaxation is produced. The resistance offered by the changed relations of the articular surfaces and the liga- ments is to be overcome by the surgeon making such man- ipulations, founded upon his knowledge of the anatomy of the parts, as Avill make the ligaments, muscles, and bones assist in the reduction of the dislocation. In recent dislocations by the use of extension and man- ipulation, especially if an amesthetic be employed, the reduction is usually accomplished without the use of much force, but in old dislocations, where absolute muscular shortening has taken place, the use of extending bands is often required, and in securing these bands to the limb the clove-hitch knot is useful. (Fig. 285,) 388 DISLOCATIONS. The treatment of dislocations after reduction consists in placing the joint at complete rest by the application of suitable splints and bandages, and in treating any inflam- matory complications if they arise, by the application of Fig. 285. Clove-hitch knot applied. (Erichsen.) evaporating lotions, and in a week or two after the injured ligaments have been repaired passive' motion should be resorted to for restoring the function of the joint. Special Dislocations. Dislocations of the Yertebilu. Dislocations of the lumbar and dorsal vertebral, as simple dislocations, are extremely rare accidents; they arc occa- sionally met with, but are more often associated with frac- tures of the vertebra' in these regions ; their occurrence in the cervical vertebra' is more common. The treatment of dislocations of the vertebra1, whether complicated with fracture or not, consists in attempting reduction by mak- ing extension and counter-extension with manipulation, aud by this means in many cases the luxations can be reduced. If, however, the efforts at reduction arc unsuc- cessful, permanent extension should be applied by means of a weight-extension apparatus from both legs, and from the shoulders and head, The after-treatment consists in DISLOCATION OF THE JAW. 389 keeping the patient at rest upon his back in bed upon a firm mattress, and if the cervical vertebrae have been in- volved the head and neck should be supported by short sand-bags, and in case of the vertebras below this point, the application of a plaster-of-Paris jacket may be used to give support and fixation to the parts. The general man- agement of the ease as regards complications is similar to that in cases of fracture of the vertebra?. Pis/ocfdions of the coccyx are reduced by manipulation with the finger in the rectum and external manipulation at the same time. The only after-treatment required is rest in bed for a few days, and the administration of opium to keep the bowels quiet. Dislocation of the Jaw. Fig. 286. Bilateral dislocation of the jaw. (Ashhurst.) This dislocation may consist in the displacement of one or both condyles of the jaw from the glenoid fossae, eonsti- 390 DISLOCATIONS. tuting the unilateral or bilateral dislocation of the jaw; the latter is the more common form of dislocation of the jaw- met with, and the deformity resulting is shown in Fig, 286. The reduction of a dislocation of the lower jaw is accom- plished as follows: The surgeon placing his thumbs, well protected by strips of bandage or a towel, on the molar teeth or behind them presses the angles of the jaw down- ward while he elevates the chin with his fingers, and by this manipulation the condyles of the jaw usually Method of reducing dislocation of the lower jaw. (Hamilton.) slip back into place with a snap. After reduction of the dislocation the jaw should be fixed for a week or ten days bv the application of a Barton's bandage or a four-tailed sling. (Fig. 287.) Dislocation of the Hyoid Bone. A few cases of dislocations of the hyoid bone have been recorded; the treatment consists in throwing back the head as far as possible, to place the muscles of the neck upon the stretch, depressing the lower jaw and pressing the luxated bone into position. DISLOCATIONS OF THE PELVIS. 391 Dislocations of the Ribs. The ribs may be dislocated at their vertebral articula- tions, or at the junction with their costal cartilages. The treatment of these dislocations consists in reducing the displacements by manipulation and pressure and then in fixing the chest to secure immobility of the ribs by strap- ping the affected side Avith strips of adhesive, plaster, the same dressing being applied as in case of fracture of the ribs, the dressing being retained for three or four weeks. Dislocation of the Sternum. Dislocation or diastasis of the sternum may occur at the junction of the manubrium and gladiolus or at the junc- tion of the ensiform cartilage and gladiolus. The reduc- tion is effected by extension of the chest bv bending the dorsal spine over a firm cushion placed under the back and by pressure upon the projecting bone ; when the dis- placed bone has been reduced a compress should be placed over the seat of injury and held in place by broad strips of adhesive plaster or by a bandage to keep the parts at rest. The dressing should be retained for three or four weeks. In the few examples of dislocations of the ensiform cartilage which have been reported the displacement of the cartilage has in some cases given rise to persistent vomiting, which was relieved by reduction of the displace- ment ; it is, however, almost impossible to keep the frag- ment in place after reduction, and the vomiting gradually disappears after a time in these cases where it is impos- sible to keep the cartilage in its normal position. Dislocations of the Pelvis. Dislocations or diastasis of the bones of the pelvis may occur at the pubic or sacro-iliac symphyses. These are generally serious injuries, as they are apt to he complicated by lesions of the pelvic viscera. 392 DISLOCATIONS. The reduction of these dislocations is effected by pressure and manipulation, and after reduction the parts should be supported by a compress held in place by a stout binder or by broad strips of adhesive plaster, the patient being kept quiet in bed, and the pelvds being supported by means of sand-bags. The dressings should be retained for from four to six weeks. Dislocations of the Clavicle. Dislocations of the clavicle may occur either at the sternal or acromial end, and the latter injury some writers describe as a dislocation of the scapula, following the gen- eral rule that the distal bone is the one dislocated. Dislocations of the sternal end of the clavicle may occur in a forward, backward, or upward direction, and the dis- placement is generally well marked. (Fig. 288.) The Fig. 288. Fig. 289. Dislocation ot sternal end of clavicle Dislocation of clavicle at acromial forward. (Bryant.) end. (Bryant.) reduction of this dislocation is effected by placing the knee against the spine and drawing the shoulders outward and backAvard and pressing the displaced end of the clavicle into place. The reduction is generally easy, but it is often difficult to keep the end of the bone in its proper position. To accomplish this, a compress should dislocations of the scapula. 393 be placed over the end of the bone, and this should be secured in place by broad strips of adhesive plaster; the shoulders should be brought well backward and secured by a posterior figure-of-eight bandage of the chest and the arm of the injured side should be fastened to the side of the chest by spiral turns of a bandage. In some eases, in addition to the compress over the end of the bone, securing the arm of the injured side in the Velpeau posi- tion will be found all that is necessary to retain the bone in position. Dislocation of the acromial end of the clavicle may be upward, downward, or backward. (Fig. 289.) The re- duction is effected by manipulation of the arm and scapula and by pressure over the displaced end of the clavicle; the displacement is usually reduced without much trouble, but it is often a matter of difficulty to keep the end of the bone in its proper place. The dressing consists in placing a compress over the acromial end of the clavicle and holding it in place by broad strips of adhesive plaster; the arm should at the same time be fixed in the Velpeau position. These dress- ings after reduction of dislocations of the clavicle should be kept in place for at least three weeks. Although in many eases a certain amount of deformity persists, the disability resulting from the injury is not often marked. Dislocations of tup: Scapula. Dislocation of the acromion process of the scapula from the outer end of the clavicle, which has been described under dislocation of the acromial end of the clavicle, is classed by some writers as a scapular dislocation. Dislocation or projection of the inferior angle of the scapula, due to its escape from under the latissimus dorsi muscle or relaxation of this muscle and of the serratus magnus, is sometimes described as a dislocation of the in- ferior angle of the scapula. The reduction of this deformity consists in the employment of manipulation and pressure to overcome the displacement and the use of a compress 394 dislocations. held in place by broad strips of adhesive plaster to secure the bone in its proper position. Dislocations of the Shoulder. The head of the humerus may be dislocated downward, forward, or backward. Subglenoid or downward dislocation of the head of the humerus is that variety of dislocation in which the head of the bone rests in the axilla. (Fig. 290.) Fig. 290. Subglenoid dislocation of the shoulder. (Stimson.) Subcoracoid or forward dislocation of the head of the humerus is that varietv of dislocation in which the head dislocations of the shoulder. 395 of the humerus rests beneath the coracoid process of the scapula. (Fig. 291.) Subclavicular dislocation of the head of the humerus may be considered an aggravated form of the latter variety of dislocation ; the head of the humerus in this variety of dislocation rests beneath the clavicle. Fig. 291. Subcoracoid dislocation of the shoulder. (Stimson.) Subspinous or backward dislocation of the head of the humerus is that variety of dislocation in which the head of the humerus rests beneath the spine of the scapula. (Fig. 292.) The reduction of dislocations of the humerus is effected by manipulation, by extension and counter-extension, and by a combination of these methods. Manipulation in the reduction of subglenoid dislocation 396 dislocations. of the humerus is practised by first flexing the forearm upon the arm to relax the long head of the biceps muscle; the elboAV is next seized and abducted so as to bring it to the side of the patient's head, thus relaxing the deltoid and supra-spinous muscles ; the surgeon or an assistant next places his hand upon FlG- 292- the head of the humerus in the axilla, and, as the arm is drawn outward to a right angle with the body by the other hand, he pushes the head of the bone into the glenoid cavity. In the reduction of sub- glenoid and subclavicular dislocations the manipula- tions are the same except that the arm is to be ro- tated outward before being carried downward. In the reduction of sub- spinous dislocations after the arm has been abducted it should be rotated in ward and direct pressure should be made upon the head of the bone as the arm is adducted. Reduction may also be effected by extension and counter-extension as in Cooper's method, where extension is made from the arm dowmvard and counter-extension is made bv the heel in the axilla. (Fig. 293.) Kocher's Method of reduction of dislocations of the shoulder consists in flexing the elbow at a right angle and pressing it closely against the side, the forearm at the same time being turned as far as possible away from the trunk. While the external rotation is being maintained the elbow is carried well forward and upAvard and the arm is rotated imvard and the elboAV is loAvered. Subspinous dislocation of the head of the humerus. (Erichsen.) dislocations of the shoulder. 397 Fig. 293. Reduction of shoulder by heel in the axilla. (Erk iiskx.) Fig. 294. Reduction of shoulder by extension upward. Reduction may also be accomplished by extension made upward, as in Mothe's method, the scapula being fixed bv the foot or hand placed over the acromion process. (Fig. 294.) 18 398 DISLOCATIONS. After reduction of dislocations of the head of the humerus the arm should be bound to the side of the body bv the turns of a spiral bandage of the chest, or should be held against the side by the application of a Velpeau bandage (Fig. 51, p. 60); this dressing should be removed at intervals of a few days, and after ten days or two weeks all dressings should be dispensed with, passive motion should be employed and the patient allowed to move the arm. Dislocations of the Elrow. Dislocation of the Bones of the Forearm. Dislocations of the bones of the forearm at the elbow may either be backward, forward, or lateral. The backward dislocation is the most common form. (Fig. 295.) Fig. 295. Dislocation of both bones of the forearm backward. (Liston.) The reduction of backward dislocations is effected by making traction upon the forearm and at the same time making pressure upon the lower end of the humerus as the forearm is flexed upon the arm. Or the reduction may be accomplished by bending the arm slowly and forcibly over the knee placed upon the inner surface of the elbow so as to press upon the radius and ulna, separating them from the humerus and freeing the coronoid process from its abnormal position. (Fig. 2915.) Lateral dislocations of the bones of the forearm at the DISLOCATIONS OF THE ELBOW. 399 elbow arc reduced by making extension from the forearm, and at the same time making direct pressure on the dis- placed bones and counter-pressure on the lower end of the humerus. Fig. 296. Reduction with the knee in the bend of the elbow. (Hamilton.) Forward dislocations of the bones of the forearm at the elbow are reduced by making forced flexion at the elboAV, together with extension or counter-extension, or by mak- ing forced extension of the forearm at the elboAV, pressing the humerus backward and suddenly flexing the fore- arm. The dressing, after the reduction of dislocations at the elbow, consists in the application of a well-padded anterior right- or slightly obtuse-angled splint, to keep the forearm in a flexed position—the dressing being practically the 400 DISLOCATIONS. same as that for fractures of the lower end of the humerus, with an anterior angular splint (Fig. 297). This dressing should be retained for two or three weeks, being removed Fig. 297. Dressing after reduction of dislocation of the elbow. at intervals of several days; after the removal of the splint, passive motion should be practised, to prevent stiffness of the elbow-joint. Dislocation or the Head of the Radius. The head of the radius may be displaced forward, out- Avard, or backward, the forward dislocation being the most frequent. (Fig. 298.) The reduction of these disloca- tions is effected by making extension from the forearm and counter-extension from the lower end of the humerus, and at the same time the head of the bone is pressed into its proper position. The dressing after reduction of the displacement consists in the application of a compress over the head of the bone, and the arm and forearm should be placed upon a well -padded anterior angular splint, which is secured by a roller bandage. The dressing in similar to that employed in fractures of the lower end of the humerus, in which an anterior angular splint is em- ployed (Fig. 253, page 348). Difficulty is sometimes ex- perienced in keeping the head of the bone in position after reduction, so that the use of the compress in addition to DISLOCATION OF UPPER END OF ULNA. 401 Fig. 298. Dislocation of head of the radius forward. (Liston.) the use of the splint is often required. The arm should be kept upon the splint for three weeks, being re-dressed at intervals. Dislocation of the Upper End of the Ulna. The upper end of the ulna may be displaced backAvard, the olecranon projecting behind the condyles of the humerus, while the" head of the radius occupies its normal position. The reduction of this displacement is effected in the same manner as that of both bones of the forearm 402 DISLOCATIONS. backAvard, and the dressing after reduction is similar to that employed Avhen both bones have been displaced. Dislocations at the Wrist. The lower end of the ulna may be dislocated from the radius forward, backward, or inward. The reduction of these displacements is effected by fixing the radius and pushing the ulna back into place. The dressing after re- duction consists in placing the Avrist-joint at rest by the application of well-padded anterior and posterior straight splints. The splints should be retained for three or four weeks, dressings being made at intervals of two or three days. Dislocations of the carpus upon the bones of the forearm may be forward (Fig. 299), or backward (Fig. 300). The Fig. 299. Fig. 300. Dislocation of the carpus forward (Hamilton.) reduction in either variety of displacement is effected by extension from the hand and by pressure. After reduc- tion of the displacement, which does not tend to recur, the hand and forearm should be placed upon a well- padded straight splint applied to the palmar surface of the Dislocation of the carpus backward. (Hamilton.) DISLOCATIONS OF THE FINGERS. 403 hand and forearm. The splint should be retained for ten davs or two weeks. Dislocations of the Bones of the Carpus. The displacement of the individual bones of the carpus occasionally takes place, the os magnum, the semilunare and pisiform being the bones most usually displaced, although other bones of the carpus are sometimes dislocated Re- duction is effected by means of extension and pressure, and the part should afterward be dressed with a palmar splint and compresses. Dislocations of the Metacarpal Bones. The metacarpal bones may be dislocated upon the carpus; the bones most commonly displaced are those of the thumb, and of the index and middle fingers; the latter are usually displaced backward, while the metacarpal bone of the thumb may go either backward or forward. Reduction is effected by extension and pressure. The dressing after reduction consists in the application of a palmar splint to the hand and forearm and a compress over the displaced bone. The dressings should be retained for two weeks. Dislocations of the Fingers. Fig. 301. Backward dislocation of phalanx. Reduction by extension. (Hamilton.) 404 dislocations. Dislocations of the phalanges of the hand usually take place at the metacarpophalangeal junction, but sometimes occur at the intra-phalangeal joints. The reduction is usually easily effected by extension (Fig. 301), or by push- ing the phalanx back until it stands perpendicularly upon the metacarpal bone, when by strong pressure upon its base, from behind forward, it is readily carried by flexion into its natural position. Where difficulty is experienced in making extension in the reduction of these dislocations, the ingenious appa- ratus of the late Dr. Levis (Fig. 302), or the " Indian puzzle" apparatus (Fig. 303), may be employed with success. Fig. 302. Fig. 303. Extension hy Indian puzzle. (Bryant.) Iii dislocations of the proximal phalanx of the thumb backward (Fig. 304), great difficulty in reduction is often experienced from the head of the metacarpal bone slipping between the two heads of the short flexor muscle, or between the lateral ligaments. The interposition of the external sesamoid bone is considered by some surgeons to be the cause of difficulty in the reduction of this dis- placement. In this dislocation reduction is effected by firmly press- ing the metacarpal bone of the thumb strongly toward the palm of the hand to relax the two portions of the short dislocations of the hip. 405 flexor muscle. The thumb is next extended upon the wrist until its tip points to the elbow. An assistant noAv places his finger behind the proximal phalanx to prevent its slipping backward and by bringing the thumb doAvn to the flexed position the bone slips into place. It some- times happens that all efforts at reduction fail, and in such cases it may be necessary to divide one head of the short flexor muscle subcutaneously or through an open wound, before the displacement can be relieved. Fig. 304. Dislocation of proximal phalanx of thumb backward. (Farabeuf.) The dressing of dislocations of the phalanges after re- duction consists in the application of splints of wood, or moulded splints of binder's-board or gutta-percha to fix the joint, which should be retained for ten days or two weeks. Dislocations of the Hip. The head of the femur is most frequently dislocated backward, downward or upward, although it may assume other positions in exceptional cases. Posterior or backward dislocations of the head of the femur arc either backward and upward, and are described as iliac or dorsal, the bone resting upon the dorsum of the ilium (Fig. 3()o). Or the dislocation may be backward, 18* 406 dislocations. the head of the bone resting upon the ischiatic notch ; these are known as ischiatic dislocations or dislocations of the femur dorsal below the tendon (of the obturator in- ternus), according to Bigelow (Fig. 306). Fig. 305. Backward and upward dislocation of femur. (Cooper.) The reduction of the posterior dislocations of the femur can generally be effected by manipulation. The patient being anaesthetized and placed upon his back, the surgeon grasps the leg at the ankle and knee, flexes the leg upon the thigh, and the thigh upon the pelvis ; he then abducts the limb and rotates it outward, bringing it in a broad sweep across the abdomen, and by bringing it down to its natural position the head of the bone will slip into the acetabulum. (Fig. 307.) Downward Dislocation of the Head of the Femur, or Downward and Forward Dislocation.—In this variety of DISLOCATIONS OF THE HIP. 407 dislocation the head of the bone rests upon the thyroid foramen ; this form of displacement is sometimes spoken of as a thyroid dislocation. (Fig. 308.) Fig. 306. FlG. 307 Backward dislocation of femur. Keduction of backward dislocation (Cooper.) of femur. (Bigelow.) The reduction of downward and forward dislocations of the head of the femur is effected by flexing the leg and thigh and bringing the limb into a position of abduction; it is then adducted and rotated iinvard in a broad sweep across the abdomen and brought down to its uatural posi- tion, and the head of the bone slips into the acetabulum. (Fig. 30!I.) 408 DISLOCATIONS. In making these manipulations the head of the bone sometimes slips back upon the dorsum of the ilium, con- verting the doAvmward dislocation into a posterior one;>if Fig. 308. Fig. 309. Downward and forward dislocation Reduction of downward and for- of femur. (Cooper.) ward dislocation of the femur. (Bigei.ow.) this accident occurs the displacement should be remedied by making the manipulation appropriate for the reduction of the latter dislocation. Upward Dislocation, or the Dislocation Forward and I pward, of the Head of the Femur.—In this variety of dislocation the head of the bone rests upon the pubis; this form of displacement is also spoken of as a pubic dis- location. (Fig. 310.) I he reduction of forward and upward dislocations of DISLOCATIONS OF THE HIP. 409 Fir,. 310. the head of the femur is effected by much the same ma nipulation as is employed in the reduction of down ward and forward dislocations, except that in the pubic disloca- tion the flexed limb should be carried across the sound thigh at a higher point. The thigh being flexed the head of the bone is drawn down from the pubis; it is then semi-abducted and rotated inward to disengage the bone completely. While rotating in- ward and drawing on the thigh the knee should be carried inward and downward to its place bv the side of its fellow, and the head of the bone will usually slip into the acetabulum. As before stated various anoma- lous displacements of the head of the femur occasionally occur; the head of the bone may pass directly upward, ordownward between the sciatic notch and thyroid foramen, ordownward and backward on the body of the ischium, or downward and backward into the lesser sci- atic notch, or downward, inward, and forward into the perineum. These anomalous displacements usually occur where there has been extensive laceration of the capsular and Y-ligaments. The dressing of cases, after reduction of dislocations of the head of the femur, consists in keeping the patient at rest in bed upon his back, and the limb should be kept at rest by sand-bags applied to either side of the limb, or the knees should be tied together. The patient should be kept at rest for two or three weeks, and at the end of this time may be allowed to get out of bed and u'o about on crutches. Forward and upward disloca- tion of the femur. (Cooper.) 410 DISLOCATIONS. Dislocations of the Patella. The patella may be dislocated outward, inward, or up- ward, or it may be rotated upon its own axis. The out- ward dislocation is the displacc- FlG-3U- ment most usually seen. (Fig. 311.) UpAvard dislocation of the patella can only result from laceration of the ligamentum patellae, and the treatment in such cases is similar to that for fracture of the patella. The reduction of dislocations of the patella is effected by ex- tending the leg upon the thigh, and flexing the thigh upon the pelvis to relax the quadriceps femoris muscle, when the patella can usually be forced back into place; in some cases alternate flexion and extension of the leg will accomplish the same result. The dressing after reduction of the displacement consists in outward dislocation of the the application of a posterior patella. (Duplay.) straight splint or a moulded binder's-board or felt splint to keep the joint at rest; the splint should be worn for a week or ten days. Dislocations of the Knee. The head of the tibia may be dislocated forward, back- ward, or laterally; the latter dislocations are always incomplete, forward dislocation being the variety of dis- placement most commonly met with. (Fig. 312.) The reduction of dislocations of the knee is effected by DISLOCATION OF SEMILUNAR CARTILAGES. 411 extension and counter-extension Avith forced flexion of the knee with pressure, aided by rocking movements. The treatment of cases of dislocation of the knee after reduc- tion consists in fixing the knee-joint by the application of a straight posterior splint or a moulded splint of binder's Fig. 312. Patella board. As there is usually marked swelling following these injuries from violence to the joint-structures, the application of evaporating lotions for a few days will be found useful. As soon as the swelling has subsided the joint should be put up in a plaster-of'-Faris dressing, and this should be retained for four weeks. Dislocation of the Semilunar Cautilages. The displacement here consists in the slipping forward or backward and wedging of the semilunar cartilages be- tween the femoral condyles and the tibia. Reduction of the displaced cartilages can usually be effected by hyper-flexion of the knee followed by sudden full extension, or by alternately flexing and extending the joint. Excision of the displaced cartilages is sometimes required in eases in which they cannot be reduced by manipulation. The dressing of these cases after reduction of the dis- placed cartilages consists in the application of a posterior straight splint or a plaster-of-Paris dressing to fix the knee-joint; the splint should be worn for three or four 412 DISLOCATIONS. weeks, and if there is a tendency to ledisplaeement the patient should Avear a knee-cap of leather or muslin to partially fix the joint, with compresses so arranged as to make pressure upon the edge of the joint. Dislocation of the Fibula. Dislocations of the fibula may occur at either of its ex- tremities, and the direction of the displacement may be forward,, backward, or upward, dislocation of the head or upper extremity of the fibula being the most common, although all are rare forms of displacement. The reduction of dislocations of the head of the fibula is effected by flexing the leg upon the thigh and making direct pressure and extension. Dislocations of the lower extremity of the fibula are reduced by manipulation and pressure. The dressing of cases after reduction of dislo- cations of the fibula consists in the application of a com- press and moulded binder's-board splint, and the dressing should be retained for three or four weeks. Dislocations of the Ankle. Dislocation of the foot upon the bones of the leg results from the separation of the articular surface of the astragalus from that of the tibia and fibula, and the dis- placement may he forward, backward (Fig. 313), or lateral (Fig. 314), the latter variety being often associated with fracture of the malleoli. The reduction of dislocations of the ankle is effected by traction, combined with flexion and rotation of the ankle- joint, the leg being first flexed upon the thigh to relax the tendo Achillis, and in some cases the subcutaneous division of this tendon is required before the reduction can be satis- factorily accomplished. The dressing of dislocations of the ankle after reduction consists in the application of a fracture-box, or of paste- board splints to fix the ankle, care being taken to see that the foot is fixed at a right angle to the leg, and in the dislocations of the tarsal bones. 413 application of evaporating lotions for a few days; after the swelling has subsided, a plaster-of-Paris dressing should be applied and retained for three or four weeks. Fig. 313. Fig. 314. \ | \ Dislocation of foot (Bryant Dislocations of the Tarsal Bones. The astragalus may be dislocated from the bones of the leg and from the other tarsal bones, being thrust forward, backward, outward (Fig. 315), or inward. The reduction of dislocations of the astragalus outward is effected by first Hexing the leg upon the thigh and making extension from the foot and rotating it at the same time, direct pressure being made upon the displaced bone ; in some eases subcu- taneous section of the tendo Achillis has assisted materially in the reduction of the displaced bone. Backward dis- location of the astragalus is usually irreducible ; the patient, however, in many cases recovers with a useful foot. In eases of irreducible dislocations of the astragalus, ex- cision of the astragalus may ultimately be required. After the reduction of dislocations of the astragalus, the foot and leg should be put at rest in a fracture-box, backward. ■) Dislocation of foot inward. (Bryant.) 414 dislocations. Fig. 311 or bv means of moulded splints of pasteboard or felt; evaporating lotions should also be employed to the region of the injury for a few days, and Avhen the swelling has sub- sided, a plaster-of-Paris dress- ing should be applied and retained for three or four weeks. Dislocations of the calca- neum and scaphoid upon the astragalus, or of the calca- neum upon the astragalus and cuboid, or upon the astragalus alone; of the scaphoid and cuboid upon the calcis and astragalus; or of the cuboid, scaphoid, or cuneiform bones, are occasionally met with. Their reduction is effected by traction and direct press- ure, and, after this has been accomplished, the parts should be put at rest by the appli- , , cation of a splint and coni- Dislocation of astragalus outward. 1 (Hamilton.) presses. Dislocations of the Metatarsal Bones and Phalanges of the Toes. These dislocations usually result from crushing forces which destroy the vitality of the soft parts so completely that amputation is required. Their reduction in cases of simple or uncomplicated dislocations is effected by traction, manipulation, and pressure. After reduction of the dis- placement, the parts should be kept in position by the application of splints and compresses. old dislocations. 415 Old Dislocations. The reduction of old dislocations is attended with more difficulty and danger than that of recent dislocations, due to the permanent contraction and structural changes which occur in the muscles, and to the abnormal adhesions which form between the displaced bone and the parts with wdiich it is in contact. The reduction of old dis- locations can usually be accomplished by the manipula- tions appropriate for recent dislocations of the same variety, but occasionally the use of more forcible extension is required, wdiich is made by bands and pulleys (Fig. 316), Fig. 316. Reduction of old dislocation of the femur by pulleys. (Cooper.) or by vertical extension (Fig. 317). The first step in the reduction of old dislocations consists in thoroughly break- ing up the adhesions which have been formed between the displaced bone and the surrounding tissues; this has, in some cases, resulted in the laceration of muscles, nerves, and bloodvessels, and in the fracture of the displaced bones or neighboring bones, so that the manipulations should be made with the least force that will accomplish the object desired. After the reduction of old dislocations, difficulty is sometimes experienced in maintaining the bone in its 416 dislocations. proper place, due to the changes which have occurred in the articular surfaces. FIG. 317. Reduction of old dislocation of hip by vertical extension. (Bigelow.) Ccimpound Dislocations. These arc always grave injuries, and amputation or excision is often required. When, however, operative measures are not required, the reduction is effected in the same manner as in simple dislocations of corresponding parts, the greatest care being taken to render the wound aseptic, and to keep it in this condition by the application of a full antiseptic dressing. congenital dislocations. 417 Complicated Dislocations. Tn dislocations complicated by fracture near the seat of displacement, the displaced bone should, if possible, be first reduced, and this in many cases is a matter of much difficulty as the fracture prevents the surgeon from using leverage otherwise present, in the reduction, and he has often to depend entirely upon pressure and manipulation to restore the displacement. After reduction of the dislocation the fracture should be reduced and dressed. Dislocation complicated by rupture of the main artery of the limb may require, after reduction of the displace- ment, exposure and ligation of the Aessel or amputation of the limb. Rupture of an important nerve trunk com- plicating a dislocation may call for subsequent exposure and suturing of the divided nerve. Spontaneous Pathological and Congenital Dislocations. In the treatment of these varieties of dislocations after the reduction of the displacement by manipulation and pressure much difficulty is often experienced in maintain- ing the reduction. To effect the latter object the use of splints and bandages is employed and also the use of many ingenious forms of apparatus adapted to particular dislocations. Tenotomy or myotomy arc often required to prevent recurrence of the deformity, and continuous extension is also of much value in the treatment of these displacements'. PART V. ligation of arteries. In the application of a ligature to an artery in its con- tinuity the surgeon should make his incision in the line which corresponds to the general course of the vessel, and he should be thoroughly familiar with the anatomy and with the surgical landmarks of the part. A portion of the vessel, when possible, should be selected for the appli- cation of the ligature half an inch or an inch from any large collateral branch. The position of the incision being selected the surgeon steadies the skin with two fingers and makes an incision of the required length through it with a scalpel; the superficial fascia is next picked up on a director, any large superficial veins which come into view being displaced, and divided to an equal length with the incision in the skin; the deep fascia being exposed it should be nicked and divided upon a director; the inter- muscular space or the edge of the muscle or muscles which are the guide to the vessel should next be sought for, small vessels coming from the main vessel through these spaces will often serve as valuable guides to the position of the vessel. The surgeon next separates the tissues with the director, handle of the knife, or the finger until the sheath of the vessel is exposed ; this is recognized by its communicated pulsation and by the absence of the smooth shining surface and pinkish-white color which the surface of the artery presents. The sheath of the artery should be picked up with forceps and nicked with the point of the knife applied flatwise; the incision into ligation of arteries. 419 the sheath should be very limited, only large enough to allow the aneurism needle to pass through it around the vessel; extensive dissections or separations of the sheath from the vessel should be avoided, as the nutrition of the arterv at the point of ligature may thus be impaired and sloughing and secondary hemorrhage may result. A dis- tinct sheath is found only about the main arterial trunks, Fig, 318. " Fig. 319 Opening sheath. Passing ligature around the Aneurism needle. vessel. Tying artery. (Bjiyant.) which is replaced in the smaller arteries by a layer of loose cellular tissue. The wall of the artery being exposed an aneurism needle is passed around the vessel, threaded with a catgut ligature, and withdrawn; the needle may be threaded before being passed, in which ease the ligature is grasped with forceps and drawn through while the needle is withdrawn. The best material for ligatures is carefully prepared chromicized catgut. The needle should be passed away from important structures such as accom- panying veins and nerve's. 420 ligation of arteries. Before the ligature is tied the surgeon should satisfy himself that the ligature when tied will control the circula- tion in the vessel below its point of application, by placing the tip of his finger upon the vessel and drawing upon the ends of the ligature so as to occlude the vessel at the point of application. Being satisfied as to this point the ligature is tied with a reef-knot, or a surgeon's-knot and reef-knot combined. Some authorities recommend the application of two ligatures a short distance apart in the ligation of vessels in their continuity, and a division of the vessel between them, so that both ends can retract into the cellular sheath. The ends of the ligature are cut short in the wound, which is irrigated and drained if necessary, and is closed by the application of a few sutures, and an antiseptic dressing is applied. Ligation of Special Arteries. Ligation of the Innominate Artery. The innominate artery lies immediately behind the sterno-elavicular articulation, and is in relation in front with the innominate veins and pneumogastric nerve, on the inner side with the trachea, on the outer side and behind with the pleura. Incision.—A V-shaped incision, each branch of which is two and a half or three inches in length, one of which lies over the anterior edge of the sterno-cleido-mastoid muscle, and the other parallel to and a little above the clavicle. (Pig. 320, A.) The incisions are carried down to the superficial fascia and a flap is dissected up. If the anterior jugular vein is met with it should be displaced. The sternal and clavicular attachments of the sterno- cleido-mastoid are next divided upon a director half an inch above the bone. The sterno-thyroid and sterno- hyoid muscles and the middle cervical fascia are next ex- posed, covered by the thyroid veins. The outer fibres of ligation of the subclavian artery. 421 the sterno-hyoid and sterno-thyroid muscles are next divided, the thyroid vein being held aside, when upon tearing through the fascia with a director the common carotid artery is exposed and traced down to the innomi- nate artery ; the innominate veins are pressed against the sternum with the finger and the artery is separated from its sheath about half an inch below its bifurcation, and Fig. 320. Line of incision for—A, innominate artery ; B, right subclavian artery ; C, left subclavian artery; D, vertebral or inferior thyroid artery; E, axillary artery below clavicle. (Stimson.) the aneurism needle is passed around the vessel from the outer side so as to avoid the vein, pneumogastric nerve, and pleura. Ligation of the Subclavian Artery. This artery may be tied at three points; in its first portion, between the trachea and scaleni muscles; in its wont] portion, behind the scaleni muscles, and in its third portion external to the scaleni muscles. 19 422 ligation of arteries. The left subclavian artery in its first portion is larger and more vertical in its direction than the right subclavian and is situated more posteriorly; from the difficulty in exposing this portion, and from the possibility of injuring the thoracic duct, the ligation of this artery in its first portion has been seldom attempted. Incision for the first portion of the subclavian artery is the same as that for the innominate (Pig. 320, A), and Fig. 321. Ligation of subclavian and lingual arteries. (Bryant.) the ligature is passed from the outer side, the pneumo- gastric and phrenic nerves being pressed inward toward the carotid artery. The right or left subclavian arteries are also seldom ligation of the vertebral artery. 423 tied in their second portions, that is behind the scaleni muscles, but are frequently tied in their third portions, that is external to the scaleni muscles. Incision for the second portion of the subclavian artery begins an inch external to the sterno-clavieular articulation half an inch above and parallel to the clavicle, and is three or four inches in length. (Fig. 320, B or C.) The steps of the operation arc the same as for ligation of the third portion, and when the scalenus anticus muscle has been exposed it is divided upon a director; the phrenic nerve which lies upon its anterior aspect is to be avoided. Incision for the third portion of the subclavian artery is the same as for the second portion. (Fig. 320, B or C.) The skin and platysma being divided, the jugular vein is exposed and drawn to one side or divided between the ligatures; the superficial fascia is next divided upon a director; the posterior belly of the omo-hyoid muscle is next found and drawn upward and outward; the outer border of the scalenus anticus is next felt for and followed down to the tubercle of the first rib—the artery lies against this, between it and the lowest bundle of the brachial plexus. The artery is next denuded with the director and the needle is passed from below, care being taken not to include the lowest bundle of the brachial plexus in the ligature. (Pig. 321.) Ligation of the Vertebral Artery. Incision for the ligation of the vertebral artery is three or three and a half inches in length, parallel with the an- terior edge of the sterno-cleido-mastoid muscle, ending an inch above the clavicle. (Fig. 320, D.) The anterior edge of the sterno-cleido-mastoid being exposed the middle cervical fascia is divided and the carotid artery and jugu- lar vein are exposed and drawn inward. The gap between the longus colli muscle and the scalenus anticus muscles is next felt for about an inch below the carotid tubercle; the fascia covering it is next torn through and the musdes are separated and the vertebral vein comes into view; this is 424 LIGATION OF ARTERIES. held aside and the vertebral artery is exposed, and the ligature is then passed around it. Ligation of the Inferior Thyroid Artery. Incision for the inferior thyroid artery is the same as that for the vertebral artery. (Fig. 3)20, D.) The anterior edge of the sterno-cleido-mastoid muscle being exposed it is drawn outward, the middle cervical fascia is next divided and the carotid artery and internal jugular vein are drawn outward with a retractor. The head being flexed slightly, the surgeon feels for the carotid tubercle, and then sepa- rates the cellular tissue with a director, and the artery should be found beloAV the carotid tubercle. The needle should be passed between the artery and vein. Ligation of the Internal Mammary Artery. Incision, a vertical one, two and a half inches in length, commencing at the lower border of the clavicle, parallel with and three lines external to the margin of the sternum. Divide the skin and superficial fascia and expose the fibres of the pectoral muscle, the external intercostal aponeurosis and the muscular fibres of the internal intercostal muscle. liaise the fasciculi of the latter muscle upon a director and divide them, and the vessels will be exposed. The internal mammary artery is not often tied below7 the fourth intercostal space. Ligation of the Common Carotid Artery. The point of election for the ligation of the common carotid artery is just above the omo-hyoid muscle, about three-quarters of an inch below the bifurcation of the vessel, which takes place at a point on a line with the upper border of the thyroid cartilage. Incision for the common carotid artery is three inches LIGATION OF COMMON CAROTID ARTERY. 425 Fig. 322. Line of incision for common carotid artery at point of election. (Stimson.) Fig. 323. \Carelid \artery .......••• -Jfcs-.^. rntljutj[Ular >'. vein Ligation of common carotid artery. Ligation of facial artery. (Bryant.) i 426 LIGATION OF ARTERIES. in length along the anterior border of the sterno-cleido- mastoid muscle, the centre of which corresponds with the crico-thyroid space. (Fig. 322.) Div ide the skin, platysma and cellular tissue and apo- neurosis, avoiding the superficial veins, and expose the anterior edge of the sterno-cleido-mastoid ; seek for the interspace betw ecu this muscle and the sterno-hyoid and sternothyroid muscles, draw the latter muscles inward and the artery will be exposed with the jugular vein external to it; the descendens noni nerve lying upon its sheath, wdiich should be displaced outward. The sheath is next picked up and opened and the artery is separated from it with a director; the artery lies internally, the in- ternal jugular vein externally and somewhat more super- ficial, and the pncumogastric nerve lies between the two and is more deeply placed. (Pig. 323.) The sympathetic nerve is posterior to the vessel external to the sheath. The needle is passed from without inward, care being taken to avoid injury of the vein and nerve. (Fig. 324.) Fig. 324. Relation of the left common carotid artery above the omo-hyoid muscle. (Esmaech.) ligation of internal carotid artery. 427 Ligation of the External Carotid Arterv. Incision for the ligation of the external carotid artery is over the inner edge of the sterno-cleido-mastoid muscle from the angle of the jaw to a point corresponding to the middle of the thyroid cartilage. (Fig. 325, B.) The skin, platysma and cellular tissue being divided, the external jugular vein is drawn aside when encountered ; the deep fascia being opened, the facial and lingual veins will be exposed, Avhieh should be drawn to one side; the artery is next exposed covered by the hypoglossal nerve and the stvlo-hvoid and digastric musdes. The vessel should next be isolated from the internal carotid arterv and in- ternal jugular vein, both of which lie along its outer side. The needle should be passed from without inward. Ligation of the Internal Carotid Artery. Fig. 325. Line of incision for-^. Lingual artery. B. External and internal carotid artery. C. Occipital artery. D. Temporal artery. E. Facial artery. (Stimson.) 428 LIGATION OF ARTERIES. Incision the same as for the external carotid arterv (Fig. 325, B); the vessel is external to the external carotid artery, and in passing the needle the point should be directed from the internal jugular vein, that is from without inward. Ligation of the Superior Thyroid Arterv. Incision about three inches in length along the anterior border of the sterno-cleido-mastoid muscle, starting a little lower down than that for the external carotid artery. The skin, superficial fascia, platysma, and deep fascia being divided, the cellular tissue in the sulcus between the upper portion of the larynx and the great vessels of the neck is broken up with the director and the vessel is exposed. The needle should be passed around the vessel from above downward. Ligation of the Lingual Artery. Incision a curved one two inches long, its concavity directed upward from the anterior edge of the sterno- cleido-mastoid muscle FlG-326- half an inch above the great horn of the hyoid bone, to a point one inch short of the median line of the neck. (Fig. 325, A.) Divide the skin and platysma, displacing the superficial veins, and open the dee]) fascia, when the sub- maxillary gland will be exposed; this is displaced upward with the handle of the knife and the tendon of the digastric muscle attached to the hvoid mh Relations of the lingual artery. (Esmarch.) LIGATION OF THE TEMPORAL ARTERY. 429 bone, and the hypoglossal uerve will be exposed; next divide the fibres of the hyoglossus muscle midway between the hypoglossal nerve and the hyoid bone, and the lingual artery will be exposed. (Fig. 326.) The needle should be passed around the vessel from above downward in order to avoid the nerve. Ligation of the Facial Artery. The facial arterv passes over the inferior maxilla just in front of the anterior edge of the masseter muscle and is accompanied by the facial vein, which lies nearer to the muscle. Incision either a horizontal one along the lower border of the maxilla or a vertical one an inch in length. (Fig. 325, E.) The skin, subcutaneous tissue, and fascia being divided, the arterv is exposed and the needle should be passed around the vessel away from the vein. Ligation of the Occipital Arterv. Incision two inches in length, starting from a point half an inch below and in front of the apex of the mastoid process carried obliquely backward parallel to the border of this process. (Pig. 325, C.) Divide the skin and fascia and expose the insertion of the sterno-cleido-mastoid muscle, which is also divided, and the aponeurosis of the splenitis is exposed ; this is also opened and the digastric groove is felt for, and wdien the belly of the digastric muscle is exposed the artery is brought into view by separating the cellular tissue in the anterior angle of the wound with a director. (Fig- 327.) Ligation of the Temporal Artery. Incision a transverse one, one inch in length, starting from the tragus of the ear forward over the zygomatic arch (Fig. 324, D), or a vertical one of the same length a little in front of the tragus of the ear. 19* 430 ligation of arteries. Divide the skin and expose the subcutaneous cellular tissue, which in this region is very dense and fibrous. This tissue should be broken up with a director and the artery should be found in it about a quarter of an inch in front of the ear. (Fig. 328.) The temporal vein accompanies Fig. 327. Fig. 328. Ligation of the occipital artery. Ligation of the temporal artery. (Skey.) (Skey.) the artery and lies nearer to the ear, and in some cases the auriculo-temporal nerve is in close relation to the artery. The needle should be passed from behind forward. Ligation of the Axillary Arterv. The axillary artery extends from the middle of the clavicle to the insertion of the teres major into the humerus ; the axillary vein lies upon the inner side and in front of the artery. The axillary artery is tied either in its upper portion, just below the clavicle, or at its lower portion in the axilla. Ligation of the Axillary Artery Below the Clavicle. Incision four inches in length from the summit of the coracoid process inward a short distance belcnv the clavicle (Fig. 320, E), or an incision three inches in length, com- ligation of the axillary artery. 431 meucing at a point one-half an inch from the sterno- clavicular articulation and carried obliquely downward toward the axilla. The skin and subcutaneous tissue haying been divided the deep fascia is exposed and opened, or the axillary artery may be reached by following the intermuscular space betAveen the sternal and clavicular fibres of the pec- toralis major which leads upward toward the clavicle and to the pectoralis minor; or the fibres of the pectoralis major being exposed are cut through and the costo-coracoid fascia is next torn through with a director, care being taken to avoid injury of the cephalic vein at the outer portion of the wound ; the pectoralis minor is now seen, and after separating the cellular tissue with a director the axillary vein is seen crossing from the upper edge of the muscle to the clavicle; the Aein almost completely covers the arterv, which is exposed by drawing the vein inward. The needle is passed around the artery from within outward. Ligation of the Axillary Artery in the Axilla. Incision two and a half inches long, started at the upper part of the axilla and carried down the arm at the edge of the coraco-brachialis muscle. (Fig. .'529, A.) The skin Fig. 329. A. Incision for axillary artery in axilla. B. Incision for brachial artery. (Stimson.) 432 LIGATION OF ARTERIES. only is divided in the first incision and the deep fascia is picked up and divided upon a director, and the fibres of the inner border of the eoraeo-brachialis muscle are ex- posed and held aside by a retractor, and the operator will see the median nerve, the miisculo-cutaneous nerve, and the axillary artery. To the inner side of the artery arc Fig. 330. Relations of right axillary artery in axilla. (Esmarch.) the axillary vein, ulnar and internal cutaneous nerves. The needle should be passed around the artery from the vein toward the coraco-brachialis muscle. Ligation of the Brachial Artery. Incision at the middle of the arm three inches long on a line corresponding to the inuer edge of the biceps muscle. (Pig. 329, B.) The skin and cellular tissue being divided, care being taken uot to injure the basilic vein, which should be drawn posteriorly, the deep fascia is next cut through and the fibres of the biceps muscle are exposed (Fig. 331); this should be drawn forward, and the sheath LIGATION OF THE BRACHIAL ARTERY. 433 of the vessels enclosing the artery, veins, and median nerve is exposed ; this is opened, the median nerve is pressed aside and the artery is separated from its veins Fig. 331. Relations of right brachial artery at middle of arm. (Esmarch.1 and the needle is passed from the side of the nerve around the vessel. In ligating the brachial artery the occasional high division of the vessel must be borne in mind. Fig. 332. Tendinous, llioneurotis divided Ligation of the brachial artery at bend of elbow. (Bryant.) 434 LIGATION OF ARTERIES. Ligation of Brachial Artery at Bend of Elbow. Incision two inches in length, along the inner border of the tendon of the biceps muscle. Divide the skin, super- ficial fascia, and the bicipital aponeurosis, under which the artery will be exposed, resting upon the brachial is anticus muscle. (Fig. 332.) The median nerve is to the inner side and some distance from the artery. The needle should be passed around the vessel, after isolating the veins, from within outward. Ligation of the Radial Artery. The radial artery extends in a straight line from a point half an inch below the centre of the fold of the elbow to the inner side of the styloid process of the radius. The radial arterv may be tied at its upper, middle, or lower third, or at the root of the thumb. Ligation of the Radial Artery in the Upper Third of the Forearm. Incision for the radial arterv at its upper third is two and a half inches in length on a line draAvn from the middle of the bend of the elboAV to the ulnar side of the styloid process of the radius; the incision should begin one and a half inches below the bend of the elboAV. (Fig. 333, A.) Divide the skin and superficial fascia, avoiding the superficial veins. When the deep fascia is exposed find the edge of the supinator longus muscle and divdde the aponeurosis along its ulnar side and expose the fibres of the pronator radii teres muscle. The vessel lies in the interspace between these muscles surrounded by adipose tissue, and upon being exposed the veins should be isolated and the needle passed from without inward. The radial nerve lies so far external to the artery that it is not often exposed in the operation. (Fig. 334.) ligation of the radial artery. 435 Fig. 333. Fig. 334. Relations of right radial artery in the upper third of the forearm (Esmarch.) Fig. 335. Line of incison for—A. Radial artery in upper third. B. Radial artery in lower third. C. Ulnar artery in upper third. D. Ulnar artery in lower third (Stimson.) Relations of right radial artery above the wrist. (Esmarch.) Ligation of the Radial Artery in the Middle Third of the Forearm. Incision two inches iu length, following the same line as that for the upper third of the artery. After dividing the skin, superficial and deep fascia, the artery is found in the interspace between the flexor carpi radial is on the 436 ligation of arteries. inner side and the supinator longus on the outer side; the radial nerve at this part of the arm is in close relation with the vessel to the radial side, and the needle should be passed around the artery from without inward. Ligation of the Radial Artery in the Lower Third of the Forearm. Incision two inches in length following the same line (Fig. 333, B), ending one inch above the wrist. The skin, superficial fascia, and deep fascia being divided, the artery will be found between the tendon of the flexor carpi radial is on the inner side and the tendon of the supinator longus on the outer side. (Fig. 335.) The veins being separated the needle may be passed in either direction. Ligation of the Radial Artery at the Root of the Thumb. The radial artery may also be tied at the root of the thumb. Incision one inch in length between the tendons of the extensor ossis metaearpi pollicis and extensor primi inter- nodii pollicis on the outer side, and the tendon of the ex- tensor secundi internodii pollicis on the inner side. The skin and superficial fascia being divided and the radial vein being displaced, the deep fascia is opened and the artery is exposed at the bottom of the wound; the needle may be passed in either direction. Ligation of the Ulnar Artery. The ulnar artery is tied at the junction of the upper and middle third of the forearm aud at the lower third. Ligation of the Ulnar Artery at the Junction of the Upper and Middle Thirds of the Forearm. Incision three inches in length, starting four inches below the internal condyle of the humerus, on a line passing from the internal" condyle of the humerus to the ligation of the ulnar artery. 437 outer border of the pisiform bone. (Fig. 333, C.) Divide the skin and superficial fascia, and when the deep fascia lias been exposed the interspace between the flexor carpi ulnaris and the flexor sublimis digitorum appears, enter this interspace and raise the flexor sublimis digitorum and work transversely across the arm, and the arterv will be found resting upon the deep flexor, with the ulnar nerve to the ulnar side. The needle should be passed from the nerve around the arterv. (Fig. 33b.) Fig. 336. Relations of the right ulnar artery at upper third of forearm. (Esmarch.) Ligation of the Ulnar Artery in the Lower Third of the Forearm Incision two inches in length a little to the radial side of the tendon of the flexor carpi ul- naris, which is attached to the pisiform bone, ending an inch above the wrist. (Fig. '■):]:), D.) Divide the skin and superficial fascia and open the dec]) fascia, and the artery will be exposed, with accompanying veins, between the tendons of Relations of right ulnar artery above the wrist. (Esmarch.) 438 LIGATION OF ARTERIES. the flexor carpi ulnaris and flexor sublimis digitorum, the ulnar nerve being to the ulnar side of the vessel. The needle should be passed from within outward to avoid the nerve. (Fig. 337.) LIGATION OF THE INTEROSSEOUS ARTERY. Incision similar to that employed in the ligation of the ulnar artery in its upper third. Ligation of the Abdominal Aorta. Incision in the linea alba from a point three inches above the umbilicus to a point three inches below it. The superficial structures being divided the peritoneum is opened upon a director, and the intestines are pressed aside and the aorta is exposed covered by peritoneum, with the filaments of the sympathetic nerve resting upon it, and the vena cava to the right side. Tear through the peri- toneum and pass the needle from left to right around the vessel. After tying the ligature the ends should be cut short, and the external wound should be closed as in the ordinary cceliotomy wound. The vessel may also be exposed by an incision along the anterior border of the quadratus lumborum muscle, from the last rib to the crest of the ilium. The skin, lumbar muscles, and fascia transversal is being divided, the wound is held open with blunt hooks, so that the retro-peritoneal space is exposed and the aorta brought into view. The vessel being separated from the vena cava and nerves, the needle is passed around it and the ligature applied. Ligation of the Common Iliac Artery. The aorta divides into the two common iliac arteries on the left side of the fourth lumbar vertebra, and these arteries are usually about two inches in length, and bifurcate opposite the saero-iliac synchondrosis to form the internal and external iliac arteries; the length of the ligation of common iliac artery. 439 common iliac artery, however, may vary considerably, being three or four inches in length in some cases. Incision for ligation of the common iliac artery is four to six inches in length, beginning one-half inch alxne the middle of Poupart's ligament, and is carried outward, curving upward after passing the anterior superior spine of the ilium. (Pig. 33S, A.) Divide the skin, superficial fascia and aponeurosis of the external oblique muscle, and then divide the fibres of the internal oblique and transversalis muscles upon a director and expose the transversalis fascia. This is Fig. 338. Line of incision for—A, common iliac artery. B, external iliac artery. C. femoral artery in Scarpa's triangle. (Stimson.) opened at the lower part of the wound, and the finger is introduced and the peritoneum is pressed back ; the open- ing in the transversalis fascia is next enlarged, and the peritoneum is carefully drawn imvard and upward with the fingers toward the inner edge of the wound. The operator next feels for the external iliac artery, and passes 440 ligation of arteries. the finger along this until the common iliac artery is reached. The loose cellular tissue in which it is imbedded is next separated, and the needle is passed from within outward, to avoid the common iliac vein (Fig. 339), which on the left side lies on the inner side of the artery, and on the right side lies behind the artery. The ureter generally remains attached to the peritoneum ; if not, it is seen crossing the bifurcation of the common iliac with the Fig. 339. Ligation of the common iliac artery. (Liston.) genito-crural nerve, and care should be taken to avoid injury of these structures if present. The common iliac artery may also be exposed and tied by an incision made over the artery through the peritoneal cavity; the vessel being tied, the ends of the ligature are cut short, and the external wound is closed in the same manner as that resulting from the exposure of the ab- dominal aorta by incision through the peritoneum. ligation of external iliac artery. 441 Ligation of the Internal Iliac Artery. Incision in the same line as for the common iliac arterv, but it need not be quite so long. (Fig. 338, A.) The peri- toneum being exposed, it is pushed upward and inward, and the internal iliac arterv is exposed. The vessel is care- fully isolated from the vein, which lies behind and on the inner side, and the needle is passed from within outward. Ligation of the External Iliac Artery. Incision three or four inches in length, half an inch above the middle of Poupart's ligament, made at first par- allel to it and then curved upward. (Fig. 338, B.) The tissues of the abdominal wall being divided and the peri- Fig. 34C. f toneum exposed, it is pushed upward and inward in the same manner as for exposure of the common iliac artery. The artery lies at the inner border of the psoas muscle, the vein on its inner side, and the anterior crural nerve 442 ligation of arteries. covered by the iliac fascia on the outer side; the genito- crural nerve passes obliquely across the artery. (Fig. 340.) The needle should be passed from within outward. Ligation of the Gluteal Artery. Incision three or four inches in length, from the posterior superior spinous process of the ilium to a point midway between the tuber ischii and the great trochanter. (Fig. 341, A.) After division of the skin and fascia, the fibres Fig. 341. Line for—A, gluteal artery. B, sciatic and internal pudic artery. (Stimson.) of the gluteus maximus muscle are separated and held apart, and the deep fascia is divided, and the artery is sought for above the piriformis muscle at the upper border of the great sacro-sciatic notch. It is accompanied by large veins, injury to which should be avoided in exposing the artery and passing the needle. ligation of the femoral artery. 443 Ligation of the Sciatic and Internal Pitdic Arteries. Incision three or four inches in length, a little lower than that employed for exposure of the gluteal artery. (Pig. 341, B.) Divide the skin, superficial fascia and fibres of the gluteus maximus muscle and deep fascia, and search for the vessels as they leave the great sciatic notch at the lower ed^e of the pyriformis muscle. The internal pudic arterv enters the pelvis through the lesser sciatic notch, lying on the inner side of the sciatic artery during its passage over the spine of the ischium. The vessels are isolated and the needle is passed so as to avoid injury of the veins. Ligation of the Femoral Artery. The femoral artery may be ligated just below Poupart's ligament, at the apex of Scarpa's triangle, at the middle of the thigh, or in Hunter's canal. Fig. 312. Relations of the right femoral artery below Poupart's ligament. (Esmarch.) 444 ligation of arteries. Ligation of the Femoral Artery below Poupart's Ligament. Incision beginning midway between the anterior superior spinous process of the ilium and the symphysis pubis, one-fourth of an inch above Poupart's ligament, and ex- tending two inches downward. Divide the skin and superficial fascia and the deep fascia and expose the sheath of the vessels; open this one-half an inch below Poupart's ligament and isolate the femoral artery from the femoral vein which lies to the inner side; the anterior crural nerve lies to the outer side. Pass the needle from within out- ward. (Fig. 342.) Ligation of the Femoral Artery at the Apex of Scarpa's Triangle. Incision three inches long, the centre of which should be a little above the point where the sartorius muscle crosses Fig. 343. Lines of incision for the femoral artery. (Stimson.) a line drawn from the middle of Poupart's ligament to the inner condyle of the femur. (Fig. 343.) Divide the skin, superficial fascia and deep fascia, avoiding the internal saphenous vein, and expose the edge of the sartorius muscle, which may be recognized by the direction of its fibres. This muscle is drawn outward and the sheath of ligation of the femoral artery. 445 the vessels is exposed and opened; the vein lies on the inner side and somewhat behind the artery and the long saphenous nerve is on the outer side. (Fig. 344.) Pass the needle from within outward. Ligation of the Femoral Artery in the Middle of the Thigh. Incision in the line above mentioned, its centre being a little above the middle of the thigh. Divide the skin, Fig. 344. Fig. 345. Relations of right femoral Relations of the right femoral artery at the apex of Scarpa's artery in the middle of the thigh. triangle. (Esmarch.) (Esmarch.) superficial and deep fascia and expose the sartorius muscle wdiich is drawn outward after the leg has been flexed; the sheath of the vessel is exposed and opened; the long saphenous nerve lies upon the artery and the femoral vein lies behind the artery; the saphenous vein lies more super- ficially and internal to the vessel. Pass the needle from within outward. (Fig. 345.) 20 446 ligation of arteries. Ligation of the Femoral Artery in Hunter's Canal. Incision three inches in length along the tendon of the adductor magnus, the centre of which is at the junction of the lower and middle thirds of the thigh. (Fig. 343.) Divide the skin, superficial fascia and deep fascia, care being taken not to injure the internal saphenous vein, which should be displaced, and expose the sartorius muscle, which should be displaced downward and expose the apo- neurosis which forms the anterior wall of the vascular canal; this should be opened upon a director, and the artery is uncovered and should be separated from the vein, which lies upon the outer side. The needle is passed from with- out inward. Ligation of the Popliteal Artery. Fig. 346. Relations of the right popliteal artery. (Esmarch.) ligation of anterior tibial artery. 447 Incision three or four inches in length, along the exter- nal border of the semi-membranous muscle. Divide the skin and superficial fascia, taking care not to injure the saphenous vein, and open the deep fascia. The edges of the wound being held apart the adipose tissue is broken up with a director, and the internal popliteal nerve will be Ligation of popliteal artery. (Smith.) first exposed, and next the vein—both external to the artery. (Fig. 340'.) The artery is isolated and the needle is passed from without inward. (Fig. 347.) Ligation of the Anterior Tibial Artery. The anterior tibial artery may be tied in the upper, middle, and lower thirds of the leg; the general direction of the artery corresponds with a line drawn from the middle of the space between the head of the fibula and the tubercle of the tibia to the middle of the anterior inter- nialleolar space. Ligation of the Anterior Tibial Artery in the Upper Third of the Leg. Incision two and a half to three inches in length, one and one-fourth inches external to the spine of the tibia. Divide the skin and superficial fascia, and when the dec]) 448 LIGATION OF ARTERIES. fascia is exposed open it on a line corresponding to the intermuscular space between the tibialis anticus and the extensor longus digitorum mus- fig. 348. eles. Separate the muscles and work down in this interspace, and the arterv will be found with a vein on either side of it, and the anterior tibial nerve externally. (Fig. 348.) The needle should be passed from without inward, after isolating the veins. Ligation of the Anterior Tibial Artery at its Middle Third. Incision three inches in length in the same line as that for the upper portion of the vessel. After dividing the skin, superficial and deep fascia, the interspace between the tibialis anticus and the exten- sor longus digitorum muscles is opened and a third muscle comes in view, the extensor proprius pol- licis. The arterv lies between the extensor proprius pollicis and the tibialis anticus muscles, and the anterior tibial nerve is to the outer side. The veins should be isolated and the needle should be passed from without inward. \ Ligation of the anterior tib ial artery at its upper third (Stimson.) Ligation of the Anterior Tibial Artery in its Lower Third. Lncision two inches in length, beginning three inches above the ankle-joint on the line of the artery. Divide the skin, superficial and deep fascia, and seek for the tendon of the extensor proprius pollicis muscle, the second tendon from the tibia. The artery is found in the inter- space between this tendon and the tendon of the extensor longus digitorum muscle, the nerve being to the outer LIGATION OF DORSALIS PEDIS ARTERY. 449 side. The veins are isolated from the arterv, and the needle is passed from without inward. Ligation of the Dorsalis Pedis Artery. Incision one inch in length on a line drawn from the middle of the anterior inter-malleolar space to a point midway between the extremities of the first two metatarsal bones or along the outer border of the tendon of the ex- tensor proprius pollicis. Divide the skin, superficial and Fig. 319. A.y/r//.so/ brevis digitorum, muscle - {Tr/ir/o/i of ",' r./'frnso'r ■n/imfiriiis i fiolliris Ligation of the dorsalis pedis artery. (Bryant.) deep fascia, and the arterv will be found lying next to the inner tendon of the short extensor muscle of the toes. (Fig. 34!).) The nerve is to the outer side. After separating the; veins the needle is passed from without inward. 450 LIGATION OF ARTERIES. Ligation of the Posterior Tibial Artery. The course of the posterior tibial artery is indicated bv a line drawn from the middle of the popliteal space to a point midwav between the FlG35°- tendo Achillis and the in- ternal malleolus of the tibia. The posterior tibial arterv may be ligated in its upper, middle, and lower thirds. Ligation of the Posterior Tibial Artery at its Upper Third. Incision three inches and a half in length, one-half inch from the inner edge of the tibia, beginning two inches from the upper edge of the tibia. (Fig. 350.) Divide the skin and superficial fascia, avoiding large superficial veins; next open the deep fascia and detach the origin of the soleus muscle from the tibia, and on raising it, its under surface will present a white shining sheath of ten- dinous material, beneath wdiich will be seen a layer of fascia covering the tibialis posticus muscle. If search is made toward the middle of the leg, the artery will be found covered by the inter- muscular fascia, the nerve being to the outer side. The needle is passed from wdthout inward after the veins have been separated from the arterv. (Fig. 351.) Lines of incision for the posterior tibial artery. (Stimson.) LIGATION OF POSTERIOR TIBIAL ARTERY. 451 Ligation of the Posterior Tibial Artery at its Middle Third. Incision two and a half inches in length, parallel with the inner ed^e of the tibia and half an inch from its borcler. Divide the skin, superficial and dee]) fascia, and the inner ed^v of the soleus will be exposed ; press this Fig. :;.M. Relations of the right posterior tibial artery iu itsiupper third. (Esmarch.) outward and the arterv with its veins will be exposed, also the posterior tibial nerve to the outer side. Pass the needle from without inward after separating the veins. Ligation of the Posterior Tibial Artery Behind the Inner Malleolus. Incision a curved one two inches in length, midway between the tendo Achillis and the internal malleolus. (Fig. 350.) Divide the skin and superficial fascia and lift the dee]) fiiscia upon a director and open it freely and the arterv will be exposed with the tendons of the tibialis 452 LIGATION OF ARTERIES. posticus and flexor longus digitorum muscles on the inner side and the posterior tibial nerAe and the tendon of the Fig. 352. Ligation of the posterior tibial artery behind the inner malleolus. (Bryant.) flexor longus pollicis muscle on the outer side. (Fig. 352.) After separating the veins from the artery the needle should be passed from without inward. PART VI. AMPUTATIONS. The term amputation is now generally applied to the removal of a limb, and this may be removed through the bones, when the operation is spoken of as an amputation in the continuity of the limb; or it may be removed through its joints, and is then known as an amputation in the contiguity or a disarticulation. Methods of Amputating. Amputations may be performed by the circular, flap, oval, and elliptical methods; the modified circular operation, and Teale's method by rectangular flaps, are also employed. Fig. 353. Amputation by circular method. (Drcitt.) 20* 454 AMPUTATIONS. Circular Method. In performing an amputation by this method the inci- sion of the skin is made at a distance below the point where the bone is to be divided. An assistant grasps the limb and draws the skin evenly and firmly toward the root of the part and the surgeon passes the heel of the knife well into the tissues and makes a circular sweep around the limb and completes the division of the skin and cellular tissue with one motion of the knife. (Fig. 353.) In some cases a cutaneous sleeve consisting of the skin and cellular tissue is dissected up and turned back, and some- times it may be necessary to make a slit on one side of the flap to alloAv it to be turned up. The second incision in an ara- Division of muscles in circular . , ,, • i ,1 i amputation (Smith.) putation by the circular method consists, after retraction of the skin, in making a circular cut through all of the tissues down to the bone. (Fig. 354.) The third step in an amputation by the circular method consists, after retracting the skin and muscles and holding them back by a retractor, in the division of the bone with a saw. Flap Method. This method of amputating is susceptible of many variations. There may be one or two flaps of equal or unequal length; the flaps may be cut antero-posteriorly, laterally, or obliquely. (Fig. 355.) They may be made by transfixing the limb and cutting outward, or they may be cut from without inward, or they may be made to in- clude the whole thickness of the tissues down to the bone, or merely the skin and superficial fascia, the deeper struct- METHODS OF AMPUTATING. 455 ures being divided by a circular incision. The flaps mav have a curved outline or may be rectangular in shape, iii amputating by the antero-posterior flap operation the sur- Fig. 355. Double-flap amputation ; antero-posterior and lateral flaps. (S. Smith.) geon grasps the limb and enters the point of a long knife into the tissues at the side nearest himself, and pushing it Fig. 356. Amputation by antero-posterior flaps. (Bryant.) across and around the bone or bones brings its point out through the skin at a point diametrically opposite its point 456 AMPUTATIONS. of entrance. He then shapes the flap by cutting down- ward with a rapid saAving motion and then cuts obliquely forward until all the tissues are divided. The flap being turned up, he re-enters his knife at the same point and passes it on the other side of the bone or bones and cuts the second flap in the same manner. (Fig. 356.) A re- tractor is next applied and the bone is divided with a saw. The Oval Method. The oval amputation is really a circular one in which the cuff of skin has been slit at one side and the angles rounded off. This is the form of amputation frequently performed at the metacarpophalangeal and metatarso- phalangeal joints, and is one of the methods of amputation at the shoulder-joint. Elliptical Method. This is a form of the oval method of amputation which is employed in amputations at the knee- and elbow-joints, Fig. 357. Modified circular amputation, (Skey.) METHODS OF AMPUTATING. 45' the incision forming an ellipse coining below the joint on the front or outside of the limb, the resulting flap being; folded upon itself. S Modified Circular Method. In this method of amputation two oval skin flaps, antero-posterior or lateral, arc turned up, and the muscles are next divided by a circular sweep of the knife down to the bone (Fig. :$57). Teale's Method by Rectangular Flaps. In this method of amputation, two flaps are made of unequal length; the incisions are so planned that the shorter flap contains the main vessel or vessels. The Fig. 358. Teale's method of amputation. (Bryant.) flaps arc cut of equal width and the length of the long flap should be one-half of the circumference of the limb at the point where the bone is to be divided ; the length of the short flap should be one-eighth of the circumference of the limb. The flaps are cut from without inward, and embrace all of the tissues of the limb down to the bone. After the flaps have been dissected up, the bone is divided 458 AMPUTATIONS. wdth a saw, and the long flap is folded over and sutured to the short flap (Fig. 358). The disadvantage of this method of amputation is that in muscular limbs it requires the bone to be divided at a higher point than would otherwise be necessary. Periosteal Flaps. In any of the methods of amputation previously de- scribed the periosteum may be dissected up in two flaps attached to the muscles, or pushed up as a sleeve by means of a director or periosteotome before the bone is sawed. This procedure is most easily accomplished in young sub- jects. \\ hen these flaps are made and they are brought together, the periosteum covers the cut surface of the bone, to which it soon forms adhesions. Instruments Required for Amputations. The instruments required for amputations are knives of various shapes and sizes, saws, dissecting forceps, bone forceps, artery forceps, tenacula, haemostatic forceps, scis- sors, periosteotome, tourniquets, Esmarch's bandage and straps, retractors, ligatures, sutures, and suture needles. Amputating Knives. The knives required for amputations vary according to the method of amputation and the part to he amputated. Fig. 359. Scalpel, 111 certain amputations a scalpel (Fig. 359) or straight bistoury may be used (Fig. 360), while in other cases the employment of amputating knives of various sizes will be found more satisfactory. For amputations of the thigh a instruments for amputations. 459 knife Avith a blade of eight or nine inches is generally employed, and for smaller limbs a knife with a'blade of six or seven inches in length ; double-edged catlins are Fig. 360. Straight bistoury. employed in amputations of the leg and forearm to divide the interosseous tissues before applying the saw. The amputating knives now employed arc constructed with Fig. 361. Amputating knife and catlin. solid metal handles so that they can be rendered thoroughly aseptic bv immersion in boiling water before being used. (Pig. 361.) Amputating Saws. Several kinds of amputating saws are in general u^e ; one with a blade ten inches long by two and a half inches Fig. 362. -,,kJ Amputating saw. wide, with a heavv back to give it additional firmness, is a very good variety of saw (Fig. 362). For amputations 460 amputations. about the foot or hand a narrow saw with a movable back will be found very convenient. (Fig. 363.) A bow saw Fig. 363. Small amputating saw. with a metallic handle and a reversible blade is a very useful variety of saw, as it can be used either in amputa- FlG. 364. Amputating saw with reversible blade. tions or in excisions, and, being constructed entirely ot metal, it can be easily rendered aseptic. (Fig. 364.) Bone-Forceps, or Cutting Pliers. These instruments are used in smoothing off any rough edges of bone left after the use of the saw, or for the Fig. 365. Bone-forceps, or cutting pliers. division of the small bones in amputations of the fingers and toes. The forceps should be from ten to twelve instruments for amputations. 461 inches in length, with blades from one to one and a half inches in length. (Fig. 365.) Periosteotome. The periosteotome, or raspatory, is employed for dis- secting up a flap of periosteum, which, after sawing the Fig. 366. I'eriosteotome. bone, is drawn down over the sawed end of the bone. (Pig. 366.) Artery Forceps and, Tenacula. These instruments are used for taking up the vessels, and one of the best forms of artery forceps is that known as the double-spring artery forceps. (Pig. P'6, p. 271.) Tenacula are also employed for the same purpose. Haemo- static forceps will also be found most useful in cases of amputation, for the rapid control of hemorrhage from small vessels after the tourniquet has been removed, the vessels being secured by ligatures before the haemostatic forceps are removed. Retractors. These consist of pieces of muslin six or eight inches in width, one end of wdiich is split into two or three tails; the former variety of retractor is employed where one bone is divided, as in amputations of the arm and thigh, and the latter in cases whore two bones are divided, as in amputations of the forearm and leg. (Pig. 367.) 462 amputations. Fig. 367. Retractor applied. (Esmarch.) Ligatures. The best material to employ for the ligature of vessels is juniper or chromicized catgut or sterilized silk, the preparation of which has been described. Sutures. The materials employed for sutures in eases of amputa- tion may be silkworm-gut, catgut, silk, or silver wire ; deep or buried sutures of catgut in bringing together the edges of the periosteal fiaps, muscles, and fascia, are often employed with advantage in amputations (Fig. 368), the skin flaps being brought together with interrupted or continuous sutures of silk, catgut, silkworm-gut, or silver wire. (Fig. 369.) details of an amputation. 463 Deep or buried sutures of muscles. Sutures of skin. (Esmarch.) (Esmarch.) Tourniquets. For the control of hemorrhage during the amputation the Fsmaieh's apparatus (Fig. 194), or Petit's tourniquet ( Pig. 1S7) is employed; or the employment of both at the same time will often be found most satisfactory. The Esmarch bandage and tube being applied, after the removal of the bandage the tourniquet of Petit is loosely applied at a higher point, and after the main vessels have been secured the elastic strap is removed and the tourniquet is screwed down and controls the bleeding until the smaller vessels have been secured by ligatures. Details of an Amputation. The following are the steps of an amputation of the lower part of the thigh : The skin is first thoroughly cleansed by rubbing it with turpentine and soap and water and is then washed with an antiseptic solution either of carbolic acid 1:40 or bichloride of mercury 1 : 2000. Provision is next made to prevent the loss of blood during the operation by the application nf Esmarch's banclage and tube ; the bandage being re- moved a tourniquet is placed over the femoral artery in Scarpa's triangle and loosely secured. The limb is again 464 amputations. washed with bichloride solution. The instruments having been previously thoroughly sterilized, a rubber cloth covered with towels wrung out in a bichloride solution is placed under the limb. The variety of amputation having been decided upon, the flaps are cut and the muscles are divided down to the bone; the periosteum being dis- sected up, a two-tailed retractor is applied and the tissues are held back by an assistant while the surgeon divides the bone with the saw. \Vhen the bone has been divided the retractor is removed and the surface of the wound is irrigated with a 1 : 2000 bichloride solution. The femoral artery and vein are next found and secured with ligatures, and any branches which can be found are also secured. The elastic strap is removed after screwing down the tourniquet, and by letting up the pressure on this, smaller Fig. 370. Stump showing application of sutures and drainage-tubes. (Smith.) vessels which bleed are picked up with artery forceps or lneniostatie forceps and secured. After all bleeding has been controlled the tourniquet is removed and the wound is again thoroughly irrigated with a 1 : 2000 bichloride solution. If there is much oozing from smaller vessels re-dressing of amputations. 465 this solution should be as hot as the hands of the operator can comfortably stand, which will act promptly in con- trolling this variety of bleeding. The periosteal flaps, if they have been made, are brought together by two or three catgut sutures, and a drainage-tube is next introduced or two short tubes are introduced at either extremity of the wound and secured by sutures or safety-pins; the muscles should next be brought together by a few deep or buried sutures of catgut, and the skin flaps should then be brought into apposition by a number of interrupted sutures. The inner surface of the stump is next irrigated by a stream of bichloride solution introduced through the drainage-tube, and the surface of the stump is washed with the same solution; a piece of protective is next placed over the line of the wound and over this is placed a moist carbolized, bichloride, or iodoform gauze dressing, and over this a number of layers of dry gauze ; this is next covered by rubber tissue and a number of layers of bichloride cotton, or if the dry method of dressing is preferred the rubber tissue is omitted and a number of layers of bichloride cotton are laid over the gauze dress- ing, and the whole dressing is held in place by a recurrent bandage of the stump. Ke-dresnino of Amputations. The first dressing of an amputation, if strict antiseptic precautions have been observed at the time of operation, need not, as a rule, be made for a week or ten days, except in cases wdiere the oozing is so profuse as to soak the dress- ings, or wdiere consecutive hemorrhage has occurred, or the patient's condition shows that the wound is not running an aseptic course. The re-dressing of a stump can be accom- plished without pain to the patient if the surgeon and his assistants are careful in their manipulations. The dressings to be applied, the solutions for irrigation, and the instruments required should be prepared and at hand before the stump is exposed. The surgeon and his 466 AMPUTATIONS. assistants should wash their hands carefully, and then dip them in a 1 : 2000 bichloride solution. The bandage re- taining the dressings to the stump should be divided with bandage scissors without lifting the stump from the pillow upon which it rests. After the bandage has been divided and turned aside, the gauze dressing is next unfolded and turned doAvn ; an assistant noAv slips his hands under the stump and gently raises it from the dressings, and at the same time a rubber cloth covered Avith toAvels A\rhich haAe been wrung out in a 1 : 2000 bichloride solution is slipped under the stump and the soiled dressings are remoAed. The protective covering the incision is next removed and the surface of the stump is irrigated with a 1 : 2000 bichlo- ride solution; the drainage-tubes are next examined and the cavity of the stump is irrigated with the bichloride solution through the tubes by means of a syringe or an irrigating apparatus, or the irrigation may be omitted. If the wound is aseptic and there seems to be no further indication for the use of the drainage-tubes they may be removed and the track of the tube should be washed out with the antiseptic solution by the syringe or irrigator. The sutures are next examined and if the wound is firmly healed alternate sutures may be removed ; if catgut or silkworm-gut sutures have been used they need not be disturbed at this dressing, and their removal may be post- poned until a subsequent dressing. The wound should next be covered with a piece of pro- tective, and a gauze dressing should be applied consisting of a number of layers, and over this a number of layers of bichloride cotton, and the dressings should be held in place by a recurrent bandage of the stump. In holding the stump the assistant should hold it firmly to prevent muscular spasm, and after the dressings have been secured it should be placed upon a clean pillow prepared for its reception. The same procedures are adopted at subsequent dressings, and if the wound has run an aseptic course, two or three dressings, at most, will be required. AMPUTATIONS OF THE HAND. 467 Special Amputations. Amputations of the Hand. Amputations of the Fingers. The fingers may be amputated in the continuity of the phalanges or in their contiguity, and, as a rule* as it is important to save as much as possible of the finger, the former method is generally to be employed instead of dis- articulation at a higher point. The incisions should be so planned that the cicatrix does not occupy the palmar sur- face ; the larger flap should, therefore, be taken from the palmar aspect of the finger. In amputating the phalanges of the fingers in their continuity the circular method (Pig. Fig. 371. Amputation of finger : long palmar flap. (Erichsen.) • )74, B) or a short dorsal flap and a long palmar flap may be employed. In disarticulating'-a phalanx it is best to enter the joint with a narroAV knife from the dorsal side, and after having carried it through the joint, to cut a long palmar flap, keeping close to the bone. (Pig. o71.) In locating the position of the phalangeal joints, it is Avell to remember that the prominence of the knuckle, w hen the 468 AMPUTATIONS. finger is flexed, is formed entirely of the head of the prox- imal, and not of the base of the distal phalanx (Fig. 372), and also that the folds on the palmar surface of the finger do not correspond exactly to the joints. (Fig. 373.) Fig. 372 PhalaDges flexed. Guides to articulations of the finger. (Smith.) Amputation of the Finger through Metacarpo-phalangeal Articulation. In this varietv of amputation an incision is made from a point of the dorsal surface of the metacarpal bone a quarter of an inch above the articulation, which is carried through the interdigital web and back upon the palmar surface to a point a quarter of an inch above the flexor fold (Fig. 374, C). A similar incision beginning and ending at the same points is made upon the opposite side of the finger. The flaps are dissected back, and the lateral ligaments, tendons, and remainder of the capsule are divided. The finger may also be amputated at the meta- carpo-phalangeal joint by making an incision on one side and dissecting the flap back to the joint, then dividing the lateral ligament, opening the joint and carrying the knife across this, dividing the tendons and lateral ligament on the other side and cutting a flap from within outward. Removal of the head of the metacarpal bone if desired may be accomplished by the use of cutting pliers (Fig. •375), Fig. 37:',. AMPUTATIONS OF THE FINGERS. 469 but, as a rule, this procedure is not to be recommended, for, although the deformity is diminished, the strength of the hand is also diminished. Fig. 374. A. Disarticulation of phalanx, palmar flap. B. Amputation in continuity, circular. C. Metacarpophalangeal disarticulation. D. Amputation of meta- carpal bone in continuity. E. Disarticulation of little finger. F. Disarticulation of fifth metacarpal bone. O. Amputation at the wrist, circular. H. Amputation at the wrist. (Stimson.) In amputating the little and index fingers a full lateral flap may be cut on the free side and an incision is next carried across the palmar surface to the angle of the web and thence back to the joint, which is opened and the dis- articulation is effected. (Fig. 374, E.) In amputations of the finger at the phalangeal joints or at the metacarpo-phalangeal joints two vessels usually re- quire ligaturing, and after these are secured a catgut drain 21 470 AMPUTATIONS. or a small drainage-tube is introduced and the flaps are brought together by a few interrupted sutures. Fig. 375. Removal of head of metacarpal bone. (Skey.) Amputations of the Metacarpal Bones. In amputating the metacarpal bones it is advisable to leave the carpal ends of the bones to avoid opening the wrist-joint, except in the case of the first and fifth meta- carpal bones, Avhich do not communicate Avith the others and Avith the synovial sacs. The incisions for the removal of the metacarpal bones are the same as for the removal of a finger at the meta- carpo-phalangeal joint, the incision being prolonged back- Avard as far as necessary over the dorsal surface of the bone. (Fig. 374, D.) After the metacarpal bone has been bared for a sufficient distance, it is cut through with AMPUTATIONS AT THE WRIST. 471 Fig. 376. bone-pliers or disarticulated, and the distal end is raised from its bed and carefully separated from the soft parts, care being taken to avoid injury of the structures of the palm of the hand. In amputating the fifth metacarpal bone the incision should be made along the inner border of the hand and carried down to the bone between the skin and the abductor minimi digitii muscle. (Fig. 376.) The lower end of the incision passes over the knuckle to the web of the finger and backward under the palmar surface to join the first incision. Amputation of the entire thumb with its metacarpal bone is effected by making an oval flap from the palmar surface; in case of the left thumb the joint may be opened by an oblique incision on the dorsal surface of the hand, beginning a little in front of the joint and being car- ried down to the web between the thumb and forefinger; the palmar flap is then made by thrusting the knife upward to its point of entrance and cutting downward and outward. In ampu- tating the right thumb with its metacarpal bone it is better to make the palmar flap first by transfixion, the dorsal flap being made subsequently. Amputation of the hand at the carpo-metacarpal joint is occasionally performed, or between the rows of carpal bones, but is not as a rule to be recommended, as the carpal bones are apt subsequently to become diseased and require removal, so that it is better to amputate at the radio-carpal joint. Amputations at the Wrist. Circular Method. The skin of the forearm near the wrist being retracted by an assistant, a circular incision of the skin and cellular Incision for re- moval of the fifth metacarpal bone. (Smith.) 472 AMPUTATIONS. tissue is made half an inch below the point of the styloid process of the radius. (Fig. 374, 6s.) The skin and cellular tissue are next dissected back as far as the joint, which is opened and the disarticulation is completed. Antero-posterior Flap Method. This method is also employed in amputations at the wrist-joint; an incision curved downward is made on the back of the hand from one styloid process to the other; the hand being flexed the tendons are divided and the joint opened, and the palmar flap, which should extend as Fig. 377. Amputation at the wrist. (Erichsen.) far as the base of the metacarpal bones, is cut from within outward. (Fig. 377.) Amputation at the wrist is some- times done by cutting a single flap from the palm, the joint being opened by a transverse incision on the back of the hand from one styloid process to the other. Lateral Flap Method. This method (Fig. 374, H) is also sometimes employed in amputation at the wrist, and may be employed with advantage in eases of laceration of the hand, in which the AMPUTATIONS OF THE FOREARM. 473 injury to the tissues prevents the formation of the flaps u^ed in the other methods of amputation. Amputations of the Forearm. The forearm may be amputated by the circular or flap methods, or by making rectangular flaps (Teale's method). Circular Method, At the lower portion of the forearm the circular method of amputation is to be preferred. A circular incision of the skin and cellular tissue is made and a cuff is dissected up, the muscles and interosseous membrane being cut through; a three-tailed retractor is next applied and the bones are divided with a saw. Mixed Method. Amputation of the forearm by the mixed method, which consists in first dissecting up two antero-posterior oval Fig. 378. Amputation of the forearm by mixed method. (Bryant.) flaps of skin and cellular tissue and then dividing the muscles by a circular incision, is also a satisfactory opera- tion, (pjg. 37S.) In amputation at the upper portion of the forearm, antero-posterior, or lateral fiaps, cut from without inward or by transfixion, or rectangular flaps may be made with advantage. The principal vessels requiring the application of liga- tures in amputations of the forearm are the radial, ulnar, and interosseous arteries. 474 AMPUTATIONS. Amputations at the Ki.uow. The methods of amputation employed at the elbow are the anterior flap, lateral flap, and circular. Anterior Flap Method. A flap three inches in length with its base parallel to and half an inch below the condyles of the humerus, is Fig. 379. Fig. 380. Amputation at the elbow- joint. A. Anterior flap method. B. External flap method. C. Circular method. (Stimson.) Lateral flap method of amputation at the elbow- joint. (Smith.) Fig. 381. Circular amputation at the elbow. (Smith.) cut either by transfixion or from without inw ard. The joint is next opened and the lateral ligaments divided and the olecranon is exposed and the attachment of the triceps AMPUTATIONS OF THE ARM. 475 is separated and a posterior flap is cut from without in- ward, or from within outward, a little below the liue of the condyles. (Pig. 370, A.) Lateral Flap Method. In amputation at the elbow-joint lateral flaps may be employed, cut either from without inward or by trans- fixion. (Fig. 3)70, B.) An external flap three inches in length is made on the outer side of the arm, starting from a point a finger's breadth below the bend of the elbow, by transfixion or by cutting from without inward; a shorter internal flap is next cut in the same manner, and the joint is opened and disarticulation effected. (Fig. 380.) Circular Method. An incision dividing the skin and cellular tissue is made around the limb three inches below the line of the condyles of the humerus (Fig. 370, C), the skin is dis- sected up and a circular incision made through the mus- cles, the joint is opened and the disarticulation effected. (Fig. 381.) Amputations of the Arm. The arm may be removed at any point below the attach- ment of the muscles at the axilla, by cither the circular, flap, oval, or modified circular methods. Circular Method. This operation is usually employed in removing the arm in its lower third: a circular incision of the skin and muscles is first made, and when the cuff has been dissected up, a circular division of the muscles is made, and after applying the retractor the bone is sawed through. (Fig. :W2.) 476 AMPUTATIONS. Fig. 382. Circular amputation of the arm. Flap Method. From the central position of the bone in the arm the flap method in amputating the arm is preferred by many operators. The arm being grasped by the hand the point of a medium-sized amputating knife is thrust through the Fig. 383. Amputation of the arm by flap operation. (Bryant.) arm so as to pass over the humerus and make its exit at a corresponding point in the skin on the opposite side ; a flap of sufficient length is cut from within outward. The AMPUTATIONS OF THE ARM. 477 knife is next passed behind the bone and a posterior flap is cut in the same manner (Fig. 383); the bone is next cleared of muscular tissue and the flaps are retracted and it is divided with a saw. Lateral flaps may be made in this amputation in the place of the antero-posterior flaps, and they are cut from within outward in the same manner. Oval, or Modified Oval Method. This method of amputating the arm is also employed with advantage. An oval flap of skin and cellular tissue is made and dissected up, and the muscular tissue is divided by a circular incision. Or two oval flaps of skin and cellular tissue are cut and dissected up, and the mus- cles arc next divided by a circular sweep of the knife. In all amputations of the arm it is well to remember the possibility of a high division of the brachial artery, and to see that the abnormal vessel is properly secured, if present. Fig. 384. Esmarch's strap applied in high amputation of the arm. (Smith.) In high amputations of the arm there is sometimes not room enough to apply Fsniarch's strap or a tourniquet to the arm itself to control the hemorrhage during the oper- 21* 478 AMPUTATIONS. ation, and in such cases the strap may be passed from the axilla around the outer end of the clavicle, as is done to control the bleeding during amputation at the shoulder- joint. (Fig. 384.) Amputations at the Shouuoer-joint. Several methods of operation are employed in ampu- tating at the shoulder-joint, such as the oval method, or Parley's method, flap method, Pisfranc's or Dupuytren's Fig. 385. Amputation at the shoulder-joint. A. Oval, or Larrey's method. B. Double-flap, or Lisfranc's method. (Stimson.) method, and Spence's method. (Fig. 38-5.) The control of the bleeding from the axillary artery during the oper- ation is a matter of the first importance, and it may be arrested by pressure made upon the subclavian artery, as it crosses the first rib, with the thumb, or the padded handle of a large key, or by the fingers of an assistant grasping the axillary flap and compressing the vessel after the head of the bone has been disarticulated, or by the use of an elastic strap applied around the axilla and shoulder. AMPUTATIONS AT THE SHOULDER-JOINT. 479 (Fig. 384.) Wyeth's pins may also be employed with an elastic tube or stra]) to control bleeding during amputation at the shoulder-joint. The anterior pin is passed through the anterior fold or the axilla and is brought out in front of the acromion, the posterior pin is passed through the posterior fold of the axilla and is brought behind the acro- mion, the rubber stra]) or tube is then wrapped around the shoulder behind the pins and controls the hemorrhage during the operation. Oral, or Larrey's Method. In this method of amputation the point of the knife is entered just below the acromion process, and a deep Fig. 386. Amputation at the shoulder-joint by Larrey's method. incision three inches in length is made down to the head of the bone in the axis of the arm; from the middle of 480 AMPUTATIONS. this incision two others are made obliquely downward to the points where the anterior and posterior folds of the axilla end in the tissues of the arm ; the latter incision should be only deep enough to diAdde the skin and super- ficial fascia. The flaps are then dissected up until the head of the bone is Avell exposed, and, after opening the capsule and dividing the muscles inserted into the neck and tuberosities of the humerus, which division may be facilitated by rotating the head of the bone outward and inward, the disarticulation is effected by adducting the elbow ; the knife is next passed downward behind the bone and made to cut outward in the line of the cutaneous incisions—an assistant controlling the arterv before it is divided, by grasping the axillary tissues behind the knife Avith his fingers. Flap, or Dupuytren's Method. In this method of amputation at the shoulder-joint the flaps may be cut either by transfixion, or from without Fig. 387. Amputation at the shoulder-joint, Dupuytren's method. (Bryant.) inward; the large flap embraces the greater part of the deltoid muscle, and the smaller or short flap is cut from AMPUTATIONS AT THE SHOULDER-JOINT. 481 the inside of the arm after the head of the bone has been disarticulated. When cut by transfixion, the point of the knife should be entered an inch in front of the acromion process and pushed across the outer aspect of the head of the humerus, and should be brought out at the posterior fold of the axilla ; the knife is made to cut dowiiAvard until a large deltoid flap is formed. This flap is turned up, and the head of the bone is disarticulated ; the knife being placed behind it, a short flap is formed, keeping dose to the bone so that the vessel is divided with the last cut of the knife. ( Fig. 387.) An assistant should control the vessel by grasping the axillary tissues with his fingers behind the knife. Fig. 388. Double Flap, or Lisfrancs Method. In this method of amputation at the shoulder-joint, the point of the knife is entered at the outer side of the cora- coid process, and is carried across the outer aspect of the head of the humerus and brought out a little below the posterior border of the acromion process, and a long flap is cut downward. This flap is turned up and the attachments of the head of the bone are divided and it is disarticulated. The knife is again entered behind the bone, and a long posterior flap is cut from within outward. (Pig. 385, B.) Spcnce's Method. In this method of amputation at the shoulder-joint an incision is made down to the head of the humerus immediately in front of the coracoid process, and is continued downward through the clavicular fibres of the deltoid and the pectoralis Amputation at the shoulder- joint. Spence's method. (Stim- son.) 482 AMPUTATIONS. major muscles until the attachment of the latter to the humerus is reached. (Pig. 388.) The incision is now carried backward to the posterior fold of the axilla. A second incision, including only the skin and cellular tissue, is next made from the anterior portion of the first incision across the inside of the arm to meet the incision on the outer part. The outer flap thus formed is turned up and the head of the bone is disarticulated, and the operation is completed by dividing the remaining tissues on the axillary aspect. Many other methods of removing the arm at the shoulder-joint have been devised and employed, including the circular method. Amputation above the Siiouoder-joint. This form of amputation consists in the removal of the arm with a part or the whole of the scapula aud sometimes a portion of the clavicle. As this form of amputation is required in cases in which the laceration of the parts has passed beyond the shoulder- joint, or in cases of growths involving the tissues beyond the joint, no definite rule can be laid down for the in- cisions ; the only rule being as far as possible to make the incisions in such a manner that the least possible amount of skin is sacrificed, so that a sufficient covering for the wound can be obtained. Amputations of the Foot. Amputations of the Joes. The phalanges of the toes may be removed in the same manner as those of the fingers. It is better to amputate at the metatarso-phalangeal articulations than to attempt to remove them at the joints in front of this articulation, except in the case of the great toe, as the preservation of a portion of a toe is rather a discomfort than an advantage, AMPUTATIONS OF THE FOOT. 483 except in the instance mentioned. All incisions should be made so that the resulting cicatrix does not occupy the plantar surface, and it is well to remember that the web of the toes is considerably below the position of the metatarso- phalangeal joint. (Pig. 389.) Fig. 389. Fig. 390. Relations of web and metatarso- phalangeal joints of toes. (Stim- son.) Incisions for amputation of toes and metatarsal bones. (Stimson.) The toes are usually removed by an incision on the dorsal surface a little above the joint, which is carried down the bone for about an inch and then diverges into the web, and is carried under the toe and back on the cither side to the point of divergence. (Pig. 380.) 484 AMPUTATIONS. Amputation of Two Adjoining Toes. The dorsal incision should be made in the inter- metatarsal space just above the level of the joint (Fig. 390, B) and carried down to the beginning of the web; then over the toe to the beginning of the adjoining web, and under the plantar surface of both toes in the line of the digito-plantar fold, through the web and back to the point of divergence. Amputation of the Great Toe. This may be accomplished by means of the racket-shaped incision employed in amputation of the other toes or by means of a lateral flap. In the latter case the knife is made to enter the joint by cutting through the commissure, Fig. 391. Fig. 392. Amputation of the great toe. Incision for amputation of all the (Smith.) toes. (Smith.) and the operation is completed by carrying the knife through the joint and along the outer side of the bone, forming a flap of the required size. (Fig. 391.) In this amputation a short dorsal flap and long plantar flap may be employed, or a long internal flap may be used. AMPUTATIONS OF METATARSAL BONES. 485 Amputation of All the Toes. To amputate all the toes, make a dorsal incision from the head of the fifth to the head of the first metatarsal bone; the incision should be a curved one passing just in front of the joints. (Fig. 302.) Dissect up the flap and open the joints, dividing the lateral ligaments, and pass the knife behind the phalanges and cut a flap from the plantar surface. Amputations of the Metatarsal Bones. It is better in these amputations to leave the tarsal head of the metatarsal bone in place and divide the bone, or in other words to do an amputation in continuity to prevent opening up the tarsal articulations. Amputation of the Metatarsal Bone of the Great Toe. The incision begins upon the dorsal surface of the meta- tarsal bone, a little below the point at which the bone is Fig. 393. Amputation of the great toe and first metatarsal bone. (Smith.) to be divided, and is carried down below the metatarso- phalangeal joint, then diverges and passes under the toe 486 amputations. and comes back again to the point of divergence. (Fig. 390, C.) The bone is exposed and cut through with cut- ting forceps and is then lifted up and dissected loose from the tissues. (Fig. 393.) Amputation of the Fifth Metatarsal Bone. The incision for the removal of the fifth metatarsal bone is made over the bone a little below the metatarso-tarsal articulation, and is carried down and curved around the toe (Fig. 390, D), and after the bone is exposed by dis- secting back the flaps, it is divided, or the joint is opened and it is dissected out. Amputation Through the Metatarsal Bones. In performing this amputation an incision is made across the dorsum of the foot and a short dorsal flap is dissected up; the metatarsal bones are next divided with a saw and a long plantar flap is cut from within outward by entering the knife behind the ends of the bones. Tarso-metatarsal Amputations. In all amputations of the foot involving the tarsus the surgeon should be thoroughly familiar with the anatomy of the foot and the surgical landmarks of the different articulations. I shall refer to those laid down by Mr. Bryant, which are as follows : " On the inner side of the foot not far from the inner malleolus the tubercle of the scaphoid (Fig. 394 A), is to be felt as a marked prominence; about one-half an inch in front of this will be found the articulation with the cuneiform bone (B), and one inch in front of this the joint which the surgeon will have to open in Lisfranc's or Hey's operation (C); just above the tubercle of the scaphoid will be found the articulation with the astragalus, the line of Chopart's amputation (D). On the outer side of the foot, one inch below the external malleolus, a sharply defined amputations of the foot. 487 projection will always be felt, which is the peroneal tuber- cle (E), one-half an inch in front of this will be found the joint which separates the os calcis from the cuboid (F), this joint forming the outer circle to Chopart's amputa- tion. Half an inch in front again or one inch from the Fig. 394. Fig. 395. Surgical guides to the foot as expressed Incision for—A. Lisfranc's am- by anatomy. (Bryant.) putation. B. Chopart's ampu- tation. (Stimson.) tubercle, the prominence of the fifth metatarsal bone is always to be felt (//), the line above this prominence indicating the articulation Avith the cuboid bone, which forms the outer boundary of the incision for Iley's or Lisfranc's amputations." 488 amputations. Tarso-metatarsal Amputations (Lisfranc's). The incision for this amputation is a curved one carried across the dorsum of the foot from the base of the fifth to the base of the first metatarsal bone. (Pig. 395,-4.) The incision should involve the skin only, its centre lying half an inch or more below the centre of the line of the articu- lations, and it should begin and end at the sides of the foot at their junction with the sole. A plantar flap should be marked out by a curved incision crossing the sole of the foot near the origin of the toes, starting and ending at the same points as the dorsal incision. The dorsal flap is next dissected back to the line of the articulations; the tendons, muscular fibres, and fascia being Fig. 396. Amputation at tarso-metatarsal joint (Lisfranc's). (Skey.) divided, the joints between the tarsal and metatarsal bones are opened with a stout, narrow-bladed knife. (Fig. 396.) Difficulty is sometimes experienced in opening the joint between the head of second metatarsal bone and the second cuneiform bone, which occupies a position higher on the foot than the other articulations. The disarticulation may AMPUTATIONS OF THE FOOT. 489 also be facilitated by forcibly depressing the anterior por- tion of the foot. After all the joints have been opened, the knife is passed behind the ends of the metatarsal bones and a plantar flap is cut from within outward, following the line of the incision previously marked out. The plantar flap may be cut from without inward if preferred. Tarso-metatarsal Amputation (Hey's). The line of incision and the steps of this operation are similar to those in Lisfranc's amputation, with the excep- tion that I lev sawed off the projecting portion of the internal cuneiform bone after disarticulating the meta- tarsal bones. This modification, although it improves the appearance of the stump, possesses no advantages over the previous procedure. Medio-tarsal, or Chopart's Amputation. In this amputation the disarticulation is through the joints formed by the astragalus and calcaneum behind and the scaphoid and cuboid in front. An incision is made Fig. 397, Line of incision for — A. Chopart's amputation. B. Syme's amputation. C. Section of bone in Syme's amputation. D. Subastragaloid amputation. (Stimson.) 490 AMPUTATIONS. from the tubercle of the scaphoid across the dorsum of the foot an inch in front of the head of the astragalus to the lower and outer border of the cuboid. (Fig. 397, A.) The plantar flap is next marked out by an incision begin- ning and ending at the same points as the first incision and crossing the sole of the foot four or five finger- breadths nearer the toes. The dorsal flap is next dissected up, and after the tendons and fascia have been divided Chopart's amputation. (Bryant.) the joint is opened and a plantar flap is cut from within outward following the line of the previously marked out plantar incision. (Fig. 398.) Subastragaloid Amputation. In this amputation all the bones of the foot are removed except the astragalus. An incision is made beginning an inch belowT the tip of the external malleolus which is car- ried forward to the base of the fifth metatarsal bone; it is then carried over the dorsum of the foot to the calcaneo- cuboid articulation. (Fig. 397, D.) The joints between the scaphoid and astragalus and between the astragalus and calcis are opened, and the latter bone is carefully dis- sected out; the ligaments are divided and the astragalus only is allowed to remain in place. AMPUTATIONS AT THE ANKLE-JOINT. 491 Amputations at the Ankle-joint. Syme's Amputation at the Ankle-joint In this amputation, the foot being at a right angle to the leg, an incision is made from the centre of one mal- leolus directly across the sole of the foot to the centre of the opposite malleolus. (Fig. 397, B.) The tissues of the heel are next carefully dissected from the bone by keeping the knife close to the osseous surface until the tuberosity of the os calcis is fairly turned. The two extremities of the first incision are then joined by a transverse one across the instep, and, the joint being opened, the lateral liga- ments are divided to complete the disarticulation. (Fig. 399.) The knife is next used to clear the malleoli, and Fig. 399. Syme's amputation at the ankle-joint. (Skey.) they are next removed bv the saw in the line indicated. 492 AMPUTATIONS. Pirogof's Amputation at the Ankle-joint. In this amputation the posterior portion of the os calcis is retained. The incision is carried from the tip of the Fig. 400. Pirogoflfs amputation. A. Cutaneous incision. B. Line of section of bones. (Stimson.) Fig. 401. Application of saw to calcis in Pirogofl's amputation. (Eitn ii>kn.) AMPUTATIONS AT THE ANKLE-JOINT. 493 inner malleolus, OAer the instep, half an inch in front of the anterior edge of the tibia, to a point half an inch in front of the tip of the outer malleolus; a second incision, crossing the sole of the foot and carried doAvn to the bone, is next made. (Pig. 400, A.) The plantar flap is dis- sected back for a quarter of an inch, the joint is opened by dividing the lateral ligaments, and the astragalus is disarticulated, and the malleoli are exposed. A narrow" saw is next applied to the upper and posterior part of the calcaneum behind the astragalus, and it is divided obliquely downward in the line of the plantar incision. (Fig- 401.) The malleoli and a thin slice of the tibia are next removed with the saw as in Syme's amputation. (Fig. 397, C.) Some surgeons do not remove the malleoli, but press the sawed surface of the os calcis be- tween them wdien it is possible to FlG-402' do so. The position of the os calcis ( ' /;; in relation to the tibia after union has occurred, is shown in Fig. 402. Roux's Amputation at the Ankle-joint. In this method of amputation an incision is made at the outer edge of the tendo Achillis, a little above its insertion, which is carried for- ward under the outer malleolus, and across the instep half an inch in front of the anterior edge of the tibia, and back to a point just in front of the inner malleolus; the incision is carried from this point downward and partly across the sole of the foot, and then back to the point of origin of the original incision. (Fig. 403.) The flaps are dissected up for a short distance, the ankle-joint is then opened, and the disarticulation is effected, and the internal flap is care- fully dissected from the bones. Union between calcaneum and tibia in PirogofPs ampu- tation. (Hewso.v) 494 AMPUTATIONS. Other methods of amputation of the foot are sometimes employed; such, for instance, as that advocated by Hancock, who has combined Pirogoff's amputation with the sub- astragaloid method, bringing the sawed surface of the os calcis in contact with a transverse section of the astragalus. Hancock has advocated the propriety of amputating in the foot without regard to the position of the tarsal joints, cutting the flaps of sufficient length and dividing the bones with a saAV. Fig. 403. Incisions in Roux's amputation. Tripier has also modified the subastragaloid amputation by lea a dng the upper part of the calcaneum, which he saws through on a level with the sustenaculum tali, and at right angles to the axis of the leg; the external incisions are made as in Chopart's amputation. In the method advocated by Mikulicz the astragalus and calcaneum are removed, the ends of the tibia and fibula are sawed off, and the sawed surface of the scaphoid and cuboid are approximated to these, the stump resulting re- sembling the foot of pes equinus. Amputations of the Leo. The leg may be amputated at its lower, middle, or upper third, the rule being to save as much of the limb as pos- amputations of the leg. 495 sible, but as regards the application of prothetic apparatus, I think the stumps resulting from amputations in the middle and upper thirds will be found more satisfactory. It is well also in sawing the bones to divide the fibula at a slightly higher point than the tibia. Amputation at the Lower Third of the Leg. At this position the leg may be amputated by the cir- cular, modified circular, or elliptical method. Circular Method. A circular incision is made through the skin and con- nective tissue just above the malleoli and the cuff is dis- sected up for a sufficient distance, and a circular incision of the tendons and muscles is next made and the tissues being retracted the bones are divided with a saw. Modified Circular Method. In this method of amputation of the leg a circular in- cision of the skin and connective tissue and two short lateral incisions are made and the flaps are dissected up to the end of the incisions, and a circular division of the muscles is next made. (Fig. 404, A.) Or oval skin flaps are made and dissected up, and the tissues are next divided down to the bone by a circular incision and the bones are divided w ith a saw." (Fig. 40(b) Elliptical Method. In this method of amputation the incision is in the form of an ellipse; its lower end crosses the heel below the inser- tion of the tendo Achillis and the upper end of the inci- sion is about an inch above the anterior articular edge oi the tibia. (Fig. 40o, B.) Long Anterior Flap Method. An anterior flap equal in length to the diameter of the leg at its base is marked out by a curved incision through 496 amputations. the skin beginning at the posterior edge of the tibia on the inner side, a little below the point at which the bones are to be divided, and is carried over the leg to a point directly opposite over the fibula. (Fig. 405, A.) The Fig. 404. Fig. 405. Amputation of the leg. A. Modified circular method. B. Rectangular flap. C. Antero- posterior flap. (Stimson.) Amputation of the leg. A. Long anterior flap. B. Supra- malleolar long posterior flap. C. At upper third. (Stimson.) AMPUTATIONS OF THE LEG. 497 anterior muscles are divided transversely half an inch above the lower end of the flap and are dissected from the bone to the base of the flap. Fig. 406. Oval skin flaps with circular division of the muscles. The posterior flap is then made by entering the knife behind the bones at the point of the original incision and cutting directly outward. Long Anterior Rectangular Flap Method. (Teale.) In this method of amputation of the leg an incision equal in length to half of the circumference of the leg is made from the point at which the bones are to be divided on one side of the leg and is carried across the limb and back upon the opposite side to a point opposite the point of starting. The flap thus marked out is dissected up to its base and a posterior flap of one-fourth the length is next cut by a transverse incision down to the bones and is dis- sected back to the line of the origin of the first incision. (Fig. 404, B.) The long flap is next doubled back and its edges secured to the posterior flap, or the long flap may be cut from the posterior surface of the leg and the short flap from the anterior surface. Antero-posterior Flap Method. A long anterior flap including half of the circumference of the limb may be cut from without inward, composed of skin, connective tissue, and muscles, and a short posterior flap cut from within outward may also be employed. This 498 AMPUTATIONS. method is often employed in amputations in the upper portion of the leg. (Fig. 404, C.) Lateral Flap Method. In the lower and middle thirds of the leg the method of amputation by means of lateral skin flaps may be em- ployed with advantage. In this method an incision is made over the spine of the tibia and an oval flap embracing one-half of the circumference of the leg, composed of the skin and connective tissue, is dissected up; starting from the same point a similar flap is cut upon the opposite side of the leg and dissected up; the muscles at the upper ex- tremity of the flaps are next divided by a circular incision and the bones are divided with a saw. External Flap Method. (Sedillot.) In this method of amputation of the leg the point of the knife is entered a finger's breadth external to the spine of the tibia and carried outward, grazing the fibula, and is brought out as far as possible to the inner side; a flap three or four inches in length is then cut from within out- ward ; the extremities of the incision are next united by an incision across the inner side of the limb involving the skin only; any remaining muscular tissue is next divided and the bones are sawed, and the long external flap is brought over the ends of the bones and fastened to the edges of the incision on the inner side of the limb. Prof. Ashhurst modifies this operation by cutting the long ex- ternal flap from without inward, and makes also a short internal flap in the same manner. By either method the resulting stump is a good one, Avith the ends of the bones covered by the tissues of the external flap. Amputations at the Knee-joint. Amputations at the knee-joint may be done either by the circular or elliptical incision or by means of flaps, and amputations at the knee-joint. 499 mav consist in simple disarticulations or sections through the condyles of the femur. Elliptical or Oval Method. In this operation an incision crossing the spine of the tibia five finger-breadths below the lower extremity of the patella is carried around the back of the leg three finger- breadths higher than in front; the tissues on the front of the leg are dissected up until the tendon of the patella is exposed; the leg is then flexed and the ligament of the patella is divided; the capsular ligament and the lateral and crucial ligaments are next severed, care beino- taken not to injure the popliteal vessels with the point of the knife. The tibia is next drawn forward and the knife is passed behind its posterior border, and the remaining soft parts are divided from within outward. Anterior Flap Method. In this method of amputation a long cutaneous flap is formed; the incision beginning half an inch below the articulation is carried five inches below the patella; cross- ing the anterior surface of the leg it is carried back to the condyle of the femur on the opposite side. This flap is dissected up and the ligament of the patella is divided, and the disarticulation is effected. A short posterior flap, uniting the anterior incision one inch below its extremi- ties, is next cut by transfixion or from without inward. (Fig. 407, A.) The patella is not removed. Amputation through the Condyles of the Femur. In this amputation, which is knoAvn as Garden's ampu- tation, an anterior flap, whose lower extremity is three finger-breadths below the patella, is cut and the disarticu- lation is effected, and the posterior soft parts are divided. The patella is removed and the condyles next sawed through just above the ecloe of the articular cartilage. (Pig. 407, B.) 500 AMPUTATIONS. Lateral Flap Method. In this operation an incision is made just below the patella, which is carried down the spine of the tibia for Fig. 407. Fig. 408. Amputation at the knee-joint by lateral flaps. (Smith). three inches, and is then carried backward to the middle of the leg to a point opposite the begin- ning of the incision; a similar flap is cut on the opposite side of the leg, and the flaps are dissected up to the line of the articulation, and when this point is reached the joint is opened and the disar- ticulation is effected. The patella is not removed. (Fig. 408.) Gritti's Amputation at the Knee- joint. In this operation a long rec- tangular anterior flap is first cut and dissected up, and after the disarticulation has been effected the skin covering the posterior surface of the knee is cut from within outward. The condyles of the femur are l ' ' ' ■ | Amputations at the knee-joint and lower third of thigh. A. Long anterior flap. B. Ampu- tation through condyles. C. Modified flap at lower third of thigh. (Stimson.) AMPUTATIONS OF THE THIGH. 501 next removed by a saw above the edge of the articular cartilage, and the articular surface of the patella is removed by the saw or cutting forceps. The patella is next brought down so that its sawed surface is in contact with the sawn surface of the condyles, and the flaps are brought together. (Fig. 409, A.) Amputations of the Thigh. Modified Flap Method. Two semilunar flaps of skin and connective tissue, the upper extremity of which are several inches above the condyles of the femur, are cut and dissected up, and the muscles are next divided by a circular incision, and the bone is cut through with the saw. (Fig. 407, C.) Long Anterior Flap Method. In this operation an incision is made on the anterior aspect of the thigh, marking out a flap whose length is equal to one-third, and whose width at its base is equal to two-thirds, of the circumference of the limb. The anterior muscles are next divided obliquely upward and backward, so that the flap shall not be too thick, and the posterior nuiscles are cut transversely and the bone is divided with a saw. (Fig. 409, B.) Amputation in the lower third of the thigh may also be effected by employing a long anterior and short posterior Hap. The anterior flap is cut, its lower extremity extend- ing down to the lower edge of the patella, and after dis- secting up the skin and cellular tissue to the upper extremity of the patella, the muscles are cut obliquely up to the point at which the bone is to be divided. A short posterior fla]) is next cut, and the soft parts being retracted, the bone is sawed through. (Fig. 409, ('.) 22* 502 amputations. Amputation of the Thigh by Transfixion. In amputations of the thigh the flaps may also be cut by transfixion, either lateral or antero-posterior flaps being employed. (Fig. 410.) Fig. 409. A. Gritti's amputation at the knee. A'. Lines of division of the bones. B Amputation of the thigh, long anterior flap. B'. Division of the bone, C. Am- putation at the lower third of the thigh. C. Division of the bone. £>. Dis- articulation at the hip-joint. amputations at the hip-joint. 503 Amputation of the Thigh through the Trochanters. When, for any reason, it is inadvisable to amputate at the hip-joint, an amputation may be made through the trochanters, a long anterior and short posterior flap being employed Avith a circular division of the muscles. Fig. 410. Amputation of thigh by flaps cut by transfixion. Amputations at the Hip-joint. In amputations at the hip-joint it is important that pro- vision be made for the control of hemorrhage during the operation, and this is accomplished by the use of an abdominal tourniquet (Fig. 411), or by the use of Davy's lever making compression upon the common iliac artery from the rectum, or by compression of the femoral artery by the fingers of an assistant, or by the preliminary liga- tion of the femoral artery just below Poupart's ligament. Esmarch's elastic strap may also be employed for the con- trol of bleeding during amputation at the hip-joint, the stra]) being applied in such a maimer that it occupies the position of the turns of a spica bandage of the groin. (Pig. 412.) 504 amputations. Fig. 411. Abdominal tourniquet. Fig. 412. Esmarch's elastic strap applied to control hemorrhage during amputation at the hip-joint. Dieffenbach and \Vyeth, to avoid hemorrhage, make first a circular amputation in the continuity of the thigh, amputations at the hip-joint. 505 and after controlling the hemorrhage disarticulate the head of the femur and remove it; Jordan and Senn dis- articulate the head of the bone first through an external incision and control the bleeding before the amputation is completed by passing an elastic tourniquet around the soft parts above the point where they are to be divided. The methods of amputation at the hip-joint are the oval, antero-posterior flap, and lateral flap, and modified circular methods. Oval Method. This is performed by entering the point of a strong knife into the tissues below the anterior superior spinous process of the ilium and making two oblique incisions, one forward and downward and the other backward, both incisions meeting on a transverse line on the inner side of the thigh. The muscles are next divided on a little higher line, and when the joint is exposed disarticulation is effected from the outer side and any remaining tissue is divided. Antero-posterior Flap Method. In this method the point of a long amputating knife is thrust into the tissues about two finger-breadths below the anterior superior spinous process of the ilium, and is pushed through the tissues grazing the hip-joint and is brought out on the opposite of the thigh close to the junc- tion of the scrotum. The knife is next carried downward close to the bone and an anterior flap of sufficient length is cut from within outward. This flap is held up by an assistant and the head of the bone is disarticulated, and the knife being passed behind the bone, a posterior flap of equal length is cut from within outward. (Fig. 41o\) Guthrie s method of amputation at the hip-joint consists in cutting the flaps from without inward, a smaller knife being used for this purpose and the posterior flap being cut first. 506 AMPUTATIONS, Fig. 413. Amputation at the hip-joint by antero-posterior flaps. (Holmes.) Fig. 414. Amputation at the hip-joint by external and internal flaps. (Bryant.) Modified, Circular Method. In this operation short antero-posterior flaps of skin and connective tissue arc cut and dissected up, and the amputations at the hip-joint. 507 muscles are divided by a circular incision on the level of the joint, and the disarticulation of the head of the femur is next effected. Lateral Flap Method. In this operation two flaps are cut from the inner and outer side of the thigh by transfixion, or by cutting from without inward and exposing the joint, which is opened and the disarticulation of the head of the femur is effected as in the previous methods. (Fig. 414.) Wyeth's Method of Amputating at the Hip-joint. In amputating at the hip-joint by this method, the hip to be operated upon is brought well over the edge of the Fig. 415. Pins inserted and tube applied. table and an Fsmarch bandage is applied to the limb, and two stout steel mattress needles twelve or fourteen inches in length are required; the point of one of these needles is passed through the skin one and a half inches below and slightly to the inner side of the anterior superior spine 508 amputations. of the ilium and carried through the tissues about half- way between the great trochanter and the spine of the ilium external to the neck of the femur, and its point is made to emerge just behind the trochanter; the second needle is made to enter the skin an inch below the crotch, internal to the saphenous opening, and its point is made to emerge about an inch and a half in front of the tuber Fig. 416. Limb amputated and bone sawn. (Wyeth.) ischii. The points of the needles are next protected with corks, and a long piece of rubber tubing or an Esmarch elastic strap is wound tightly five or six times about the limb above the fixation needles. (Fig. 415.) The Esmarch bandage should then be removed and a circular incision of the skin and cellular tissue should be made five inches below the constricting band; this cellulo-cutaneous cuff should next be reflected to the level of the trochanter minor; a circular division of all the muscles should next amputations at the hip-joint. 509 be made at this point and the bone divided with a saw. The large vessels should next be secured and after this has been clone the rubber tube should be removed and any vessels which bleed should be tied: divide all remaining attachments of the femur, open the capsule and disar- ticulate the head of the bone. A drain should be next introduced and the edges of the flaps brought together vertically. INDEX. ABBE'S long incision in intestinal anastomosis, 251 Abdominal aorta, ligature of, 438 tourniquet, 504 Abscess or abscesses, acute, 282 chronic, 283 cold, 283 deep-seated, opening of, 282 dressing of, 282 Hilton's method of opening, 282 opening of, 282 sinuses from, 284 treatment of, 282 Absorbent cotton, 145 AC. E. mixture, 220 Acid, boric, 117 carbolic, 114 Acromial end of clavicle, disloca- tion of, 393 Acromion process of scapula, dis- location of, 393 fracture of, 343 Actual cautery, 170 Acupressure, 272 first method of, 273 second method of, 273 third method of, 274 fourth method of, 274 fifth method of, 274 sixth method of, 275 seventh method of, 275 Acupuncture, 167 Acute abscess, 282 Adhesive plaster, 149 Agnew's splint for fracture of pa- tella, 369 American bandage of foot, 80 Amputating knives, 45S Amputating saws, 459 Amputation or amputations, 453 at ankle-joint, 491 Pirogoffs, 492 Koux's, 493 Syme's, 491 of arm, 475 buried sutures in, 462 circular, 454 in contiguity, 453 in continuity, 453 details of, 463 dressing of, 465 at elbow, 474 elliptical, 456 of fingers, 467 flap, 454 of foot, 482 Chopart's, 489 Hancock's, 494 Key's, 4S9 Lisfranc's, 4SS Mikulicz's, 494 Tripier's, 494 of forearm, 473 of hand, 467 at hip-joint, 503 control of hemorrhage in, 504 Guthrie's, 505 Wyeth's, 507 instruments for, 458 at knee-joint, 49S Garden's, 499 Gritti's, 500 of leg, 494 Scdillot's, 498 Teale's, 497 ligatures in, 462 512 INDEX. Amputation, medio-tarsal, 489 of metacarpal bones, 470 of metatarsal bones, 485 modified circular, 457 oval, 456 periosteal flaps in, 458 rectangular flaps in, 457 re-dressing of, 465 retractors in, 461 above shoulder-joint, 482 at shoulder-joint, 478 Dupuytren's, 480 Larrey's, 479 Lisfranc's, 481 Spence's, 481 Wyeth's pins in, 479 subastragaloid, 490 sutures in, 462 tarso-metatarsal, 486 Teale's method, 457 of thigh, 501 of toes, 482 tourniquets in, 463 at wrist, 471 Anaesthesia from A. C. E. mixture, 220 from chloroform, 218 from ether, 213 local, 210 from chloride of ethyl, 210 from cocaine, 211 from cold, 210 from rhigolene, 210 from nitrous oxide gas, 212 from rapid respiration, 210 Anaesthetic mixture, A. C. E., 220 Anaesthetics, 209 in tracheotomy, 298 vomiting after, 217 Anastomosis, intestinal, sutures in, 250 Aneurism needle, 419 Ankle, dislocations of, 412 Ankle-joint, amputation at, 491 Pirogoff's, 492 Koux's, 493 Syme's, 491 Anterior tibial artery, ligation of, 447 Antisepsis, 109 Antiseptic bandages, 130 Antiseptic dressings, 126 improvised, 129 gauze, 126 method, 111 poultice, 158 Aorta, abdominal, ligation of, 438 compressor, Lister's, 264 Aqua ammonia, 165, 167 Aristol, 118 Arm, amputations of, 475 and chest bandage, 65 Arterial hemorrhage, 259. (See Hemorrhage ) transfusion, 183 Arteriotomy, 180 Artery or arteries— axillary, ligation of, 430 brachial, ligation of, 432 carotid, common, ligation of, 424 external, ligation of, 427 internal, ligation of, 427 dorsalis pedis, ligation of, 449 facial, ligation of, 429 femoral, ligation of, 443 forceps, 271, 461 gluteal, ligation of, 442 iliac, common, ligation of, 438 external, ligation of, 441 internal, ligation of, 441 innominate, ligation of, 420 interosseous, ligation of, 438 ligation of, 418 et seq. lingual, ligation of, 428 mammary, internal, ligation of, 424 occipital, ligation of 429 popliteal, ligation of, 446 pudic, internal, ligation of, 443 radial, ligation of, 434 sciatic, ligation of, 443 subclavian, ligation of, 421 temporal, ligation of, 429 thyroid, inferior, ligation of, 424 superior, ligation of, 428 tibial, anterior, ligation of, 447 posterior, ligation of, 450 ulnar, ligation of, 436 vertebral, ligation of, 423 INDEX. 513 Artery, wounded, ligation of, 277 Artificial respiration, 185 direct method, 187 Howard's method, 187 Marshall Hall's method, 191 Sylvester's method, 189 Ascending spica bandage of shoul- der, 56 Asepsis, 109 Aseptic method, 111 operation, details of, 136 preparation for, 133 of patient for, 135 of surgeon for, 134 surgery, materials used in, 120 Aspiration, 192 Aspirator, 193 Astragalus, dislocation of, 413 fractures of, 379 Auto-transfusion, 1X3 Axillary artery, ligation of, 430 BACILLI, 110 Bacillus pyonyaneus, 110 pyogenes fu'tidus, 110 Bandage or bandages— abdominal, 29 antiseptic, 130 application of, 17 arm and chest, 65 Barton's, 33 modified, 35 of chest, anterior figure-of- eight, 67 posterior figure-of-eight, 68 circular, 19 compound, 2, 24 crossed, of eye, 44 of both eyes, 45 demi-gauntlet, 51 Desault's, 61 dimensions of, 17 Esmarch's, 266 figure-of-eight, 23 of elbow, 55 of knee, 76 of knees, both, 77 of leer. 83 Bandage, figure-of-eight, of neck and axilla, 58 flannel, 89 of foot, American, 80 covering heel, 80 not covering heel, 81 French, 81 spica, 79 four-tailed, of chin, 28 of head, 28 gauntlet, 50 Gibson's, 36 glue, 106 and oxide of zinc, 106 gum and chalk, 104 handkerchief, 29 hardening, 91 of head, 33 and neck, 43 oblique, 47 recurrent, 39 transverse, 41 of jaw, oblique, 38 Liebreich's, 87 of lower extremity, 72 many-tailed, 28 oblique, 20 occipito-facial, 46 -frontal, 48 paraffin, 105 plaster-of-Paris, 92 application of, 92 preparation of, 93 removal of, 102 trapping of, 101 Pott's 89 recurrent, 24 of head, 39 of stump, 85 removal of, 19 rubber, 90 scissors, 19 of Scultetus, 88 for securing hands and feet, 86 silicate of potassium, 105 of sodium, 105 simple, 2 spica, 22 of foot, 79 of groin, ascending, 72 descending, 73 514 INDEX. Bandage, spica, of groin, double, 74 of shoulder, ascending, 56 descending, 57 of thumb, 53 spiral, 20 ascending, 20 descending, 21 of chest, 66 of finger, 49 reversed, 21 of lower extremity, 82 of penis, 84 of upper extremitv, 53 starched, 104 suspensory and compressor, of breast, 69 of both breasts, 70 of trunk, 66 of upper extremity, 49 Velpeau's, 59 winder, 14 Bandaging, 2, 33 rules for, general, 17 Barton's bandage, 33 modified, 35 handkerchief, 33 Bavarian dressing, 99 Bedsores, 291 Bellocq's canula, 279 Beta-naphthol, 115 Bichloride cotton, 130 of mercury, 112 gauze, 126 Binder's-board splints, 107, 322 in compound fractures, 384 Bis-axillary cravat, 31 Bladder, hemorrhage from, 281 tying catheter in, 231 washing out of, 233 Blood, transfusion of, 180 direct, 180 indirect, 182 Bloodletting, 173 Bond's splint, 356 Bone chips, decalcified, 203 forceps, 460 grafting, 202 plates, decalcified, 203 Senn's, 251 Borated gauze, 128 Boric acid, 117 Boro-salicylic lotion, 117 Bougies, 227 bulbous, 227 • filiform, 228 oesophageal, 196 rectal, 208 Bouisson's suture, 248 Bovine lymph, 197 Brachial artery, ligation of, 432 Bran bags, 323 dressing in compound frac- tures, 384 Bread poultice, 156 Breast, strapping of, 152 suspensory and compressor bandage of, 69 double, 70 Bruises, 289 Bulbous bougies, 227 Buried sutures, 241 Burns, 290 Buttock, spica bandage of, 75 Button suture, 244 nALCANEUM, dislocation of, \J 414 fractures of, 378 Cantharidal collodion, 166 Cantharis, 166 Capillary hemorrhage, 259 treatment of, 276 Capsicum, 165 Carbolic acid, 114 Carbolized gauze, 128 Carbuncle, strapping of, 155 Carden's amputation at knee-joint, 499 Carotid artery, common, ligation of, 424 internal, ligation of, 427 external, ligation of, 427 Carpal bones, dislocation of, 403 fractures of, 357 Carpus, dislocations of, 402 Cartilages, costal, fractures of, 333 semilunar, dislocation of, 411 Catgut, chromic acid, 122 for drainage, 124 INDEX. 515 Catgut, juniper, 122 ligatures, 122 sutures, 122 Catheters, 224 elbowed, 226 female, introduction of, 230 flexible, 225 introduction of, 227 Mercier's, 226 metallic, 224 prostatic, 225 securing in bladder, 231 soft rubber, 226 Cauterization in arterial hemor- rhage, 269 Cautery, actual, 170 irons, 171 Paquelin's, 165, 172 Charcoal poultice, 157 Chemical sterilization in wounds, 132 Chest, figure-of-eight bandage of, anterior, 67 posterior, 68 spiral bandage of, 66 strapping of, 152 T-bandage of, double, 27 single, 25 Children, epiphyseal separations of radius in, 357 fracture of clavicle in, 341 of leg in, 376 of shaft of femur in, 366 Chin, bandage of, four-tailed, 28 Chloride of ethyl, anaesthesia from, 210 of zinc, 115 Chloroform, 164, 167, 218 administration of, 218 apparatus, Clover's, 219 Chopart's amputation of foot, 489 Chromic acid catgut, 122 Chronic abscess, 282 Circular amputation, 454 bandage, 19 Clavicle, dislocation of, 392 acromial end of, 393 sternal end of, 392 fractures of, 337 in children, 341 Sayre's dressing for, 339 Clavicle, fractures of, Velpeau's dressing in, 340 Cleanliness, surgical, 111 Clinical thermometer, 206 Closed fracture, 313 Clove-hitch knot, 388 Clover's chloroform apparatus, 219 Cocaine, anaesthesia from, 211 Cocci, 110 Coccyx, dislocations of, 389 fractures of, 334 Cold abscess, 283 anaesthesia from, 210 compresses, 162 in arterial hemorrhage, 268 -water dressings, 162 Colles' fracture of radius, 355 Collodion, cantharidal, 166 iodoform, 115 Comminuted fracture, 313 Complete dislocation, 386 fracture, 312 Complicated dislocation, 386, 417 fracture, 314 Compound bandages, 24 dislocation, 386, 416 fractures, 313 binder's-board splints in, 384 bran dressing in, 384 dressing of, 380 felt splints in, 384 iodoform dressing in, 385 irrigation in, 385 plaster-of-Paris dressing in, 383 sawdust dressing in, 385 Compresses, 147 cold, 162 in fractures, 324 in hemorrhage, 261 hot, 158 Compression, digital, in arterial hemorrhage, 260 Condyles of femur, fractures of, 368 Congenital dislocations, 417 Consecutive hemorrhage, 259 Constitutional treatment of hemor- rhage, 259 Continued suture, 241 Contused wounds, 287 516 INDEX. Contusions, 289 Coracoid process of scapula, frac- ture of, 343 Coronoid process of ulna, fracture of, 352 Corrosive sublimate gauze, 126 Costal cartilages, fractures of, 333 Cotton, 145 absorbent, 145 bichloride, 130 Counter-irritation, 162 Cranium, fracture of, 336 Cravat, bis-axillary, 31 Creolin, 116 Crossed bandage of eye, 44 of both eyes, 45 Cruro-pelvic triangle, 32 Cupping, 174 dry, 174 -glass, 175 wet, 175 Cutting pliers, 460 Cystoscope, 233 Czerny suture, 249 DECALCIFIED bone chips, 203 plates, 203 Deep incisions, 174 sutures, 241 Deformity in fracture, 316 Demi-gauntlet bandage, 51 Desault's bandage, 61 first roller of, 61 second roller of, 62 third roller of, 63 Descending spica bandage of shoulder, 57 Diastasis of sternum, 391 Diffused suppuration, 284 Digital compression in hemor- rhage, 260 Disinfection of hands, 133 Dislocation or dislocations, 386 of acromial end of clavicle, 393 of acromion process of scapula, 393 of ankle, 412 of astragalus, 413 of calcaneum, 414 Dislocation of carpal bones, 403 of carpus, 402 of clavicle, 392 of coccyx, 389 complete, 386 complicated, 386, 417 compound, 386, 416 congenital, 417 of elbow, 398 backward, 398 forward, 399 lateral, 398 of femur, anomalous, 408 dorsal, 405 iliac, 405 ischiatic, 406 pubic, 408 thyroid, 407 of fibula, 412 of fingers, 403 of forearm, 398 of hip, 405 backward, 405 of humerus, 394 Kocher's method in, 396 Mothe's method in, 397 subclavicular, 395 subcoracoid, 394 subglenoid, 394 subspinous, 395 of hyoid bone, 390 of jaw, 389 of knee, 410 of maxilla, 389 of metacarpal bones, 403 of metatarsal bones, 414 myotomy in, 417 old, 387 reduction of, 415 partial, 386 of patella, 410 pathological, 417 of pelvis, 391 of phalanges of fingers, 404 of radius, 400 recent, 387 reduction of, 387 of ribs, 391 of scaphoid bone, 414 of scapula, 393 inferior angle of, 393 INDEX. 517 Dislocation of semilunar cartilages, 411 of shoulder, 394 simple, 386 spontaneous, 417 of sternal end of clavicle, 392 of sternum, 391 of tarsal bones, 413 of thumb, 404 tenotomy in, 417 of toes, 414 treatment of, 387 of ulna, 401 of vertebrae, 388 of wrist, 402 Dorsal dislocation of femur, 405 Dorsalis pedis artery, ligature of, 449 Double cyanide of mercury and zinc, 119 gauze, 127 ligature, 254 roller bandage, 16 T-bandage, 26 Drainage, catgut, 124 glass, 124 horse-hair, 124 rubber, 123 -tube, 123 Dressings, antiseptic, dry, 132 chemical sterilization in, 132 improvised, 129 modified moist, 133 moist, 132,139 Bavarian, 99 cold-water, 162 dry, in wounds, 132 fixed, 91 of fractures, 321 compound, 380 gauze, 126 preparation of, 126 leather, 106 moss, 129 plaster-of-Paris, interrupted, 95 uses of, 103 raw-hide, 106 sawdust, 128 of septic wounds, 143 sterilized, dry, 131 Dressings, sterilized, moist, 130 Dry cupping, 174 sterilized dressings, 131 Dressing of wounds, 285 Dupuytren's amputation at shoul- der-joint, 480 splint in fracture of fibula, 377 ELASTIC ligatures, 259 Elbow, amputation at, 474 dislocations of, 398 backward, 398 forward, 399 lateral, 398 figure-of-eight bandage of, 55 Elbowed catheter, 226 Electrolysis, 203 Elliptical amputation, 456 Endoscope, 232 Enema, 208 glycerin, 209 nutritious, 209 Epiphyseal fracture, 316 separation, 316 of radius, 357 Epistaxis, 278 Erichsen's ligature, 258 Esmarch's bandage, 266 elastic strap in hemorrhage, 263 tourniquet in amputation at shoulder-joint, 477 Ether, 213 administration of, 213 first insensibility from, 215 inhaler, 214 Exploring needle, 200 trocar, 200 External carotid artery, ligation of, 427 iliac artery, ligation of, 441 Eye, crossed bandage of, 44 Eyes, crossed bandage of both, 45 [RACIAL artery, ligation of, 429 Faradization, 205 Fascia, strains of, 294 Felt splints, 107, 322 in compound fractures, 384 23 518 INDEX. Female catheter, introduction of, 230 Femoral artery, ligation of, 443 hernia, truss for, 223 Femur, dislocation of, anomalous, 408 dorsal, 405 iliac, 405 ischiatic, 406 pubic, 408 thyroid, 407 reduction of, 406 et seq. fractures of, 360 condyles of, 368 green-stick, 367 lower end of, 368 plaster-of-Paris dressing in, 362 shaft of, 364 in children, 366 upper extremity of, 360 Fermenting poultice, 157 Fibula, dislocations of, 412 fractures of, 376 Figure-of-eight bandage, 23 of chest, anterior, 67 posterior, 68 of elbow, 55 of knee, 76 of knees, both, 77 of leg, 83 of neck and axilla, 58 Filiform bougie, 227 Fingers, amputation of, 467 dislocation of, 403 fractures of, 359 spiral bandage of, 49 First insensibility from ether, 215 Fissured fracture, 313 Fixed dressings, 91 Flannel bandage, 89 Flap amputations, 454 Flaps, periosteal, in amputation, 458 Flaxseed poultice, 156 Flexible catheters, 225 Fomentations, hot, 158 Foot, amputations of, 482 Chopart's, 489 Hancock's, 494 Hey's, 489 Lisfranc's, 488 Foot, amputation of, Mikulicz's, 494 Tripier's, 494 bandage of, American, 80 French, 81 spica, 79 fracture of bones of, 379 Forced respiration, 191 Forceps, artery, 271, 461 bone, 460 haemostatic, 265 torsion, 270 tracheal, 297 Forearm, amputation of, 473 dislocations of, 398 fractures of, 352 green-stick, 354 Foreign bodies,tracheotomy for,304 Four-tailed bandage of chin, 28 of head, 28 Fracture or fractures, 312 of acromion process of scapula, 343 anaesthetics in, 318 of astragalus, 379 -bed, 321 binder's-board splints in, 322 -box, 323, 371 bran bags in, 323 of calcaneum, 378 of carpal bones, 357 of clavicle, 337 in children, 341 Sayre's dressing for, 339 Velpeau's dressing in, 340 closed, 313 of coccyx, 334 Colles', 355 comminuted, 313 complete, 312 complicated, 314 compound, 313 binder's-board splints in, 384 bran dressing in, 384 dressing of, 380 felt splints in, 384 iodoform dressing in, 385 irrigation in, 385 plaster-of-Paris dressing in, 383 INDEX. 519 Fracture, compound, sawdust dress- I ing in, 385 compresses in, 324 of costal cartilages, 333 of cranium, 336 deformity in, 316 direction of, 315 dressing of, 321 provisional, 318 epiphyseal, 316 evaporating lotions in, 325 examination of, 317 felt splints in, 322 of femur, 360 in children, 366 condyles of, 368 green-stick, 367 lower end of, 368 plaster-of-Paris dressing in, 362 shaft of, 364 upper extremity of, 360 of fibula, 376 Dupuytren's splint in, 377 fissured, 313 of forearm, 352 green-stick, 354 of foot, bones of, 379 green-stick, 312 gutta-percha splints in, 322 of humerus, 344 condyles of, 347 lower extremity of, 347 shaft of, 346 upper extremity of, 344 of hyoid bone, 331 impacted, 314 incomplete, 312 indented, 312 of jaw, 327-328 junk bags in, 323 of larynx,331 leather splints in, 322 of leg, 371 binder's-board splints in, 375 in children, 376 longitudinal, 315 of malar bone, 327 of maxilla, lower, 328 upper, 327 2ture of metacarpal bones, 358 of metatarsal bones, 379 multiple, 314 of nasal bones, 325 oblique, 315 of olecranon process of ulna, 350 open, dressing of, 380 paper splints in, 323 partial, 312 pasteboard splints in, 322 of patella, 369 of pelvis, 354 of phalanges of fingers, 359 of toes, 380 plaster-of-Paris splints in, 323 Pott's, 377 primary roller in, 324 provisional dressings in, 318 punctured, 312 of radius, Colles', 355 head of, 352 lower end of, 354 neck of, 352 reduction of, 320 repair of, 316 of ribs, 332 of sacrum, 334 sand bags in, 323 of scapula, 343 body of, 343 coracoid process of, 343 neck of, 343 setting of, 320 silicate of potash splint in, 323 simple, 313 of skull, 336 splints in, 321 of sternum, 333 of tarsal bones, 378 of trachea, 331 transverse, 315 of ulna, 354 coronoid process of, 352 olecranon process of, 350 of vertebrae, 335 wooden splints in, 322 of zygoma, 327 ich bandage of the foot, 81 520 INDEX. GALVANO-CAUTERY, 204 Gas, nitrous oxide, 212 Gastrostomy, sutures in, 252 immediate, sutures in, 253 Gastrotomy, sutures in, 253 Gauntlet bandage, 50 Gauze, bichloride of mercury, 126 borated, 128 carbolized, 128 corrosive sublimate, 126 cyanide of mercury and zinc, 127 dressings, 126 preparation of, 126 iodoform, 127 pads, 121 pledgets, 121 pyoktanin, 128 salicylated, 128 Gely's suture, 228 Gibson's bandage, 36 Glass drainage-tube, 124 Glover's suture, 241 Glue bandage, 106 and oxide of zinc bandage, 106 Gluteal artery, ligation of, 442 Glycerin enema, 209 suppository, 209 Golding-Bird's tracheal dilator, 296 Granny knot, 239 Green stick fracture, 312 Gritti's amputation at knee-joint, 500 Groin, spica bandage of, ascending, 72 descending, 73 double, 74 T-bandage of, 26 Gum and chalk bandage, 104 Gunshot wounds, 288 Guthrie's amputation at hip-joint, 505 Gutta-percha splints, 322 HEMOSTATIC forceps, 265 Hall's method of artificial respiration, 191 Hancock's amputation of foot, 494 Hand, amputation of, 467 Hands, disinfection of, 133 Hands, removal of plaster-of-Paris from, 102 Handkerchief bandages, 29 Barton's, 33 Hardening bandages, 91 Hare-lip suture, 242 Hatter's felt splints, 108 Head, bandage of, Barton's, 33 four-tailed, 28 Gibson's, 37 oblique, 47 recurrent, 39 transverse recurrent, 41 and neck bandage, 43 V-bandage of, 42 Heat, sterilization by, 112 Hemorrhage in amputation at hip- joint, control of, 504 arterial, 259 acupressure in, 272 cauterization in, 269 cold in, 268 compresses in, 261 control of, permanent, 268 temporary, 260 digital compression in, 260 Esmarch's apparatus in, 263 hot water in, 268 ligation in, 271 position in, 268 pressure in, 269 Spanish windlass in, 263 styptics in, 268 suture in, 272 torsion in, 270 tourniquets in, 261, 262 from bladder, 281 capillary, 259 treatment of, 276 consecutive, 259 intermediary, 259 from nose, 278 primary, 259 from rectum, 281 secondary, 259 treatment of, 276 treatment of, 259 constitutional, 259 local, 260 from urethra, 280 INDEX. 521 Hemorrhage, venous, 259 treatment of, 275 Hernia, femoral, truss for, 223 inguinal, truss for, 222 irreducible, truss for, 224 umbilical, truss for, 223 Hey's amputation of foot, 489 Hip, dislocations of, 405. (See Femur.) Hip-joint, amputations at, 503 amputation, control of hemor- rhage in, 504 Guthrie's, 505 Wyeth's, 507 Hoey's clamp, 264 Hood's truss, 222 Horse-hair drainage, 124 Hot compresses, 158 fomentations, 158 water in arterial hemorrhage, as a rubefacient, 163 Howard's method of artificial respi- ration, 187 Humanized lymph, 197 Humerus, dislocation of head of, 394 Kocher's method in, 396 Mothe's method in, 397 reduction of, 395 subclavicular, 395 subcoracoid, 394 subglenoid, 394 subspinous, 395 fracture of, 344 condyles of, 347 lower extremity of, 347 shaft of, 346 upper extremity of, 344 Hydrogen, peroxide, 116 Hypodermic injections, 198 syringe, 198 Hyoid bone, dislocation of, 390 fracture of, 331 ICE-BAG, 162 I Iliac artery, common, ligation of, 438 external, ligation of, 441 internal, ligation of, 441 ! Iliac, dislocation of femur, 405 Impacted fracture, 314 Incised wounds, 285 Incisions, deep, 174 Incomplete fracture, 312 Indented fracture, 312 India-rubber suture, 242 Inferior thyroid artery, ligation of, 424 Inguinal hernia, truss for, 222 Inhaler, ether, 214 Injections, hypodermic, 198 intra-venous, of milk, 185 of saline solution, 184 rectal, 208 urethral, 234 Innominate artery, ligation of, 420 Instruments for amputation, 458 sterilization of, 134 Intermediary hemorrhage, 259 Internal carotid arterv, ligation of, . ,427 ; iliac artery, ligation of, 441 pudic artery, ligation of, 443 Interosseous artery, ligation of, 438 Interrupted suture, 240 Intestinal anastomosis, Abbe's in- cision in, 251 bone plates in, 251 sutures in, 250 Intra-venous injection of milk, 185 of saline solution, 184 Intubation of larynx, 306 feeding case of, 310 instruments for, 306 mouth-gag for, 306 -tube, 306 Iodoform, 114 dressing in compound frac- tures, 385 gauze, 127 Iodol, 118 Irreducible hernia, truss for, 224 Irrigating apparatus, 137 Irrigation, 159 in compound fractures, 385 mediate, 161 Ischiatic dislocation of femur, 406 Isinglass plaster, 150 , Issues, 168 522 INDEX. JACKET, plaster-of-Paris, 96 Jaw, bandage of, oblique, 38 dislocation of, 389 fracture of, 327, 328 Jobert's suture, 249 Joints, strapping of, 154 Jugular vein, external, bleeding from, 179 Juniper catgut, 122 Junk bags, 323 Jury-mast, application of, 99 Jute, 146 KNEE, dislocation of, 410 figure-of-eight bandage of, 76 of both, 77 -joint, amputation at, 498 Carden's, 499 Gritti's, 500 Knives, amputating, 458 Knot, clove-hitch, 388 granny, 239 reef, 237 Staffordshire, 239 surgeon's, 238 Kocher's method in dislocation of humerus, 396 Kreolin, 116 T ACERATED wounds, 286 Li Larrey's amputation at the shoulder-joint, 479 Laryngotomy, 304 Laryngo-tracheotomy, 305 Larynx, fracture of, 331 intubation of, 306 Leather splints, 106, 322 Leech, mechanical, 177 Leeches, American, 176 Swedish, 176 Leeching, 176 Leg, amputation of, 494 Sedillot's, 498 Teale's, 497 figure-of-eight bandage of, 83 fractures of, 371 ulcer of, strapping of, 154 Lembert's suture, 246 Liebreich's eye bandage, 87 Ligation of abdominal aorta, 438 of anterior tibial artery, 447 in arterial hemorrhage, 271 of arteries, 418 of axillary artery, 430 of brachial artery, 432 of common carotid artery, 424 iliac artery, 438 of dorsalis pedis artery, 449 of external carotid artery, 427 iliac artery, 441 of facial artery, 429 of femoral artery, 443 of gluteal artery, 442 of inferior thyroid artery. 424 of innominate artery, 420 of internal carotid artery, 427 iliac artery, 441 mammary artery, 424 pudic artery, 443 of interosseous artery, 438 of lingual artery, 428 of occipital artery, 429 of popliteal artery, 446 of posterior tibial artery, 450 of radial artery, 434 of sciatic artery, 443 of subclavian artery, 421 of superior thyroid artery, 428 of temporal artery, 429 of ulnar artery, 436 of vertebral artery, 423 of wounded arteries, 277 Ligature or ligatures: catgut, 122 elastic, 259 securing of, 237 silk, 121 in vascular growths, 254 double, 254 Erichsen's, 254 quadruple, 256 single, 254 subcutaneous, 257 Lingual artery, ligation of, 428 Lint, 144 Lisfranc's amputation of foot, 488 at shoulder-joint, 481 INDEX. 523 Lister's aorta compressor, 264 Local anaesthesia, 210 treatment of hemorrhage, 260 Longitudinal fracture, 315 Lotions, evaporating, in fractures, 325 Lower extremity, bandages of, 72 spiral reversed, 82 Luxations. (See Dislocations.) MACKINTOSH, 125 Malar bone, fracture of, 327 Mammary artery, internal, ligation of, 424 Many-tailed bandages, 28 Marshall Hall's method of artificial respiration, 191 Massage, 205 in sprains, 294 Maxilla, dislocation of, 389 lower, fracture of, 328 upper, fracture of, 327 Mechanical leech, 177 Mediate irrigation, 161 Medio-tarsal amputation, 489 Mercier's catheter, 226 Mercury, bichloride of, 112 Metacarpal bones, amputation 470 dislocation of, 403 fractures of, 358 Metallic catheters, 224 Metatarsal bones, amputation 485 dislocation of, 414 fractures of, 379 Mikulicz's amputation of fo 494 Milk, intra-venous injection 185 Minor surgery, 109 Moist dressings in wounds, 132 sterilized dressings, 130 Moss dressing, 129 Mothe's method in dislocation humerus, 397 Motion, passive, 206 Moulded plaster-of-Paris splir 100 Mounted needle, 236 Mouth-gag in intubation, 306 Mouth-to-mouth inflation, 186 Moxa, 169 Multiple fracture, 314 Muscle-grafting, 203 Muscles, strains of, 294 Mustard, 164 foot-bath, 164 papers, 164 plaster, 164 Myotomy in dislocations, 417 NASAL bones, fractures of, 325 Neck and axilla, figure-of- eight bandage of, 58 Needle, aneurism, 419 exploring, 200 -holder, 237 mounted, 336 seton, 169 surgical, 236 Nerve-grafting, 203 Nitrate of silver, 167 Nitrous oxide gas, 212 Nose, T-bandage of, 27 Nutritious enemata, 209 of, of, ot, of, of ts, AAKUM, 144 U poultice, 158 Oblique bandage, 20 of head, 47 of jaw, 38 fracture, 315 Occipital artery, ligation of, 429 Occipito-facial bandage, 46 -frontal bandage, 48 (Esophageal bougie, 196 Oiled muslin, 146 silk, 146 Old dislocation, 387 reduction of, 415 Olecranon process of ulna, fracture of, 350 Open fractures, dressing of, 380 Operation, aseptic, details of, 136 preparation for, 133 of patient for, 135 of surgeon for, 134 Oval amputation, 456 524 INDEX. Plaster-of-Paris bandage in fracture of femur, 362, 369 interrupted, 95 uses of, 103 jacket, 96 removal of, from hands, 102 splints in fracture, 323 moulded, 100 Plate suture, 244 Pledgets, gauze, 121 Poisoned wounds, 288 Popliteal artery, ligation of, 446 Porous felt splints, 107 Porte-moxa, 169 Posterior tibial artery, ligation of, 450 6 Potassium permanganate, 117 Pott's bandage, 89 fracture of fibula, 377 Poultice or poultices, 155 antiseptic, 158 bread, 156 charcoal, 157 fermenting, 157 flaxseed, 156 oakum, 158 starch, 157 Powder-burns, 289 Pressure in arterial hemorrhage, 269 Primary hemorrhage, 259 roller in fractures, 324 Prostatic catheter, 225 Protective, 124 Provisional dressings in fracture, 318 Pubic dislocation of femur, 408 Pudic artery, internal, ligation of, 443 Puncturation, 174 Punctured fracture, 312 wounds, 287 Pyoktanin, 118 gauze, 128 PADS, gauze, 121 Paper, paraffin, 146 Paper, parchment, 126 splints, 323 waxed, 146 Paquelin's cautery, 165,172 Paraffin bandage, 105 paper, 146 Parchment paper, 126, 147 Parenchymatous hemorrhage, 276 Partial dislocation, 386 fracture, 312 Passive motion, 206 Pasteboard splints, 107, 322 Patella, dislocations of, 410 fracture of, 369 Pathological dislocations, 417 Pelvis, dislocation of, 391 fractures of, 334 Penis, spiral reversed bandage of, 84 Periosteal flaps in amputation, 458 Periosteotome, 461 Permanganate of potassium, 117 Peroxide of hydrogen, 116 Petit's tourniquet, 262 Phalanges of fingers, dislocations of, 404 fractures of, 359 of thumb, dislocations of, 404 of toes, dislocations of, 414 fractures of, 380 Pirogoff's amputation at ankle- joint, 492 Plaster or plasters, 149 adhesive, 149 isinglass, 150 mustard, 164 resin, 149 rubber adhesive, 149 soap, 150 Plaster-of-Paris bandage, 92 application of, 93 preparation of, 93 removal of, 102 saw for, 103 shears for, 103 trapping of, 101 dressing in compound frac- tures, 383 QUADRUPLE ligature, 256 Quilled suture, 243 Quilt suture, 243 INDEX. 525 RADIAL artery, ligation of, 434 Radius, dislocation of head of, 400 Radius, epiphyseal separation of, 357 fracture of head of, 352 of lower end of, 354 of neck of, 352 Rapid respiration, anaesthesia for, 210 Raw-hide splints, 106 Recent dislocation, 387 Rectal bougies, 208 injections, 208 tube, 207 Rectum, hemorrhage from, 281 Recurrent bandage, 24 of head, 39 transverse, 41 of stump, 85 Reduction of dislocations, 387 of fractures, 320 Reef knot, 237 Repair of fractures, 316 Resin plaster, 149 Respiration, artificial, 185 direct method of, 187 Howard's, 187 Marshall Hall's method of, 191 Sylvester's method of, 189 forced, 191 Retractors, 148, 461 Rhigolene, anaesthesia from, 210 Ribs, dislocation of, 391 fracture of, 332 Roller bandage, 14 double, 16 single, 16 primary, in fracture, 324 Roux's amputation at the ankle- joint, 493 Rubber adhesive plaster, 149 bandage, 90 dam, 125 tissue, 125, 146 Rubefacients, 163 QA< RUM, fractures of, 334 U Salicylated gauze, 128 Saline solution, intra-venous injec- tion of, 184 Sand bags, 323 Saphena vein, internal, bleeding from, 179 Saw, amputating, 459 for removing plaster-of-Paris bandage, 103 Sawdust dressings, 129 in compound fractures, 385 Sayre's dressing for fracture of clavicle, 339 Scalds, 290 Scaphoid bone, dislocation of, 414 Scapula, dislocations of, 393 dislocation of acromion pro- cess of, 393 of inferior angle of, 393 fracture of, 343 of acromion process of, 343 of body of, 343 of coracoid process of, 343 of neck of, 343 Scarification, 173 Scarificator, 176 Sciatic artery, ligation of, 443 Scissors, bandage, 19 skin-grafting, 201 Scultetus' bandage, 88 Secondary hemorrhage, 259 treatment of, 276 sutures, 235 SediHot's amputation of leg, 498 Semilunar cartilages, dislocation of, 411 Senn's bone plates, 251 Septic wounds, dressing of, 143 Seton, 169 needle, 169 Setting of fractures, 320 Shears for plaster-of-Paris bandage, 103 Shotted suture, 245 Shoulder, dislocation of, 394 reduction of, 395 -joint, amputation above, 482 amputation at, 478 Dupuytren's, 480 Larrey's, 479 Lisfranc's, 481 526 IND EX. Shoulder joint amputation— Spence's, 481 spica bandage of, ascending, 56 descending, 57 Signorini's tourniquet, 264 Silicate of potassium bandage, 105 of potash splint in fracture, 323 of sodium bandage, 105 Silk, 121 oiled, 146 Silkworm-gut, 121 Simple dislocation, 386 fracture, 313 Sinapism, 164 Single ligature, 254 roller bandage, 16 T-bandage, 24 Sinuses from abscess, 284 Skin-grafting, 200 scissors, 201 Thiersch's method, 202 Skull, fractures of, 336 Slings, 28 Soap plaster, 150 Soft rubber catheter, 226 Sounds, 227 Spanish windlass, 263 Spence's amputation at shoulder- joint, 481 Spica bandages, 22 bandage of buttock, 75 of foot, 79 of groin, ascending, 72 descending, 73 of groins, double, 74 of shoulder, ascending, 56 descending, 57 of thumb, 53 Spice plaster, 165 Spiral bandage, 20 ascending, 20 descending, 21 of chest, 66 of finger, 49 reversed bandage, 21 of lower extremity, 82 of penis, 84 of upper extremity, 53 Splints, angular, anterior, 348 internal, 346 binder's-board, 107, 322 Splints, binder's-board, in com- pound fractures, 384 in fracture of the leg, 375 Bond's, 356 Dupuytren's, 378 felt, 107, 322 in compound fractures,384 gutta-percha, 322 hatter's felt, 108 in fractures, 321 leather, 106, 322 paper, 323 pasteboard, 107, 322 plaster-of-Paris, in fractures, 323 moulded, 100 porous felt, 107 raw-hide, 106 silicate of potash, in fracture, 323 wooden, 322 Sponges, 120 Spontaneous dislocations, 417 Sprains, 292 massage in, 294 Sprain-fracture, 294 Staffordshire knot, 239 Staphylococcus pyogenes albus, 110 aureus, 110 Starch poultice, 157 Starched bandage, 104 Sterilized dressings, dry, 131 moist, 130 Sterilizing of instruments, 134 -oven, 131 Sternal end of clavicle, dislocation of, 392 Sternum, dislocation of, 391 fractures of, 333 Stomach-pump, 195 -tube, 194^ Strains of fascia, 294 of muscles, 294 Strangury, 167 Strapping, 150 of breast, 152 of carbuncle, 155, of chest, 152 of joints, 154 of testicle, 151 of ulcers, 153 INDEX. 527 Strapping of ulcer of leg, 154 Streptococcus pyogenes, 110 Stump, recurrent bandage of, 85 Styptics in arterial hemorrhage,268 Subastragaloid amputation, 490 Subclavian artery, ligation of, 421 Subclavicular dislocation of hu- merus, 395 Subcoracoid dislocation of humerus, 394 Subcutaneous ligature, 257 Subglenoid dislocation of humerus, 394 Subspinous dislocation of humerus, 395 Sulpho-carbolate of zinc, 116 Superior thyroid artery, ligation of, 428 Suppository, glycerin, 209 Suppuration, diffused, 284 Surface thermometer, 207 Surgeon's knot, 238 and reef knot combined, 238 Surgeon, preparation of, for aseptic operation, 134 Surgery, aseptic, materials used in, 120 minor, 109 Surgical cleanliness, 111 needles, 236 Suspensory bandage of breast, 69 of both breasts, 70 Suture or sutures, 235 of approximation, 235 Bouisson's, 248 buried, 241 button, 244 catgut, 122 of coaptation, 235 continued, 241 Czerny's, 249 deep, 241 Gely's, 248 glover's, 241 haemostatic, 271 hare-lip, 242 India-rubber, 242 in gastrostomy, 252 in gastrotomy, 253 in intestinal anastomosis, 250 Suture, interrupted, 240 Jobert's, 249 Lembert's, 246 material for, 235 plate, 244 quilled, 243 quilt, 243 of relaxation, 235 removal of, 246 secondary, 235 securing of, 237 shotted, 245 tongue-and-groove, 245 twisted, 242 Sylvester's method of artificial res- piration, 189 Syme's amputation at ankle-joint, 491 Syringe, hypodermic, 198 TAMPON, 147 I Tarsal bones, dislocation of, 413 fractures of, 378 Tarso-metatarsal amputations, 486 T-bandages, 24 of chest, double, 27 single, 25 double, 26 of groin, 26 of nose, 27 single, 24 Teale's amputation, 457 of the leg, 497 Temporal artery, ligation of, 429 Tenaculum, 271, 461 Tenotomy in dislocations, 417 Tent, 148 Testicle, strapping of, 151 Thermo-cautery, Paquelin's, 172 Thermometer, clinical, 206 surface, 207 Thiersch's method of skin-grafting, 202 Thigh, amputation of, 501 Thumb, dislocation of, 404 spica bandage of, 53 Thyroid artery, inferior, ligation of, 424 superior, ligation of, 428 dislocation of femur, 4Q7 528 INDEX. Toes, amputation of, 482 dislocation of, 414 fractures of, 380 Tongue-and-groove suture, 245 Torsion in arterial hemorrhage, 270 forceps, 270 Tourniquets, 261 abdominal, 264 Petit's, 262 Signorini's, 264 Trachea, fracture of, 331 Tracheal dilators, 296 Golding-Bird's, 296 Trousseau's, 296 forceps, 297 Tracheotomy, 294 anaesthetics in, 298 director, 295 for foreign bodies, 304 high, 299 low, 299 operation of, 299 position of patient for, 298 -tubes, 297 -tube, care of, 303 Transfusion, arterial, 183 of blood, 180 direct, 180 indirect, 182 Transverse fracture, 315 recurrent bandage of head, .41 Trapping of plaster-of-Paris ban- dage, 101 Tripier's amputation of foot, 494 Trocar, exploring, 200 Trousseau's tracheal dilator, 296 Trunk, bandages of, 66 Trusses, 220 application of, 221 Truss for femoral hernia, 223 Hood's, 222 for inguinal hernia, 272 for irreducible hernia, 224 for umbilical hernia, 223 Tube, rectal, 207 Turpentine, 163 stupe, 163 Twisted suture, 242 ULCER of leg, strapping of, 154 Ulcers, strapping of, 153 Ulna, dislocation of, 401 of lower end of, 402 of upper end of, 401 fracture of coronoid process of, 352 of olecranon process of, 350 Ulnar artery, ligation of, 436 Umbilical hernia, truss for, 223 Upper extremity, bandages of, 49 spiral reversed bandage of, 53 Urethra, hemorrhage from, 280 Urethral injections, 234 Urethroscope, 233 V-BANDAGE of head, 42 y Vaccination, 196 Vascular growths, ligatures in, 254 Vein, jugular, bleeding from, 179 Velpeau's bandage, 59 dressing for fracture of clavicle, 340 Venesection, 178 Venous hemorrhage, 259 treatment of, 275 Vertebrae, dislocations of, 388 fractures of, 335 Vertebral artery, ligation of, 423 Vesicants, 165 Vomiting after anaesthetics, treat- ment of, 217 WASHING out the bladder, 233 Water-bed, 335 Waxed paper, 146 Wet cupping, 175 Wooden splints, 322 Wood wool, 146 Wounds, antisepsis in, 109 asepsis in, 109 aseptic, dressing of, 138 re-dressing of, 140 chemical sterilization in, 132 contused, 287 dressing of, 285 dry dressings in, 132 INDEX. 529 Wounds, gunshot, 288 incised, 285 lacerated, 286 modified moist dressings in, 133 moist dressings in, 132 method of dressing, 139 poisoned, 288 punctured, 287 septic, dressing of, 143 Wrist, amputation at, 471 Wrist, dislocation of, 402 Wyeth's amputation at hip-joint, 507 pins in amputation at shoulder- joint, 479 ZINC chloride, 115 sulpho-carbolate, 116 Zygoma, fracture of, 327 Catalogue of Books PUBLISHED BY Lea Brothers & Company, 706, 708 & 710 Sansom St., Philadelphia. 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