K&-. WO 178 P995s 1892 NLI1 D5E3717T fi NATIONAL LIBRARY OF MEDICINE ARMY MEDICAL LIBRARY WASHINGTON Founded 1836 Section. Number 3.__£.AA±. Form 113c. W. D.. S. G. O. 8po 3—10543 (Revised June 13, 1936) NLM052371798 PYE'S . STJ RGIC ALH ANDICRAFT: A M A N U A L OF SURGICAL MANIPULATIONS. MINOR SURGERY, AND OTHER MATTERS CONNECTED WITH THE WORK OF HOUSE SURGEONS AND SURGICAL DRESSERS. WITH 300 ILLUSTRATIONS ON WOOD. /First ameritan from tf>e {JfjirU HonQon dEDitton. Revised and Edited by T. H. R CROWLE, F.R.C.S., SURGICAL RBGISTRAR 10 ST. MARv's HOSPITAL; AND SURGICAL TUTOR AND JOINT LECTURER ON PRACTICAL SURGERY IN THE MEDICAL SCHOOL. COMPLETE IN ONE VOLUME. NEW YORK: E. B. TREAT, 5 COOPER UNION, 1892. wo P Durham's Tracheotomy Tubes (outer and inner) 495 218. Gum Elastic Tracheotomy Tube - 495 219. Intubation Instruments - 501 220. Ordinary Form of Guillotine (Mathicu's) - 503 221. Mackenzie's Tonsillotome - 503 222. Sharp-pointed Tenotomy Knife - 505 223. Blunt-pointed Tenotomy Knife - 505 224. Vulsellum Forceps - 512 225. Screw Clamp with Ivory Plates - 513 226. Clamp for Crushing Piles - 514 227. Chain Ecraseur - 514 228. Plug for Prolapsus Ani - 517 229. Brodie's Fistula Probe-pointed Director - 517 230. Scoop for Scraping Sinuses, etc. - 518 231. Fistula Scissors - 518 232. Plate for Ingrown Toe-nail - 524 233. Cupping Glass - - 529 234. Scarificator - - 530 (In the Appendix.) 235. Mercurial Lamp - 555 ERRATA. Page 57, line 33, for " sharp" read " blunt." „ „ „ 38, for "blunt" read "sharp." SURGICAL HANDICRAFT. SECTION I. ON THE ARREST OF HEMORRHAGE. CHAPTER I. Of Hemorrhage Generally. Hemorrhage is any escape of blood from its vessels, Definition. whose walls, through injury or disease, have been divided or torn. It is commonly described as being capillary, venous, or arterial. There are few accidents which test the qualities of courage, readiness, and energy, more than the occurrence of a violent haemorrhage; and, in such a case, the prompt adoption of common-sense measures will be found to be of far greater service than any routine of book-learnt rules. A few general principles bearing on this subject may be General rules shortly considered, under the heading of " The Primary emergency- arrest of urgent Haemorrhage." The measures which must be taken on the first emergency are, (1) Encouragement of the process of natural arrest, by exposure to the air, attention to position, and getting free circulation towards the heart in the veins. (2) Prompt digital pressure, on the wound first, and afterwards upon the trunk vessel, if necessary. (3) Absolute quiet, and the recumbent position. Natural arrest, Position, and Pressure, are the cardinal points in the primary arrest of haemorrhage. Arrest in capillary haemorrhage is usually simple and Natura^arrest quick enough. The capillary vessels proper contract, and the blood coagulates over the surface of the wound, 1 2 of hemorrhage generally. while underneath the surface of this coat of clot there is poured out a layer of highly coagulable lymph, which seals up the ends of the vessels, and is the first step towards the repair of the injury. in veins. In the veins, the chief agent in natural arrest is the con- traction of the venous walls, combined with coagulation of the blood. This contraction occurs at the cut ends only, and does so more rapidly than in the case of arteries, so that one may often see the veins on the face of an amputation stump distended with blood but with their ends completely closed, so that they take the shape of nipple-like projections. Veins do not appear to retract so perfectly within their sheaths as arteries do; with regard to the later stages of the process of natural arrest, such as the formation of external and internal coagula, etc., all that need be said here is that in its general outlines the process is similar to what happens in the case of arteries, but that it is some- what less perfect. in arteries. In the natural arrest of arterial haemorrhage, it is con- venient to recognise two stages, which may be termed those of primary and permanent arrest. Primary arrest. The process of primary arrest in the case of small arteries consists (a) in the coagulation of the blood effused around the vessel, over its mouth, and between its sheath and its proper wall, (b) in the gradual contraction of the mouth of the vessel, and the formation of a coagulum in the lumen of the tube, (c) in the retraction of the vessel within its sheath. Permanent The process of permanent arrest is a gradual one, and arrest often takes weeks to complete. It consists (a) in a con- tinued retraction of the vessel within its sheath, (b) of a general shrinking up of the vessel itself and the parts in the neighbourhood, (c) of a disappearance of the clots and effused lymph, partly by absorption, partly by fibrous changes, and (d) of an organisation of the internal coagulum. Finally all that is left of the divided vessel, up to the nearest offshoot, is a fibrous cord which itself will subsequently dis- appear. importance of If the vessel divided be a large one, or if from any cause the bleeding has been copious, there is added another factor in the arrest, namely, syncope, which within certain limits is often a most fortunate occurrence for the patient, for the lowered action of the heart ceasing to pump the blood into the vessels, gives time for clots to form, and for contraction and retraction to go on. OF hemorrhage generally. 3 Blood, like water, will not run up hill except upon compul- importance of sion. The effects of Position and of an unhindered return Posi'ion- of blood to the heart are thus very important. Yet how often may we see a man with severe epistaxis stooping over a basin, his neck the while encircled by a tight collar; or a bleeding varicose ulcer, with a garter grasping the saphena vein. Of Pressure, again, it has been well said, " There is no importance of bleeding from the exterior of the body which cannot be wi&^S? temporarily arrested by firm pressure with the fingers." * It matters not for the moment whether the bleeding be arterial, or venous, or capillary; the thing required is to stop it, and pressure will always do this. Too much stress should not be laid upon the kind of vessels involved in the bleeding. A distended vein may bleed as furiously as an artery; so may a mass of capillaries in inflamed tissues. But in all, the first means of arrest must be local digital pressure. General directions for the arrest of capillary and venous General airec- bleeding, and of severe mixed haemorrhage from injuries, ofDn»morrhaege. requiring plugging, etc., will now be described. The surgical arrest of true arterial haemorrhage is given fully in Chap. II. Brisk bleeding from small arteries, veins, or capillaries, is capillary often best checked by simply keeping the wound cold, heemoriha-8e- Exposure to the air, or to a stream of cold water will aid value of coia the process of natural arrest, while swathing up the injured and exposurei part, may, by the increased heat produced, directly increase the escape of blood. Pressure is sometimes useful, and limited incisions, or abrasions of vascular tissues, with few exceptions, are followed by oozing of blood which stops in a few minutes, or " by itself," and needs no further notice. Venous bleeding.—In some books, especially in those which venous hsemor- are written to gratify the taste of the outside public for principles?1161 al amateur or domestic surgery, we may still read that venous bleeding occurs only from the distal end of the cut vessel, and therefore the proper thing to do in the case of a cut vein, is to put a pad somewhere below the wound. Such directions are wholly misleading. For ordinary venous bleeding, the first thing to see to is that there is nothing hindering the return of blood to the heart. Next, to remember that almost all venous bleeding will cease on raising the limb; * Erichsen's Surgery, 8th Edition, Vol. I., p. 40J. 4 of hemorrhage generally. and thirdly, to remember that pressure will always effectually stop the flow of blood, if it be applied to the wound itself. The measures which are most immediately effective for the restraint of severe haemorrhage from vessels of »J1 kinds, provided it is -caused by external violence, now remain to be considered. Thoroughness Pressure will here be even more necessary than in the other essential. formSj and to be effectual it must be attained by plugging. Harm can only come of tying up a wound in a half- hearted way, laying on covering after covering, rather with the idea of hiding the danger, than mastering it. On the other hand, a furious rush of blood, such as may come from Plugging ana a wounded carotid, or a ruptured aneurism, may be for pressure. a t-me controue(j Dy a grm an(j judicious plugging of the wound, followed by pressure over it. Materials for The best and most convenient material for plugging plugging. & woun(j jg some one 0f tne absorbent and medicated Medicated wool preparations, having as a basis cotton wool from which the fatty particles have been removed, such as the "sal- alembroth" wool, which has incorporated in its meshes mercuric perchloride. This material is generally stained blue for distinction from ordinary absorbent cotton. The bicyanide wool recently recommended by Sir Joseph Lister, salicylic and boracic acid, iodoform, and some other antiseptic preparations, can be also incorporated with wool or gauze, and used for plugging. All this kind of material should be used dry, small pieces being packed away with a director, until the wound or cavity is filled. Lint. In a similar fashion must the narrow strips of lint be packed into the wound, very gradually but firmly, care being taken that the deeper parts of the wound are plugged as well as the more superficial ones. cotton wool. If simple cotton wool be used, it will generally be found best to soak it first in water, so as to express the air from its interstices, but in any case, as with the two preceding materials, the packing must be done bit by bit, and very firmly. Sponge. Pieces of sponge make a good plug used dry, or with some iodoform dusted on them after they have been washed in an antiseptic fluid. Being elastic they can be made to exercise considerable pressure. In deep wounds, or in such places as the vagina, rectum, or pharynx, it is wise to attach a string to the sponge, to be able to recover it. In recent surgery there is a growing distrust of sponge of hemorrhage generally. 5 as a plugging material for temporary bleeding, and still more as a more permanent means of arrest. The wound when plugged, usually requires a firm com- press over all. This may be conveniently made of several layers of lint, cut to the required shape, and secured by a roller bandage; or by a triangular or scarf bandage arranged so that the knot comes over the pad. It is often necessary to make a compress which shall be The graduated much thicker in the middle than at the edges. This is compress- effected by what is known as the "graduated compress," a series of pads of similar form, but diminishing in size, placed one on the top of the other until a more or less flat-topped pryramid of lint is made. The principal use for this sort of compress is for wounds in such situations as the palm of the hand, the axilla, etc., where it is often very difficult to secure efficient direct pressure. It must not be supposed that all, or even most wounds require to be plugged. A pad and bandage firmly applied will be sufficient to check most haemorrhages, and it must be remembered that plugging destroys all chance of healing except by granulation. At the present time the materials chosen for plugging or How long shouia covering a wound are all presumably aseptic at starting, ?emainl pa and many remain so for days or even weeks. But there is untouched? always a risk, in leaving the cavity of a wound which has been plugged for the arrest of bleeding longer than twenty- four hours, that if pressure is continued, as it must be if the flaccid walls cannot be brought together otherwise so as to obliterate its cavity, gangrene of the part may take place, while, if the compression is relaxed only, the bleedings from the vessels injured in its walls may fill the sac with loose blood clot. 6 OF THE METHODS OF CHAPTER IL Of the methods of Arrest of Arterial Bleeding. The proceedings to be taken for the immediate arrest of bleeding, which have been described in Chapter I. as being appropriate in cases of accident or emergency, have natur- ally to be adopted on the spur of the moment, before detailed examination of the injury, and with the single object of stopping the loss of blood, and maintaining the heart's action. In most instances it will be found that serious bleeding, when it follows a recently inflicted wound, comes chiefly from one or more arteries, and that unless these can readily be arrested by direct pressure by a pad or plug upon their torn or divided ends, they must be secured by some form of ligature tied round their mouth; or some other of the plans of constriction, presently to be described, must be adopted. But in many cases of accidents this is not immediately possible, while in that of vessels being divided or wounded in the course of a surgical operation it would be often inconvenient; so that it is a frequent practice to cut off the blood supply from the limb or part of the limb which is concerned, by compressing the trunk of the vessel against the bone, or in some similar way. We will begin then by considering the special means of arrest of arterial haemorrhage by compression. Of some Special Means for the Arrest of Arterial Hemorrhage. Arterial (1) By Digital Compression. o^tinuea8.88 The procedure which of all is the simplest, in most cases ofpeaCrralstmeans the most efficient, and the readiest in cases of severe arterial arre^bTdiguai bleeding, is the compression of the trunk vessel with the pressure. finger above the seat of the injury, against some neighbour- ing bone. It is of course only applicable in cases of haemorrhage in certain places, such as in the limbs, the neck, and some parts of the head and face. Moreover, unless relays of capable assistants can be procured, it cannot, in con- sequence of the fatigue it produces, be continued for more arrest of arterial bleeding. 7 than ten minutes or a quarter of an hour. Long before that time, however, help may have arrived, or some impro- vised tourniquet (vide infra) may be applied. The great value of digital compression lies in the fact that it can be applied at once, when those moments on which a life may hang will have been seized and saved. With regard to the compression itself, practical experience alone will enable the surgeon with absolute confidence to place his finger on the spot beneath which the artery is beating, and in the performance of it there are one or two points to attend to. He should endeavour as far as possible to compress the vessel only. Great pain is caused by bruising large nerves against the bone, and if in pressing the artery he at the same time compress the large venous trunks, or with the hands partially strangle the limb, the venous congestion, and therefore the general bleeding is increased.* In compressing we should get the artery fairly against the bone, and press directly upon it. In this way a very FlG. l.—Position of Hands Compressing an Artery. * At the same time it may be mentioned that in the case of a child, or a small limb, it is often not a bad plan to firmly grasp the whole limb with one or both hands and strangulate everything com- pletely. It is the middle course which is here the most unsafe. 8 OF THE METHODS OF moderate amount of pressure will suffice, and the pressure should be always as little as possible. The position of the hand and finger to be employed will vary, but as a rule the thumb had better be used to make the pressure (Fig. 1), and reinforced if necessary by that of the other hand. The limb must always be raised. Ca™icu!arlon °f The position and compression of particular arteries. arteries. The following directions for the digital compression of particular arteries will serve also for their compression by the various forms of tourniquets, improvised, or of the regulation patterns. The accompanying diagram (Fig. 2) gives the position of the vessels in the situations where they may be compressed against adjacent bones. For the anatomical relations of these vessels the student is referred to the ordinary text books. of head and fjie arteries of the head and neck. In cases of injury to the scalp, the underlying skull affords an admirable resisting surface for compression, and in speaking of scalp wounds this will be again referred to, but the compression of a main trunk (such as the temporal or occipital on the head), at a distance from the wound, is not often effectual, in consequence of the extremely free anastomosis existing all over the surface. Nevertheless, in some cases, compression of the trunk of one of these vessels may be useful. In such a case they are readily found, and a very slight pressure against the bone with the fingers will suffice. occipital artery. The occipital artery on the scalp at first lies behind the mastoid process, and higher up may be felt pulsating, and may be compressed half an inch behind, and on a level with, its base. The temporal. The temporal artery splits up into main divisions soon after it passes over the zygoma, and should, therefore, be compressed against that process of bone, immediately in front of the tragus of the external ear. Some of its branches may also be felt, and may be com- pressed higher up on the frontal bone. The facial. The arteries of the face, like those of the head, anastomose so freely that the compression of their trunks only arrests incompletely the circulation in their branches. It is, however, frequently necessary to compress either the facial trunk, or its coronary branches, as they encircle the mouth. The trunk of the facial artery may be easily found, an inch in front of the angle of the jaw, and may be compressed there. Fig 2.—Diagram shoving the position of the Prindpal Arteries. See p. 8. 10 OF THE METHODS OF The coronary. The coronary arteries form an exception to the rule of making digital compression against bone, for they are best compressed between the fingers introduced into the mouth, and the thumb on the face. They run round the mouth close beneath the mucous membrane, and about the third of an inch from the border of the lips. Their compression is often required in cases of operations, or cuts about the lips, and may then be effected between the blades of a pair of bulldog {see Fig. 16) forceps, or by the use of special " harelip" forceps, of which there are one or two patterns (see Fig. 3). Fig. 3.—Harelip Forceps. The neck; com- In the centre of the neck the only artery which ever has mon carotid , r j • .-i <• 7 i . 1 . • arteries. to be compressed is the common carotid, and the operation requires considerable care, in consequence of the proximity of structures which may not themselves be safely pressed on, such as the vagus nerve, jugular vein, trachea, etc. The thumb should be placed over the artery at the level of the transverse process of the sixth cervical vertebra, which is about 1£ inches above the sterno-clavicular articulation; pressure should then be made inwards and backwards. In this way the artery is forced away from the vein and nerve, and is compressed against the transverse process or the " carotid tubercle." * The subclavian. The third portion of the subclavian is the only one which it is possible satisfactorily to compress, and it is here some- times very difficult, sometimes very easy, to occlude. The bone against which it is to be pressed is the upper surface of the first rib, immediately outside the tubercle for the insertion of the scalenus anticus. In children or thin people, pressure behind the clavicle downwards and back- * In some works on medicine and surgery intended for the genera] public, this compressing of the carotid artery is spoken of as if it was the easiest and most comfortable of proceedings; indeed, we have seen it recommended for epistaxis, and this too in a work published " by Authority." Arrest of arterial bleeding. 11 wards, at the inner margin of the subclavian triangle, will control the circulation, no matter what the position of the limb and neck may be, but in even moderately fat people it will be necessary to depress the clavicle and shoulder, to bring the artery near enough to the surface. This is usually easy enough to do, but it occasionally happens in the course of operations about the axilla or shoulder, that the limb is required by the surgeon to be raised, while the assistant in charge of the vessel would prefer that it should be kept depressed. Especially does this happen in amputation at the shoulder joint, where, just at the moment when efficient pressure is most required, (i.e., just after the limb has been removed) the clavicle, freed from the downward drag of the arm, rises in the neck in a very exasperating fashion. Various devices, such as the handle of a door key (Fig. 4), properly padded, a surgical " key " of a somewhat similar form, etc., have been devised to meet the difficulty, and it Fig. 4.—Handle of Door Key, padded. is sometimes advisable to divide the skin, platysma, and fascia over the triangle, so that the finger may be placed effectually on the artery. This may be readily done by dragging the skin downwards, and dividing it on the clavicle, as in the first stage of the operation for ligature of the subclavian. This incision is sometimes, no doubt, absolutely necessary, but with regard to the use of the key, etc., nothing is so effective a compressor as the thumb, if it be put in the right place. The mistake which is generally made is either making the pressure far too much outwards, near the acromion, or else not sufficiently backwards as well as downwards. 12 OF THE METHODS Otf The axillary artery. The brachial artery. The first portion of the axillary artery can hardly be reached for compression, except after incision below the clavicle. The lower half of the second, and the third parts, however, are tolerably superficial, and can be compressed in the armpit, if that region be exposed by raising the arm. The pressure is made against the humerus in the same manner as in the following instance, and the vessel can be localised quite easily as it crosses to the outer side of the axillary space, and then lies amidst the trunks of the brachial plexus, with the coraco-brachialis to its outer side. Brachial Artery.—-This artery probably more frequently requires compression than all the others put together, by reason of the great number of accidents to which the upper limb is liable. It may practically be said to be sub-cutaneous in its whole length (Fig. 2), and may be compressed very readily against Arrest by flexion. Fig. 5.—Digital compression of the Brachial Artery* the humerus. The inner edge of the biceps which overlaps it in the middle third, is the guiding line for the vessel. Fig. 5 shows the method usually employed, but the artery is more easily and firmly compressed if the hand be placed as in Fig. 6. In flexion, too, of certain of the joints, we have a most valuable means of stopping arterial bleeding. * Some text books state that the inner seam of the coat sleeve is a guide to the brachial artery of the wearer. This is foolish. ARREST OF ARTERIAL BLEEDING. 13 The positions of the brachial artery at the elbow, of the popliteal behind the knee, and of the femoral at Poupart's ti FlG. 6.—Alternate method of compressing Brachial. ligament, are such, that forcible flexion of elbow, knee, or hip joints, combined with placing a firm pad in the hollow af the joint, will, in many cases, completely stop the blood supply to the limb. The flexion must be forcible, and may be maintained by fixing the limb with a bandage. An example of its applica- tion will be adduced b, propos of bleeding from the palm of the hand. At the bend of the elbow the artery may be compressed ^e^ft by the fingers, but not easily, and therefore arrest of haemorrhage by flexion is preferable. In the forearm also, except at the wrist, the circulation in the radial and ulnar arteries can hardly be controlled by any means, short of strangulation. At the wrist, however, both arteries become superficial, the radial somewhat more than the ulnar. The former lies between the tendons of the flexor carpi radialis and the supinator longus, the latter between the radial border of the flexor carpi ulnaris and the flexor sublimis, and here they may be readily com- pressed. The digital compression of the palmar arches is practically inconvenient, and the pressure is usually made in other ways. (See bleeding from wounds of palm.) 14 OF THE METHODS OF The aorta. The digital compression of the abdominal aorta is in some cases not so extremely difficult as is often supposed. It can generally be effected in children unless they are very fat, and in adults if they are thin, have lax abdominal walls, and a bold anterior vertebral curve, and in women, especi- ally in those who are sparely nourished and have borne children. The spot where this compression should be made is shown in the diagram as a point three-quarters of an inch above a line drawn across the abdomen from one iliac spine to the other (the level of the aortic division into the two iliacs), and a little to the left of the middle line. But before pressure is made, the exact position of the artery should be ascertained, for it frequently is in the middle, or may even deviate somewhat to the right. The digital compression is best and most readily made by the middle and forefinger of one hand, beneath which a small pad of lint should be placed, reinforced by the pressure of the fingers of the other hand. Pressure on the inferior cava trunk must be avoided as much as possible. The umbilicus is sometimes given as a landmark for the vessel, but investigation has shown that its place is so variable that it should not be taken as a trustworthy guide. p^mmon and In some cases a moderately small hand well oiled can be arteries. introduced into the rectum, and pressure may be made upon either the common or internal iliac arteries by the fingers. This procedure is not, however, at this time a common one. In the first place the introduction of the hand has to be performed under an anaesthetic, and very gradually, so that it is of little use upon an emergency; and secondly, the general belief is that the operation is one attended by considerable risk of damage to the gut and its coverings. Possibly however this mode of compression might be found useful in some rare cases of primary or secondary haemorrhage, from the sciatic or gluteal vessels, in a diffuse gluteal aneurism, or some analogous haemorrhage.* A more efficient way of effecting this pressure will how- ever be found in the very ingenious method which has been * For further remarks on the introduction of the hand into the rectum, see Mr. Walsham's paper on the subject in the St. Bar- tholomew's Hosp. Rep., vol. xii., 1876. The hand (he says) must not exceed 7J inches round. ARREST OF ARTERIAL BLEEDING. 15 devised by Mr. Davy of compressing the common iliac artery on either side, against the brim of the corresponding side of the pelvis, by the manipulation of a rod in the rectum. This instrument is commonly called "Davy's lever," and is simply a round smooth stick of metal or wood, about 18 inches long, and about \ inch thick at its widest part, which is the end, with a gum elastic sheath. Fig. 7.—Davy's Lever for the Common Iliac Artery. This, warmed and oiled, is introduced up the rectum, until it can be felt through the abdominal walls over the situation of the artery. The assistant in charge then raises the handle, and since the tissues of the perinaeum act as a fulcrum for the lever, its rounded end is depressed upon the artery, and arrests the circulation. Davy's lever is chiefly used for amputation at the hip joint, but it is obviously capable of many other applications, e.g., in opera- tion for gluteal aneurism, etc. It should, however, not be employed by an unskilled assistant who has not seen it used, and practised holding it in position. The absence of pulsation in the common femoral will be the indication of the compression. Compression of the common femoral artery as it lies over common the arch of the pubcs is frequently required. In this situa-femoral artery- tion the circulation may be completely controlled by making pressure directly downwards, i.e., at right angles to the surface, midway between the pubic symphysis and iliac spine. Care must be taken to avoid pressure on the vein as far as possible; this is best done by putting a small pad of lint underneath the finger. Frequently, however, the vein is so far behind the artery, even when they come through into the thigh, that it cannot escape the pressure. The inguinal glands, too, as they lie parallel with Pou- part's ligament, must be avoided, and if they are enlarged, this is sometimes very difficult. The line of the superficial femoral artery is one taken supernal from the point above mentioned between the symphysis femoral arcery- and spine, and the inner side of the internal condyle of the femur. When the knee is slightly flexed, and the thigh rotated 16 OF THE METHODS OF outwards, firm pressure all along this line will generally succeed in stopping the current of blood, but as the artery gets deeper in its course, more and more force will be required; the artery, also, cannot be pressed directly against the bone. Popliteal and As in the case or urn niTt'chial artery at the bend of the tibial arteries. elboWj so ^^ tne popliteal, digit d compression is very inefficient, while the circulation may be readily stopped by flexion. If a firm pad, about the size of a hen's egg, be placed in the hollow of the knee, and the knee be then bent up on it, the circulation will be quite stopped. By any means short of complete strangulation of the limb, it will not be found possible to compress either the anterior or posterior tibial vessels in the legs, but the posterior one becomes quite superficial as it lies a little internal to the middle of the hollow between the heel and At the ankle, the inner ankle, going with the nerve beneath the annular ligament, between the common flexor of the toes, and the special flexor of the great toe. Dorsal artery of The dorsal artery of the foot, the continuation of the anterior the foot. tibial, may be felt and compressed against the astragalus, scaphoid and cuneiform bones, between the extensors of the big toe and of the other toes. Here also this vessel may be the seat of a traumatic aneurism, the result of injury generally, but which has sometimes developed after teno- tomy. (2) By Strangulation of the Limb. special means The process generally known by the name of Esmarch's Esmanjh's baJ- bloodless method consists in first of all emptying the limb dage and tube. Qf ^g Diooc[ ^y rolling a long indiarubber bandage from below upwards to the spot where the circulation is wished to be controlled. At this spot a stout indiarubber tube two feet long, with a hook at either end, is passed round the limb, sufficiently tight to strangulate all the vessels, and the ends of the tube are then hooked into each other. (Fig. 8.) Fig. 8.—Esmarch's Bandage and Tube applied. ARREST OF ARTERIAL BLEEDING. 17 The indiarubber bandage is then removed, and the limb, thus rendered bloodless, will remain so until the tube is taken oft*. This method is simple enough, and with ordinary care all chance of bleeding is prevented. It is especially useful in such operations as the removal of sequestra, scraping or gouging carious bone, etc., where it is important to have the exposed parts as dry and bloodless as possible; but it will also serve in the place of a tourniquet in amputations, or in other cases where it can be applied at some little distance from the seat of operation. The strangulation by this method is so complete, veins, arteries, and capillaries being all compressed, that it is not safe to allow the tube to remain on long. Its use therefore is not fitted for the restraint of accidental haemorrhage, except as a temporary measure, and indeed in some very prolonged operations it is wise to remove the tube before the operation is finished. When the Esmarch's bandage has been used in an opera- tion, and only general oozing is expected to occur in the wound, it is generally convenient to apply the dressings, using such pressure as may be required, before the tube is taken off, for the absolutely bloodless condition of the small vessels has caused a temporary loss of tone in their walls, so that when the blocd current is allowed to flow into them again, they for a time are much dilated, the whole limb becomes injected, and unless the wound has already been bandaged up, and pressure applied, there may be a very brisk flow of blood, and a corresponding delay in the dress- ing. This applies only to the smaller vessels ; and arteries large enough to give trouble, should be secured by forceps or ligature before taking off the tube. There has been latterly an increasing desire to simplify Professor Esmarch's procedure, and to do away with the indiarubber bandage, while retaining the tube. It is found that if the limb be raised and the larger veins emptied of blood by the passage of the hand along the limb towards the trunk, that the latter may be rendered nearly blood- less, and that the application of the tube alone is able to keep it so. The limb should simply be raised, before putting on the tube, in cases of septic inflammation or malignant growth ; as morbid products may be forced into the blood stream if pressure be applied over the affected area. The tubes used for encircling the limb should always be 2 18 OF THE METHODS OF As a figure of 8 Special means ot arrest. (3) By tourniquets. Three principal kinds. The improvised tourniquet. Its application. Screw ' tourniquets. Petit's. tested before they are used, for they are very liable to crack or break unexpectedly, especially at the ends where the hooks are fastened. In cases of operation about the shoulder, or hip, the tube may very usefully be put on in the form of a figure of 8, and in this way even such operations as amputation at the shoulder or hip joints have been rendered almost bloodless. The plan succeeds best where there is much emaciation. (3) By Tourniquets. A tourniquet is, properly speaking, an apparatus for screwing down a pad upon a vessel. Practically, however, the term is applied to any means by which pressure may be put upon a vessel and mechanically maintained. The principal forms, which alone will be described, may be roughly separated into three classes—improvised, scre\\r, and indiarubber or elastic, tourniquets. The improvised tourniquet is an efficient and ready im- provement on the time-honoured method of stopping bleeding from any part by tying something round it, somewhere between the wound and the heart, tightly enough to strangu- late all the tissues. In the improvised tourniquet especial pressure is put upon the main artery, and therefore the force required is very much less, and the venous return is at least not wholly obstructed. Its manufacture and application are simple enough. A handkerchief is taken, folded up like a cravat, and a piece of cork or wood, or a pebble, is inserted between the folds, so as to act as a pad. This pad is placed over the artery, and the cravat loosely knotted round the limb, the knot coming on its outer side. (Fig. 9.) An umbrella, or ruler, or any moderately strong rod or stick is then passed between the limb and the knot, and twisted round. The leverage thus obtained is very great, and the amount of compression must be estimated, or it may be afterwards found to have been damaging the tissues. This form of tourniquet is known also by the names of "The Garrot" or the "Spanish Windlass." Of screw tourniquets, the oldest form which is still retained in use is known as Petit's (Fig. 10). Its action and method of application can be readily enough seen from the woodcut. The strap is first fastened round the limb, not so tight as to make any compression, ARREST OF ARTERIAL BLEEDING. 19 but sufficiently to prevent the whole tourniquet, or the smat Fig 9.—The Improvised Tourniquet or " Garrot." pad of lint generally placed underneath the larger pad from shifting about. ' The tourniquet should be unscrewed to its full extent before the strap is buckled. When pressure is to be made, the screw must be turned very rapidly, and great care should be taken that the pad never shifts from its position on the artery. Fig. 10.—Petit's Tourniquet (modernized). fr wi]l be noticed that in this pattern? as in the Spanish its drawbacks, 20 OF THE METHODS OF windlass, in addition to the especial pressure on the artery, the limb is tightly grasped by the strap. In consequence, Petit's tourniquet is very painful, and could not possibly be used for long. But the following screw tourniquets have all been designed to free the venous circulation through the limb, by making pressure only between two opposite points. signorini'B. The principal forms of these are, Signorini's (Fig. 11), which is easy of application, but is liable to slip round the limb. Fig. 11.—Signorini's Tourniquet. Bkeys. Carte's or Skey's, (the safest pattern) (Fig. 12), for the vessels of the thigh, and Lister's, for the abdominal aorta. FlG. 12.—Skey's Tourniquet. An effective tourniquet for the subclavian artery is still much to be desired. ARREST OF ARTERIAL BLEEDING. 21 _ With regard to the use of these tourniquets, the localisa- tion of arteries has been sufficiently dealt with; in all the pressure should be made very gradually, and either a small pad or the finger should be placed over the artery itself, underneath the pad of the instrument. The compression of the abdominal aorta by Lister's Lister's, for instrument is in itself a serious proceeding, apart from the aoft°a?inal operation to which it is an adjunct. Some, at any rate, of the important abdominal viscera must be appreciably com- pressed, and it seems impossible to make sure of avoiding such organs as the main branches of the solar plexus, the pancreas, and intestines, injury to which might well cause a collapse even more serious than that which the instrument is designed to prevent. For these reasons this tourniquet is not frequently used its application. now. The best way to apply it is for the patient to lie on the right side, while it is put on and roughly adjusted; in this way the great part of the intestines, etc., escape the risk of pressure. The patient then lying on his back, the artery must be found as mentioned before, and pressure made extremely slowly. In addition to the elastic band used in Esmarch's method, Eiastio which has been already described, a solid indiarubber cord tourniquet" fitted into a groove in an ebonite or wooden compress may be used. It is portable and readily applied, but is somewhat liable to slip; there are two or three patterns on this principle. It would be difficult to mention an improvement in the importance oj art of surgery greater than the introduction of the practice k^""0* of tying the mouths of vessels. This was introduced and advocated by Ambrose Pare,* to whom the credit of the advance is due, although he admits the idea was suggested to him by some observations of Galen. * Par6, when serving as barber surgeon in the French army in Lombardy, circa 1536, began the practice. In his account he says : " Wherefore I earnestly entreat all Chirurgians that they would (being admonished) give over that cruel and butcherly kind of curation, and practise this which I have prescribed, taught me, as I interpret it, by the suggestion of some good angel. For I neither learned it of my masters, nor of any other man, only I read in Galen, in the first book of his "Methods," that to stay a fluxe of blood, there is no remedy so present as to tie up those vessels that bleed, towards their roots, that is towards the liver and the heart. Now I conceived that this doctrine of Galen's for the binding and sewing of veins and arteries in fresh wounds might well be used in the like vessels after a dismembering, and so I put it in practice," 22 OF THE METHODS OF The methods of There are three principal methods of putting a ligature on a divided artery. The first consists in seizing it, and it only, with a pair of forceps, holding it up and tying a cord of some kind round its mouth in a reef knot. (See Fig. 15.) The second consists in passing a sharp curved needle in a handle, called a tenaculum, beneath the vessel as it lies in the tissues, and then after raising up the vessel and its surroundings, putting a ligature around all, below the needle, which is itself withdrawn after the knot has been tightly tied. Fiio-pressure. A third way consists in passing an eyed tenaculum beneath the vessel near its open mouth. The needle may be threaded before or after it is passed, with a catgut or silk ligature, which may then readily be tied over the vessel and the small amount of tissue which will be included in the noose. Thus— Fig. 13.—Filo-pressure—(after MacCormac). Forceps Jf it is desired to seize the vessel for the purpose of immediate ligature, nothing does better in skilful hands than the common dissecting forceps, with well roughened points, and with no spring to get out of order, but more commonly a special form of forceps is employed, with the points notched so as to fit into each other, and thus to " bite" the artery; usually they have a spring catch to hold the blades together, and on the whole, the most satis- factory pattern is the " fenestrated " of AVakley or Lister. In catching the vessel it should be taken up as cleanly as possible, with none of the surrounding tissue, and slightly drawn upon. The ligature should then be thrown round the forceps and slipped over the vessel and tied. tightly in a reef knot, ARREST OF ARTERIAL BLEEDING. 23 Fig. 14.—Fenestrated Forceps. It is very desirable for the student to get into the habit of tying vessels neatly and quickly. The commonest faults are tying a "granny" instead of a reef knot, engaging the points of the forceps in the noose, and neglecting to keep the two forefingers close to the forceps and vessels. If this last point be well attended to, it will be found best to take the forceps off the vessel after the first part of the knot is formed, but before it is completed, as in this way the knot is more tightly tied. Fig. 15.—Ligature of an Artery (position of hands). The materials used in ligation are silk, hemp, catgut, and Materials nsea some other animal materials, as kangaroo tendon, ox aorta, m h£atlon" etc. At the present time, silk, catgut and kangaroo tendon alone need to be considered. Silk was in former times the most suk. esteemed as being the easiest of application. Then in later years and up to the present time many surgeons considered it necessary to leave one end hanging out of a corner of the wound until it came away, and this involved risk of septic infection from the fistulous track thus formed. The silk at that time was softer and less twisted than that Ave use now for ligature, so that it was difficult to make it aseptic, or keep it so, especially when the loose ends of the threads were allowed to project from between the lips of the wound, 24 OF THE METHODS OF Catgut. At its commencement the practice of making surgical wounds retain their normal condition of asepsis through- out all their healing processes, threw naturally a dis- credit on silk as a ligature, and though it never went quite out of use, catgut succeeded in taking its place in general usage, and Sir Joseph Lister had convinced the surgical world that with matured catgut, prepared, but not over-prepared, the knotted ends of the thread might be cut quite short in the wound, there to be absorbed in the course of a few days (or at most three weeks). " Carboiized." There are two principal varieties of it, both introduced by Professor Lister. The original " carbolized catgut" is made by soaking the gut in carbolic acid and olive oil, in proportion of 1 - 5, with a little water, for some months. "Chromicizea." The other,* the "chromicized" gut is made by steeping it in a solution of one part of pure carbolic acid to twenty of a 1 - 4000 solution of chromic acid. The catgut before it is used should be made supple by soaking in a 1-40 solution of carbolic acid, and this, if the gut be properly prepared should render it supple only, and not cause it to swell and become flabby. A good chromicized catgut is nearly perfect as a ligature, but the uncertainty of one sample being like another both in breaking strain and capacity of being absorbed, renders the perfect ligature still a thing to be looked for. Possibly it may be found in the long tendons of a kangaroo's tail, or some similar tendon, where there is great strength and flexibility combined, with a capacity of being absorbed, or partly organized. During the last few years the manufacture of both liga- tures and sutures of silk thread has improved the strength and firmness of the twist or plait, and abdominal operations have proved how well almost all tissue bears the presence of small foreign bodies if they are clean, as silk should be. It is, as a fact, coming back into general use. use of the The same ligature materials are employed for the tena- culum as for the forceps, and the instrument itself is extremely useful in picking up arteries in situations such as between, or close to, bones, oi in tense bands of fascia, or indeed anywhere where the vessel cannot readily be picked up with the forceps. Another frequent occasion for the use of the tenaculum is when from any cause there is troublesome haemorrhage from * gee Prof. Lister on the Catgut Ligature, Lancet, Feb. 5th, 1881, ARREST OF ARTERIAL BLEEDING. 25 a vessel, the position of which cannot exactly be made out, or from a small number of vessels, or when a vessel is nicked, but not divided. In these cases frequently the readiest way to stop the bleeding is to push a tenaculum somewhat deeply beneath the bleeding, and pass a ligature round it. Tenaculum ligatures must be tied up very tight, or they will slip. For this reason silk is perhaps better than cat- gut ; at any rate it is more frequently used at the present time. Two small instruments for arrest of bleeding by pressure The bulldog ana maybe mentioned here, the "bulldog" forceps (Fig. 16), Berrtflne- and the "serrifine" (Fig. 17). Fig. 16. " Bulking " Forceps. Two patterns of Serrifines. They are both " clips," which may be quickly put on to a bleeding point or vessel, and may there be left until, either by the pressure of their springs the vessel has ceased to bleed, or until the surgeon has leisure to ligature it. The serrefine is also used sometimes for the purpose of carefully adjusting superficial wounds in exposed parts, such as the face or neck. Forci-pressure.—This rather barbarous name more especi- Forci-pressure. ally designates the use of a pattern of self-closing forceps suggested by Sir Spencer Wells, for the purpose of stopping temporarily the bleeding from small arteries and arterioles in the course of operations upon the abdomen, especially from the divided abdominal walls, to avoid the flow of blood into the peritoneum. Fig. 18.—Ford-pressure Forceps. Fig. 17 26 OF THE METHODS OF They have their bows so fashioned that the first finger and thumb can instantly unfasten the catch on the shanks. Their great usefulness consists in the fact that they can be clipped on to a bleeding point in a moment, as during the course of an operation, and then may be left hanging until the bleeding is arrested permanently by their compression, or the surgeon has leisure to twist or tie the vessel. Much blood and much time are saved by having a good supply of these forceps handy at any operation where bleeding is likely to be free, for they are strong enough to hold a trunk artery, and well enough made to catch any thing smaller, down to an arteriole. These forceps make also very good sponge or needle- holders, and should be in every dresser's pocket-case. Torsion. In machinery accidents, where a limb has been very badly injured, or it may be, completely torn from the body, it generally happens that there is little or no bleeding from the large arteries divided across; and if these are examined they may often be seen pulsating quite down to their extremities, which yet are as firmly closed as if they were ligatured. its principle. The explanation is that the vessels have been pulled asunder, and that in this pulling, the two inner coats have first parted, while the external coat has only yielded after considerable extension. The aperture of the tube is there- fore narrowed before it finally gives way, and the vessel comes in two. The outer coat afterwards retains its narrowed condition, and the elastic ones inside retract. These inner coats therefore will be thickened to such an extent that their sides will come into contact within the narrowed outer coat of the vessel, and will effectually close it up. its history. xhe properties thus possessed by the coats of the vessels were first applied to their artificial closure when divided, by Amussat, in 1829, and soon afterwards by Velpeau, since whose time it has been known as the method by "Torsion." In this proceeding the vessel is not pulled asunder, but the end is twisted round many times. The inner and middle coats are thus broken across, and by retracting become thicker, as above described. The narrowing of the outer coat of the vessel is effected by the continuous twist- ing. Mr. Bryant, in 1868, advocated strongly the advan- tages of torsion, giving 200 consecutive cases of amputation in which the main artery was twisted without a single case of secondary haemorrhage. ARREST OF ARTERIAL BLEEDING. 2? Fig. 19.—Torsion Forceps. round and round six or eight times, but for large vessels the operation requires more care. The vessel should first be Limitea torsi, separated from its sheath and pulled out of it for about one- third of an inch. At the point of its exit from the sheath it should be held with a pair of narrow forceps, and then, its end being held in the torsion forceps so as to leave as much as possible of the artery free for twisting, this should be quickly done, the forceps being held parallel to the long axis of the vessel. Fig. 20.—Method of Torsion. Some surgeons twist the vessel until the part in the forceps comes away ; others give six or eight turns only, probably the preferable plan. For this treatment to succeed, the arterial coats must be vessels must be free from disease, such as atheroma, or those more insidious healthy- forms of arteritis present in chronic syphilis, gout, etc. When first introduced in the days of the old silk ligature, the advantage of having no foreign body hanging out of 28 METHODS OF ARREST OF ARTERIAL BLEEDING. the wound was very great; nowadays the twisted end of the vessel is in just the position of a catgut ligature cut short: both in healthy wounds will be absorbed, and neither can be regarded strictly as foreign. Acupressure In a similar way "acupressure," when first introduced, was hailed as a great advance on the old or silk ligature, but at the present time the occasions on which its employ- ment is especially advantageous are becoming more and more rare; while except in the case of exposed wounds there is this constant disadvantage, that opposing surfaces can hardly be brought together for union by first intention, when needles are used. The essence of the procedure consists in the passage of a stiff steel needle through the tissues in the neighbourhood of a vessel, and then to arrest the bleeding by its pressure, either on the tissues in situ, or when twisted round, or by passing the needle in below the vessel and passing a loop of wire or silk over it, the vessels being included between the two. The needles should be withdrawn between twenty-four and forty-eight hours after their insertion. If the loop of silk or wire be used, the needle must be drawn out first, and the loop will then be free. For further details on this method, which at one time was worked out with great elaboration, the student is referred to. the surgical writings of Professor Pirrie, of Aberdeen. For wounds about the face, and wherever great accuracy of coaptation is required, and notably about the mouth, a form of acupressure is employed which serves the double purpose of arresting bleeding, and adjusting the edges of the wound. This will be treated of in the section on wounds. (See hare-lip pins.) Deep sutures. Another useful method of stopping bleeding in certain cases is also allied to this principle of acupressure, namely, the passage of sutures of stout silver wire through or beneath the bleeding part. The reader will readily imagine cases in which this proceeding would be of avail; but, as an instance, the common practice of leaving to the sutures the office of stopping the numerous small vessels that are divided in the edges of amputation flaps, may be adduced. OF CERTAIN SPECIAL KINDS OF HAEMORRHAGE, ETC. 29 CHAPTER 1TL. Of Certain Special Kinds of Hemorrhage and their arrest. From an imperfectly divided vessel. If this form of bleed- Haemorrhage ing be not efficiently arrested it is always troublesome, fectiy aaiviaeaer and sometimes even dangerous. It most commonly occurs vesse1, on the scalp, or from a wound in the cleft between two fingers, or from the artery of the frasnum. Again, when the transfixion method of amputation was more common than it is now, the vessels were apt to be split, instead of being cleanly divided by the knife. This was a frequent cause of secondary haemorrhage. The bleeding is obstinate, because the process of its natural arrest is interfered with ; for the cut edges of the wound in the arterial coats retract as far as they can, and this retraction keeps open the orifice in the vessel, instead of tending to close it. The tube thus being only half cut across cannot retract its ends within the sheath as it is wont to do when completely severed. In all cases the thing to do is to enable the natural arrest to go on by completely dividing the vessel. In the case of an imperfect dieision of a digital artery between the fingers, From a aigitai the bleeding is sometimes very troublesome. In such a case aiteiy- the vessel should be cut down upon and carefully exposed without injury to the neighbouring nerve trunks. A liga- ture should be placed above and below the wound in the vessel, and then it should be divided. An Esmarch's bandage previously applied will make the dissection more easy; the dressing should be put on, and the fingers tied together before the indiarubber band is removed. The artery of the frasnum of the penis is sometimes rup- From the artery tured during coitus. If it be torn right across the bleeding t,f the fr£enum- is slight, but if only half divided it is sometimes very profuse. In this case all that is necessary is to divide it completely with a pair of scissors, and then to apply moderate pressure. Wounds of the scalp often bleed very freely, especially at From a scalp first. In dressing them the hair should be cut off all round wound- the wound, which itself should be well washed. Even if 30 OF CERTAIN SPECIAL KINDS OF the spouting vessels are plainly to be seen, it is almost always waste of time to try and pick them up for the pur- pose of ligature. A good firm compress, secured with a knotted bandage, will, by ensuring pressure against the underlying bone, arrest any ordinary haemorrhage. If a vessel must be ligatured in the scalp tissues, it will most easily be done with a tenaculum, or by the methods of filo- or forci-pressure (pp. 22 to 25); and it is best to use a piece of strong silk. From the Wounds of the palmar arch are very troublesome, and the bleeding from them is very apt to recur. This is due partly to the vascularity of the parts, and partly to the difficulty of applying efficient pressure, the vessels themselves lying beneath, and protected by the thick bands of the palmar fascia. Although it is difficult to apply pressure, in most cases it is necessary to do so, for other means would tend to cripple the mechanism of the muscles and tendons of the palm. Sometimes no doubt it is advisable to dissect out the bleeding vessel in this crowded region, and put a ligature on it, but as a rule, the hazards of this proceeding outweigh its obvious advantages. In applying pressure to the palm of the hand, a firm smooth pad must be used, and the palmar fascia must be relaxed. These two conditions are well fulfilled by bending the fingers over a round piece of wood, like a ruler, covered with three or four layers of lint, or over a tight roller bandage. If this be firmly grasped, and the fingers bandaged over the cylinder, very good pressure will be made. (See Fig. 21.) Should the bleeding still continue, the forearm should be Fig. 21.—The Hand bandaged for a Cut in the Palm. HEMORRHAGE AND THEIR ARREST. 31 forcibly flexed at the elbow, with or without the addition of a pad of lint in the flexure of the joint. This will almost always stop the bleeding, but should it fail (and it is wonder- ful how this form of bleeding will persist) it will be necessary to compress the radial and ulnar arteries at the wrist. This is best done by laying two pieces of wood, e.g., portions of a lead pencil, over two small pads placed on the arteries, and fastening them firmly with strapping, the hand, forearm, and arm being firmly bandaged from below upwards. But it may happen that even yet the bleeding recurs, and by this time, as several expedients have been fruitlessly adopted, the patient may be getting exhausted by loss of blood. A tourniquet or digital compression of the brachial artery can be a temporary expedient at any stage of the proceedings; but this cannot be kept on for long, especially in this exsanguine condition of the patient. The course usually recommended in books is to tie the radial and ulnar arteries at the wrist, but if pressure has been properly applied and has failed, it is hard to see how ligature can have happier results. On the whole the best plan seems to be, first of all to open up and thoroughly examine the wound, and if it appears feasible by dissection, to find, and tie the bleeding vessel or vessels, and failing this, to tie the brachial artery, high up in the arm—a somewhat desperate remedy truly, and one which can very rarely be required if the milder measures before mentioned have been thoroughly carried out. It should be borne in mind that the tourniquet can always be put on for an hour or two, so that the visiting surgeon can be sent for; and also that bleeding so obstinate as this may probably be associated with a morbid condition of the blood or its vessels. (Vide Haemorrhagic Diathesis.) Vessels, either veins or arteries, may be so connected with Hemorrhage the surrounding tissues, that when divided, their walls ve°sseisfnallse<3 neither contract nor retract. Their mouths are thus kept open and they are said to be canalised. Thus the jugular and other veins at the base of the triangles of the neck, are so bound down by the cervical fascia, that if they are divided, and especially if divided in the angle of a wound, they gape and bleed. This is especially dangerous in this situation, not from the Entrance of air haemorrhage, but from the danger of entry of air into the getr0o,f?mb-dan blood current going to the right heart.* "See Chapter XXVIII. 32 OF CERTAIN SPECIAL KINDS OF other But canalised vessels may give trouble in other situations difficulties of. kesides tne r00t of tne neckj especially at the angle of a wound held open by its gaping, in tissues the seat of fibrous thickening or chronic inflammation, or when vessels, them- selves atheromatous, are inelastic and rigid. Atwthunangle °f -^or vesse^s at ^ne an9^e °f a wound the best way is to extend it slightly, when they will retract. But those running in aiseasea through tissues, the seat of chronic inflammation are often troublesome, as in amputations for long-standing disease, when almost every vessel, insignificant though its size may be, requires a ligature, because it will not retract. Atheromatous This also is the case with atheromatous arteries, but there is this additional difficulty, that because of the disease of the arterial walls, a ligature is very apt to cut through, so that great care and well softened ligatures will be required. Rupturea Bleeding from a burst varicose vein is often one of the most furious, and yet one of the most easily arrested of haemor- rhages. It is important to rightly understand it, for many lives are thrown away every year in consequence of the foolish unreasoning conduct of would-be assistants, when this accident happens. ' No one can be long in a hospital casualty department, with- out seeing some such case as the following. A man who for a long time has had varicose veins, and subsequently a condi- tion of chronic eczema and ulceration of the legs, stupified by cold or drink, subjects the legs to some slight violence, so slight that often it is hardly noticed. Presently he is aroused to the sensation of something warm trickling down the ankle, and looking down he sees his boot and stocking full of blood, which is coming from the position of the ulcer. He then becomes faint and falls. A crowd collects, and (the prone position on the ground being the safest for him) they immediately lift him and try to make him sit up. They then get some brandy, and proceed carefully to choke him, while he is unable to swallow. A bystander then sees the blood tricking along the floor or ground, and so he takes his handkerchief and ties it tightly somewhere round the leg, which is still allowed to hang down. The patient being then put into a cab, is driven off to the hospital, perhaps to die before he gets there, as^ the blood is escaping from his leg all the time. All this might have been easily avoided by the exercise of common sense. Since the recumbent position is the best for syncope, the patient should not be raised from the ground until a suitable stretcher is provided. Then, the leg being HAEMORRHAGE AND THEIR ARREST. 33 raised a foot or so, the bleeding surface should be exposed, and any constriction round the limb on the " heart" side removed. In all probability the bleeding will practically cease immediately the limb is raised, and a small pad and bandage being placed on the wound, it will not recur while the patient is lying down. It should be remembered that the blood comes prin- cipally from the proximal end of the ruptured vein, the valves of which have been rendered incompetent by the dilatation. If however, the patient must walk soon after he has had a burst vein, the leg and foot should be firmly bandaged from the toes upwards, to a little above the bleeding point, on which there must first have been placed a pad and bandage. It is also necessary to keep the patient warm ; the loss of blood is often very great, and such patients cannot bear it well, so that it sometimes happens that after the bleeding has been stopped, they get a sudden failure of the heart's action, and die because they have been allowed to get too cold. Nose bleeding is either idiopathic or traumatic, and is From the nose- venous and capillary in character. It is of all kinds and lts varieties- degrees of severity, and may require for its arrest a number of expedients, some very simple, some requiring consider- able skill. But it is often desirable not to check the bleeding at all, as when to be left when it occurs in children in good health, and young adults a of a lusty habit; or in some cases in young women in whom the haemorrhage is vicarious to the menstrual flow. Idiopathic epistaxis may be roughly divided into two if iaiopatnic, classes; the one in which it depends on simple congestion oTpassiveC.tlve of the mucous membrane of the nose, occurring in healthy people, and the other in which it is a strictly passive con- gestion, caused by cardiac or hepatic disease. The haemorrhage in the first class tends to stop of itself, f^eT of latte' when by the bleeding the congestion is removed; but in the second the cause is constant, and the longer the epistaxis goes on, the more difficult it is to stop, in consequence of degenerative changes taking place in the blood. The bleeding in these cases is not a brisk flow accompanied with a good pulse and other signs of a strong circulation, but is rather a feeble dribbling, sometimes stopping alto- gether, and then being again a little more rapid. In this way a great deal of blood may be lost by those who cannot spare it, and the bleeding, instead of being a relief, is 3 31 OF CERTAIN SPECIAL KINDS OF accompanied by great depression, a feeble fluttering pulse, shallow respiration, etc. A little experience of the aspect of sick people will enable the student to recognise those who are suffering from vis- ceral disease, whether it be morbus cordis, or cirrhosis of the liver, or chronic Bright's disease, or a malignant growth, and to sharply separate in his own mind those in whom moderate epistaxis is rather a relief, from those in whom it is certainly an alarming symptom, and may be a source of danger. In these latter it should always be promptly checked ; in the former, delay is never hurtful and may be useful. The expedients for checking epistaxis are very numerous, and are best described in order of their importance, and as in practice they should be employed; the simpler measures being always tried before those which cause discomfort or pain. Position. In the first place, position is as important in these cases of bleeding as in any other. The patient's head should never be bent down over a basin, nor should the circulation be stimulated by his remaining standing. The best position is the sitting one, with the head thrown back. A towel spread in front like a bib will prevent the clothes being soiled, and moveover will obviate that constant blowing and wiping of the nose, which is most harmful. If, in addition to this position, the venous return to the chest be promoted by everything being made quite loose round the neck,* in very many cases nothing further need be done, and an epistaxis, which has perhaps lasted two or three hours while the head was held down over a basin, will stop in as many minutes. If it still persists the next thing to do is to raise the arms above the head, or to rest the hands on the top of the head. This has a very good effect, probably by increasing the chest capacity, and thus lowering the intra-thoracic blood pressure in the right heart and the large venous trunks. Application of The application of cold externally is the next expedient. cold' Ice, or a cold evaporating compress is recommended to be put over the bridge of the nose, but it is very doubtful, if there, it does any good. But cold applied to the nape of the neck, * It may be worth while to remind the reader that the collar of the jersey luay be tight, while that of the outer shirt looks quite loose. In the case of women it is also wise to loosen the stays. HEMORRHAGE AND THEIR ARREST. 35 undoubtedly, is a very powerful agent for arrest. Slipping a door key down the back is therefore no mere superstition, but good effects are better secured by an ice-bag fastened over the upper cervical spine. If these measures have failed, we must proceed to more Loca.i vigorous ones in the form of local applications to the applic bleeding part, by means of a syringe or nasal douche, by an astringent powder, or by plugging. Fig. 22.—Nasal Douche. The nostrils may first be syringed out with iced water, using Syringing. a common syringe, or better, one of Higginson's pattern, or a nasal douche (Fig. 22). In using the latter, the water should be forced into one nostril, so that it can flow round the posterior nares, and come out at the other. This is effected by keeping the mouth wide open and the soft palate there- fore raised. Instead of iced water, a weak solution of perchloride of iron, say one to two drachms of the liq. ferri perchloridi, to a pint of water, or of the sulphate of iron, or of alum in similar proportions, may be advantageously used. Epistaxis may be checked also by the use of solid astrin- Alum ana gents, as powdered alum or tannin, used as snuffs. The 36 OF CERTAIN SPECIAL KINDS OF powder, when placed in a paper, folded so as to make a trough, is "sniffed" strongly up the nose. This is a very irritating and disagreeable proceeding, and is not to be recommended if other means of arrest are at hand. Plugging. In cases of continued failure, we fall back on the last resource of plugging the bleeding nostril; for digital com- pression of any external artery is obviously useless, and compression of the nostrils can only be useful in very super- ficial haemorrhages, and these are not common. The nostrils may be plugged, either from the front alone, or by completely shutting up the nasal cavity on one or both sides, by plugging the posterior as well as the anterior nares, or by means of a nasal tampon or inflating bag. By the anterior Pluqqinq from the front alone. If this operation be thoroughly performed, it will not often be necessary to resort to the disagreeable and not altogether safe practice of plugging the posterior nares. To plug from the front, a strip of lint, at least 18 inches long, and a third of an inch wide, and a stiff director are required. The strip may be dipped in perchloride of iron solution, or in carbolic oil, if it is thought desirable (the latter is very useful to prevent decomposition), and must then be packed right back to the posterior nares, and the full length of the floor of the nose must be borne in mind. The back part being well filled, the more accessible parts of the cavity are plugged easily enough, the strip of lint being gradually coiled away until the whole nostril is full. Plugging the To plug the posterior nares, a " Belloc's sound " or some r nares. g^g^^e for it, will be required, and two suitable little plugs fashioned to fit the anterior and posterior nares respectively. They are best made of lint, tightly rolled, so as to make two cylinders about an inch long, and half an inch wide. The one which is to go into the posterior nares, must be tied round the middle with a piece of string, so that two ends, not less than a foot long, hang from it in front, as in the figure (Fig. 23), while another piece, not shown in the illustration, should be fastened to it behind, so that when the plug is adjusted into the posterior nostril, this may lie in the pharynx, ready to be brought forward out of the mouth when the plug has to be removed. These being ready, the sound, consisting of a cannula, within which is a piece of watchspring, which will curl round the soft palate into the mouth on being pushed out of the tube, is introduced along the floor of the nostril which is bleeding. The watch spring is protruded, and is hooked forward by the HEMORRHAGE AND THEIR ARREST. 37 forefinger of the left hand, into the mouth, and loth ends of '11 Fig. 23.—Section through the head, showing Nasal Plugs in position with Belloc's sound. the string, which are attached to the plug of lint, are quickly passed through the eye, which will be found at the end of the watchspring. This is then retracted into the cannula, and the latter, when Avithdrawn through the nostril, will carry the strings with it. The strings must noAv be separated from the cannula, and draAvn through the nostril. The plug will thus be drawn into the mouth and carried backAvards to the soft palate; it must then be passed behind this Avith the fingers, and pushed upwards into the upper part of the pharynx, and traction being made on the strings, it can be adjusted by the fingers, to fit into the proper opening of the posterior nares. This being done, the other plug is adjusted into the anterior nostril, between the ends of string, Avhich are firmly tied over it and fasten it tightly to the nostril, Avhich is thus converted into a shut cavity. The principal difficulties in this plugging operation are, first, the introduction of the sound, and the bringing forAA'ard of the watchspring, and secondly, the adjustment of the posterior plug. It is often aAvkward to pass it round the soft palate, but this being done, the rest is easier. Still it is not difficult to mistake the opening into which the plug is to be placed, and to avoid this, the fingers must be passed right back, and the nostrils thoroughly explored. If a Belloc's sound cannot be got in an emergency, an improvised one may be made from a soft gum elastic or rubber catheter, about No. 6 to 8. Passing this through the nostril, it can be hooked forward from the pharynx out of 38 OF CERTAIN SPECIAL KINDS OF lrane of the anus, partially strangulated From mucous as it is when prolapsed, frequently bleeds. It, hoAvever, anus.1 and causes violent bleeding, and there are even one or ineunsm. ^wo cases on record in which the occurrence has resulted in the cure of the disease.' The surgical proceedings which should be taken for the permanent arrest of this bleeding are not Avithin the scope of this work to discuss, but the measures for stopping it at first, and at once, we must here consider. Contrary to what one would expect in such cases, the giving way of the tumour occurs insidiously; the aneurism leaks rather than bursts (we are speaking of those on the external HEMORRHAGE AND THEIR ARREST. 47 surface of the body); the skin gets irregularly ulcerated over it, and the first appearance is rather that of a superficial bleeding sore. The bleeding too, is intermittent, and at first, apparently not serious. The loss however at each attack be- comes greater and greater, and soon there is a general yielding of the skin, which is now all that restrains the flow, and a gush of blood, Avhich may be immediately fatal, takes place. What should be done in the first instance ? We will take Treatmenc. as an example an aneurism of the superficial femoral, say, in Hunter's canal. If the condition be that of a slight intermittent oozing from one or two apparently super- ficial ulcers, in the reddened unhealthy skin lying over the pulsating tumour, the leg should be raised and carefully ban- daged from the foot upAvards. A Martin's india-rubber ban- dage is best, and this should be carried somewhat more firmly over the tumour, a folded piece of lint being placed betAveenthe skin and the bandage. Some form of tourniquet, e.g., Signorini's (Fig. 11), or Esmarch's india-rubber cord should then be adjusted, so that it can be tightened up in an instant if required. This being done, there is little immediate danger, and time .Avill be given to the visiting surgeon to de- termine whether he Avill turn out the contents of the aneurism after opening it freely, and then proceed to ligature both ends of the vessel; whether he will pass a ligature round the femoral, or external iliac arteries; or whether he will adopt any other proceedings for the permanent cure of the disease. But supposing the case has been alloAved to drift on, until there comes a furious gush of blood from a considerable yielding of the skin and sac ? There Avill be no time for deliberate bandaging, but the finger must at once be placed on the main artery (in this case the common femoral) and retained there until replaced by a tourniquet. The bleeding cavity must then be packed most carefully and firmly with compressed sponge or strips of lint, until it is absolutely full, and then pressure made on it from above with a firm ordinary bandage, or an india-rubber one, over a pad. The lint strips are generally dipped in perchloride of iron solution, but if this can be avoided, it Avill be better, as the parts are already inclined to slough. Finally, it may be necessary in some situations, to put the finger into the cavity which is bleeding, to feel for the place whence the rush of blood proceeds, and to arrest it by keep- ing the finger on the spot till help arrives. The wound once effectually plugged and compressed, the 48 OF CERTAIN SPECIAL KINDS OF tourniquet may be gradually slackened, and if the bleeding does not recommence, should be left loose, but in position. We have been particular in describing the temporary arrest of this form of hemorrhage, although it is rare, because it serves as an example, that a man should never be allowed to bleed to death from any external hemorrhage, inasmuch as it may ahvays be arrested, first with the finger placed on the bleeding point, or on the main artery, and then by plugging and pressure. Secondary haemorrhage. SECONDARY HAEMORRHAGE. Its divisions. Eecurrent haemorrhage. Its causes. A bleeding is called secondary when it comes on at some period subsequent to the division or injury of the vessels maimed, either by an accident, or in the course of an operation. It is itself divided into recurrent hcemorrhage, true secondary hcemorrhage, and intermediary haemorrhage. Eecurrent, or reactionary hcemorrhage, is that form Avhich comes on as soon as the period of lowered cardiac action and partial collapse, which is occasioned by the shock of an operation, or of an accident, passes off, i.e., within four or five hours of the injury. By this time, too, the contraction occasioned by the exposure and division of the vessels, has largely passed away. There is then present a condition of increased cardiac activity and relaxed vascular Avails, so that it is not surprising that very frequently there is free general oozing from a wound, which at the time it was done up appeared quite dry. The bleeding is chiefly capillary, or proceeds from small arterioles, Avhich had been so firmly contracted as not to declare their presence at the former examination. Now, too, larger trunks Avhich have been tied, but not very firmly, may burst their bonds and bleed freely. If this be slight, as it often is, the serum and blood will remain Avithin the aseptic dressings, and will do no harm. If it show outside, the dressings must be undone and the wound exposed. It may now be syringed out with cold perchloride or carbolic lotion, and a few minutes' delay granted to see its effect. Should the hemorrhage still go on, the Avound must be opened up and the clots cleared out; it will then be seen whether the hemorrhage proceeds from any vessels requiring torsion or ligature, or Avhether it is purely capillary. If the former, the vessels HEMORRHAGE AND THEIR ARREST, 49 must of course be secured; if the latter, the clearing out the clots will have had a very good effect, and this, with a few minutes' exposure to cold, or the application of a hot flannel (see pages 64 and 65) will be sufficient to arrest the bleeding. The wound must then be redressed and put up rather firmly. It must be recollected that a smart reactionary hemorrhage and the means taken for its arrest, may be sufficient to cause a collapse, similar to the original one. The bleeding Avill then cease as it did before, and from the same causes, and it may also be succeeded by a reactionary state, sufficient to cause a further loss of blood. In these cases, therefore, after reactionary hemorrhage has once occurred, the patient should be watched. True secondary hcemorrhage rarely occurs earlier than a True sewrHrj Aveek or ten days after the injury or operation, and its cause h8emoillia°c- is almost always some ulcerative or sloughing condition of the walls of the larger vessels. Thus it may come from an artery which has been ligatured in its continuity, in conse- quence of the coats near the ligature taking on an unhealthy action; or it may come from a lacerated wound at the time of separation of the sloughs, or from ulceration of a vessel ligatured in the flaps of an amputation Avound, etc. The single exception to this form of hemorrhage pro- ceeding from a morbid inflammatory process, is in those rare cases in which an animal ligature has become absorbed too quickly, or a silk one has cut the coats or come untied, so that the arterial coats, weakened by the tying, will then give Avay. Secondary hemorrhage, if it be not more frequent from its arrest. arteries than from veins, as is sometimes stated, is at least in the former case very much more serious. Here it constitutes a most formidable complication, and in considering the means for its arrest, questions of amputation, re-amputation, liga- ture of main vessels, etc., have to be weighed by the visiting surgeon, but for us the subject is narrowed to the best ways for its immediate arrest. When the bleeding comes on, there is often some Avarning, as by a little dribbling, before there is any great rush of blood, and in that case, elevation and firm compression out- side the wound may arrest the Aoav, until some plan of action has been decided upon. A tourniquet, hoAvever, should be in readiness for instant application if required. If the hemorrhage be from an artery ligatured in its ^rom^n aviery continuity, the steps which ought to be taken immediately, contmruity,n 50 OF CERTAIN SPECIAL KINDS OF and Avhich may suffice in some cases for its permanent an\>s>-, are precisely the same as in the case of an aneurism which has undergone external rupture, and to these the reader is referred. (Page 47.) From an ampu- If it occurs from the stump of an amputation, it must be nation stump. arrested in the first instance by elevation, and compression of the main artery by the fingers or a tourniquet. The means to be adopted for the permanent arrest will depend on the condition of the stump; Avhenever it is practicable, the most satisfactory proceeding is to open up the flaps, and tie the artery. This is sometimes not possible from the slough- ing condition of the parts, and sometimes not advisable because the flaps are firmly adherent; in these cases the choice will lie betAveen re-amputation, and ligature of the trunk vessel higher up. From a slough- If the hemorrhage proceed from extensire sloughing of a lacerated Avound, it takes place about the time of the sepa- ration of the sloughs; in dressing bruised Avounds therefore, great care should be taken about the tenth day not to tear the sloughs away before the vessels have become occluded by natural processes. The bleeding is generally arrested by plugging and com- pression, but any vessel that will hold a ligature should be tied. The actual cautery may be used with good effect, but styptics, especially the perchloride of iron, should be avoided. intermediary There is a third form of bleeding, intermediary htvmor- from'tVmporary rhage, Avhich is neither reactionary, nor exactly true secondary congestion. hemorrhage. It comes on a few days after the infliction of the wound, and appears to proceed from some temporary congestion or undue vascularity of the part, so that the granulations give way. This form is not so important as either of the other kinds, for it does not depend on any serious morbid process. If the bleeding goes on long enough, the congestion will be relieved, so that this form tends to stop "of itself," and in any case, elevation and moderate compression will arrest it. Bleeders. Reference has been made several times to the constitutional conditions known as the "hcemorrhagic diathesis," and those possessing this diathesis are generally called "bleeders." It is in a very marked degree hereditary, and is transmitted by both the male and the female sides, but it affects males far more frequently. "Bleeders" manifest their complaint either by spon- taneous hemorrhages from such parts as the gums and palate, the rectum, or the bladder; or by persistent bleeding HEMORRHAGE AND THEIR ARREST. 51 from some wound, large or small, or by the effusion of blood or blood and serum into the synovial or serous cavities. In the case of wounds the importance of the case only General gradually develops; there is no furious gush of blood, but a general " weeping" of the whole surface, Avhich looks as if it only required a little time to stop of itself, but at the end of twenty-four hours the position of affairs is precisely the same, with the exception that the loss of blood, continuous as it as been, has caused a distinct constitutional effect, while very probably the pressure employed in futile attempts to check the drain has produced sloughing of the edges of the wound, and hence an enlargement of the bleeding surface. And so matters go on. The blood, natural in its ap- pearance at first, becomes thin and watery, Avhile the patient is exhausted to the last degree, and seems likely to die, it may be from such a trivial injury as an extracted tooth, or a cut finger. Death may indeed occur, but fortunately, and rather curiously, just when the case looks most hopeless, it very frequently begins to improve; the Avound takes on a healthy action, the bleeding ceases, and the patient begins to repair the enormous drain on his resources. In considering the best means of checking this loss of blood, constitutional as well as local remedies must bethought of, so it is important to find out in any case of unusually prolonged bleeding, whether the patient be a genuine " bleeder " or not. Enquiry will generally get out a history, either of some previous injury in which the bleeding "seemed as if it never would stop," or of a father, uncle, or brother who had shoAvn signs of the suspected diathesis. With regard to the local means of arrest, pressure and Local means oi plugging should be first resorted to, and in some situations arr may be applied with sufficient firmness to make a certainty of success; but in many cases it will be found'extremely difficult, and sometimes impossible to adjust the compress firmly enough to arrest the bleeding, and yet not so as to cause sloughing of the edges of the wound. The material for plugging maybe soaked in a concentrated solution of perchloride of iron, and Ave have seen a bad case quite arrested by filling the wound Avith the German " styptic charpie," readily procurable in London. Powdered alum, tannin, perchloride of iron, sulphate of copper, and the Avhole range of those styptics Avhich are not escharotic in their character may be tried as local applica- tions, and have all been found successful in certain cases. But failing pressure, the Avisest course will be to apply the 52 OF CERTAIN SPECIAL KINDS OF Constitutional treatment. Useful drugs. Iron perchloride. Turpentine. Er^ot and ergotine. actual cautery, very carefully, and at the dullest red heat possible. Owing to the difficulty of keeping Pacquelin's cautery at such a low heat for more than an instant, the old cautery irons are more convenient. The bleeding surface must be quite dry at the instant the iron is applied. The character of the bleeding puts the idea of trying to ligature any of the bleeding vessels out of the question, and a little reflection makes it plain that ligation of the trunk vessel is only substituting two bleeding wounds for one. It is, how- ever, sometimes advisable to strangulate the bleeding part, if it can be isolated, e.g., by passing hare-lip pins deeply below it and twisting silk over them; but there is still some risk of bleeding from the pin-holes. In a small wound the bleeding may be stopped by means of a pad of wool soaked in collodion, and forcibly held in position until the collodion has set. If a " bleeder" happens to acquire an ulcer from any cause, the granulations are exceedingly apt to bleed; indeed, a common ulcer en the leg is, to such a person, a very dangerous lesion. As a rule the bleeding is not only on the surface, but takes place in the substance of the granulations, so that the appearance is that of a purple black fungating mass, looking very like true "fungus hematodes." In such a case, the best plan is first of all to scrape off the infiltrated granulations down to the underlying fascia; this done, pressure, or the other local means alluded to, can be applied Avith a much greater prospect of success. The constitutional treatment of this form of hemorrhage is very important; indeed there are few illnesses which fall properly under the surgeon's care, and in Avhich he has to trust so much to the physiological effect of certain drugs on the blood and blood vessels. All those drugs which are in most common use as hemostatics, and which will be described a little later on, may at times be found useful in this disease; from them, however, one or two may be selected as being the more approved. Foremost among these is the perchloride of iron, (liq. fer. perchloridi) in large doses, say 5ss. - 5j, frequently repeated. This often has undoubtedly a very marked effect. Turpentine again, in doses of mm. v, x, or xv, at short intervals, has been found very useful. From physiological grounds, the preparations of ergot should be here especially indicated, and ergotine in doses of mm. iii to v, is very useful and trustworthy, but for some HAEMORRHAGE AND THEIR ARREST. 53 reason the liquid extract of ergot has been found to be often almost inert, although freshly prepared. The local effects of subcutaneous injection of ergotine are so marked, that this is probably the best way to administer it. The action of opium in quieting and regulating the Opium. circulation, gives it a great therapeutic value as an indirect hemostatic in this form of bleeding, Avhen the heart's action becomes feeble and the pulse empty and jerky. From our account of the diathesis it must not be supposed that every injury to a "bleeder" is necessarily followed by extreme consequences, nor, on the other hand, that every case of troublesome capillary bleeding, stamps the patient as an example of the condition. There are borderland cases, and also cases which simulate the diathesis, either through simple flabbiness and laxity of the Avascular walls, or from the presence cf some other constitutional vice, such as leucocythemia, or scurvy, or the condition commonly known as "scurvy rickets.' u OF SOME PRINCIPAL FORMS OF INTERNAL CHAPTER IV. Of some Principal Forms of Internal Hemorrhage, and their arrest, and of the transfusion of blood. Internal haemorrhage. General considerations. Immediate treatment. To prevent further loss. The important points to be attended to in promoting the arrest of internal hemorrhages, may here be briefly con- sidered, those cases only being taken into account in which the loss of blood is sudden, and is the prominent symptom at the moment, whether the cause of the loss be a traumatic or a constitutional one. Thus apoplexy will be considered under another heading, and for chronic hemoptysis, renal hematuria, etc., the reader is referred to works on the practice of medicine. Whenever a large quantity of blood escapes from the blood vessels, whether it flows away from the body, or into one of its cavities, the prominent symptoms are those of cerebral anemia. There is a sudden feeling of nausea and giddiness, with a buzzing in the ears, then the sight goes, and the patient falls to the ground and becomes insensible. In such a case there is sometimes a superficial resemblance to an epileptiform or apoplectic seizure, but as a rule the extreme pallor and the fluttering pulse, which is often near- ly extinguished at the wrist, will be sufficient indications of what has happened Usually, the syncope and the horizontal position in- voluntarily assumed will in a few minutes effect a reaction (omitting cases immediately fatal), and there is a partial return of consciousness and strength. The indications for the immediate treatment of severe internal hemorrhage are sufficiently simple. They may be summarised thus :— 1. Measures to prevent further loss of blood. 2. Measures to keep the circulation quiet. 3. Measures to keep up the blood supply of the nerve centres in the brain for circulation and respiration. And later on 4. Measures to promote rapid formation of new blood. 5. Measures to prevent waste of tissue as far as possible. (1) The measures for preventing further loss will differ HAEMORRHAGE AND THEIR ARREST, ETC. 55 in different cases, but the chief ones are—absolute rest, local application of cold, and lowering the functional activity of the organs affected, as much as possible. Thus, if the bleeding be from the lungs, the patient should be kept lying flat, with very light clothing, very loose ; be made to suck ice, and enjoined not to speak. In this way the lungs are placed at rest, as far as it is possible for them to be. If the bleeding proceed from an ulcer in the stomach, in addition to lying flat, lumps of ice must be SAvalloAved, cold may be applied to the pit of the stomach, and no food, or anything that may excite the gastric secretion, ought to be taken. (2) The absolute rest Avill greatly tend to equalise the To equalise the circulation, but it is especially Avith this view that venesec- circu Hon is employed in internal hemorrhage. This expedient, Avith the practice of venesection in general, has been out of fashion for many years now, but there are indications that it Avill soon again be recognised as a convenient and sensible method of lowering the blood pressure. The art of discriminating between the fit and unfit cases for venesection must be elseAvhere learned, but it may be broadly stated that blood-letting is indicated in hemor- rhages associated with high arterial tension, as in some cerebral injuries, or Avith acute local congestion, as in pneu- monia with hemoptysis ; or Avhen, from any cause, the right side of the heart is overloaded, and its action em- barrassed.* (3) The fulfilment of the third indication—the blood t° maintain the supply of the respiratory and cardiac nerve centres—is best brain.bUpp y attained by lying flat. We all knoAv that this is the best position for syncope, because, then, the feeble heart can most readily drive its scant supply of blood to the brain. Placing a patient head downwards, when the breathing has stopped during the administration of chloroform, is only an extension of the same principle. But in very severe hemorrhage, position alone may be Extreme insufficient, and we may see the syncope getting nearer and syncope- nearer to death, from the bloodless condition of- the base of the brain. In the first place, all the blood that is in the body should be utilized for the purpose of brain supply. To do this effectually, the head must be lowered and the * How to perform venesection is described later. For a discussion of the indications for its employment and its value, see Dr. Hare's, Address, " Good Remedies out of Fashion" (Churchill's, 1883), fifi OF SOME PRINCIPAL FORMS OF INTERNAL pelvis raised ; the arms held so that the veins tend to empty themselves into the heart, Avhile the legs should be raised, and bandaged from below upAvards—an elastic bandage (Martin's) is best—so as to squeeze all the blood out of them, as far as possible. All these proceedings are some- times called " auto transfusion." Artificial In extreme syncope from bleeding, as from any other cause, the surgeon must be prepared for complete failure of the breathing, and must be ready to begin artificial respira- tion (q.v.) whenever he sees the mo\"ements of the chest Transfusion. becoming suspiciously shallow. But further, there can be no doubt that, rather than allow a patient to die simply from lack of blood, the deficit ought to be supplied from elsewhere, and so far as our knowledge goes at present, when human blood is not available, that of a lamb or calf may be apparently as beneficial, at any rate in the immediate results; still, the blood of no animal is so efficient as the blood of a healthy man, and no other fluid is as efficient as blood. At the same time those who give their blood should know that sometimes the loss of it in this way has produced ill effects disproportionate to the few ounces which have been taken ; and it is certainly better to refrain from bleeding a man or woman who has that sensitive, nervous organisation which so often goes with cultivated intellect, and desire for self-sacrifice, for such an one may be seriously damaged. On the other hand, a man of the type and habits of life of our great grand- fathers, who used to be bled every spring and fall of the year, may be even benefited by the loss. Whether the fibrin is transfused or not is a matter of no importance; it is the supply of the red corpuscles, as oxygen carriers, that is the object desired. Whenever transfusion is necessary, time is of the utmost importance, and apparatus may not be at hand ; there are therefore recognised two principal methods of transferring method. tne Dl°°d, "mediate and immediate. In mediate transfu- sion the blood is taken as in ordinary venesection (q.v.) into a bowl, which is placed in water of about 100° F. The fibrin, as it forms, is removed by a fine wire brush, or what answers very well in a hurry, an egg or " cocktail" whisk. Within the vessel which receives the blood must be placed a strainer of some kind, e.g. a muslin bag or a coffee strainer, through which the defibrinated blood must pass before it is used. If a proper syringe with a nozzle which can be inserted into the vein be at hand, all that is necessary is to. HEMORRHAGE AND THEIR ARREST, ETC. 57 warm it, and fill it carefully, so that no air is injected. In inserting the nozzle, it is better to expose the vein for a quarter of an inch Avith a scalpel, in order to make sure that the pipe is fairly inside, and is not, as may easily happen, pushed between the sheath and the vessel. If no proper syringe be at hand, a small glass one, with a well- rounded point, may be made to do service. In the cases of extreme bloodlessness, it is often very difficult to find a suitable vein, and it is therefore all the more necessary to fully expose what is taken to be the vessel. Generally one of the veins at the bend of the elbow is selected ; if that cannot be clearly seen the saphena would probably be the largest and most easy to find, from its fixed position, as it goes through the saphenous opening. The quantity of blood transfused in different cases varies; as much as tAvelve ounces have been used, but as a rule from five to six ounces are sufficient sensibly to relieve the syncope. The immediate method of transfusion is hoAvever by far immediate the readiest and most convenient way of transferring blood Avehng-s! from one person to another. It consists essentially in plac- ing the venous systems of the giver and receiver in communication, and then allowing the blood to flow from the former to the latter, and in that direction only. The best knoAvn of the apparatus are Koussell's and Aveling's ; the latter only Avill be described, as it is the simplest and we believe it to be also the most efficient. As seen in the illustration (Fig. 26.) it consists of india- rubber tubes, with a ball between, like a Higginson's syringe, but without the Aralves. These tubes are armed, the one with a sharp pointed cannula, the other Avith one rounded off at the end (sometimes both are sharp). The vein is first found in the giver, and the sharp cannula fairly inserted into it and connected with the ball and tubes, which are themselves filled with warm water. The blood is then allowed to enter by turning on the taps, and as it does so, it expels the water. When the apparatus is full, so that it is certain that there is no air in it, the blunt cannula is pushed into the vein of the receiver, an incision having been made into it Avith a scalpel. Two assistants will be required, the first to hold the cannule in position, while the second, with the one hand alternately compresses and relaxes the ball, thus drawing blood from the giver, and with the other compresses the tube behind the ball when it is full or being squeezed, and 58 OF SOME FORMS OF INTERNAL HEMORRHAGE, ETC. in front of it Avhile it is expanding. This hand thus does away with any necessity for valves ; each squeeze of the Fig. 26.—Aveling's Transfusing Apparatus. ball drives in three drachms of blood, and in this way five or six ounces of blood can be quickly and easily transfused, the main points to be attended to .being to avoid the entrance of air, and to inject sloAvly and very steadily, so as to avoid distressing the feeble circulation. Also to be sure that the vein is entered fairly by the cannula. make fresh (4) The fourth indication, to promote the formation of fresh blood, is not easy to fulfil. The loss of liquid from the body shoAvs itself in the great thirst always present after serious hemorrhage. This must be satisfied by iced milk and water ; such alcohol as appears to be Avanted must be freely diluted. In the case of severe hematemesis fluids must be given with more caution, and ah\-ays be well iced. luTwIste. (5) T°. Prevent> as far as may be, tissue change, or work of any kind of the body is also important. The absolute rest and quietness already advised must therefore be kept up for some days ; in many cases moderate doses of opium will be found very useful. OF STVPTICS, CAUSTICS AS STYPTICS, ETC. b(J CHAPTER V. Of Styptics, Caustics as Styptics, and of the Actual Cautery. Styptics are substances Avhich, when applied to a bleeding styptics. surface, tend to staunch the blood. This they may effect in enmtlon" two or three different ways : thus they may simply form an artificial scab over the surface, or they may condense the tissues and astringe the Aressels by combining Avith and coagulating the albumen present; or this condensing action on the tissues may be poAverful enough to destroy their vitality, and so by these " caustics" a destruction com- parable with that of the actual cautery may be produced. The use of styptics was, in former times, far more fre- quent than it now is.; healing by first intention was hardly hoped for, and the surface of a Avound received far more well-meant but meddlesome attention than nowadays we are disposed to give it. The occurrence of a superficial slough on its surface was, therefore, looked upon as almost a necessary incident in what was knoAvn as the " digestion " of the wound. But it is now recognised that any astringent which is objection to either caustic, or strongly astringent, inflicts damage to the use* tissues to which it is applied, and that it should not be used if the hemorrhage can be otherwise arrested, or merely for the sake of saving a little time or a little blood. All styptics do not damage the tissues, but all the more powerful ones do, and to a surgeon's eye there are few more irritating causes of offence than to see a clean cut Avound, or some unimportant graze, blackened with perchloride of iron, or nitrate of silver, just because the medical attendant could not wait, or could not properly bandage, or pick up a small artery. This being understood, the immense value of styptics in proper cases may freely be admitted. The most important may here be enumerated and their application described. 60 OF styptics, caustics as styptics, Mechanical styptics. Matico. Cobwebs. Collodion. Mechanical. Cobwebs. Matico. Contractile Collodion. Styptic Tow. Cotton Wool. Astringent. Oil of Turpentine. PoAvdered Cinchona Bark. Creasote. Hazeline. Astringent and Caustic in varying degrees. Carbolic Acid. Sulphate of Copper. Sulphate of Iron. Tannin. Perchloride of Iron. Caustic. Chloride of Zinc. Nitrate of Silver. Chromic Acid. Potassa Fusa. Nitric Acid. Before applying any styptic care should be taken that the part is dry. This may be ensured by keeping firm pressure on the wound until the moment of application. The dried leaves of " Piper Angustifolium," or the Matico plant, are imported from Peru, and have a peculiar cobweb- like doAvn on their under surface. Some astringent principle is also contained in the tissue of the leaf. If the under surface of the whole leaf be applied to a bleeding part, or if the leaves, ground up into a powder, be dusted on it, the fine downy filaments will, Avith the blood, form a firm adherent scab, and the bleeding will be staunched. This mechanical action is probably the begin- ning and the end of the " marvellous " action of matico. The infusion or poAvder taken internally is quite harmless. In precisely a similar fashion does the domestic remedy act, of gathering as many cobAvebs as can be quickly col- lected, and putting them over the surface; and, indeed, although the remedy may seem too homely for the surgeon to use, of its efficacy in staying a brisk capillary oozing, none who have tried it will doubt. These are not in practical use now, but matico is still in the Pharmacopoeia. Their places are noAV taken by the two following:— Collodion, prepared by dissolving one ounce of gun cotton in a mixture of thirty-six ounces of ether, and tAvelve ounces of rectified spirit, is extremely useful in cases of wounds AND OF THE ACTUAL CAUTERY. 61 about the face, in which, if a scar has to be avoided, the edges have not only to be brought together, but must be held together firmly enough to prevent blood being effused be- tAveen them. This is readily done by painting three or four coats of this collodion over the Avound with a camel's hair brush, or by saturating a piece of lint in it and applying it to the wound. The collodion, as it dries, contracts, and thus the required pressure is kept up. Flexible collodion, prepared by adding to six ounces of collodion, two drachms of Canada balsam, and one drachm of castor oil, may be used instead of the above. It is not so liable to crack, but is not so contractile as ordinary collodion. The next three styntic substances on the list after styptic Astringents tow and styptic cotton, are all asinngent, but not at all Turpenune?'' caustic, that is they do not produce any sloughing. They nShie. are all said to coagulate albumen, on which property plus their effect on the blood vessels, their styptic action depends. Their application does not necessarily prevent healing by the first intention. These substances are oil of turpentine, creasote, and hazeline. Of these the first two may be " dabbed " on the bleeding surface with some lint.* The third may be applied as a lotion, or a pad of lint soaked in it may be placed on the wound. It is worthy of notice that all three substances are stated to be powerful hemostatics Avhen taken internally. This is certainly true of the two first, but " hazeline," which is prepared in America from the " Avitch hazel" (Hamamelis Virginica) is a drug still upon its trial. We come noAV to styptics, Avhich, when solid, or in con- caustic centrated solutions, are more or less caustic. The most astnnsents- convenient way Avill be to take them in order of their causticity. Sulphate of copper and sulphate of iron are both (in the sulphates ot crystalline state) slightly caustic, as Avell as highly astringent, coppci and they are often found very useful in both capacities. Thus, spongy and bleeding granulations may be rubbed over AA'ith the crystals, as may also a leech bite or a bleeding gum. In solutions of various strengths they lose their caustic character, but remain highly astringent, and are used then * Oil (commonly called spirit) of turpentine should not be dropped on a pad of lint, placed on a wound, and covered up, or it will vesi- cate the part. 62 OF STYPTICS, CAUSTICS AS STYPTICS as local applications in cases of relaxed mucous membranes, fungous granulations, etc. Perchloride of The perchloride of iron has quite a specific power as a iron- local application to stop bleeding. The bleeding part may either be touched Avith the solid salt, or the Liq. Fern Perchloridi Fort (P.B.) may be brushed over them, or, pro- bably best of all, strips of lint soaked in the same solution may be used to plug the Avound or bleeding cavity. The solid perchloride may also be poAvdered and dusted on the bleeding surface, while lotions of different strengths, made by diluting the Liquor Ferri Perchloridi, may be used as astringent and hemostatic applications to the nose, urethra, vagina, uterus, etc. In the concentrated forms this iron salt seems to act by forming a particularly firm spreading clot; it also coagulates the tissues, causes the blood vessels to greatly shrink, and forms clots Avithin them. The parts which are actually in contact with the strong perchloride will die and be cast off in the course of a few days. Efficient as this styptic is, it is very disagreeable. The in- tensely astringent taste renders it particularly unpleasant in all injuries about the mouth, and the discolouration and apparent foulness of the Avound to which it has been applied, combined with the delay in healing which its use entails, lead most surgeons now to reserve its employment for a last resource ; and then its value cannot be over estimated. i^nnin Alum and tannin in powder are astringent, somewhat escharotic, and rather powerfully hemostatic. They have a similar action when taken internally, the tannic being changed into the gallic acid.* These styptics are commonly applied to bleeding parts in the form of powders, dusted on, but they are still more frequently used as mild eschar- otics for growths, such as condylomata. The dried alum (A. exsiccata) which has been deprived of its water of crystallisation, is the more powerful. carbolic acid. ' Probably the best use of carbolic acid as a styptic will be found in checking the general capillary oozing of wounds, by washing them over with a solution of a strength of from 1 -15 to 1 - 25. If a sponge or syringe be used the parts * The value of the well known patent medicine " Kuspini'a Styptic " appears to depend upon its containing gall nut extract. Mention of existence of this remedy should not be omitted here altogether, if only on account of the high opinion Brodie and Watson entertained of its value as a haemostatic; and there can be no question as to its efficacy in many cases, although it is not so often used now as heretofore. AND OF THE ACTUAL CAUTERY. 63 are bathed for a very feAv seconds. Generally all capillary bleeding ceases, there is no escharotic action, and the antiseptic nature of the solution tends to promote rapid healing. In all wounds this " washing through" with a strong carbolic lotion, at the end of the dressing, Avill be found very efficient in preventing excessive capillary loss of blood. The following substances when concentrated are all Caustic powerful caustics, and to this property OAve their poAver of styptlCo" stopping bleeding. This action alone will be considered here, for they all, in Aveak solutions, are employed for other purposes. This caustic action is used also for the removal of growths, but this will be aftenvards referred to. The caustics most frequently employed are, in order of severity, nitrate of silver, caustic potash, chromic acid, chloride of zinc, and nitric acid. Nitrate of silver or lunar caustic combines Avith the Nitrate of silver. albumen of the tissues, and Avhen applied in the solid form produces a superficial slough, Avhich is limited in depth, for the silver and albumen compound is hard and dense, and prevents any excess of the caustic that may be present, from causing the cauterisation to be too deep. To this fact its value to a great extent is due. Lunar caustic is applied in the form of a moulded stick, pointed like a pencil, and held in a metal clip. Its appli- cation is almost painless. The point of the stick has but to be held firmly against the bleeding point (e.g., a leech bite, or a dog's bite) for about five seconds, and the bleeding Avill almost certainly be arrested. It is not suitable for applica- tion in this form to a large bleeding surface. This substance is sometimes " mitigated" by the addition of some inert substance, but it is not then used as a styptic, nor are its solutions. Caustic potash is moulded into sticks, and applied like the Caustio potash. above. It differs in its action, however, in that this is not limited to the place of application, but, forming a sort of soap with the tissues, spreads to an extent rather difficult to estimate beforehand. It is a very fairly efficient styptic, and like the silver salt may be " mitigated " and rendered less deliquescent by admixture with lime. Caustic soda may be used in all cases as a styptic instead Caustic soda. of the potash salt, to which, in all respects, it is similar, save that it is slightly weaker and slightly less deliquescent. Chromic acid is a powerful caustic, but its deliquescence chromic acid. renders it difficult to use. It is most conveniently applied 64 OF STYPTICS, CAUSTICS AS STYPTICS, Chloride of zinc. Nitric acid. Cold. Usefulness of exposure. by fusing a crystal of the acid upon the end of a silver probe. It is chiefly employed for the removal of small polypi, and will be again mentioned under that head. Chloiide of zinc is a very poAverful escharotic, but its action does not spread indefinitely through the tissues. It may be applied either as a moulded stick, or as a paste mixed with flour. It is more used to remove cancerous groAvths, etc., than as a styptic. (Further notice of its general use in solution in the dressing of wounds will be given under that head.) Nitric acid combines Avith the albumen of the tissues to form picric acid, and thus its action is limited, for the latter has not any caustic action. It is an extremely poAverful, and, in proper cases, a most useful styptic; thus it may be used in bleeding from fungous or malignant granulations. Its employment as a styptic, however, is not common. The application of cold to a bleeding part has always been recognised as one of the most valuable means of arrest. Free exposure to the air is often alone sufficient to promote coagulation of the blood, and constriction of the blood vessels. This may be seen in cases of recurrent hemorrhage after an amputation or any other large cutting operation, Avhen a few hours after the operation the wound or the flaps become distended Avith blood, which may be dripping away at quite an alarming rate. In such a case if the flaps be opened and the clots cleared out, so that the air can get to the surface of the Avound and to the ends of the vessels, the bleeding Avill very probably cease without anything further being done, provided of course, that no big vessel has been overlooked. Should exposure to air not be enough, cold water or ice (the latter especially), may be very powerful styptics. A lump of ice applied to a bleeding surface may cause an artery, nearly as large as the radial at the wrist, to contract and cease to bleed. The ether spray. Another very efficient way of applying cold is by means of the ether spray. The effect of this spray should not be pushed so far as to cause the parts to be absolutely con- gealed, if this can be helped, for they become very painful on thawing, and the blood vessels being partly paralysed the bleeding is apt to recur. By means of this spray Ave have seen furious bleeding from a fungating cancer of the breast completely arrested in less than fifteen seconds. Cold water or ice. AND OF THE ACTUAL CAUTERY. 65 As a converse to this method of freezing, another way of Arrest by means 4. _ • i • • i ° i -, . J, . ot hot water. stopping general oozing is too rarely employed m this country, namely, by the application of a flannel wrung out of water as hot as can be borne by the skin, i.e., about 120° F., but not so thoroughly as to be quite dry, and applied immediately. This should be pressed on the bleeding surface (e.g., to an amputation flap) for a few seconds. On its removal, the tissues will have a whitish look and the hemorrhage will have all but ceased. The mode of action would seem to be a direct stimulation of the vaso-constrictor nerves, or perhaps of the musculature of the arterioles, as a temperature of 100° to 105° is known to produce a tonic contraction of muscular tissue. The effect of hot Avater injections on uterine hemorrhages is very well understood by obstetricians. We come noAV to " that cruel and barbarous method " of Actual cautery. stopping bleeding Avhich Ambrose Pare denounced, and Avhich was a few years ago only employed rarely, and in cases Avhere the bleeding vessel could not be secured in any other way. Now, however, OAving to the improvements in the instru- ments, and to the fact that anesthesia has robbed the actual cautery of half its terrors, it is very frequently employed to arrest hemorrhage, or for counter irritation, or for the removal of tumours, and by some surgeons even in operations, such as for strangulated hernia, which are generally considered as essentially requiring the use of the knife. The principal forms of apparatus for the application of the actual cautery are the old cautery irons, the galvano- cautery, and Pacquelin's thermo-cautery. Other forms there are, such as the gas cautery of Dr. Bruce, but they are not now in general use. Cautery irons (Fig. 27) are still frequently employed to Cautery irona stop bleeding, or for the purposes of cautery. They, how- ever, are gradually being displaced by the newer forms mentioned above. These irons are of precisely the same shape and size as they were in the days of Scultetus, or still further back. They consist of pieces of iron Avith ends of various shapes, themselves of iron or copper, set into ordinary handles; they, indeed, are just like a whitesmith's soldering iron, ending either in a point or a " button," a straight or bent " olive," etc., and the best way to heat them is to put them into the fire 66 OF STYPTICS, CAUSTICS AS STYPTICS, Fig. 27.—Examples of Cautery Irons. rrorer heat. The most efficient heat for the arrest of bleeding is just a visible red, not glowing, but still plainly red hot. If this heat be exceeded, the Iron begins to cut rather than sear the tissues. The iron should be wiped clean from the fire, and the bleeding part itself should be dried as far as possible. Mode of The iron should be passed over the surface very lightly, application. Qr fcne bleeding point should be quickly touched, for con- tact of the tissues Avith the iron for more than a moment leads to the parts sticking to the metal, sometimes so much so that they are pulled aAvay Avith it, and there is still a worse hemorrhage. To bone should The cautery used often to be applied to the bleeding sur- be avoided. face Qf a ^one, but tnjs should be avoided lest necrosis folloAv. Cauterisation. seems to cause necrosis more cer- tainly than any other injury to bone, so that it should not be used for counter irritation on the scalp, or the prominences of the jaAvs, or wherever the bone is close to the skin. In old days the bone in amputations Avas regularly seared with the iron, and as regularly necrosed away, so that Ave find in the directions for the after treatment of these cases, that the Avound had to be kept open for months after the operation, to allow of the escape of the sequestrum. Gaivano- Galvano-cautery. This apparatus is a great adA^ance upon the cautery irons, and is itself Avell enough adapted for arresting bleeding. It cannot, however, be got ready quickly, and hence is more used for surgical purposes as ecraseur, or for burning aAvay Avarty grOAvths, etc., than as a styptic apparatus; but it Avill be convenient to describe it here. AND OF THE ACTUAL CAUTERY. 67 The principle on which it depends is that platinum, a Not commonly metal of high resistance and great infusibility, will get red styptic? a or white hot, if a galvanic current of sufficient intensity be passed through it. The wires from a battery, such as Smee's or Daniell's, of from 4 to 6 cells, are connected by binding screws to the galvano-cautery. By pressing on a knob the electric circle is completed by making contact between the positive and negative wires respectively from the battery, and the two terminals of the rheophore or cauterizing part, which fit into the handle as shoAvn in the figure. In this way the current passes through the rheophore, whether it be a noose of wire or of some other shape, when the knob is pressed, and then only. Fig. 28.—Form of Galvano-Cautery. The resistance to this current in the platinum is so great that heat is generated sufficient to cause the wire to become of a dazzling whiteness. If the rheophore used be of the kind known as the Gaivanio galvanic ecraseur, the wire which has to be heated, is so 6craseur- arranged that it can be shortened up like a snare as shown in the figure. 68 OF STYPTIC'S, CAUSTICS AS STYPTICS, Two great advantages are possessed by this gal van o- cautery. The first is that a very small pointed rheophore may be used to a limited bleeding surface without its losing heat before it can be well applied. The second is that the wire as a noose can be fitted round whatever requires cauterisation with the fingers, before the knob is pressed, and the wire becomes hot. This, as may be imagined, is very often an enormous gain. The difficulty of its use is the keeping the tempera- ture of the wire low enough, when once contact has been made. Fhe^mo^a'uterv The latest development in the Avay of a cautery is Pac- ^' quelin's (Fig. 29.) It depends on the principle that when the vapour of benzoline or some other high olefine is driven over heated platinum, its rapid incandescence is sufficient to maintain this heat very perfectly indeed. In the figure it will be seen that with an ordinary Higginson's syringe and safety ball to give a continuous blast, atmospheric air is blown over the surface of the benzoline, and then being saturated with its vapour, passes on through the tube and through the holder, and thence into the air through the platinum point, which contains some spongy platinum. The platinum point having been first heated in a spirit flame until it just begins to glow, the ball of the syringe is worked by hand, and the air charged with benzoline under- goes active combustion as it passes through the point, and thus not only maintains its heat, but increases it to whiteness. AND OF THE ACTUAL CAUTERY. 69 The readiest way to heat the platinum is to use the spirit lamp as a blow-pipe flame, for which it is generally arranged, and, as before, the heat to employ as a styptic is a dull almost invisible red. The points are of various shapes, some of which are shown in Figs. 30 to 32, and in Fig. 33 is seen the principle applied to a pair of scissors, one blade of which is of steel Fig. 33. 70 OF STYPTICS, CAUSTICS AS STYPTICS, ETC. nickel-plated, and the other, through which the vapour passes, is of platinum. These various shapes, and the fact that they are called " knives " of different kinds, point to the employment of AppUcations. this form of cautery for the division of tissues. By its means amputations have been performed, and hernias re- lieved from strangulation, and though these extreme appli- cations may not be found practically useful, still for the removal of tumours, etc., it is impossible to overrate the importance of this nearly bloodless method of operation. The cautery should be in charge of an assistant who has nothing else to do to distract his attention, and care must be taken that the benzoline is quite pure. OF SOME PRINCIPAL DRUGS USED INTERNALLY, ETC. 71 CHAPTER VL Of some of the Principal Drugs Used Internally for the Arrest of Bleeding. A list of all the drugs which have been administered some of the with the intention of directly or indirectly arresting hemor- usedCina ru5S rhage, would be found to comprise a very large sectionh8emorrhage' of the Pharmacopoeia. Such a list, moreover, unaccom- panied by full descriptions of all the cases in which the drugs might individually be indicated, would only be useless. But the drugs now to be mentioned have all proved themselves hemostatics of more or less power, and a know- ledge of their comparative activity is very necessary to the practitioner. It is, naturally, in cases of internal hemorrhage that hemostatic drugs are most often used. It seems unnecessary to employ constitutional remedies when the loss of blood can be mechanically restrained, and so it happens (though it may Avell be doubted whether in this practice we are wise) that those remedies which affect the vessels, the vaso-motor nerves, the blood, or the cardiac activity, and which may effectually restrain a loss of blood from any part, are brought into service only when the bleeding comes from parts out of reach of surgical interference. The principal types of these internal hemorrhages will be described directly. Heading the list of the internal remedies for bleeding come the astringent preparations of iron,, and more especially iron. of its perchloride salt. The employment of this drug has been so often mentioned that it is unnecessary to do more than to remind the student that, as a hemostatic, the doses must be full, say 30 or 40 drops of the liq. ferri perchlor., or 6 to 10 of the liq. ferri perchlor. fortior. The acetate of lead, especially when combined with opium, Acetate of lead. is of frequent use in hemoptysis and similar bleedings. A common preparation is the pil. plumbi subacetatis c. opio, in iii.-v. grs. doses. The proportion of the lead salt in the pill is large (f of the whole), therefore, although at first it may be necessary to repeat the dose at short 72 of some of the principal drugs used intervals, it must not be persevered with for more than two or three days. It is also extremely useful in typhoidal hemorrhages from the bowels. opium or Opium or Morphia has also been used alone in hemoptysis, morphia. gjyen in gmall an(j frequent doses, and with very good results. For example, the hypodermic injection of one- sixth of a grain of morphia, followed by injections of one- eighth of a grain at intervals of three hours is often very successful. Turpentine. Turpentine has been already mentioned as a hemostatic, and it is undoubtedly a very valuable one. It is very fre- quently used in hematuria, from whatever cause it may arise. In cases not dependent on or complicated by Bright s disease, as much as a drachm, every three or four hours, may be given, but if this disease be present, smaller doses must be employed, as v. to x. drops. These smaller doses, frequently repeated, appear in most cases to be as useful as the larger, and do not excite purging. Turpentine is also used to check bleeding from the lungs, intestines, nose, uterus, etc.* ergotine13 Ergot and Ergotine. The active principle of ergot of rye has a very powerful effect on all organic muscular fibre, and especially on the Avails of the blood vessels, and of the uterus. There is little doubt that the dry gangrene, caused by eating bread made from " spurred rye," is due to the prolonged spasm of the arterioles of the extremities. As might be expected, therefore, preparations of ergot are powerful hemostatics; the principal ones used are the liquid extract of ergot and ergotine. The former is given by the mouth, in doses of 20 to 40 drops, or a drachm, the latter in three to five minim doses, generally hypodermically. The liquid extract is most commonly used, but it is not trustworthy, even when freshly prepared. Bon jean's ergotin (an alcoholic extract of a watery extract of ergot) is the preparation generally used for injection, which should be made in such a place as the gluteal region, deeply in the muscular tissue. For the special action of ergot on the uterus, and the in- dications for its employment in hemorrhage therefrom, and as a stimulant to its muscular contraction, the student is referred to works on midwifery; in hemoptysis, epistaxis, hematemesis, typhoidal hemorrhage, the hemorrhagic * For a fuller account of its action, see Dr. Ringer's " Handbook of Therapeutics." INTERNALLY FOR THE ARREST OF BLEEDING, 73 diathesis (v. sup.), and in purpura, it may be successfully administered. According to Kinger there is sometimes a good deal of local irritation caused by its injection. This probably depends on the mode of preparation. Digitalis, whose constitutional action on the arterioles in Digitalis. many ways resembles that of ergot, may also be used as a hemostatic, especially in hemoptysis, menorrhagia, and in some forms of recurrent nose-bleeding. It must be given in bleeding with the same precautions as when employed in other cases. The tincture and the infusion are the most useful preparations, and there appear to be certain advantages in using a mixture of these, e.g., half a drachm of the tincture with half an ounce of the infusion for a dose. Most of the acids used as therapeutic agents, but especially Acids— sulphuric acid, are useful in checking bleeding from various p unc internal organs ; thus the dilute sulphuric acid, or the aroma- tic sulphuric acid, in doses of 10 to 30 minims, is found use- ful in hemoptysis, but it is rarely if ever given in acute cases of internal hemorrhage. In addition to these principal drugs, the following should be mentioned as having a reputation as hemostatics, but which do not require a detailed description, namely, pre- parations of alum, gallic and tannic acids, ipecacuanlia, creasote, and hamamelis. This last, prepared from the Witch Hazel, is credited Avith truly marvellous powers, restraining bleedings of all kinds, internal and external. It can hardly yet, however, be considered to have an established place in this country, but it is quite probable that it may be useful in bleeding piles, and dysentery, or in hematuria, in doses of about 20 drops of the tincture to a drachm of water; the value of gallic acid, hoAvever, rests on a Gallic much surer foundation, especially in cases of hematuria; it has already been mentioned that Kuspini's styptic probably owes its virtues chiefly to the presence of this acid. 74 OF BANDAGES AND KNOTS. SECTION II. OF APPARATUS FOR RESTRAINT AND SUPPORT (BANDAGES, SPLINTS, Etc.). CHAPTER VII. Of Bandages and Knots. The first part of this section deals with the several kinds of bandages, and the second part with splints in their varieties and modes of application. of bandages. On all sides the tendency of modern surgery is towards co6ns?dtrations. greater simplicity in dressing wounds, and in other proce- dures which involve the use of bandages. The number of distinct " patterns " of bandages now in use is very much less than we find described even in recent books on the subject, and infinitely less than classical authors, such as Scultetus or Pare considered it necessary to describe and figure. Only those Avays of applying bandages Avhich are now in constant use will here be described. Bandages may be roughly divided into " triangulars," or " scarfs," " rollers," and bandages of special form, such as the "T," the "H," or the "many tailed." The material of which they are made is usually grey shirting, i.e., un- bleached calico, but roller bandages are often made of flannel, or of some woven material, for greater elasticity or strength; or of muslin for holding plaster of Paris, etc. These, with some other special forms of bandage will be described later. choice of kind The choice of the form of bandage, and of the material, will depend on consideration of such points as these:— The amount of restraint or support required. Thus, a simple triangular bandage will serve best to keep a water dressing on the scalp, while a twisted or knotted roller will OF Bandages and knots. 75 be required to restrain the hemorrhage from a recent wound there. The effect of the bandage on the skin and drculation of the •part. Consideration of this point leads to the selection of material, care as to its tightness, and choice of the best method of applying it. Thus in a limb likely to swell, an elastic pattern, such as a " figure of 8," will be chosen, while if firmness be most required, the " turned " bandage should be used. The length of time the bandage will have to be kept on. If the bandage be for a temporary purpose only, there will not be the same elaboration required as if it were meant to be kept on for some time; in this latter case the particular plan will often be settled from considerations of future cleanliness. The triangular or scarf bandage is the half of a square 36 banaariengular inches, and is usually made of unbleached calico. This bandage has for some years been used in military surgery, but in the surgical Avork of civil hospitals it is still much. neglected, although its use now is beginning to be more recognised. It is peculiarly applicable to out-patient sur- gery, or to the dressing of accidental injuries, and can be used for dressings of very different kinds, indeed, in almost all forms except when a smooth, even, and regular pressure is required.* The first and most obvious use of this bandage is to As a cravat. simply tie it round where it may be wanted with a reef knot, it having been previously folded up into a cravat. In a case of Arenesection the arrest of the venous circulation above the incision may be effected thus, or improvised splints may be attached, or a leg swung from a cradle, etc. The sling is another very useful bandage, and very The siing. quickly put on; indeed, of all the applications of the A b'----------' c Fig. 34.—TJie Triangular Bandage. * The very numerous uses to which this bandage may be put were first worked out by a Swiss surgeon, Dr. Mayor. Professor Esmarch has also strongly advocated its usefulness in civil and military ambulance work. 76 OF BANDAGES AND KNOTS. triangle it is the most frequently required. Although its application may be shown in a few seconds, a written des- cription of it, as with other bandages and knots, is more complicated. Let the right angled corner be called A, and the upper and lower acute angled ones B and C respectively.* Standing in front of the patient, corner A should be placed in the axillary line on the affected side, midway between the axilla and the ilium, B should reach up to, and hang over the opposite shoulder. The line B to C will then hang diagonally across the body, and between it and the arm to be slung. The arm should be placed in the required position, and 0 brought up over the shoulder on the affected side and tied with B in a bow behind the neck. The elbow should then be kept in position by pinning A round it as shown in the figure. (Fig. 35.) The short siing. In slinging the fore-arm the sling should be made just short enough to slightly elevate the shoulder, or the patient will not trust all the weight of the limb to it. The hand should be a little higher than the elbow. Sometimes, as in fractures of the humerus, the weight of the forearm is used Fig. 35.—The Sling and Head Bandages. as an extension, while the hand and wrist alone are slung by the bandage folded up into a cravat, three or four inches wide, and tied behind the neck. In this case the positions * These letters apply to the rest of the triangular bandages where they appear on the figures in the same way. OF BANDAGES AND KNOTS. 77 of the ends of the sling should be reversed, the anterior going over the shoulder of the unaffected side. The head bandage (Fig. 35) differs hardly at all from the The head picturesque head-dress of the Italians, Avhich may be seen worn in the metropolis by the women organ-grinders of Saffron Hill. It is very useful as a cap to retain dressings in their place on the scalp, but it is not fitted for compression. As a cap it is infinitely superior to the " capeline " roller bandage, which is hot, and difficult to apply. Standing behind the patient, who should be sitting down, the middle of the long side of the bandage, opposite A, is placed along the forehead above the eyes, the triangle covering the head, and corner A hanging down behind; the rest of the long side is then brought round the sides of the head, taking care that the hands, as they apply the bandage, are kept low, so as to bring the lower edge well beloAv the occiput. The tails B and C should be crossed, not knotted, over A, beloAv the occipital protuberance, and brought for- ward again round the head to the forehead, Avhere they must be tied. A is then turned up and pinned to the surface of the triangle on the head. The only points to be attended to, are the keeping the hands low while Avorking from before backAvards, and to cross the ends well beloAv the occiput. If this is done the cap cannot slip off, and if not, no tightness will make it firm. The chest or back bandage (Fig. 36 and 37) is again very chest or back Fig. 36.—The Chest Bandage. 78 OF BANDAGES AND KNOTS. useful for retaining such applications as poultices to the trunk, and its employment saves much laborious and Avaste- ful use of broad roller bandages, Avhich do not answer the purpose nearly as Avell. The method is the same Avhether the bandage be applied in front or behind, so that one description will suffice for both back and front, if the terms are reversed. Standing in front of the patient the right angled corner A is placed over one shoulder, and the long side adjusted round the waist. Then the ends B and C are tied behind, on the same side as the shoulder over Avhich A is hanging. Fig. 37.—The Back Bandage. Thus one of the ends Avill be left long at the AA-aist behind, and this should be taken up and fastened to A, Avith a knot or a safety-pin, the junction being about the posterior border of the scapula, and therefore out of the way of pressure when the patient lies doAvn. The shoulder The shoulder is most securely bandaged with two triangles as in Fig. 38. One, folded into a scarf, is fastened diagonally across the body, over the injured shoulder, and under the opposite arm-pit. The corner A of the other is then pinned to it so that the centre of this bandage covers the point of the shoulder, and B and C are crossed over and tied round the arm below the axilla. The shoulder may also have a dressing retained upon it by OF BANDAGES AND KNOTS. 79 using one triangle only, on the same plan as for the knee (Fig. 39), namely, by placing the bandage so that the point of the shoulder is covered by its centre, with A pointing toAvards the ear, and the long side lying horizontally across the arm. B and C are brought round and crossed behind the arm below the arm-pit, and then brought up and tied above the shoulder over A, which may be turned down and pinned. In these bandages there is no pressure upon, or restraint of the joint itself; this can only be attained by the roller. Fig. 38.—The Shoulder Bandage, with two Triangles. The same remark applies to the application of the triangular Fig. 39.—Bandage for the Knee, etc. 80 OF BANDAGES AND KNOTS. For the knee or bandage to the elbow, knee, hand, and foot. The methods of application in all these cases are similar. In the elbow and knee A is put upAvards, the joint is covered by the middle of the bandage, and the long side lies horizontally across the forearm or the leg. B and C are then crossed behind the limb, brought round and tied in front, and A is then For hand or turned down over the knot and pinned. For the hand or £oot- foot the limb is placed with the digits pointing to A, and with the end of the big toe or the middle finger at the centre of the bandage. A is turned over the hand or the Fig. 40.—The Hand, bandaged. foot; B and C are then brought up and crossed over the back of the Avrist or the ankle, and tied in a bow or reef knot For a stump, behind. In the same way a stump (Fig. 41) may be easily and well tied up, provided that pressure be not required. Fig. 41.—A Stump, bandaged. OF BANDAGES AND KNOTS. 81 Bandages of the gluteal region. The most useful are the For the gluteal gluteal, the perineal, and the scrotal. In all of these, tAvo region" triangles will be required, the one for the part itself being attached to the other, which is fastened as a belt round the waist. In the gluteal bandage (Fig. 42), the belt being tied round, A is fastened to it behind, above the posterior iliac spine, so that the middle of the base of the triangle falls Fig. 42.—Gluteal Bandage. just below the gluteal fold. B and C are then brought round the top of the thigh and knotted or pinned together. Both buttocks of course may be bandaged if three triangles are used. The bandage for the perinceum is usually applied by For the folding both bandages into cravats, and fastening one as a permaeu belt, and the other in the middle line behind and in front, passing it between the legs and spreading it out a little in the perinseum. A more efficient bandage, Avhich serves at the same time to cover the buttocks, can be made by reducing the bandage from a right angled to an acute angled triangle, by taking in a plait of about six inches in the base, or long side of the triangle, then fastening A in front of the pubes, and the middle of the base (for the width of the plait) behind, to the belt with safety pins. There will then be three folds of the bandage smoothly covering the perinseum, Avhile B and C being brought round 82 OF BANDAGES AND KNOTS. to the sides, will cover the buttocks, and may be fastened to the belt towards the middle line in front. For the The scrotal bandage generally requires a smaller second scrotum. triangle than the others, or a large one folded once will do. It is adjusted thus :—The belt being put on as before, A is fastened to it in the middle line in front, so that the middle of the base comes to the central point of the perinseum. The scrotum and penis are then slung up and covered by bringing up B and C, turning them round the belt on either side of the middle line, from behind forwards, and passing underneath first. They are then tied together in a bow or knot over the root of the penis, as is usually figured, or secured Avith pins to the belt, as in Fig. 43. Fig. 43.—Scrotal Bandage. For the groin. Lastly, a tolerably efficient bandage for one or both groins may be fashioned by folding a triangle as a scarf and then applying it as a simple figure of 8 (often wrongly called a spica), placing the middle of the scarf at the apex of the fork of the legs, carrying the extremities along the fold of the groin in front, and of the buttock behind, crossing them at the great trochanter, and then carrying them round the pelvis to the opposite side, keeping beloAv its brim, and tying the ends together (Fig. 44). The roller To bandage neatly is to bandage well, and to be able to bandage Avell is essential to the practical surgeon. The art OF BANDAGES AND KNOTS. 83 of using the roller bandage properly is one not to be learned without practice, even though it be freely alloAved that the subject has been quite uselessly complicated by needless rules and patterns. As to the materials for these roller bandages, it has been Materials. said before that a strip of any stuff Avhich fulfils the condi- tions of sufficient strength, Avith lightness and softness, will do. The length of the strip varies from 4^ to 6 yards, the Fig. 44.—Bandage for Groin. width from 2 to 4 inches ; 1\ and 3| inches being the com- monest sizes. For the purposes of description roller bandages may be divided into elastic, semi-elastic, and in-elastic kinds. Elastic bandages, of Avhich there are several kinds, woven, Elastic. india-rubber, etc., will be described under the heading " Special Bandages." The semi-elastic bandages are either woven in a special semi-eiastic. manner or made of a someAvhat elastic material. Under this heading come all flannel bandages, domette, cotton or silk net, etc. The application of these bandages is much more simple The application. than that of the in-elastic, for they will lie smoothly if they are merely rolled on firmly, so that they hardly ever require turning or other manipulation. They should be rolled up rather loosely before use. 84 OF BANDAGES AND KNOTS. The in-elastic. The in-elastic, or common bandages, are the most fre- quently used, especially in hospital, Avhere the other kinds Avould be too expensive, even if they Avere firm enough for the requirements. They are usually made of " grey shirting " or unbleached calico, or the same bleached; or for bandages about the eyes or face, a very cool light bandage may be made of finer cotton stuff or linen. Very old Avorn damask linen is not infrequently used for covering pads or cushions, and speak- ing generally, it may be said that washed stuffs are better than new, Avhich are apt to contain a stiffening dressing. They should always be torn, and no self-edges retained. The general rule is to use the 2| inch bandage for the arms and head, the 3| inch for the legs and pelvis, and the 4J inch Avidth for the chest and abdomen. Except for the trunk, hoAvever, it will be found that the narrowest bandage is the easiest and the most comfortable to apply in all cases. Application of In order to apply the common roller bandage to any part reversing. of the body, the first thing to learn is how to judge of the firmness and support required, and to distribute the pressure evenly about the limb. For this purpose the bandage must always be kept rolled up (dropping it is a sure sign of a bungler or beginner), and held (as in Fig. 46) three or four inches away from the part, while the finger Fig. 45.—Forearm bandaged below with a simple Spiral; above with the "Reversed" Spiral Roller. The latter grasps the limb evenly, the former does not. and thumb are used to retain the bandage in its place when it is being applied. The next point is the manipulation known as " turning " or " reversing," by means of which the bandage is turned over on itself while it is being applied. The object of this turning is that the bandage OF BANDAGES AND KNOTS. 85 may lie smoothly, and be firm as well, for inasmuch as all parts of the limbs, etc., are constantly varying in diameter, and the edges of the bandage will not stretch to make one side longer than the other, it folloAvs that if it be simply rolled on in a spiral fashion, only the largest diameter of the limb covered by each turn of the bandage will be grasped by it, and the bandage Avill be loose elseAvhere, as in Fig. 45. To avoid this, the bandage is, when necessary, turned over as in Fig. 46, and by this means the upper and lower edges are frequently changed, so that the whole width of the bandage grips the limb. This turning requires a little knack, but is easily learned. The secret of doing it well consists in having the portion in the hand (Fig. 46) quite loose, so that by bringing the roller down, it naturally Fig. 46.—Application of the Reversed Spiral. falls over. The thumb must, therefore, be holding the turn of the bandage last applied during this manoeuvre. Moreover, the bandage should be brought across the limb with a good slope upwards, say 45° to the long axis, and the reverse similarly be brought boldly down, so that the bandage is well doubled over, otherwise some of the fold will appear on the other side of the limb when the bandage comes round. The most common fault is that of screwing the roller 88 OF BANDAGES AND KNOTS. round on its own axis, instead of alloAving the bandage, to fall over into position, as it should do almost of its own accord. As a rule it is best to turn every time the bandage comes round, and the turns should be made in the same straight line; but these points are not essential, and indeed both depend rather on the aesthetics of bandaging, than on any practical advantage. Another rule, Avhich may often be more honoured in the breach than- in the observance, is that the bandage must be rolled on from Avithin outwards. Thus in fractures of the thigh (See Fig. 120), if the leg be adjusted to the splint, and the bandage put on in accordance with this rule, every turn that is made will tend slightly to increase that external rotation which is the great obstacle to proper position, Avhile the reverse will be the case if the bandage be applied from without inwards. The roller bandage with reverses is the commonest of all the ways of bandaging. It may be applied to the trunk or limbs (as in Figs. 46 and 47), to fasten splints, and on an infinite number of other occasions. Fig. 47.—Reversed Spiral of Foot and Leg. Nevertheless it is somewhat liable to slip, is not elastic, and is not suited for the neighbourhood of joints. The double- In its stead, a pattern of roller bandage which is hardly wtto revMses. ever used in England, might well be employed more fre- quently, namely, the double headed spiral with reverses. (Fig. 48). Its description, like that of many other bandages, is more complex than its application. The bandage is a combination of a simple spiral roller, Avith a reversed spiral, so that whilst one head of the roller is applied spirally, each of the turns thus made is covered and fixed by a reversed OF BANDAGES AND KNOTS. 87 turn made with the other head. Inasmuch as even com- pression can always (other things being equal) be more efficiently made Avith a double headed, than Avith a single roller, the value of this pattern lies in the firmness Avith Avhich it can be applied to a limb, Avhile it is nearly impossible that it should slip. The heads must of course be of unequal length ; that used for the reverses being the longer. The pattern requires some practice to apply with ease, but the labour will be well spent. A pattern which is at once firm and elastic, and Avhich Figure ot * can be applied over most articulations, is the figure of 8 (Fig. 49). This bandage, when applied to the length of the limb, or over a joint so as to cover it completely, presents much the same appearance when finished as the spiral roller with reverses (compare Figs. 46 and 49), but in its applica- tion it is entirely different. The illustration on page 88 (Fig. 49) will give a better idea of its application than any words can do. The great point to bear in mind is to make Fig. 48.—Double-headed Spiral with Reverses. the loops of the 8 as open as possible, by going boldly up the limb and coming doAvn again as far as the bandage will allow. As has been implied, this bandage may be employed in almost all the cases in which the turned bandage is generally used, and it is often really preferable, being not less firm and yet more elastic, but as a rule its employment is confined to the neighbourhood of joints, so that if a limb and a joint, or joints, have to be bandaged, say the ankle, leg, knee, and thigh, there Avould be a turn or two placed round the 88 OF BANDAGES AND KNOTS. foot, then the ankle Avould have the figure of 8 (leaving out Fig. 49.—Application of the Figure of 8 Bandage to a Limb. the heel), the leg the turned (See Fig. 47), the knee the 8, and the thigh the turned again. One practical reason for this changing is that the figure of 8 requires twice as much bandage to cover a limb as the turned spiral does. The 8 bandage is also used for joints, simply as one or two turns, crossing over the centre of the flexor aspect of the joint. (Fig 50.) This pattern is useful in a number of cases, which may be imagined. Fig. 50.—Figure of 8 for bend of Elbow. ii0oVreeiboew ■^ie point of the heel, and the point of the elbow, with their respective joints, may be completely covered by a series of enlarging figures of 8, starting from the centre, having the crossing placed over the front of the joint, and the loops OF BANDAGES AND KNOTS. 89 above and below the line drawn from the middle of the front of the joint to the heel or the olecranon, and getting ahvays more and more open, and further away from the middle line as the bandage progresses. (Fig. 51). In this Avay the elbow may be conveniently bandaged. The heel pattern is nearly or quite the hardest one to adjust of all the common forms. It is very neat looking, but it is seldom worth the trouble of its application save as an exercise in bandaging. Fig. 51.—Bandage taking in the Heel. TJie spica (spike or spathe, a botanical term applied to The spica heads of seeds arranged as in an ear of wheat) is extremely an age' useful for applying firm pressure to joints, or fastening dressings over them. The pattern is the same, Avhether the bandage be applied to the shoulder, groin, thumb, or great toe, and is that of a figure of 8, combined Avith a firm attachment to a limb in the neighbourhood of the joint,— the wrist for the thumb, the arm for the shoulder, the thigh Fig. 52.—Spica of Groin. for the groin, and the ankle for the great toe. Taking the spica of the groin as an example (Fig. 52), the bandage begins spica of groin. 00 OF BANDAGES AND KNOTS. by two or three reversed turns from within outAvards (or overlapping 8's) round the top of the thigh. The bandage is then carried outwards over the groin to just below the anterior spine of the ilium, and then round the back, taking care to keep just below the iliac crest. The bandage is then brought obliquely across over the symphysis pubis, crossing over the starting point to reach the outer part of the top of the thigh, and is then passed round it, and brought up ready to repeat the roll, but this time a little lower down, and so on till the groin and hip are sufficiently covered. The hip should be very slightly flexed at the time, and care must be taken not to slip on to the abdomen with the bandage, as it is passed round the brim of the false pelvis. Double spica. With a long bandage the spica may be easily enough applied to both groins, starting from one side and repeating every manoeuvre on the other before returning; but in practice this is a bandage very rarely used, and requires mention only. The principle of the spica being understood, a detailed description of the different applications of the pattern is not called for, and the especial points only will spica of be noticed. The spica of the shoulder is an extremely firm Buouldcr. bandage (Fig. 53); the starting point is taken from the upper arm, the turns being rolled round as high as the axillary folds will allow. The bandage is then brought through .the axilla, and over the shoulder and round FlG. 53.—Spica of Shoulder. OF BANDAGES AND KNOTS. 91 the chest, passing under 'one opposite armpit, and the crossing of the first turn should go as high up upon the shoulder as the bandage Avill lie. The succeeding turns will come successively loAver and lower doAvn, until the shoulder is covered in. This pattern requires a long bandage, and it may, as in the case of the groin spica, be doubled for both shoulders if required. The spica of the thumb (Fig. 54) is the regular bandage Spica of thumb. Fig. 54.—Spicas of the Thumb and Big Toe. for the common sprain of that joint. As A\dth the bandages for the phalanges, the roller must be quite narrow, not more than three-quarters of an inch wide. The spica is begun Avith a feAv turns round the Avrist, from within outAvards, if the outside of the thumb is to be the most supported, and the reverse if the ball be the part requiring the firmer pressure. It is then taken round the thumb as high as the bandage Avill lie, and the succeeding turns lower and lower (as in all spicas), till the ball is covered. It is then fastened round the Avrist either by a safety pin, or by splitting the end of the bandage into tAvo tails, which are tied together. The spica of the big toe (Fig. 54) is applied in precisely the spica of big toe. same way, the ankle standing in the place of the wrist. It is, hoAvever, more difficult to apply without getting an awkAvard quantity of bandage material between the toes. The fingers may sometimes be sufficiently covered with a The finger simple spiral bandage, or with reverses, or 8's, using a narrow bandage with neat edges, commencing at the tip, and finishing off at the root of the finger. But, as a rule, to bandage the fingers or the whole of the 92 OF BANDAGES AND KNOTS. thumb efficiently, a combination of spirals and 8's Avith the spica is required. Taking the forefinger as an example (Fig. 55), the bandage is fixed by a feAv turns round the AATist, and is then brought up across the back of the hand from the radial side of the Avrist (or along the palm from the ulnar side if preferred), and is passed between the fore and middle fingers, and half round the former as if to make a spica. Instead of completing the 8, hoAvever, the bandage Fig. 55.—Finger Bandage. is carried in a bold spiral up to the tip of the finger, which is then bandaged carefully downwards to the root. This may be done with simple close spirals, or with small 8's, or reversed spirals if the bandage be wanted to look very neat. The bandage is then finally brought out between the fore and middle fingers, and descending, is crossed at the knuckle over the ascending portion, to go to the ulnar side of the wrist, round which it is fastened in the usual way. To bandage ail If the description has been followed, there will be no difficulty in understanding how all the fingers may be bandaged successively in the same way (Fig. 56) with one bandage, by starting round the wrist as before, and going Fig. 56.—Bandage for all the Fingers, OF BANDAGES AND KNOTS. 93 OA-er first to the little finger, then round the wrist, then to the ring finger, and so on. In this way the palm is left free, and the back of the hand covered, but if it be desired to cover the palm and leave the back of the hand, this is readily done by starting from the ulnar side of the wrist and going across the palm to the thumb or forefinger, as in the case of the single finger. As a rule it is convenient to make a separate bandage of the thumb, but it may be included if desired. In any case a long bandage, not more than | inch wide, must be chosen, and unless the bandage be soft, and have clean-cut unfrayed edges, it can hardly be made to look very neat. The principal use of this pattern is as a precaution against oedema of the fingers; it is not so often put on now as it used to be. All applications of a roller bandage to a conical part must To bandage a inevitably be somewhat insecure unless put on very tight, s ump' and this is generally unwise. It is therefore difficult with any form of roller bandage to apply exactly the amount of pressure which is deemed desirable to an amputation stump, and yet have the bandage secure against slipping off. The Fig. 57.—Recurrent Bandage for Stump. bandage for a stump (Fig. 57) is a pattern known as the recurrent bandage. The roller for this should never be'more than two inches wide, and for an amputation of the arm, or for a " Syme " it may Avell be still narrower. The bandage is first attached three or four inches above the stump by one or two circular turns, and then, the thumb being placed over the middle of these turns in front, and the forefinger similarly behind, it is brought right over the face of the 94 OF BANDAGES AND KNOTS. stump from the middle line in front to the same point behind. Tnis reverse is kept in its place behind by the fore-finger, and the bandage is brought back again, noAV a little to one side of the middle, but conveiging to that point when it reaches its starting point. This is then fixed by the thumb, and the bandage is brought over again, passing this time to the other side of the middle line, and converg- ing to it behind. These reverses are continued till the whole stump is covered, and then by one or two firm circular turns they are fixed in the position in which they Avere held by the thumb and finger, as shown in the figure. It is often Avise to make a circular turn or tAvo in the course of making the reArerses, so as to fix those already made, but in bandaging a stump, the dresser must avoid making the parts hot by unnecessary folds of the roller. This pattern may also be put on so as to cover half or all the head, and may be made tolerably secure if care be taken that the circular turns are kept low doAvn on the forehead and Avell below the occipital protuberance. , hhedddUrbliTr Amputation stumps and also the head may be bandaged by for stumps, or a method which although it results in a pattern Avhich looks the capeline.' like the recurrent, is yet different in principle, and firmer—■ namely, by the use of a "double headed" roller, a bandage, Fig. 58.—Double-headed Roller, or Capeline. that is, both ends of Avhich are rolled up towards each other in the centre. This is the bandage Avhich when applied to the head is known as the " capeline." The application for a stump is the same in all respects. To put on the capeline it is more convenient for the patient to be sitting. The surgeon standing behind takes one head of the roller in each hand (Fig. 58), and places the middle of the bandage on the forehead. The two parts are then brought round Of bandages and knots. 95 and crossed below the occiput. One of the ends is then continued round, and the other, which is lying below it, is turned up and brought over the head as in the "recurrent" bandage. It is noAV met by the other half of the bandage which has gone round the head, while this half has gone over it, and the former continued round, fixes the bandage so that it can again be brought over the head, Avhen the manoeuvre is repeated. In this way by adjusting the subsequent turns of the bandage alternately to one side and the other of the first one, which Avas in the middle, either half (Fig. 59) or the whole of the FlG. 59.—Capeline for Half the Head. head may be covered with folds converging to the middle line in front and behind, and a someAvhat attractive bandage is made. Its appearance is, hoAvever, almost its only good quality. It is firmer than the simple recurrent bandage Fig. 60.—Double Spiral Bandage. 96 OF BANDAGES AND KNOTS. but is still very liable to slip. It is troublesome to apply, hot, and if at all tight round the head, apt to become pain- ful, while it fulfils few indications Avhich cannot be at least as well met by the more homely, but far more comfortable triangular bandage. When applied to a stump, hoAvever, it may sometimes be useful. Double spiral. Another application of the double headed roller which is not often used in this country may here be mentioned, namely, the double spiral (Fig 60). The two spirals crossing each other in front and behind, make an open bandage which is convenient enough for retaining dressings. The knotted The twisted or knotted bandage for the head (Fig. 61) is generally described as one which requires a double headed Fig. 61.—Twisted Bandage for Head. roller, but this is not at all necessary or desirable. It is an extremely useful bandage, and is easy to apply. For example, taking the neighbourhood of the temple as the situation in which the pressure of the tAvist is required, the bandage should be unrolled for about a foot, and the end held in the right hand, Avhich is kept close to the temple. The roller is then carried round the forehead and occiput, so that it comes back to the unrolled end at the wound. The roller is then twisted round sharply as shown in the figure, and is carried down below the chin and round to the vertex. On coming to the temple again the same tAvist is made, and the roller is once more passed round horizontally; Avhen sufficient pressure is obtained, the bandage is fixed by knotting the two ends together. In discussing the treatment of fractures of the loAver jaw, the four-tailed bandage will be again referred to, but it may properly be described here. It is a Aery useful pattern and Four-tailed bandage. OF BANDAGES AND KNOTS. 97 serves for the attachment of dressings in wounds about the chin or face, as Avell as for fractures. For the bandage (Fig. 62), a piece of shirting four or five inches wide and two feet long is required. It is then doubled on itself and torn down, until a piece four inches long only is left undivided in the Fig. 62.—Four-tailed Bandage for Jaw, with Chest Bandage. middle. In the middle of this a slit two inches long is generally cut, in which the point of the chin is inserted, but this is often omitted. The middle of the undivided part is placed over the chin, and the under pair of the four tails made by tearing the bandage are then brought up over the side of the face in a line Avith the masseter muscle, and loosely knotted or held half an inch in front of the vertex of the skull. These pass underneath the other pair, which are brought round to just beneath the occipital protuberance, and firmly tied together with a reef knot. The first pair on the vertex are then tied with sufficient firmness to fix the loAver jaw against the upper one ; and finally the vertical part is kept from slipping for- Avards, and the horizontal from slipping downwards, by tying the four tails together (this is not shoAvn in the figure). In adjusting this bandage it is necessary to see that the length of the undivided part fits the jaw to which it has to be applied, and this can only be done by trying it on before it is finally fixed. In bandaging the chest there is a tendency for the chest bandage. 98 OF BANDAGES AND KNOTS. bandage to slip doAvn on account of the decrease in size of the thorax from above doAvn. This is best overcome lo- using a brace and bandaging from beloAv upAvards. A piece of bandage should be split in the centre, and the head passed through the opening, so that one end hangs down in front and the other behind. The bandage should be applied over this, being fixed by one or tAvo turns round the chest, and then carried up Avith a reverse in each turn, thus overcoming the tendency to form an open spiral. Finally, the two ends of the brace should be brought up and fixed (Fig. 02). Breast bandage. The roller is first fixed by a couple of turns round the chest, starting from .and beloAv the affected gland ; it is then carried upwards over the loAver part of the breast and the opposite shoulder, descending across the back to the original starting point, then horizontally round the chest. These turns are then repeated, each oblique turn being fixed by the succeeding horizontal one, and rising higher on the breast until it is covered. It is important always to bandage from the affected side (Fig. 63). FlG, 63,—Breast Bandage, OF BANDAGES AND KNOTS. 99 The single T bandage (Fig. 64) is most frequently used for The singi fixing dressings to the perinseum. Its application there is an age' simple enough. The horizontal part being fixed round the e T Fn:. 64.—Single T Bandage. waist, the other end is brought round betAveen the legs and fastened in front. The bandage can also be applied to the head or elseAvhere. For the perinseum a good average size is five feet for the horizontal piece and three feet for the vertical, and it should be about three inches wide. For the perinseum, a better pattern than the single T is The double t the "double T" complete (Fig. 06), or incomplete (Fig. 65). banoils in jone or two Avashings. "Alloa yarn" or "five-ply or four- ply fingering" on the other hand, are improved for the purpose of these trusses by washing, and they are not too harsh for the skin of any except the tenderest infant, in Avhose case a skein of " lambs'-wool" does best. Nothing except avooI or Avorsted seems to act as an efficient truss when applied in the same way ; this is due, no doubt, to the elasticity of the animal fibres, which is distinct, although limited. In some cases in which the ruptures were large, and occurred in children betAveen three and five years of age, I haAre found it useful to increase the elasticity by using, instead of the simple skein, a loop of the same material loosely knitted, or crocheted into a flat band about two inches Avide, and applied in the same fashion. I doubt Avhether a skein of tAventy threads only, as Mr. Lund advises, will be found thick enough, except for very small infants, and I have sometimes found it necessary to use as many as double that number. It must be clearly understood that no pad of any sort is to be worn under- neath the loop. Nurses often mike this mistake; indeed, as to the whole method, some little patience will be called for in order to secure that it shall be carried out intelli- gently, or disappointment will surely ensue. But this patience will not be thrown aAvay if the end is gained of saving mothers from the endless worry and expense Avhich a ruptured infant so frequently entails upon them ; and if I seem to be needlessly particular as to details, it is because I am convinced of the value of this old-fashioned treatment, and am anxious that it should not get discredit from lack of fulness of description. The circumference of the skein runs from three feet to fiAre feet, i.e., the loop is from eighteen inches to thirty inches long,* and a fresh skein should be put on every morning, the soiled one being rinsed out and hung up to dry. caruseSsPo0fShe!nia Tw0 Sreat predisposing causes of rupture in infants may in infants. here be mentioned. One is the foolish habit of sewing a * I may here refer to a paper by myself which will be found in '•Brit. Med. Journal," 28th May, 1887. Also to Mr. E. Owen'a "Lettsomian Lectures," in 1889 (Bailliere). OF ELASTIC BANDAGES, TRUSSES, ETC. 115 tight abdominal "binder" round the unfortunate baby ; the other is the frequent occurrence of phimosis. It will often be found that a rupture Avill undergo spontaneous cure after circumcision, and although on this account the appli- cation of the truss should not be postponed, still the operation, always advisable in phimosis, or Avhen the fore- skin is long, becomes the more urgent when the child is also ruptured. Though it may seem superfluous, it will be found not infrequently necessary to caution mothers against putting on a truss over the neck of a rupture when it is doAvn, instead of returning it first. Umbilical hernia in infants is extremely common; in chil- Umbilical dren it is less often met with, and in adults, especially in corpulent women, it is not infrequent. In the latter, how- ever, it is more common to find the bowel coming through a little to one side of the true umbilicus. In children this condition can usually be cured readily enough by wearing a spring truss, or what is much more common, a belt Avith a pad in front. A better way of treating this affection in infants, how- ever, is to fix a pad made of a piece of cork, covered Avith lint, over the navel with pieces of strapping. Care must be taken that both this pad and that of a truss are sufficiently large to press upon the aperture, not to fit into it, or absorption of its margin may take place. Umbilical hernice in adults should always be supported by a truss, for though their aperture is generally large, they are as liable as others to become strangulated, and the mortality after herniotomy for this condition is very high. An unusual form of hernia may be mentioned, requiring vaginal hernia. a truss of a different kind, namely, the protrusion into the vagina, of the walls of the vesico-vaginal pouch. In this hernia there is generally no definite sac; it occurs in child- hood, and tends generally to get well of itself, but if support be required it must be given as in prolapsus ani, by a pad in the vagina, attached behind to a perineal strap fastened to the middle of a belt, and ending in two straps in front, which pass along the folds of the groins on either side, to opposite the iliac spines.* The only measurements necessary for the common kinds of ^ats1)ursesm5nU inguinal, femoral and umbilical hernise, are the circumfer- * This condition is described and drawn in Holmes's "Diseases. of Children," p. 560. 12 G OF ELASTIC BANDAGES, TRUSSES, ETC. For partially descended Hernia of the ovary. Rare hernise. ence of the abdomen at the umbilicus for the latter, and of the pelvis just below the iliac crest and over the pubic symphysis, for the two former. When an undescended testis has never entered the inguinal canal at all, nothing requires to be done, but when, as often happens, it lies in the course of the canal, it will there be very liable to injury and consequent inflammation, unless some hollowed pad be placed over it for its protection. This, though not a truss proper, is fashioned like one, and will have to be specially made. In adult cases the testis usually remains within the abdominal cavity, but sometimes becomes engaged in the internal ring, giving rise to pain, or to the more acute symptoms of strangulation. In these cases it is generally advisable to treat this descent of the testis as an ordinary inguinal hernia, and to keep it up with a truss out of harm's way, but it will be wise to remove the organ if the irritation persists. In the female, too, hernia of the ovary, into the neighbour hood of one of the labia, not uncommon in childhood, requires a light inguinal truss, which almost invariably effects a cure. The rarer kinds of hernia, such as the obturator, the ventral, the lumbar, etc., can not usefully be considered fully here. They will generally be treated by trusses or belts of special form, but made on the same principles as those for more common ruptures. The first two kinds are well knoAvn, but are rare; the third, the Lumbar hernia, or protrusion of abdominal contents through the loins, is very rare; the best description to be found is by J. Hutchinson, junr.,* to which the reader is referred. In all probability a belt is the right treatment in these cases, although Mr. Owen records a case of radical cure by operation.! It may finally be mentioned that in cases of spinal bifida, or meningocele, which are indeed hernias, some form of truss, or of support and compress combined, is sometimes indicated. * "Brit. Med. Journal," July 13th, 1889. t " Brit. Med. Journal," May 5th, 1888. OF TJIE USE OF ADIIESIA7E STRAPPING. 117 CHAPTER IX. Of the Use of Adhesive Strapping. The use of this material in surgical dressing, for the Adhesive purposes of mechanical support, is steadily increasing, and s iappms the number of medicated plasters is being almost daily added to. Of these latter very little need be said, for with few exceptions, their value is still undecided. One or two how- ever are certainly of great service in appropriate cases. The ordinary adhesive strapping, diachylon or lead plaster On linen. (emplastrum plumbi) is the form which is still in most general use, and unless otherwise mentioned, must be understood to be the material employed. It is sometimes spread on paper, Avhen it is almost useless, but is generally laid on linens of varying fineness, or upon leather. No good purpose is served by using a fine linen, and the best strapping for all ordinary occasions is what is known as "Leslie's Hospital quality," sold in rolls eight inches wide. Other kinds of plaster are often spread upon chamois on leather. leather, or on white basil, and, as will be mentioned directly, leather should generally be employed when pressure is required, as in strapping an inflamed joint, by reason of its stretching powers. Recently, a very useful form of strapping, the basis of Rubber ^ which is indiarubber, has been introduced, namely, Seabury iappin' and Johnson's rubber adhesive plaster. Its advantage is that no heating is required, the adhesive surface being protected by a layer of coarse muslin until it is used. Another very good kind, for small surfaces, is the isinglass isinglass plaster, made by painting thin silk with that material. It plaster- requires wetting only, and is very cleanly. For clean cut Avounds about the face, etc., and in other cases Avhere great nicety is required, court plaster or gold- beater's skin (a thin film of collodion) is generally used- No detailed description is required of the Avays in which Danger of strapping may be cut into strips, and used to fasten splints oirsnapping? or dressings. But the Avarning given so eloquently by Sir James Paget * may well be borne in mind whenever this * «' Clinical Lectures," p. 60. The Calamities of Surgery. 118 OF THE USE OF ADHESIVE STRAPPING. rigid material is being used. Such a disaster, as he in his lecture describes (a fatal case of acute cellulitis following the application of a circular piece of strapping), can hardly occur if the plaster be spread on any kind of leather; but this, from economical reasons, Avill often not be the case, and it may be taken as a rule to be folloAved almost invariably that strapping should be put on either spirally, or obliquely so as to form the half of an 8. If strapping is to be applied round a limb, it should be cut in strips and put on so as to secure an even, steady pull from both ends, otherAvise the skin may be painfully wrinkled. It should always be thoroughly Avarmed first, for which purpose cylindrical hot Avater tins are generally used, or some gas apparatus. Sometimes strapping is soft- ened by dipping it for a moment in very hot Avater; this makes it more pliable, and not much less adhesive. When the strapping is required to accurate])7 adjust or support the edges of wounds, of amputation naps or the like, the strips should never be stuck first on one side and then pulled over to the other, or "cockling" will certainly occur, but should be cut in pairs, and applied as in Fig. 79, Fig. 79.—Strapping applied to close a Wound accurately. or on some similar plan. One strip is placed on one side of the wound and the other on the other; the middle parts are slipped the one within the other, and then an even regular pull can be made simultaneously on both sides. of some Some special cases in which strapping is a common plan of s?rapping!es treatment will here be shortly described. The case of fractured ribs will be afterAvards a^ain refer- chest. red to. Not only in fracture, but Avhere the thoracic walls have been badly bruised it is often desirable to place them as completely at rest as possible. This may be done very OF THE USE OF ADHESIVE STRAPPING. 119 effectually by strapping them as if they had actually been broken. (See broken ribs.) Enlarged phalangeal joints may often be strapped Avith Fingers. common plaster or Avith the iodine strapping to be hereafter mentioned. The method of doing this is the same as for the larger joints, and does not require a separate description. The wrist, either for a simple sprain or for the common wrist. teno-synovitis of the extensors of the thumb lying over it, may be strapped Avith strips of linen or leather plaster applied in the same manner as for the knee, Fig. 80; or a single piece of chamois leather may be used in the Avay which is described beloAv. Every dresser should knoAV hoAv to strap the knee joint effi- Knee. ciently, for it is one of the principal methods for the treat- ment of chronic derangement of this articulation. The usual plan is to apply strips of the plaster, overlapping each other, from beloAv upwards, in half loops of 8, until the whole joint is covered. This may be done well with the plaster Fig. 80.—Knee, Strapped (ordinary way). spread on linen or holland if great care be exercised, but it is better to use leather, on account of its superior elasticity. A better way of strapping this joint in the less acute forms of its disease, is one which is little knoAvn, and so may here be described in detail. If the plaster be spread on chamois leather it will be found quite easy to firmly envelop the Avhole joint Avith one piece, provided the adhesive material be Avell spread and well Avarmed. The piece should be oblong, and large enough to go round the knee and overlap about one inch, and should be from ten to fourteen inches long. After warming it well, the centre of the leather must be very evenly applied to the skin in the popliteal space ; one-half of it must then be dniAvn over the inside and front of the knee, Avith force enough to produce the pressure required ; this Avill be found to stretch the leather sufficiently to bring it well over the front. The other half is then brought quickly and firmly over the other side. If the leather has 120 OF THE USE OF ADHESIA7E STRAPPING. been properly Avarmed, it will stretch so as to overlap for nearly three inches, and the plaster will be applied so closely to the skin that it will follow every wrinkle in it when the knee is flexed, and yet a firm, even compression will be attained. (Fig. 81.) Fig. 81.—Knee, strapped with one piece of Chamois Leather. Ankle. The ankle, similarly, may be strapped either by narrow strips of linen or leather, or by one broad piece of chamois, the middle of which is applied to the sole of the foot, and the tAvo ends brought up and crossed in a figure of 8 over the front of the foot, and round the malleoli. Breast. Long strips of adhesive, or diachylon strapping, may be usefully employed to support, and to a moderate extent, to compress an enlarged or inflamed breast. The centre of the strips must be placed below and the ends crossed above, working from below upwards, the breast being thus sup- ported by the overlapping plaster. But, as a general rule, this kind of support can be more easily and comfortably maintained by the use of " Martin's " rubber bandage. Testis. To efficiently strap an enlarged testis is difficult, unless the organ be very large. The art, however, must be acquired, as the compression thus produced is a most valuable method of treatment in cases of inflammatory exudation. The look of a properly-strapped testis may be gathered from Fig. 82, but it is always difficult to make a neat job of it. Leather should be used if possible. First of all, the parts having been shaved, the testis must be fixed down into the scrotum by a long strip passed round and round its upper part. The body of the gland may then be compressed by over- lapping strips put on circularly, that is, horizontally, from below upwards, or vertically, to produce the same appear- ance as in the recurrent bandage for a stump, or with a combination of these two ways. In truth nobody ever straps two testes in the same way, or obeys any fixed rules so long as the compression is attained. Another good way of applying even compression to an enlarged testis is to envelop the gland in a layer of cotton wool, and then to stretch over this a square piece of thin indiarubber sheeting OF THE USE OF ADHESIVE STRAPPING. 121 (the best is that used by dentists, but that similar to Martin's bandage material will do), securing it at the top by slipping on an indiarubber ring. It has hitherto been assumed that the strapping has been Medieatea employed simply for the purpose of mechanical support, or plaster3- of compression. But frequently the adhesive material possesses in itself (or is applied over ointment possessing) medicinal properties. As examples of these special plasters the Emplastrum belladonnce and E. opii are frequently used Fig. 82.—Enlarged Testicle—strapped. for their anodyne properties; the E. hydrargyri or hydrarg. c. ammoniaco and E. potassii iodidi for promoting absorption. As stimulants, the E. galbani or E. picis (poor man's plaster) are supposed to have merits, as to which Ave may be allowed to be a little sceptical, Avhile the use of the milder cantharides plaster, E. calefaciens, explains itself. Lastly, in addition to the soap and lead preparation, the emplastrum ferri (£. roborans) has great adhesive power, and is often applied to the lumbar region, with the idea of strengthening the muscles of the back. Of the anodyne preparations, the belladonna plaster is most frequently used for the purpose of allaying pain in the breast, and for arresting the lacteal secretion, but it is a good anodyne for general use. For strapping joints, etc., the E. hydrarg. c. ammoniaco will be found on the whole to be the most useful. 122 OF THE USE OF ADHESIVE STRAPPING. An extremely useful strapping is the iodine plaster, prepared by Ewen, of Jermyn Street.* strapping over One of the most effective modes of treatment of enlarged ointment spread jointS) inflammatory bursal enlargements, chronic orchitis, etc., is to cover strips of lint with some absorptive ointment, to lay them over the part and then strap it up firmly with soap or lead plaster. The ointments most commonly used are the various mercurial ones, all the iodine, iodide of lead, and iodide of potassium preparations, but especially the cam- phorated mercurial ointment, the Avell known Scott's dressing.} Scott's dressing. The strapping, Avith the ointment beneath it, should be left on until the latter is absorbed, or until the parts beloAv have shrunk so as to make it loose; it may then be re-applied if necessary .J To remove When strapping has been applied to any part of the skin which is hairy, its removal is always painful, sometimes very much so, unless the adhesive material be softened. This may be done with very hot water, but a better way is to soak a pledget of lint in spirits of turpentine, and to soften and dissolve the plaster from the hairs, as the strapping is turned gradually back. * This, when spread on chamois leather, and applied in the way already described, forms the most satisfactory strapping for enlarged joints which we have yet met with. It should be freshly prepared or kept in a tin case. t So called from the name of the surgeon who introduced it. Vide " Scott on the treatment of Diseases of the Joints, etc." London, 1857. X The subject of blistering plasters, fluids, etc., will be discussed Eater. Of splints—considered generally. 123 CHAPTER X. Of Splints—Considf.rfxi (1p.nf.i>\ttt. Definition. A splint is a contrivance or apparatus possessing of splints. absolute or relative rigidity, which when attached to some part of the body increases its natural stiffness, or remedies undue mobility caused by disease or injury. It will 1 o seen therefore that the subject of the applica- tion of spb/ii,s is a very Avide one, and even a simple list of the various arrangements devised by surgeons from time to time, to fulfil the requirements of disease or injury, would be a catalogue as long as it Avould be useless and wearisome. We propose in the first place to give only a general descrip- tion of the principal methods of splinting, and of the common forms of splints, postponing a more exact account of many of them until the various fractures and injuries Avhich require their employment come to be discussed. In many parts of the body, an uninjured bone in the Natural splints. neighbourhood of one that is broken, will often serve to keep the fragments of the latter in their place, and in other parts the attachment of ligaments, etc., will serve the same purpose. Thus, in fractures of the fibula, the tibia, if un- broken, will make a very efficient splint for it. The same may be said of the ribs, where the muscles and ligaments, which form, Avith them, the cage of the thorax, very often prevent serious displacement. A fractured loAver jaAv, again, may often be kept in good position by keeping the fragments close against the upper jaAv, and many other instances might be adduced. There is hardly a limit to the number of the materials improvised which may be pressed into the service of the surgeon, to splints' form splints in the first instance, in cases of fracture or of some other injury. The usefulness of cardboard, book-covers, newspapers, fircAvood, and many other things familiar in daily life, will be mentioned in this connection under the heading of " Im- mediate treatment of Fractures." But the list is only limited by the ingenuity of the surgeon concerned. It will be convenient here to give a short classification of 121 OF SPLINTS—CONSIDERED GENERALLY. the splints and splint materials Avhich are recognised as be- longing to the surgical armament. surgical splints Surgical splints may be divided into those of some fixed -their different form an(J ghap^ and of gome rigid materf^ as wood or iron, to which the trunk or limbs may be attached by bandages or strapping ; and those Avhich are capable of being moulded to injured or diseased parts, to give them the needful sup- port or to remedy deformity. All of these latter possess the property of being soft Avhen applied, and then of setting or hardening. Rigid splints. These are for the most part of Avood or iron, though other materials, such as vulcanite, etc., are sometimes used. They may be sub-divided into those of a simple, and of a compli- cated form. simple wooden Plain wooden splints are the simplest of all, and ay ill need splints. t,ii • • t i • i • j: little description. In most cases they are simply pieces ot white pine, of various lengths and breadths, planed, and Avith their edges rounded off. They are used for fractures of the limbs, or to prevent flexion of joints, as in the common "patella splint," etc. Not infrequently they are made of strips of Avood lined Avith canvas, on the plan of the kettle-holder splinting, to be presently mentioned, and other materials such as rattan, cane, etc., have been used from time to time. The pistol-shaped splint is again an example of a simple wooden splint, the use of Avhich will be explained, with other forms, in considering Colles' fracture, and similarly, the use of Cline's, or of Lis ton's splints will be described in relation to the conditions they are devised to remedy. Angular splints. Angular splints (Figs. 83, 84) with or without a hinge Fig. 83.—Wooden Angular Splint with Hinge. at the elbow, are very useful in various injuries of the arm, and, like other forms of wooden apparatus (e.g., the OF SPLINTS—CONSIDERED GENERALLY. 125 back splint for the knee), are far more comfortable if they are somewhat hollowed out, a proceeding which adds but little to their expense. 84.—Simple Angular Splint. Figs. 85, 86, illustrate an angular metal elbow splint in- vented by Mr. Thomas Jones of Manchester, especially for Figs. 85, 86.—Angular metal Elbow Splint. compound injuries of that articulation; it is described in the Lancet, vol. i, 1885, p. 1125, and is very simple, effec- tive, and cheap. Of the more complicated splints, in which Avood is the complex principal material employed, the chief are " Bryant's " for wooaen Bpli1' excision of the hip, fracture of the thigh, etc., "Gant's" for the treatment of genu valgum, splints for fractured patella, and the double inclined plane; these, and others, will be noticed in their places. It is often necessary, in cases of compound fracture, or interrupted after excision of joints, etc., where we must be able to getsplmts' at a wound which therefore must not be covered by the splint, to make an inh rruj-finn. as it is termed, and although this is done in iron (Fig. 1)2) as well as in Avooden splints, it 126 OF SPLINTS—CONSIDERED GENERALLY. is far more easy in the latter, as in Fig. 87. In making such a splint it is best to choose one as if the necessity for the interruption did not exist, and then to saw aAvay the Fig. 87.—Iron Back Splint, with "Interrupted" Wooden Side Splint. parts required to be removed, after having fastened on the iron supports. iron splints. Iron Splints may be simple or complicated ; as examples may be mentioned the common angular elboAv splint (Fig. Fig. 88.—Iron Angular Splints, with arrangements for Pronation and Supination. 88), generally having a hinge at the elbow; the simple back splint for the leg and thigh, with a foot piece, com- monly used for fractures of the leg, generally called "Neville's splint;" and the different patterns of that very useful splint, " Maclntyre's " or " Liston's " (Fig 89), Avhich consists of a movable foot piece, and leg and thigh'pieces, with a joint between them, and with some mechanical arrangement of screws or rack and pinion, to alter the angle at the knee. These can be adjusted for limbs of different lengths by means of the movable foot-piece OF SPLINTS—CONSIDERED GENERALLY. 127 All leg splints for fractures should be furnished with cross pieces, to enable the limb to be swung from a cradle, as shown in Fig. 126. Fig. 89.—Maclntyre's Splint. There are numerous patterns of splints used after excision of the wrist, elbow, and knee, of which examples are given in Figs. 87, 88, and 91. Splints are also made of tin or some other flexible metal Piexibie splints. which can be readily bent into any required shape. These are often used in the treatment of talipes (q.v.). Fig. 90.—Dr. Guillery's Flexible Splint. Fig. 90 is a draAving of a German flexible splint which is sometimes used in this country. The splints are made of different sizes for the arm, forearm, thigh, and leg, and are accurately blocked to the contour of each limb, and retain them in good position in cases of fracture after the displace- ment has been reduced. They can readily be blocked up differently if any abnormality in the shape of the limb be present. The splint can be procured at most instrument makers. They are named after their inventor, Dr. Guillery. Woven wire splints are also still used in cases of fracture, but not so commonly as heretofore. They are at once light and strong. 128 OF SPLINTS—CONSIDERED GENERALLY. Oooche-s "Kettle-holder" or " Goodies Splinting" is made by attach- ing long thin strips of wood to canvas or leather with strong Fig. 91.—Perforated Metal Angular Splint. Fig. 92.—dines' Metal Splint, interrupted. glue. It is made in large sheets, and splints of different patterns can be cut or saAvn out of it. Its great merit lies in the fact that it is flexible in one direction and rigid in the other. It is especially used for fashioning splints to partially encircle a limb, as in fractures of the arm, or in combination Avith a back splint in broken thighs. Padding splints. To avoid repetition, a few general directions may here be given as to the Avays of padding splints and attaching them, but they can only be of the most general kind. All splints, before they are applied, should be padded, to avoid injury of the softer parts. This may be done in several ways, and Avith different materials. Of all pad- dings, hoAvever, the most elastic and convenient is tow, Avell teased, so that the fibres lie all one way, and with no lumps in it. Soft linen, such as old napkins, etc., makes the best covering for the toAv. Fur the simple forms of splints, the pads should be made like miniature pillows, and either seAvn on Avith a lace stitch OF SPLINES—CONSIDERED GENERALLY. 129 at the back, Avhich is best, or fastened—but as a makeshift only, Avith bands of strapping Arery smoothly applied (Fig. 93). Pads should ahvavs be complete cushions, not layers of toAV laid upon the splint and covered. FlG. 93.—Pad, sewn or strapped upon a Splint. Next to toAV as a stuffing comes cocoanut fibre, and last of all cotton wool, which is very apt to work into hard lumps. Very good but extravagant pads may be made of several folds of lint. In all cases where moist or oily dressings, or the discharge covering with from wounds, can possibly soil the pads, they should be 0ll"sllk' etCi covered with some form of oiled silk or Avith gutta-percha tissue. The former must be seAvn on, but the best and neatest Avay of fastening the latter is to moisten the edges Avith a piece of lint dipped in chloroform, Avhen they will readily adhere. Iron splints are usually perforated for the seAving on of the pads, but if not they must be managed like the Avooden ones. Before padding them it should be seen that the metal is not exposed by the Avearing off of the lacquer, or the cover Avill be iron-moulded. In jointed splints the pads should be made separately for importance oi each part, and especial pains must be taken to have them smo° very smooth and of the proper thickness Avhere they have to protect prominences of bone, such as the trochanters or malleoli. This is particularly true of the heel, under Avhich the pad should be firm and rather thin, Avhile the tendo Achillis immediately above it should be Avell supported with a thicker pad. A "sore heel" is a surgical disgrace to the dresser of a fractured leg or thigh. Too much pains cannot be taken to select perfectly fitting splints and such as are in good condition. They should, in almost all cases be a little wider than the limb for Avhich they are chosen ; if this be attended to, partial strangulation, through their being put on too tight, is almost impossible. With regard to the various methods of attachment of splints, Attachment oi we need only mention here, that strapping, bandages, and sp 1B buckled straps of Avebbing or leather are the chief agents employed; any one or all combined may be found most suitable, in each particular case. In bandaging the same 130 OF SPLINTS—CONSIDERED (-ENKRALLY. rules apply as have been already given, but Avhatever way of attachment is selected, it should if possible be so managed that the limb can be examined from time to time Avithout disturbing the Avhole apparatus, and in the case of the extremities, the fingers or toes should be easily got at, in order that the condition of the circulation may be noted. Lastly, complaints of pain or even of discomfort, in parts Avhich are covered by splints, should never be neglected or thought lightly of. SPLINTS FASHIONED OUT OF PLASTIC MATERIALS. Moulded splints. These splints fall naturally into tAvo divisions; in the first are placed all those Avhich arc fashioned accurately to the part, out of a mass or a sheet of a material Avhich can be moulded Avhen softened (generally by heat), and which is then alloAved to set. The second division comprises those made by enveloping the part to be splinted with pieces of flannel or other suitable material of the desired shape, or Avith rollers saturated Avith a material, liquid at the time of application, but Avhich afterwards hardens. Division 1. In this division are included splints moulded from leather, felt, gutta-percha, cardboard, etc., the skilful fashioning of which is an important branch of mechanical surgery. Leather splints. Far too often money is thrown away Avith very unsatis- factory results, through the mistaken notion that the making of these splints is either beloAv the surgeon's or dresser's dignity, or above his mechanical powers. There can be no doubt, a leather splint for such a case as a chronic enlarge- ment of the knee, or a fractured patella, Avill be more efficient, if made by one Avho understands the surgical necessities of the case, than by an instrument maker who must, from the nature of his trade, proceed in a beaten track, and according to a fixed pattern. Something of finish and appearance Avill no doubt be sacrificed, but the one splint will do its Avork, the other, very often indeed, will not. With a little care a dresser may easily turn out a very good looking leather splint, without giving any inordinate time or trouble to it. The best leather for the purpose is ordinary sole leather, of medium thickness, arm splints requiring a lighter kind than those for the leg. In all cases the leather should be carefully examined for flaws. The piece being chosen, it must, before softening, be cut out to the required pattern with a very sharp knife, OF SPLINTS—CONSIDERED GENERALLY. 131 Patterns for the chief kinds of moulded splints are given Patterns for, in Fig. 94, buc in all cases the shape should first be cut out in paper and fitted as nearly as possible to the limb. The figure shouia then be marked out on the leather before cutting. Splints may be made of leather for the ankle, knee, hip, spine, shoulder, elboAv, wrist, and jaw. The question of spinal splints will be considered in a separate chapter, and inasmuch as among the rest, those for the elbow and knee are by far the most common, and as many of the directions for making them will hold good for splints fashioned out of the other plastic materials, these two will be described in detail. The back splint for the knee is a splint which is often Leather spiini required for the treatment of fractured patella in the later stages of union, or for chronic disease of that joint, or after its excision has been performed. The pattern should first be cut in paper (of the shape shown in Fig. 94, No. 5), of sucn a length as firmly to grasp the leg and thigh, and of a Avidth such as will allow an interval of about half an inch betAveen the two sides of the splint in front. The paper pattern must be carefully fitted to the part, and the leather then cut out from it. This must then be thoroughly softened in a bucket of cold water, which will take from twenty-four to forty-eight hours; if it should be desirable to shorten this time, a tumblerful of vinegar or of dilute acetic acid may be added to the water, when three or four hours Avill be enough to soften the leather. The splint should then be applied to the limb Avhich has previously been covered Avith a flannel bandage, or Avhat is far better, to a plaster cast of the limb, and bandaged firmly, Avhile it is at the same time moulded to fit the curves Avith all the exactness possible. Too much care cannot be exercised in this, the most important stage of the work. When it is done, the leather must be alloAved to " set" on the limb, a process Avhich will take some hours, Avhen it may be care- fully taken off and alloAved to dry thoroughly. It is then fit to be tiimmed and finished by cutting aAvay whatever leather is redundant, or where the edges seem as if they might chafe. The edges too must be bevelled on the inside » Avith a very sharp knife. If it is considered advisable further to strengthen the splint Avith an iron backing, this may iioav be riveted on by a smith. The lining is best done Avith chamois leather; it must be cut out from the same shape as the splint, but large enough Fig. 94.—Patterns for the principal forms of Moulded Splints, OF SPLINTS—CONSIDERED GENERALLY. 133 to overlap it everyAvhere for about half an inch. The inside of the splint is iioav brushed over with very hot thin glue, and the chamois leather stuck on. It Avill adhere very firmly; and the edges must be turned over and similarly fastened doAvn, and then trimmed to an even Avidth. The finishing touch is given by punching the necessary holes for lacing and inserting the brass rings Avith the proper boot-maker's tool. If it be desired to polish the leather outside, this may easily be done Avith beesAvax and oil melted together, and rubbed in Avhile Avarm with a flannel. In Fig. 95 is shoAvn an ordinary knee splint, finished and applied. Fig. 95.—Moulded Back Splint for the Knee, in leather or felt. There are tAvo principal ways of moulding an angular Elbow splint splint to the elbow, both about equally efficient. The pat- tern for the first is as in Fig. 94, No. 2,* the arm piece cut long enough to reach to the axillary fold, and that for the forearm, to the Avrist. The leather is softened as before, and then, by bending the arm piece up at right angles to that for the forearm, they Avill overlap each other at the elbow, the arm ones going outside. The splint thus bent, is moulded by bandaging it on in the same way as for the knee, and may be trimmed, lined, and finished, as has just been described. The pieces at the elboAv are fastened together by a feAv stitches of Avhipcord, or by passing through and bending over, some of the common clips used to fasten papers. This splint, it will be seen, is made of one piece, and may be laced along the middle line in front, or fastened there by two or three Avebbing straps. It is shoAvn finished in Fig. 96. In the other pattern, Iavo pieces * Jn this pattern the portion for the forearm is drawn too small. 134 OF SPLINTS—CONSIDERED GENERALLY. of the shape of No. 11, Fig. 94, are cut out, softened, and moulded to the outer and inner sides of the arm and fore- arm. They may, Avhen finished, be simply fastened round the limb by Avebbing, or leather straps ; or a neater Avay is to glue the tAvo halves along the back to a broad piece of tape or soft leather, so as to make a hinge : they can then be laced together along the front. The advantage this splint has over the other is that it may be put on and off Fig. 96. very readily, but it is more troublesome to make, and is not quite such a firm support. Blocking splints It often happens that joints, suitable in other ways for leather splints, are too tender to bear the necessary mani- pulation of moulding. In this case, if it be decided to have one of this kind, a plaster cast must be taken of the limb, and the leather moulded to that ("blocked" as it is termed), when much greater force can be applied.* Poroplastic felt. A material closely resembling leather in its mechanical properties, but more easily applied, is noAV to a great extent superseding it for moulded splints, both large and small. This is felt saturated with some resin, in such a way, that while it preserves its porosity, and is but slightly increased in weight, it is rendered quite plastic by heat, but becomes again extremely stiff when cold. The advantages it pos- sesses over leather are its lightness and porosity. Its * This procedure will have to be adopted also in all complicated forms of splints where the leather has to be stretched much out of its original shape. The dresser will, however, in such cases be wise if he adopt some other material, such as poroplastic felt, or guttar, percha. OF SPLINTS—CONSIDERED GENERALLY. 135 disadvantages are that it is not so strong, and is more liable to crack or break. The fact that it sets very quickly cuts both ways, being sometimes useful, sometimes embarrassing. This material is noAV well knoAvn under the name of poro- plastic felt. It is sold in sheets of various thicknesses and qualities; of the latter the medium are the best. As with leather, the description of the use of this felt in spinal cases is given later. For other splints, the patterns in Fig. 94 are those in most common use; most of them may be had ready made, or they may be cut out of sheets of the material. The best Avay of softening is by means of a steam chamber, made for the purpose, but an oven will do very well if the felt be first thoroughly moistened, and for most cases, water, nearly boiling, Avill answer the pur- pose. If softened in this way, the felt must be laid flat and quickly pressed bctAveen the folds of a toAvel to remove the superfluous Avater, before it is applied to the limb. The method of moulding is in all respects the same as for leather, save that in consequence of the extreme rapidity with Avhich it sets, the manipulation has to be very quickly performed. These splints may be lined, and eyelet holes punched as in the leather, but care has to be taken not to break the edges. If required, portions of the splint may be left unstiffened, or the resin may be removed from such parts after moulding by soaking them in methylated spirit. Next in usefulness to poroplastic felt comes gutta-percha Gutta-percha sheeting, which is even more readily moulded. It is not, however, porous, and is not so comfortable as felt or leather, while in durability it is far inferior to them; on the other hand it admits of much more complete softening, so that it can be moulded more easily to tender parts, or to pans of a complicated shape. The sheeting, of about the thickness of sole leather, having been cut out, is softened in water as hot as can be borne by the hands and rapidly moulded to the part, Avhich should first be moistened. If the water be of the proper heat, some care Avill be required to keep the sheet from losing its shape through undue softening; and if it be too hot this will certainly happen, Avhile on the other hand, water merely "hot" (e.g., 100° F.) Avill not render it sufficiently pliable. The splint Avill quickly set sufficiently to allow it to be removed without losing its shape, and it should then be plunged into quite cold water, which will give it greater rigidity than it would h tve if allowed to remain on con- tinuously. It may then be trimmed, and if desirable, lined, 136 OF SPLINTS—CONSIDERED GENERALLY. and punched for lacing, as before. It Avill, hoAvever, gener- ally be best simply to put it on the limb over a piece of soft lint, and to secure it Avith webbing straps and buckles, for the gutta-percha is rarely durable enough to make the former proceedings Avorth the trouble. Cardboard. In the absence of leather, felt, or gutta-percha, a fairly efficient moulded splint may be made from common mill- board or cardboard. After having been cut out of very stout board to the required form it must be thoroughly softened in water, and the details of manipulation may be in all respects similar to those for plastic felt. In most cases, hoAvever, the best support will be obtained by cutting the millboard in strips, about l-£ inches wide, softening and then applying them to the limb, one or two at a time, while a roller is at the same time applied, so as to mould and fix them as well. In this way the strips come to be Avithin the layers of the bandage, and give considerable rigidity to the limb. The splint thus applied has to remain on, and cannot be finished up like the preceding ones, and for this and other reasons the cardboard splints are now nearly super- seded by the felt. other materials. There remains to be mentioned one or two materials, occasionally, but more rarely used in general or special surgery, as, for example, gutta-percha in mass, vulcanite, and gum resins. All these are principally used in dental surgery, and their employment in cases of fractured jaw will be described under that head; but the student may be reminded that for splints of delicate construction, materials such as these may be used ; so, too, metals, others than those already mentioned, may sometimes be found useful, e.g., lead, silver, or aluminium, the last being specially valuable for its lightness, although its cost prevents its extensive employ- ment. splints or ban- Division II. Moulded splints made of bandaqes, saturated with a stiffening with a plastic material. Whatever be the stiffening agent used, the principle is the same for all the splints described in this division, namely, that the part required to be supported must be covered with bandages, into the inter- stices of Avhich there may be introduced some material Avhich, soft at the time of application, becomes aftenvards hard, so that the part is enclosed in an accurately fitting case. The materials in common use for this purpose are platter of Paris, gum and chalk, silicate of potash, stearine and starch; glue mixed with spirits of wine, to enable it to dry, has also OF SPLINTS—CONSIDERED GENERALLY". 137 been used. These will be described in the order just mentioned. Plaster of Paris is the best and the most commonly used P-aster of Paris material for most kinds of splints, for injured limbs, and also for one important variety of spinal support. It is a fine white powder, and is obtained from burning, and thus expelling the water of crystallisation from gypsum, a peculiar form of sulphate of lime. Its value depends upon its poAver of quickly reabsorbing this water and solidifying. In surgery it is used (a,) as a means of stiffening roller its uses. bandages, as will be described below; (b,) as a means of giving a similar stiffness to pieces of coarse flannel, which, having been shaped and immersed in the plaster, are then moulded to the limb; (c,) for making casts on Avhich splints of other material can be blocked, and for a variety of other purposes. Whichever plan is adopted, bandage or shaped flannel, the skin must be protected from direct contact with the plaster; for example, if a plaster roller Avere required for the leg and foot. The part to be splinted should be first evenly covered Piaster ^ with a soft flannel bandage, or some Avell fitting flannel an ae * clothing. The bandages, which should be about two-thirds the length of an ordinary roller, and 2^ inches wide, are made of a very coarse muslin, to which the name of crinoline is generally given. They are prepared by rubbing the dry plaster in poAvder well into the meshes, and then rolling up loosely. When made they should be kept lying on their sides in a tin box till required. To make the splint it is only necessary to put the ban- dages in water till all the plaster is well soaked, and then to roll them on the limb, alloAving them to take their own course to a great extent, avoiding reverses, and not attempt- ing to form any regular pattern. The more oblique the general direction of the bandage is, and the more figures of S are made, the better. Three layers of the bandage are generally enough to make a firm case. In all cases Avhere a stiff bandage is applied to the leg, great care must be taken to keep the foot at right angles. This is easily done by passing a clove hitch round the big toe Avith a long piece of bandage, Avhich may be fastened to the head of the patient's bed, or round his neck. When the case has been applied, it must be kept quite still until it has set; this Avill require from half an hour to three hours, 133 OF SPLINTS—CONSIDERED GENERALLY. according to the weather, the dampness of the bandages, etc. The setting may be hastened by hot water bottles or proximity to a fire. Sometimes it is desirable to retard the setting; this can be done by soaking the bandages in mucilage and water. When this plan is followed, some surgeons cut the saturated and moistened bandages into strips, which are laid doAvn, over-lapping each other; the limb is then laid upon them and they are brought round it in order, and the ends crossed in front in a spiral fashion so as to produce the appearance of an 8 bandage (see Fig. 80). This mode will be alluded to again under the head of spinal jackets. Bavarian Sometimes the plaster may be used as a mass moulded spimts. between two shaped bandages. This is, indeed, the original " Bavarian splint," a method noAV almost obsolete. These splints are usually made for cases of simple fracture of the leg, but are not confined to these injuries. Taking the leg as an example: two pieces of flannel or stout canvas are cut out to a pattern Avhich can be accurately got by cutting open a stocking which Avould fit the patient, along the front of the leg and foot and then spreading it out; or more roughly, by making "a double" of No. 12 in Fig. 94. The pieces of flannel or canvas are then laid one on top of the other and stitched down the middle line. The limb being laid upon them, the piece next to the leg and foot is brought round these parts and fastened along the front with safety pins. The corners only of the outside piece are then brought up, and pinned or stitched to the corresponding corners of the inner one, so that there is a kind of bag open along the top, on each side of the leg and foot (Fig. 97). Fig. 97.—Bavarian Splint (semi-diagrammatic). The plaster is then quickly mixed in a basin and stirred with the hand until it is of the consistence of thick cream. It is then poured into the bag on either side, the stitching along the back of the leg of course preventing the plaster from going right round. When enough has been poured in, OF SPLINTS—CONSIDERED GENERALLY. l3§ it is pressed and moulded in all directions by the hands so as to make an even layer of plaster, about a quarter of an inch thick, between the flannel or canvas sides. A roller may then be put on to complete the moulding while the plaster sets, Avhich will take from half an hour to an hour. The splint is then taken off by unpinning the inner layer of the bag in front; there will then be found a kind of hinge behind where the two layers were stitched together, ena- bling the sides to open. The case is now trimmed and lined, or simply put on over a flannel roller and secured with webbing straps.* The plaster in this and all other cases must be very dry; it is, therefore, a Avise precaution to have it put into an oven for an hour before it is wanted. In all cases when plaster of Paris is used, while the bandage is being put on, a moderate amount of the plaster, moistened, should be rubbed into it, and the hands, well Avetted, should be passed up and doAvn to distribute the plaster evenly, and to rub it into the bandage thoroughly. The silicate case is made with ordinary bandages and a silicate. saturated solution of silicate of soda, with or without the addition of a little chalk or whiting ; it is applied in pre- cisely the same Avay as the gum and chalk one so that one description Avill do for both. In their mechanical properties, also, the tAvo cases are very similar. The silicate is slightly heavier, and perhaps not quite so durable; on the other hand it sets rather more quickly, taking from three to four hours, while the gum and chalk take from twelve to eighteen. Gum and chalk. We OAve the first description of this Gum ana chaik, form of encasing splints, we believe, to the late Mr. Smee, who brought it into use at St. Bartholomew's Hospital. A sufficient quantity of dry powdered chalk, free from lumps, is mixed in a basin Avith mucilage, until it is of the consistence of gruel. The limb being first bandaged with flannel (and in the case of the leg or thigh, the foot fixed at right angles with the heel elevated on a block), is care- fully bandaged with a common calico roller, the flannel roller extending beyond it for about half an inch. The mixture is then rubbed into the bandage with the hands, so as to permeate it thoroughly. Another bandage is then * This form of splint is now almost abandoned in London in favour of those made of coarse flannel, soaked with plaster of Paris cream, after Mr. Croft's, or some similar method; these are described under the heading of treatment of fractures of the leg (q.v.). 140 OF SPLINTS—CONSIDERED GENERALLY. put on and treated in the same Avay, and generally a third will be found necessary. The case is then left to dry. The advantages of a Avell made gum and chalk case are many. It is lighter Avhen dry than plaster of Paris, and though abundantly strong, has a certain flexibility Avhich prevents it cracking. On the other hand it requires more time and patience in application, and the length of time it takes to set is sometimes inconvenient. It is, hoAvever, generally preferred by those who are accustomed to put it on. stearine or The stearine case suggested by Mr. Lawson Tait, is A-ery paraffin. dean and very rigid, but it is liable to crack. It is most suitable for limbs which require to be fixed upon splints for some length of time while the patients are confined to bed, or at least have not to move much. Thus it is a A^ery good way of fixing the leg and thigh on to the splint in cases of resection of the knee. The paraffin is cut up into small chips and heated in a vessel placed in a saucepan full of boiling water, for the wax itself should not be heated above 212° F. Gauze bandages, similar to those used in anti- septic dressings, are then immersed in the melted wax. The paraffin takes about two minutes to thoroughly penetrate to the centre of the roller. The bandages must then be applied to the limb over a flannel bandage while they are as hot as the operator's hands can bear. starch. Starch is the least efficient material for making a sup- porting case, but, on the other hand, it is one which is always ready to every one's hand. It is applied like gum and chalk, by rubbing starch paste into the interstices of ordinary bandages. Four, or even five thicknesses will be required for any useful degree of support. The limb must be kept very still while the case is drying. It may here be mentioned that a common roller bandage (e.g., one used for securing fracture splints) has a more neat appearance, and is less liable to be disturbed if a little thin starch paste is brushed or rubbed over it after it has been put on. Its chief drawback is the shrinkage which occurs as the splint dries on the limb, which is not present when other materials are used. This may even produce gangrene, and must prove a source of anxiety, necessitating careful obser- vation of the circulation until the splint is drv. spicas. Plaster of Paris, or gum and chalk spica" bandages are very frequently used in early or convalescent cases°of hip OF SPLINTS—CONSIDERED GENERALLY. 141 disease, or in fractures about the neck of the femur. They are applied like the ordinary spica, but require a rather firmer and longer hold on the thigh. That part of the bandage Avhich goes round the pelvis does not require to be so much stiffened as the rest. It is often necessary to apply a stiff bandage or case to Trap-aoors. some part where there is a wound. If the discharge from this be extremely small, it will be sufficient to cover it with dry lint; but if not, an opening or "trap-door" must be made. This is best done with a very sharp knife after the splint is firmly set, a careful note being taken at the time of application as to the exact position of the wound. It will happen, every now and again, that through chafing, or some other cause, a sore develops underneath one of these splints. In such a case no time must be lost in cutting away the chafing part. This may be sufficient, but very often the whole splint Avill have to be removed, and the sore alloAved to heal. It is, therefore, very evident that every care must be taken Avhile applying the case to avoid creases or constrictions in the bandages, Avhich may lead to such serious consequences. Another common act of carelessness which may lead to the above result is that of leaving pins Avithin the folds of the bandage. When plaster or gum and chalk cases have to be removed, To remove a pair of strong cutting pliers (Scutin's) may be used, or an p as er case instrument devised by Mr. Davy, Avhich is a combination of a knife and a saAV, and which is very suitable for the pur- pose, if the splint is to be cut up along the middle line Avithout other damage so that it may be used again. In other cases a strong jack knife will do, and on the other hand, if the limb be very tender it may be best to soak it and the splint in Avater until the plaster or chalk is suffi- ciently softened to allow of the layers of bandage being peeled off. A few words as to the manner in Avhich plaster of Paris How to nse should be practically handled, Avhen used for the purposes plasterof P; of support, or any other surgical objects, may be useful. It should be recollected that, except it is used on a very small scale, it is always a very messy thing to apply, and it is difficult to clean up afterwards. Clothes, carpets, and everything that is upholstered, should be protected or removed. Aprons, and sleeves (or bare arms) will be wanted also. If the roller bandage is the method chosen, the dry plaster, in powder, must be distributed, as evenly as pos- U-i OF SPLINTS—CONSIDERED GENERALLY. sible, on the unrolled bandages a short time before they are wanted. But they will keep a week if they are put in a tin in a dry place. The best Avay to charge the bandages from end to end Avith the powder, is to pass them over a table or board Avith a heap of loose plaster upon it, and then to sprinkle them Avith it, rubbing it lightly into their meshes ; passing them on from left to right, and rolling them up at the end of the table. The manner of wetting the bandages has been already mentioned. It may be added that the vessel in which they are immersed must contain Avater at a depth sufficient to cover them. None must be put in Avater until everything else is ready. Then one only is to be thoroughly wetted through and the air expelled, and as it is taken out of the basin to be applied, an assistant puts another into the water. The times of application and of soaking will then coincide in a convenient fashion. It will be seen that there is no regular rule given here for the amount of water to be taken up by the roller, and practically as much Avill be taken up by the powder as it lost as gypsum in the furnace, and no more. But a little more accuracy and practice is required if the second way of applying the plaster is adopted, namely, by so adding the dry poAvder to the water that the mixture is a complete and creamy fluid, in which the pieces of course house flannel, already shaped as required, can be immersed and saturated Avith it, and still be flexible enough to be moulded to the limb before setting. The best way is to take a quantity of water, in a basin or bucket, equal to about two-thirds of the quantity of plaster cream Avhich is estimated to be wanted; then taking the powder, and gently and slowly scattering it on the surface of the water all over, let it sink by itself. This it will do very quickly at first, and then more slowly, until the plaster ceases to be dissolved but remains on the top of a cone of thoroughly moistened plaster in the Avater. The contents of the basin must now for the first time be stirred and this is best done by the hand at the bottom, and quietly so that there are no surface bubbles; it will soon become uniformly thicker, and can be used at the thickness of rather thin cream. At the end of the setting it hardens very quickly. The cream for taking solid casts, as of the limbs or trunk, is used rather thinner than it is for stiffen ing flannel; that is, it is used as soon as it is mixed. Of the IMMEDIATE TREATMENT OF FRACTURES. 143 SECTION III. OF FRACTURES. CHAPTER XI. Of the Immediate Treatment of Fractures, Improvised Splinting, etc. In this section, only such fractures as require manipulative General surgical treatment will be considered, and only such ofconslderatlona these as the dresser or house surgeon may reasonably expect to meet with, and Avhich he must learn to treat, during his hospital experience. With regard to apparatus and manipu- lations, we shall describe chiefly those which are commonly used in London hospitals. But before proceeding to the treatment of fractures indi- vidually, there are certain general points Avhich must be understood. The first time the student makes a post mortem examina- The extent oi tion on a recent case of fracture, hoAvever simple, even if Uljury- there be to outAvard seeming only a very slight amount of injury, he cannot fail to be astonished at the extent to Avhich the tissues have really suffered, at the amount of bruising and disorganisation of the muscles, and at the infiltration of all the softer parts Avith extravasated blood. And yet, pro- vided that such a fracture be simple, or if compound, that septic forms of inflammation are successfully Avarded off, it is astonishing hoAV quickly tissues, bruised and hurt as these are, Avill recover. A further examination of a recent fracture on the post mortem table will shoAv that the injury of the soft parts has been, to a large extent, due to the working of the sharp, splintered fragments among the more yielding tissues; indeed, in fractures by indirect violence, this is the only cause of their injury. In considering then, the general line of conduct in cases 144 OF THE IMMEDIATE TREATMENT OF FRACTURES. of fracture, the student should think of the condition of the limb inside the skin, and appreciate that it is probably much worse than appears upon the surface; and further, he should recollect that betAveen the time of the occurrence of the frac- ture and its being set, careless or improper handling may do much mischief, so that it not infrequently happens that by movements on the part of the patient or of his friends, a simple fracture is converted into a compound one; or, much more rarely, an important vessel or nerve is seriously in- jured. It will therefore be seen that there are many points for consideration in the treatment of a case of fracture, in addition to the actual, and so to speak, permanent setting of the bones. So long as the patient can be left lying, little further harm can come to the broken bones, so that there need be no hurry. chief points in The chief points in the immediate treatment of fractures immediate r treatment. are :--- 1. The prevention of further injury (a) by means of some improvised support or splint, (b) by proper precautions in transport. 2. The arrangement of the bed on which the patient has to lie, probably for some weeks, the getting him into it, and the general management of affairs in the interval which must elapse before the setting. I.—MEASURES FOR PREVENTION OF FURTHER INJURY. improvised Improvised Splinting.—This is desirable when there is any appreciable movement between the fragments, any painful spasm of the muscles, or Avhenever the patient has to be moved to any distance. The Avays in which more or less efficient splints may be made are very numerous, so that in this matter the principles of the improvisation being indi- cated, the details must be left to the individual readiness and energy of the surgeon. Whatever comes first to hand will of course be used first, as firewood, match-boarding, cigar boxes, bookcovers, paper, etc., and it will hardly ever be found difficult to give sufficient support to any fracture. Even a newspaper will be of great service, if it be folded often enough, especially if it be bent round so as to form a portion of a holloAv cylinder. In fractures of the leg, or thigh of one side, the use which may be made of the OF THE IMMEDIATE TREATMENT OF FRACTURES. 145 opposite sound one as a splint, by tying the two limbs together, should always be remembered.* Fig. 98.—Illustration of Improvised Splinting. Fig. 98 has been drawn to show a few of the ways in which common materials, such as firewood, towels, and handkerchiefs, may be used for the temporary support of fracture of the collar-bone, humerus, and of the bones of the leg. As a rule removal of clothes is unwise until the patient is Eemovai of about to be put into bed, when it can be done deliberately, and so as to cause as little pain as possible, but if the frac- ture be badly compound, or if there be serious haemorrhage, the clothing must be remoAred for more careful examination of the parts. These cases of haemorrhage in connection with fracture are ahvays serious, and the necessity of attending to this condition will take precedence of the question of supporting the broken bones. Improvised splints should always be put on in a way AVhich will alloAv of their ready removal, and in applying them there need be no effort made accurately to replace the fractured parts, but merely in a general and gentle fashion to reduce the deformity, and give support. The following directions Avill serve as examples of what • The reader will understand that much of what is here written applies especially to fractures of the lower limbs, which generally Etand in need of more active assistance. 10 lio OF THE IMMEDIATE TREATMENT OF FRACTURES. lower jaw. bone. may be done in some of the more common accidents invol- ving fracture of bones, in the way of a rough and ready splinting, it being understood that they are examples only. Fracture of the (1.) Fractured lower jaw. This Avill have occurred as a result of some direct \dolence, and there will be a good deal of bruising of the soft parts. All that will be required in the first instance will be to tie up the loAver jaAv against the upper one Avith a soft handkerchief, passed under the chin and over the vertex of the skull. The patient must not talk, and if any nourishment has to be taken it should be poured sloAvly into the mouth at one of the angles. of the collar- (2.) Broken collar-bone. This in adults may happen from direct violence, as by a bullet or any severe direct blow; in such a case the symptoms Avill be Avell marked. Or it may occur at birth or in young infants, by rough handling or slight drags or falls, in Avhich case it may often be overlooked. But it is generally the result of an indirect shock, as by falling on the shoulder, or on the out-stretched hand. The patient instinctively supports the elbow and forearm of the injured side with the other arm, and so pushes up the shoulder, which would otherwise droop. If the patient can be conveniently put to bed on a hard mat- tress, flat on the back, Avith a small pilloAv betAveen the shoulders, and a very small one (or none at all) under the head, the fragments of the clavicle will come absolutely into apposition. But often Avhen this accident happens the sufferer has to travel for some distance, and although by merely slinging the arm all risk of any great additional damage will be avoided, a better plan is to use a couple of toAvels or triangular bandages in the Avay now to be described. With these the arm can easily be fixed in a position which will give complete comfort, and indeed, in many cases will bring the fragments into sufficiently good position to enable union to take place without any notice- able deformity. This method is also suitable for the permanent setting, and is mentioned later on under that head. The indications to'be fulfilled in cases of fractured clavicle are—that the shoulder must be Avell pushed up, the arm must be fastened to the side Avith the elboAv behind a ver- tical line dropped from the point of the shoulder, and that the shoulder joint should be forced away from the thorax by a pad placed in the axilla, to counteract the tendency of the broken ends of the clavicle to overlap. A Avay in which this may readily be done is shoAvn in Fig. 99 (and OF THE IMMEDIATE TREATMENT OF FRACTURES. 117 also in Fig. 98). A soft, but firm pad, of about the size of one's fist is made, as with a cricketing cap or a newspaper, and is placed in the axilla; * the forearm is crossed over the chest, with the hand pointing to the opposite shoulder, Fig. 99.—Treatment of Fractured Clavicle with two towels, or Triangular Bandages. the point of the elbow being held well back. A towel is Method of then folded as a broad scarf, the elbow is settled into the towels.W1 middle of it, and then, by tying the ends over the opposite shoulder, the hand and forearm being covered by the scarf, the arm on the injured side can be pushed well up. The other towel is then brought round so as to fasten the arm, forearm, and hand, firmly to the trunk, and the ends are knotted or pinned beneath the opposite armpit. A reference to the figure will explain better than words can do, these simple but efficient arrangements. (3.) Fracture in the neighbourhood of the shoulder joint. Fracture near For this, inasmuch as the displacement and mobility of the fragments are both often either slight or obscure, a Avell- adjusted sling is all that is required at first, or during removal. (4.) Fracture of the shaft of the humerus. Here the dis- of the shaft of placement may be considerable, and the ends of the broken bone, by moving on each other, may cause much pain and * This direction is according to the orthodox teaching, but unles3 it seems to be obviously useful, it may be omitted. 148 OF THE IMMEDIATE TREATMENT OF FRACTURES. muscular spasm. The weight of the forearm must be utilised to prevent overlapping of the fragments, and a little gentle traction may be made at the elbow. Some short pieces of firewood, cardboard, etc., should then be tied round the limb, outside the sleeve, Avith handkerchiefs, or something of the kind, care being taken that those on the inside are so short that the circulation is not impeded at the elbow (see Fig. 98). The hand and wrist should then be slung in a towel folded scarf Avays. About the (5.) Fractures about the elbow joint. The forearm should elbow. |je siung; but jt w[\\ ke unwise to attempt any reduction of the fracture, which is often complicated with dislocation, till arrangements have been made for its regular setting. of the forearm. (6.) Fracture of the bones of the forearm. The limb should be supported by two splints, which need not be very rigid (broAvn paper folded several times will do very well), placed along the front and back of the hand and forearm, and reaching from the elbow to beyond the tips of the fingers. The hand should be placed midway between pronation and supination, with the thumb upwards; the splint on the flexor side must not embarrass the brachial artery when the arm is bent. The splints may be tied on with handker- chiefs, and the arm supported with a broad sling. coiies' fracture. (7.) Colles' fracture at the wrist. Impaction is almost always present in these cases, so there is no risk of undue mobility. A simple sling, therefore, is all that will gener- ally be necessary, but sometimes, when there is painful spasm of the flexors of the fingers, relief is afforded by a soft splint along the front of the hand and forearm, lightly tied on. The fracture should ahvays be set as soon as possible, in one of the ways to be described later. Fractured ribs. (8.) Fractured ribs. When an accident has happened, which in the nature of things may have caused one or more ribs to ^ive way, and the injured person complains of a stab- bing pain or "catch" in the breath, on inspiration, with other signs of embarrassment of the breathing movements, it will not be necessary in the first instance to distinguish whether there has been a bruising or an actual fracture of the thoracic walls. In the majority of cases it will be found that immediate relief is afforded by placing the hands on either side of the chest, and compressing the thoracic walls gently, but firmly. Very often the patient will have found this out, and may even have tied his scarf tightly round his body. Until a more complete support can be given to the thorax by strapping and bandaging, something in the way OF THE IMMEDIATE TREATMENT OF FRACTURES. 149 of a scarf or towel must be tied round the chest with the tightness which will give the greatest amount of relief. A patient with broken ribs may thus be able to get home without much suffering, but he should be cautioned against any movement which would require any but the shalloAvest respiration, for though he may be comfortable enough so long as the diaphragm alone is concerned in the performance of breathing, his pain would be much aggravated by any effort which would bring the chest walls into play. (9.) Fractured Spine. Whenever, or under whatever p^*ured circumstances the back appears to be broken, no question of splinting can arise, but the harm, or rather the disaster, which may be wrought by rough or careless handling, cannot be too thoroughly realised. The symptoms of fractured spine being present, the injured person should be placed in the supine, or prone position, on the ground, with the trunk as straight as it can be gently put. In the absence of a stretcher, a gate, hurdle, shutter, or some other rigid platform should be procured, and placed close to the patient, who must be placed on it with the least possible alteration of position. (For the methods of transportation, see page 151.) (10.) Fractured Pelvis. This may occur from a fall, but Fractured in most cases the cause will be the p issage of some crushing weight, as the wheels of a wagon. Little requires to be done in the first instance; but relief may be given by tying a broad scarf or belt round the pelvis, and the patient must be quickly placed on a stretcher or its substitute. It sometimes happens that even after a severe injury to the pelvis, the patient is able to walk after a fashion, but this must never be alloAved. (11.) Fracture of the neck of the Thigh-bone:—1. Fracture Fracture of the in old people. This will only require that the patient be femur? moved Avith gentleness on a stretcher; no other precautions are necessary. 2. Fracture with violence, and injury to the softer parts around. This Avill usually be extra-capsular, and generally occurs in adults. In any case precautions must be taken to prevent further damage in removal; these, however, will be practically the same as are required in the following case. (12.) Fracture of the shaft of the Femur. In consequence of its shaft. of the length and strength of this bone, its fracture may be attended with great disorganisation of the surrounding parts, and the injury is very easily made more serious still by rough or unskilful handling. In these cases the principal 150 OF THE IMMEDIATE TREATMENT OF FRACTURES. difficulty is that of transport, and the reader has only to imagine what might be the consequences of ill-advised efforts to move a heavy man with his thigh broken in the middle and unsupported, to see at once that no attempt should be made to move an adult thus injured till the limb has been rendered fairly stiff by improvised splinting. The end desired is practically to make the patient's body rigid from the armpit to the ankle, so as to prevent all risk of a bending or buckling up of the broken ends of the bone, which would otherwise readily occur. The patient should be kept lying absolutely flat on the back, and search should be made for something long and strong enough to serve as a " girder " to run the whole length of the body (a rifle or a broomstick will do admirably). This must then be laid along the injured side, the top going beneath the axilla, and the limb should be very gently straightened, since by this time it will probably have become much abducted, and rotated outwards. Then with numerous handkerchiefs, towels, etc., this long splint must be fastened on, passing the bandages round the thorax and pelvis. Along the inner side of the leg, a short splint, say an umbrella, should then be placed, and a back splint of thin board, or stiff paper folded, may be placed along the back of the thigh. These supports must then be fastened round the thigh, leg, and foot, as can best be managed. Finally, the injured limb must be tied to the sound one in two or three places. If these proceedings have been thoroughly carried out, it should be possible, although it would be unwise, to carry the patient simply by the head and heels, without any bending. of the lower (13.) Fracture near the knee joint. Here the risk of injury femur. ° is very much less, and one of two plans may be adopted. If the limb be lying fairly straight, an inside and an outside splint, as two walking sticks, should be tied on Avith several handkerchiefs, avoiding the actual seat of fracture ; or what will be found more comfortable, especially if the limb be bent, will be to place beneath the joint a thick pillow or other support, keeping it in the flexed position with a feAV bandages tied round all. of the patella. (14.) In a fractured Patella, the great indication is to avoid increased separation of the fragments and further damage to the knee joint beneath. This will best be done by a strong back splint of umbrellas, boarding, etc., running behind the whole length of the thigh and leg, and tied on firmly with handkerchiefs. Of the leg (15.) Fractures of one or both bones of the leg generally occur OF THE IMMEDIATE TREATMENT OF FRACTURES. 151 from direct violence, and because the skin is so thin over the shin bone they are very apt to become secondarily com- pound, and may be so from the beginning. These fractures are thus often extremely severe injuries, and require much care and gentleness in handling. If the limb be very much crushed, Avith comminution of the bones, whether the frac- ture be compound or not, probably the best plan Avill be to take a soft pilloAv and arrange the stuffing so as to form a trough, lay the limb in it, and tie it up Avith soft bandages. In slighter cases, splints long enough to reach below the feet must be put on both the outer and inner sides, or on the outer one only. (See Fig. 98.) If the boot can be easily taken off, as by cutting up the side springs or laces, this should be done, but it should be left alone if it seems that removal could cause the slightest damage. (16.) In Putt-s fracture with dislocation at the ankle joint, Pott's fractu e it will be unwise to use any force to rectify the deformity, which will often be considerable. The boot should be cut off, and a splint, extending from the knee to beloAv the foot, should be put on the inner or the outer side, as seems best, Avith handkerchiefs. The foot should be placed in as nearly a natural position as it will readily come to. Finally, in those cases of compound dislocation of the General crush' *J 7 -*■ J irig of foot or ankle, or of a general crush of the parts about the foot, caused leg. by great Aiolence, little can be done, except to tie the parts up in a pillow, or to use such other materials for soft support as the circumstances of the case "will admit of. Method of transport of cases of fracture, and precautions to be Transport. taken therein :—r In military surgery it naturally happens that great stress is laid upon the best ways of moving people, helpless from injury, whether through fracture or otherwise. A regular stretcher drill is laid doAvn, and other plans for lifting and carrying are carefully considered. But in civil practice, and in connection with the proper work of house surgeons and dressers, elaborate descriptions of the different kinds of stretchers and of kindred details Avould be out of place ; still, it is desirable that all civilian dressers, surgeons, or porters, Avho have to do with helpless prople, should have some acquaintance Avith the best ways of lifting and moving them, and one or tAvo of these ways Avill here be mentioned, supposing always that the injured person is unable to walk at all. (The case of children need not here occupy our time.) If two people only, A and B, are available for the trans- J^irscaan 152 OF THE IMMEDIATE TREATMENT OF FRACTURES. port, and the person is able to sit up a little, the best way to manage will be for them to make a " sedan chair" by crossing their arms. Of this "chair" there are three pat- terns, but one only is figured because it is the best for general use. varieties of. In the first of the other two plans, the fingers of the right hand of A, and the left hand of B are interlocked to form a seat, while A's left hand is placed on B's shoulder, and vice versa, to make a back support. In the second plan both A's and one of B's hands are joined to form a triangular seat, and B's other hand rests on A's shoulder, forming a chair back. The best way. But the third way (Fig. 100) is the best, where both / Fig. 100.—Hands forming Sedan Chair. pairs of hands are used, locked together to form a scat, and where the patient supports himself by his hands placed upon the bearers' shoulders. Tojmapatient If the patient be quite helpless or senseless, whether zon a y. ^q kas to ^q carried any distance, or has only to be lifted on to a stretcher or bed, the assistance of three people is desirable, two, A and B to do the lifting, and the third, C, to look after the injured limb and the patient generally. A and B take up a position on the opposite sides of the patient, near his haunch bones, facing each other ; they then stoop down, and each gradually gets one hand under his back, near the shoulder blades, till they meet and are clasped; the other hands are then passed and locked under the breech. Having secured a firm grasp they rise together from the stooping posture with the patient, and are ready to move. OF THE IMMEDIATE TREATMENT OF FRACTURES. 153 It is not advisable for either to kneel, unless they cannot stoop low enough, but if one does, both must. A patient lifted in this way can readily be placed on a bed, or be loAvered on to a stretcher for more convenient carriage. In lifting a stretcher the taller of the bearers should go to the head, and should give the directions as to the time of lifting, etc. The head should always be lifted a little before, and lowered a little after the feet. In carry- ing anyone on a stretcher, the bearers should not keep step, but the left foot of the one must be put forward with the right of the other, to avoid swaying. It is not here con- sidered necessary to give an account of the actual stretcher drill, where the bearers are numbered off, and have their several duties sharply defined, for the purposes of military discipline. With regard to conveyance in cabs, a four-Avheeler is conveyance in much better than a hansom. If the injury be very severe the patient should be lying down if possible, either from seat to seat, or if that space is insufficient, a stretcher may be laid across the floor of the cab, both doors being opened. When a patient has been brought to the bedside, it will generally be found convenient to remove the boots and outer clothing as he lies on the stretcher, and then to lift him on to the bed as described above, when the removal of the clothes may be completed at leisure. Of the diagnosis of fractures. But few words need be said on this point beyond what is Diagnosis of to be found in any surgical text book, to which the reader is referred for an enumeration of the classical and orthodox signs of fracture. They may, any or all of them, be absent, but the cases will be few in which a general knowledge of anatomy, guided by common sense, will not enable the surgeon to decide whether a bone is broken or not. Doubt- ful cases, however, do sometimes happen ; on the one hand the fracture may cause so little displacement, and the other symptoms may be so slight that the condition is overlooked, Avhile on the other, the injury to the vessels and soft parts and the swelling therefrom may be so great as to mask the condition of the bones. In the first case no great harm will come of the failure to detect the break, and in the second the question will be cleared up when the swelling subsides ; but in all cases of doubt there is only one rule to follow, namely, to treat the case in all respects as if a fracture were known to be present. 154 OF THE IMMEDIATE TREATMENT OF FRACTURES. II.—OF FRACTURE BEDS. Evils of ordin- ary bedsteads. Fracture beds. There are certain points to be looked to with regard to the bed on which a patient with a fractured limb will have to lie, and inasmuch as it is probable that once there, any further movement will be hurtful, they should be considered and met before the patient is placed on it. The essential qualities which the bed should possess are, that there should noAvhere be any " sagging" or possibility of giving way, that the surface should be evenly smooth and comfortably elastic, and that the foot of the mattress should be somewhat higher than the head. In practice it Avill be found that very feAv bedsteads fulfil these requirements, even the best (the wire-woven beds, or those with interlaced iron bands), will allow of a certain giving way where the greatest Aveight of the body comes, Avhile this occurs to a much greater extent in sacking, or sofa spring beds. The evils of this yielding and the formation of a hollow under the patient are not so apparent at first as they afterwards become ; the patient gradually slips down, the head and shoulders are pushed forward, and the heels come up, until, instead of lying in a straight line, the body forms two sides of a triangle, the apex of Avhich is at the ischial tuberosities, to the grievous alteration of the parts about the seat of fracture, and to the great risk of the form- ation of bed sores. Fortunately the remedy is easy, and involves no appar- atus, all that is required being a light wooden frame or a few light boards placed on the bedstead, underneath the mattress. If the mattresses are of the kind to be described directly, no discomfort will be felt after a very little time from the rigidity of these boards, even by those Avho are accustomed to lie softly, while they are quite as efficient as any special bedsteads that have ever been devised. A big bed is a misfortune in all cases of sickness, but especially in fractures. The best size is that of the ordinary single bed, as found in hospitals and elsewhere, namely, 6 ft. 6 in. by 3 ft. or 3 ft. 6 in. It is a matter of great importance that the mattresses in fracture cases should possess the qualities of smoothness and elasticity in perfection, and for this reason any form of "bed," either of feathers or any other material, is quite inadmissible. Flock mattresses are objectionable, as, even if they are AA-ell made, they tend in time to form knots or lumps. The best combination of all is a straw palliasse, Fracture boards. Size of bed. OF THE IMMEDIATE TREATMENT OF FRACTURES. 155 and over that, one or two horse-hair mattresses, 3|in. to 4in. thick.* Over the mattress one blanket is generally found useful. The sheets, etc., require no particular directions, save that if a draw-sheet and macintosh are required, they should be arranged before the patient is put to bed. In cases of fracture of the lower extremities, or of the spine, all pillows, bolsters, etc., are harmful, except the merest cushion beneath the head, at any rate in the early stages of union; and if the patient can be induced to lie thus flat, the position will not produce discomfort after the first day or two. Any pilloAvs should be small and firm, and covered with separate slips. The bed being ready, the patient, if completely disabled, Putbtiris patient should be very gently lifted on to it; the clothing should be removed, cutting off the boots and ripping up the seams of the clothes, if this has not been done before, the sound arm or leg being the one Avhich should first be slipped out of the sleeve or trouser. As a rule, everything in the shape of temporary splints may noAV be taken off and the limb should be placed in the most natural position in Avhich it will easily lie, on a pilloAv fashioned into a kind of trough. Sandbags are very often useful in restraining spasmodic movements or in steadying the limb. All pressure of the bedclothes must be taken oil' by a regular cradle, or one im- provised out of some such thing as a bandbox split open. Lint dipped in some evaporating lotion may then be applied to the surface of the fractured limb. If the case be a severe one, especially if there be much spasm, a hypodermic in- jection of morphia will noAV be found extremely useful. Directions for arranging the bedding in cases where con- tinuous irrigation is required will be found under that heading. * The best are made thicker at the foot than at the head, but they are not always to be procured. 15G FRACTURES OF THE UPPER HALF OF THE BODY, ETfJ. CHAPTER XII. Of the Permanent Setting of Fractures Considered Generally, and Especially of Fractures of the Bones of the Face, Upper Extremities, and Spine. I.—general considerations. We have now to consider this most important branch of the surgical craft, a branch in which failure brings discredit and blame out of all proportion to the credit earned by even a perfect adjustment, and though the blame is often unjustly bestowed, it must be confessed that not seldom, carelessness, or want of attention to details, or neglect of opportunities for experience, have permanently condemned many an unhappy patient to an ungainly, or partially useless limb. Students in London hospitals certainly should not com- plain of lack of opportunities for practice, for in all, we believe, it is the custom to leave the setting of ordinary fractures to the house surgeons and dressers, and the ex- perience they thus gain is one of the most valuable results of holding such appointments. importance of No pains should be spared to get the adjustment of the andVeataess. bones to a nicety; makeshifts of all kinds should be avoided ; the splints, cradles, etc., should be of just the kind and size required ; the padding, elastic, firm and neat; the whole arrangement, in short, should be workmanlike and pleasing to the surgical eye. Nothing betrays the character of the Avork of the house surgeon and his subordinates more surely than the appearance of the fracture cases in his wards; in one ward the clothes may be thrown off any case of, say, a broken leg, with the certainty of finding the limb swinging free of the bed, with the heel well down, the splints, straps, etc., symmetrical, and the whole thing looking " like a picture ;" while in another a similar inspection will shoAv, perhaps, that the bandages have not been looked at for days, and have been pulled about by the patient in his efforts to scratch, until the limb, loosened from the splint, has slued itself half round, and there lies with the toes pointing, and the heel a couple of inches away from the foot-piece. In both cases, doubtless, the bones will unite Fractures of the upper half of the body, etc. 157 but with what a difference to the earning power of the patient, for months at least—for life perhaps ! What is the best time for putting up a fracture 1 To Best time for this there is only one answer: as soon as possible after it Fractufes.P has happened. Swelling, and muscular spasm are thus diminished or avoided. But cases not infrequently happen, in which the old fashion of allowing some days to elapse and the swelling to subside before adjusting the fragments, may be advantageously followed. Such cases are those in which there has been much comminution and extravasation, with little spasm. Here, at first, it would be sometimes almost impossible to properly adjust the fragments; but if the limb be allowed to lie on a pillow, betAveen sandbags, for a week or so, the blood will have been absorbed to a great extent, and the position of affairs can be more exactly ascertained. It must never be forgotten that a limb which is the seat Necessity for ., . . . °. . , . , , free circulation. of fracture, is one with its circulation much embarrassed, especially in the way of the return of venous blood. Under certain conditions of lowered vitality, it needs only a slight increase of this embarrassment, as by some unwise pressure or constriction by bandages or strapping, and the border line between life and death, between merely bruised and gan- grenous tissues may be passed. This grang.ene may be local and limited, but it may also assume that fierce arid illimit- able character which characterises the true spreading gan- grene, and causes it to be one of the most dramatic of all surgical conditions. Here there is no attempt at arrest from first to last; confined to a finger one day, in twenty-four hours the Avhole limb may be dead, and tAvelve hours later, that peculiar emphysematous crackling which indicates decomposition beneath the skin, may be felt from the neck to the pelvis. We do not assert that tight bandaging is more than one of many factors in a given case of acute traumatic gan- grene ; the general constitution, the nature of the injury, and other causes, all bear their part; still it is certain that cases occur, and that but too frequently, in Avhich a careless or ill-considered constriction has been its main effective cause. In such a case, grave indeed is the responsibility of the surgeon. Sir James Paget relates* Iioav a piece of strapping placed * Clinical Lecture, 1875, p. 60. The whole lecture (on "The Calamities of Surgery ") should be read by every hospital dresser before he begins his work in the wards. 15$ FRACTURES OF the upper HALF OF THE BODY, ETO. round a thigh, above an operation wound, and overlooked for two days, was the cause of a condition of a Hairs not very different from that above described; and to the eloquent remarks of that great surgeon the reader is referred. care in the use Adhesive strapping, it may be mentioned in passing, of strapping. uniess tne material be spread on leather, always requires careful application when used for limbs ; it is unyielding and very strong, and often the temptation to forcibly fasten a limb down to the splint in good position leads to a dangerous amount of compression. Properly employed it is extremely useful in fracture cases; it should, however, never be put round the limb alone, but ahvays round the limb and splint together, and should rarely be put directly on to the skin without a layer of lint intervening. Even if undue tightness does not produce death of the tissues, in many Avays it is harmful. It gives pain and aggravates spasm, while almost certainly, it is a cause of those cases of delayed union which give so much annoyance and dis- appointment. The reparative processes cannot be expected to go on quickly when the venous blood remains, perhaps for days, in engorged channels, and the lymph-canalicular system is distended to bursting. The setting of II.—OF FRACTURES OF THE BONES OF THE FACE AND OF fractures.118 THE UPPER EXTREMITY, AND OF THEIR SETTING ; AND OF FRACTURES OF THE SPINE. Of the skuu. Fractures of the skull. The concussion and other results to the cerebrum which follow upon such injuries to the head as fractures of the vertex, or of the base of the skull, are considered in the chapter on general emergencies, and since the major operations of trephining, or elevating do not come within the scope of this book, these fractures need not here be further mentioned, as they call for no mechanical treat- ment. The reader, however, may be reminded of the extreme ease with which effusion beneath the scalp may be mistaken for a depressed fracture of the skull. The accepted cause of this deceptive feeling of depression, is that there is a ring of fibrinous material round the margin of the effusion. Firm pressure in the middle, not at the sides of the tumour, will enable the finger to feel the bone undis- turbed below, and it is to be noted that a real depressed fracture is never mistaken for this condition, which is surgically known by the name of hematoma. (See bruises later.) x ' FRACTURES OF THE UPPER HALF OF THE BODY, ETC. l5d Fractures of the nasal bones are common enough in ot the nasal surgical practice, and a lifelong disfigurement is the result carriages! of neglecting to remedy the displacement of the bones. In these injuries either the nasal bones themselves, or their cartilages, or the septum narium, or all of these structures, are displaced or broken. The first point to bear in mind is, that the sooner the parts displaced are put into position, the better and easier that restoration will be. The swelling may be very troublesome; to reduce it, hot fomentations will be found most useful. Leeches have been recom- mended, but for obvious reasons they can only be used very sparingly to the outside of the nose. In most cases the line of treatment is a simple one. The displaced or depressed bones must be lifted into place again by manipulation, Avith such an instrument as a stiff steel director, inserted into the nostril; once replaced, they will generally remain in position, if not they must be kept there by plugs of lint or cotton, soaked in carbolised oil. Displacement of the cartilages is more obstinate than that of the bones, and generally requires careful plugging with pledgets of lint, frequently changed, to cure the deformity. This is especially true of displacement of the septum, causing obstruction to the respiration through one nostril, catarrh of the mucous membrane, etc. In these cases the septum must first be straightened with an ordinary pair of dressing forceps, or if they are at hand, with the flat bladed forceps invented by Mr. Adams, and should then be kept in its place by appropriate plugs. All attempts at moulding by pads, lint, etc., placed out- side the nose, appear to be useless, but a carefully moulded gutta-percha " cap," is often very serviceable. In cases of old standing deformity, it is probable that the wearing of some such apparatus as the nasal truss devised by Mr. Adams would be of considerable use.* Other fractures of the bones of the face, e.g., of the zygoma, the malar bone, etc., occur so rarely in practice, and differ so Avidely in every case, that it Avould be but lost labour to lay down any general rules of treatment. Fractures of the upper alveolar process, with more or less of the upper of the body of the maxilla, occur from great direct violence. Jaw In some cases, Avhere this injury is not accompanied by general disorganisation of the face, the displaced portion of bone may be readily replaced by manipulation, and the • Vide Medical Society's Proceedings. Vol. IV. p. 78. 160 FRACTURES OF THE UPPER HALF OF THE l'.oDY, ETC. fragments Avill as a rule stay in position ; if not, unless the teeth of the lower jaw can be made to serve the purpose, an interdental splint may be fashioned as described in fractures of the mandible, or the teeth may be wired together. The accident is a very rare one. pt the lower Fracture of the loAver jaAv, on the contrary, is very com- mon, and occurs with very varying degrees of severity. We will consider first those cases Avhich may be satisfactorily treated by the general surgeon, who does not claim to possess the special manipulative skill Avhich belongs more properly to those who have given particular attention to the surgery of the teeth and of the parts connected with them. An ordinary fracture of the jaw occurs from direct vio- lence, and is frequently compound. Provided that necrosis does not take place, this fact does not materially alter the process of union, or the treatment, and the fragments as a rule unite firmly enough. In most cases it will be sufficient to carefully mould a gutta-percha, or plastic felt splint to the outside of the jaAv, as shoAvn in Fig. 101, and to fix it with a firm four-tailed Fig. 101.—Moulded Splint for Lower Jaw. bandage (see also Fig. 62), so that the upper teeth may fit to the lower ones, and thus serve as a natural splint. The moulded splint should be fashioned out of an oblong piece of gutta-percha or felt, about 10 in. by 5 in. for an adult man (the size will, of course, vary), and must be cut down the middle of its length, except for about three inches in the centre, so that it is of the shape of the centre of the FRACTURES OF THE UPPER HALF OF THE BODY, ETC. 161 four-tailed bandage which has been before described. To mould and apply it, the four ends thus made must be folded up while it is warm, exactly as the bandage is. It Avill be wise to cut out a paper shape first to secure an exact fit. If it be necessary, as for the dressing of a wound on the chin, a trap door may be cut in the splint. In more severe cases, additional firmness may be attained by fastening together the unloosened teeth on either side of the fracture with a stout silver wire; this with care is often of great service. Again a rough interdental splint may be made by warming and moulding a mass of gutta-percha of about the size of one's thumb, and pressing up the teeth on the side of the fracture into it, and when the fragments are in good position pressing the whole mass upwards against the upper teeth. Loosened teeth should always be left alone unless they are obviously shattered. For the first week or ten days all food must of course be liquid, and for the first day or two it will generally be found possible to get nourishment enough taken through a tube, or poured in at the corner of the mouth. But the patient will soon manage to suck in and swallow fluids, and later on soft semi-solid food, Avithout disturbance of the fragments. Fractures of the jaw of ordinary severity, and which do not present unusual complications of displacement, may be successfully treated on the foregoing lines. Cases hoAvever will present themselves which require special apparatus and special mechanical knowledge to keep the fragments in good position. For the following account of the manage- ment of such fractures I am indebted to my colleague, Mr. H. Hay ward. Of the Treatment of Severe Fractures of the Jaw Requiring Special Apparatus for Each Case. I.—OP PEACTUBB OF THE LOWER JAW. Until 1816 no advance was made upon bandaging as a means of Of severe keeping steady the broken ends of the lower jaw. About that time ^^"jaw Malgaigne, Lonsdale, and others, suggested the plans of tying the teeth near the fracture together with silk or wire, or of boring holes in the alveolus on either side of the fracture, and then tightly twisting up wires passed through them. The next distinct advance in this direction was due to Lonsdale, who employed an apparatus with a concave semicircular ivory groove as a cup for the teeth ; this was fixed to a curved screw-bar, go attached to a lower padded chin-piece, that by the screwing up 162 FRACTURES OF THE UPPER HALF OF THE BODY, ETC. Methods of modelling. The metal gplint. of a nut,.the front teeth (if any were present) were tightly pressed on their cutting edges, and the jaws pressed up to the teeth. The chief objection I have always found to Lonsdale's splint has been its liability to catch in the bedclothes, and to be dragged out of position during sleep, and in any case a splint made on this principle would not be comfortable or trustworthy for mouths which were edentulous, or where molar teeth only existed. Nevertheless, for cases of great displacement, especially if the fractures are compound, metal cap splints can be made (generally silver is used) which are able to fit the teeth and gums and keep the fractured ends of the bones and the teeth (if any) in absolute apposition, and the jaws in normal coaptation, but for this treatment to be successful, the attainment of an accurate model is a sine qua non. As far back as 1858 some cases of very serious compound fracture of the jaw with displacement came under my care, and in Mr. Christopher Heath's work on Injuries and Diseases of the Jaw, enough is quoted from my notes to give a fair idea of this method of treatment. There are two ways in which an exact model may be procured. If the fractured bone can be held in accurate position while the model is taken in wax, carried in a well-selected dentist's impres- sion tray, such as is used for modelling for artificial teeth, an impression may be easily and quickly made which will do quite well; but if there is much displacement or comminution, or if the jaw presents much swelling and tenderness, the forcible retention of the displaced parts long enough in position to secure a good mould is not possible, and the second plan must be resorted to. This consists of taking a model of the displaced bone as it is, and then altering the cast from it by sawing it in pieces and again uniting these in their proper position. When the teeth are fairly numerous in both jaws, this task will be rendered much easier from the guides which the faceting of their worn surfaces will afford. The fragments thus coapted may be retained in place with melted beeswax, and then a solid plaster of Paris mould may be made, upon which dies and matrices may be cast, on which again gold, silver, or platinum plates can be struck up (Pigs. 102,103), or vul- canite ones moulded. Fig. 102.— Metal Cap Splint for Fractured Lower Jaw, seen from above. To fit all the teeth and the gums for about one-third or to half an inch below the teeth on the tongue and lip side, this cap should extend back so far as to fit over at least the furthest back tooth FRACTURES OF THE UPPER HALF OF THE BODY, ETC. 163 which is embedded in a misplaced piece of jaw. If the fracture be compound, several holes should be drilled in the plate in those situations where the discharge takes place. It is often sufficient to place this cap or plate in the mouth, and steadily press up the teeth into their proper receptacles, and then to bandage outside with the usual " four-tailed " bandage over a well-fitted gutta-percha socket, made to the horizontal ramus of the Fig. 103.—Metal Cap Splint for Lower Jaw, seen from beloio. jaw after it has been set. The chief advantage of a metal plate is the comparatively small space it occupies in the mouth—the salivary glands soon cease to be stimulated by it. I have adopted numerous modifications, commencing in 1860, by lining the metal splints with chamois leather, gutta-percha, or vul- canite. But since 1862, in cases where there were either but few teeth, or when many were loose, or when, from the depressed condition of the patient, medicines or liquid food were frequently necessary, or when an excessive foetid discharge necessitated repeated disinfectants, I have used interdental splints, with a space lute dental or spaces between them to allow either of tubes to feed with soup, svlmls- or to wash out discharges. In such cases splints have to be made and fitted to each jaw, and when the correct coaptation has been secured, the two pieces can be joined together by vulcanite, leaving spaces for tubes for feeding and for the use of antiseptics. As the author of this work has stated (page 160), gutta-percha, or gum resins, may be used as temporary interdental splints very conveniently, particularly in young mouths. Fin. 104.—Vulcanite Interdental Splint. Fig. 101 is a representation of the first interdental splint I jnadq 164 FRACTURES OF THE UPPER HALF OF THE BODY, ETC. in 1860 for a patient with compound fracture of both jaws and dis- placement of the teeth in each. I used beeswax to take the first impressions, cast plaster into these, set the fracture by cutting through the plaster and fitting the teeth together, so as to secure the normal bite, making a vulcanite socket for each jaw so bet, and subsequently, when comfortably fitted, uniting thein together. In severe cases, at least one aperture between the splints should be made to pass a tube for food, or a syringe for washes. Such splints often require no bandaging, but if necessary, a four-tailed bandage may be used, or a chin-piece, with the ends sewn together at the back of the neck. This may be united to a skull cap made of india- rubber webbing, by a vertical piece in front of the ears. It is very desirable to sew all the parts, as the knots in tied bandages are liable to become loose during sleep, or to cause pain by their pressure on cutaneous nerves. Of the upper Fractures of the upper jaw, with or without broken or displaced 3aw< teeth, are of much more frequent occurrence in civil practice than formerly, due chiefly to the development of football, cricket playing, and cycle riding. The treatment of such cases is similar to and simpler than that of fractures of the lower jaw, as we have now a fixed basis for an interdental splint, or one fitting only to the teeth, gums and hard palate. The greater vascularity of the bones and soft tissues is an immense advantage, and for this reason any portionsof bone having the smallest attachment to soft parts should be replaced in their normal situations, also teeth whose fangs are broken in their sockets, or those entirely detached should be replaced after being thoroughly cleansed in warm water and the coagula removed from their sockets. The recuperative power of the vascular tissues is so great that the most determined effort should be made to avoid the sacrifice of any part of the jaw, alveolar process, or tooth, which has any soft tissue connection. It is, therefore, especially import- ant to replace the disturbed bones and teeth as soon as possible. Care must be taken if there is much comminution, not to pinch any soft parts between the broken fragments in replacing them, otherwise much pain, swelling, and delayed union will result. Splint for. When the fragments have been satisfactorily replaced, a gold, silver, platinum, vulcanite, gutta-percha, or gum resin splint, or a metal splint lined with gutta-percha or vulcanite, modelled as already described for fractured lower jaw, may be fitted if necessary. The clavicle. Fractures of the Clavicle. This fracture is stated by statisticians to stand fifth in the order of relative frequency, but it is probable that its real place is higher. The error (if error it be) having perhaps arisen from the tables being largely drawn from in-patient records, while the majority S!qaacec"den°t? of t¥se fractures are treated in the casualty rooms of hospitals, and may never come upon their books. More- over, it is certain that in infants the fracture is often not recognised or treated at all. At any rate the injury is exceedingly common, and every FRACTURES OF THE UPPER HALF OF THE BODY, ETC. 165 student may count upon seeing a sufficient number of cases. Yet there is no fracture about the setting of Avhich text- books give more bewildering and contradictory directions. The great points of difference are, first, as to the position of the arm, and especially of the elbow; second, as to the use of an axillary pad; third, whether some set form of apparatus, or strapping, or bandaging, is best. Leaving unconsidered the varying questions as to the treatment of complex clavicular fractures which may arise in particular cases, the methods commonly employed for setting the ordinary examples of the fracture are here described. In the first place, there is probably only one way in Treatment bj which the fracture can be so treated that there shall be no ymg permanent deformity, and that is by compelling the patient to lie absolutely flat and still, with a small cushion between the shoulders, until there is sufficient cohesion of the frag- ments to prevent any displacement. For this at least a fortnight will be required, and no bandage or apparatus of any kind is called for so long as the position is main- tained, for the fragments come naturally into their places. When it is considered safe to trust to their cohesion, the arm must be fixed for a week or tAvo in some one of the ways to be directly described. FeAV indeed will be the instances in Avhich the patient will submit to, or the surgeon advise, so irksome a treatment, but it happens occasionally that perfect symmetry and t.',race are very important factors in social life or happiness, and for such patients the game Avill be Avorth the candle. But in most cases it will be generally undesirable even to confine the patient to bed; the fracture must therefore be firmly fixed in some Avay or another, even though absolute apposition be very difficult or impossible to attain. Taking the case of the common fracture in the middle Nature of the third ; the deformity to be rectified is, when the patient is lsp acei erect, a dowmvard, inward, and backward displacement of the inner end of the outer fragment; the shoulder therefore requires to be elevated and to be pressed outwards and backAvards; and to fix the parts in this position, the arm must be fastened to the side. To attain this raising of the shoulder, all authorities are conditions agreed that the elboAV must be well pushed up, and most "heerSepirace°r advise that a pad should be placed in the axilla; but ment- Avhether the elbow should be carried forward across the ehest? or should remain in the axillary line, or be carried. 166 FRACTURES OF THE UPPER HALF OF THE V.ODY, ETC. backwards, are questions about which there is great diversity of opinion. Cases naturally differ, but in most instances, we think it is easy to show that the arm, if it be carried Avell behind the axillary line, pulls the shoulder back with it, and rectifies the deformity, so that any plan by Avhich the elbow may be pushed up, carried back, and kept there while the shoulder is forced outAvards, will effect in most cases a satisfactory setting of a broken clavicle. Treatment with These conditions are Avell fulfilled Avith a moderately roller.mary broad roller bandage, and with a Avcdge-shaped axillary pad about two and a half inches thick at its base.* This latter being placed in position (pressure on the axillary plexus being carefully avoided) the arm is fixed in the line which best reduces the deformity, with the elbow well back and pushed up. The end of the bandage is then fastened round the arm just above the elbow with a clove-hitch (a Fig. 105.—Fractured Clavicle fixed with a Roller Bandage. soft handkerchief or lint may be put round the arm first to avoid chafing) and then carried backwards round the body and arm, which is placed across the chest. Movement of the arm being thus prevented, the bandage must be continued, at first horizontally, round the body and arm, * This wedge-shaped cushion must be placed with its base or broadest part upwards, fitted into the top of the axilla. Tapes are often fastened to its corners to tie over the shoulder, and oth'-r shapes than the wedge are in common use, FRACTURES OF THE UPPER HALF OF THE BODY, ETC. 167 from below upwards, until the limb is fixed to the side; and then a sufficient number of turns must be taken obliquely over the hand and forearm, and beloAv the point of the elbow, so as to support it (a slit being cut there if necessary) until the hand and forearm are covered in. (Fig. 105.) In hot Aveather it is advisable to dust starch or violet poAvder over the skin before the bandage is applied, espe- cially in the folds of the axilla. HoAvever carefully and well the bandage may be put on, still it will get loose in a few days, and must be tightened up ; the interval hoAvever may be considerably lengthened by rubbing a little starch paste into the folds of the bandage, a useful procedure, it may be mentioned in passing, in all cases where any length of bandage is employed. Although the roller is more generally employed than any Treatment b> other form of bandage in putting up fractured clavicles, a careful application of two triangular' bandages, in the Avay already mentioned under the heading of the improvised treatment of these fractures, is more simple, and often effects the reduction of the fracture quite as effectually. As will be seen in Fig. 106, the scarf round the body binds the arm firmly to it, and the one passed obliquely under the Fig. 106.—Fractured Clavicle, traded by the method of two Triangular Bandages. elbow, and over the opposite shoulder, confines the hand and forearm, and pulls the point of the elbow at once 168 FRACTURES OF THE UPPER HALF OF THE BODY, ETC. backwards and upwards. The tAvo triangular scarves being fastened in reef knots, can readily be tightened up. The rules as to the axillary pad are the same as in the previous case. The fracture in In infants and very young children, incomplete fractures of the clavicle are very common, and are easily overlooked. It is almost hopeless to try to follow any fixed rules as to the setting of these fractures, but they generally unite A\rith little deformity if the arm be brought to the side, the fore- arm and hand crossed over the chest, and the limb fixed in that position by strips of adhesive plaster (out of any ordinary bandage, a baby will wriggle in ten minutes); all precautions being taken to avoid chafing of the skin. clavicular or -^or ^ne more infrequent fractures Avhich involve the inner stemai end. or the outer extremities of the clavicle, it is difficult to lay doAvn any general rules of treatment. It may first be said, that in all cases where there is much displacement, the fracture should be put up on the same lines as if it were one in the middle third. If, however, the fracture be quite close to the sternum, any bandage which will confine the arm to the side, and the hand and forearm across the chest, for a fortnight, will suffice. If again the fracture be near the acromion, and there is not much displacement, a shoulder cap of gutta-percha or felt, as in fractures of the neck of the humerus (q.v.) will be an efficient mode of treatment. Axillary pads in these last cases are not generally required. other methods. The following modes of setting fractured collar-bones should not go Avithout mention, for although we do not advise any one of them for general use, cases occur in which one or the other may prove of service. The double figure of 8 for the shoulders, is recommended for cases of single or double fracture. It is very pretty on paper, but inefficient in practice. Velpeau's bandage is classical, and is figured in almost all text books ; but it is complicated, and brings the elbow almost to the middle line in front, the hand resting on the opposite shoulder. sayre's method. Treatment by broad strips of adhesive plaster is a plan introduced by Dr. Sayre, which is now in very general use in this country. Although it is not without its drawbacks, it certainly is an efficient method of setting the fracture. The principle and practice of this method will be under- stood from Figs. 107 and 108. Two strips of adhesive strapping are cut (" moleskin" strapping is the best), FRACTURES OF THE UPPER HALF OF THE BODY, ETC. 169 three to four inches wide, and of sufficient lengrh. The arm being held in position, one piece is first fastened round it, just above the centre, and secured by a feAv stitches; the strip is then carried backwards round the body, and is fastened to itself behind, as shown in Fig. 108. The second piece is carried downAvards from just behind the Fig. 107.—Sayre's Method for Fractured Clavicle. (Front.) uninjured shoulder, and obliquely across the back, the point of the elbow is received in a slit, and the strapping is then carried up over the forearm and hand, which are flexed on the chest, and fastened at the place it started Fig. 108.—Sayre's Method for Fractured Clavicle. (Back.) 170 FRACTURES OF THE UPPER HALF OF THE BODY, ETC. from. Dr. Sayre does not appear to use an axillary pad, but if it improves the position it should be employed. The names only of the four following methods Avill be given for they are hardly ever used in this country. A full description of them Avill be found in Professor Hamilton's book "On Fractures," or in similar treatises. Desaults' method.—Classical, but clumsy, and compli- cated. Fox's "Ring, Sling, and Pad" has the disadvantages inherent to all set forms of apparatus, and does not confine the arm to the side. It is stated to be useful for fractures of the acromial or sternal ends of the bone. Lewis' Apparatus.—A slight modification of Fox's. Brasdor's Apparatus.—Designed to fulfil the indications of the posterior figure of 8, by means of straps and buckles. Fracture of Fracture of the sternum is rare, but may occur in conse- quence of direct or of indirect violence. Care must be taken in examining the thorax after injury, not to mistake some congenital or acquired in-curvation of this bone, for a fracture. The displacement, if there he any, can often be reduced by making the patient take an inspiration, or by bending the shoulder-blades back, or by laying the patient down over a sand-bag, or a wooden block placed under the middle of the back. The deformity however is apt to recur in an obstinate manner, and is then hardly amenable to treatment. In the course of time the parts will often come of themselves into fair position, so that they may be left alone unless, as sometimes happens, an embarrassment of breathing calls for special operative treatment. In ordinary cases, the ends being brought into a's good position as may be, all that is required is a broad calico or flannel roller, applied as for broken ribs, or the double figure of 8 of the shoulders may be applied. Fractured ribs. The proceedings to be taken in cases of fractures of the ribs, differ widely with the nature and extent of the accident. Taking the ordinary cases first, it will be found that the patient has been badly squeezed in a crowd, or has been run over by a light cart, or has suffered some similar injury. He complains of a catching stitch or stab on in- spiration ; he leans forward, and holds his breath as much as possible, and quickly learns that by pressing his hands to. his sides, the pain and difficulty in breathing are lessened. On examination of the seat of pain (probably about the FRACTURES OF THE UPPER HALF OF THE BODY, ETC. 171 seventh or eighth rib), by firm pressure, obvious crepitus and mobility may often be detected, but this is by no means invariably the case, especially in fat people. The stetho- scope will frequently detect the crepitus when the sense of touch fails to do so, but in any case, a sufficient injury, followed by symptoms such as the foregoing, gives pre- sumptive evidence of one or more ribs being cracked or broken, and it will always be safe to treat the patient accordingly.* In such a case, one, two, or three ribs may be broken, but they are still retaining tolerably firm relations with their fellows; the pleura is but slightly injured, and there is practically no displacement. Firm pressure on the thorax restrains the play of the ribs, and thus the source of pain is avoided. It may easily be shown that pressure on one side of the Reasons for thorax does not control its movements appreciably ; so long sides. as the other side is free to expand, both will endeavour to work together. On the other hand it may be seen that in these slighter cases of injury to the thorax, not only are the diaphragm and abdominal muscles quite able to effect the oxygenation of the blood, so long as the patient remains still, but that actually a good deal more air can be drawn in with comfort, when both sides of the chest are restrained in their movements, than can be Avith difficulty inspired, if the uninjured side be left free to drag upon the hurt one. For these reasons, it is advisable, that if it is proper to con- fine the play of the ribs at all, this should be done on both sides, and that the application of strips of adhesive strapping someAvhat obliquely round the chest, is the best way to do this. The plaster is best spread on leather, but linen strap- Method of ping is commonly used; it should be cut into strips 11 stiaPPms- inches Avide, and long enough to be within three inches or so of meeting in front. The strips should be applied successively from below upwards, starting at the floating ribs. The surgeon, standing in front of the patient and applying the centre of the strip to the middle line behind, should bring the tAvo ends, evenly and firmly, forAvards and someAvhat upAvards, so as to compress the chest walls from behind forwards. The strips should overlap about half an inch, and should be continued as a rule, up to the third or • The post mortem table teaches us how often, in cases of acci- dent, fractures of the ribs are overlooked in the presence of other and more obvious injuries. 172 FRACTURES OF THE UPPER HALF OF THE BODY, ETC. fourth rib. Over the strapping a flannel or any ordinary bandage should then be firmly rolled, as shoAvn in Fig. 109; this may be prevented from slipping doAvn by the brace shown in the figure, which is simply made by tearing a hole in a piece of broad bandage and putting the head through it, so that it hangs doAvn in front and behind. The bandage is put on outside this brace, the ends of which are then turned up and fixed. When the injury is less severe, it may be unnecessary to apply the strapping, a firm bandage being all that is Fig. 109.—Chest Bandage. required. In any case the patient will probably be unable to lie flat down in bed for some days. Fracture from But the foregoing rules of treatment will have to be direct violence .-, i'n 1 i l i • . i with injury to greatly modified or abandoned in the more serious cases viscera, etc. where there is severe injury to the lungs, or great crushing of the thoracic walls ; such an injury for example as that which the direct kick of a horse may inflict, where the rib, instead of being bent outwards until it breaks, is forcibly driven into the chest cavity; or Avhere the whole chest wall may be crushed out of shape, and its belloAvs action almost or quite abolished. In such a case the dyspnoea will be extreme; the symptoms of hsemo- or pneumo-thorax may quickly develop with surgical emphysema, and haemo- ptysis will almost certainly be present. FRACTURES OF THE UPPER HALF OF THE BODY, ETC. 173 Under these circumstances it is clearly unsafe to put any further restrictions on the processes of oxygenation; indeed, no tight bandage or strapping Avould be borne by the patient for one minute ; all that can be done locally, is to give a gentle support to the chest Avails with a broad flannel roller. If one of the broken ends remains permanently Elevation of depressed, efforts may be made by manipulation to elevate of PribSs?ed parts it; it has been suggested that the end of the portion which has retained its position should be depressed to the level of the other, in order that the two fragments may interlock, Avhen the spring of the undisplaced end may raise the other Avith it. The deep inspirations produced by ether inha- lation have been recommended, and have doubtless some- times remedied the deformity, but from the nature of the accident, it does not seem advisable to subject these patients to the action of this vapour. The employment of any sharp hook to forcibly raise up the fragment is noAV generally condemned, and it should be recollecte.d that this displacement tends to rectify itself by degrees, as with recovery, freedom of respiration advances. The haemoptysis is not generally dangerous in itself, but iniulT and should be watched anxiously in consequence of the pneu- causes of monia which is apt to develop in the area of injury. If pneumonia" this occurs, there is a very serious increase in the em- barrassment to the breathing, and great engorgement of the right side of the heart, evidenced by a quick hard pulse, and partial asphyxia. In such conditions, antimony, aconite, and similar drugs are indicated, but we believe that no treatment is so ready and effectual as a moderate vene- section, which may be repeated if necessary. The good effect of taking away ^vii or gviii of blood is most striking, and it is a pity that this is not more frequently done. The method of performing the operation of bleeding is described later. With regard to the surgical emphysema, it is rare for it surgical to be a serious embarrassment, although it has sometimes, by spreading beneath the deep cervical fascia, caused difficulty in breathing or swalloAving. It is best left alone, or controlled by bandaging only; but if it must be diminished—and cases are on record in Avhich the features of the face were obliterated, and the whole body blown out—small punctures may be made, or, still better, several of " Southey's trocars " may be introduced into the cellular tissue, the ensheathing cannulse, which must of course be strictly aseptic, being allowed to remain in situ. 174 FRACTURES OF THE UPPER HALF OF THE BODY, ETC. The treatment of pneumo- and ha3mo-thorax cannot here be discussed, but it must be founded on those general rules Avhich are laid down in all systematic surgical works. Fracture of the Detailed descriptions of the various fractures to which the scapula is liable may be found in all text books on the subject. Individual cases, hoAvever, differ so very much that it is not easy to lay down general rules. For the purpose of treatment, tAvo forms of fracture may be distinguished, those, namely, in Avhich there is an obvious dropping of the shoulder, and those in which this feature is absent. If this deformity be present the injury has a strong superficial resemblance to dislocation of the joint, from which it may be distinguished by the fact that pushing up the elboAV causes the shoulder to assume its natural shape." In such cases it is best to do this, and to fill up the armpit Avith a pad. But Avhether there be dropping or not, the simplest and best way of fixing the scapula is to fit a gutta- percha or poro-plastic shield, of a shape similar to that which will be immediately described for the humerus, but rather larger behind, moulded so as to embrace and fix the arm as well as the shoulder blade. This shield may be made in leather, but inasmuch as it will not probably have to be Avorn more than about three weeks, this is not generally worth while. Fig. 110.—Shield for Fracture of the Neck of the Humerus, etc. FRACTURES OF THE UPPER HALF OF THE BODY, ETC. 175 In fractures of the anatomical neck of the humerus, the Fractures of shield just mentioned will prove very useful, without a pad IffiruS? of in the axilla ; but the elbow must noAv be allowed to hang free, \yith the hand only placed in a long sling. As a rule there is little or no deformity. This shield and sling are shoAvn in Fig. 110. If the fracture be at the surgical neck, the case is different. There may be little deformity, and that little may readily yield to slight extension, but in many cases the shortening is obvious and difficult to remedy. But, generally speaking, if the shield be carefully applied, and extension be kept up at the same time, good position Avill be obtained. In some obstinate cases it is advisable to place a stirrup on the arm in the same manner as for the leg (q.v.), and to make ex- tension with a weight and pulley fastened to the side of the bed (to Avhich the patient must be confined), the forearm being flexed over the chest.* In addition to this extension, the shoulder must be fixed with a moulded felt or leather shield, or a plaster of Paris spica. The weight will probably only be necessary for a few days. Finally, slight fractures, without displacement, anywhere about the shoulder girdle, may often be efficiently treated without any other apparatus than a firm spica bandage, well starched, or saturated with plaster of Paris or gum and chalk. Passive motion must ahvays be begun early. No joint is Passive motion. more often relieved by bone-setters, who break doAvn ad- hesions which surgeons have carelessly alloAved to form. This is particularly true of people advanced in years, or with any tendency to rheumatic arthritis or gout. Fracture of the shaft of the humerus is very common, Fracture of and in most cases is easy to get into good position. It is humerus frequently comminuted but seldom compound. With regard to the setting, it is impossible to say positively that any one or two of the many Avays recommended are better than the rest, for indeed they will almost all give satis- factory results. The ends to be attained in putting up this fracture are that the arm shall be fixed while slight extension is kept up in such a way that the forearm may be flexed and slung • A stirrup and weight have been recommended to be applied in such cases, without confinement to bed. But it is found that the swinging of the weight with every movement of the body, by keeping up muscular spasm, undoes all the good effect of the extension. 176 FRACTURES OF THE UPPER HALF OF THE BODY, ETC, at bend of elbow. without obstruction of the circulation of the elboAV. Thus, three or four splints, properly padded, fastened round the arm Avith a bandage or strips of plaster, or webbing straps and buckles, while an assistant keeps up moderate extension, will fix the fracture very well. These splints must be of different lengths; the outside one should extend from the condyle to the acromion, the inside and front ones should fteT^rcuiation ^e mucn shorter, and particular care must be taken that when the forearm is flexed these do not press in the slightest degree either on the veins, the nerves, or the artery at the elbow. The inside splint may often usefully be a simple angular one fixing the forearm as well as the arm. In whatever way the arm be put up, the troublesome operation of bandaging the fingers, hand, and forearm, to prevent swelling, may generally be omitted. It is better to sling only the hand and wrist, leaving the elboAV free. Another good plan is to put up the limb in plaster of Paris, Avith or Avithout wooden splints as well; or kettle holder splinting with webbing straps; or a moulded splint may be fashioned out of gutta-percha, leather, or poroplastic felt, the best way being to cut out the material so that the splints fit like a cap over the point of the shoulder and grasp two-thirds of the circumference of the arm, the inside third being supported by a short, straight, Avooden splint, and the whole fastened together with webbing straps; the splint will be much of the shape of Fig. 110. Careful measurements should always be taken in these and other fractures of the humerus. The best line to take is the lower and back part of the acromion process, where a sharp edge of the bone can always be felt, to the point of the elbow in the middle of the olecranon ; this is a more exact spot than the end of the external condyle. Although, and perhaps to some extent because, this fracture presents little difficulty in the setting, it is more frequently folloAved by delayed or non-union than any other. Immobilisation therefore must be very rigidly carried out, and any obstruction to the circulation guarded against. It is probable that one cause of failure is a tendency for the natural movement of the elboAV to be transferred to the seat of fracture. If at the end of three or four weeks when the splints are taken off, it be found that union has not advanced properly, but that there is some partial cohesion, the frac- ture should straightway be put up again (best in plaster of Paris), and not touched for another month, when union will Measurements. Delayed union. FRACTURES OF THE UPPER HALF OF THE BODY, ETC. 177 generally be complete. If, on the other hand, the frag- ments seem as movable, or more so, than at first, and there is an ominous absence of pain and swelling, the best plan is to take off all splints for three or four days, during which time the fragments should be freely and frequently rubbed together, until swelling and tenderness of the parts are pro- duced. The arm should then be put up most carefully and left undisturbed for six or seven weeks. If at the end of that time there is still no union, the case may be said to be one of " non-union," progressing toAvards a false joint, False joint. the treatment of which does not fall within the scope of this work.* The differential diagnosis of fractures from dislocations of ^'act1ubres about the elboAV-joint, and of the various forms of these frac- tures, one from another, is always considered very fully in systematic surgical works, and it is quite true that it is most important to know whether we have to do with the one or the other, or what is more probable, with both the one and the other; this question, however, will almost always be solved during the manipulation which will in all cases be necessary for the reduction of the deformity. The different Avays in which the bones forming the elboAV joint may be broken, are so numerous, that hardly two fractures in this situation can be quite alike, and yet the same general rules of treatment will apply to the great majority (with the exception of fractures of the olecranon process). Briefly stated, the best line of treatment to be folloAved Reduction of in most fractures in the neighbourhood of the elboAV joint (Avith or Avithout dislocation) consists in making manual extension and counter-extension till the deformity dis- appears, and then fixing the limb, flexed at right angles at the elboAV, upon an angular splint (as those shown in Figs. 84 to 87). One very efficient way of making this extension is to flex the forearm over the surgeon's knee, or over a firm body, such as a roller bandage, placed in the bend of the elbow, thus, so to speak, unlocking the joint; but various manoeuvres will have to be employed in different cases, and although in not a few of those in Avhich disloca- tion is present, some deformity and hampered movement * I have on two occasions seen such cases cured of their delayed union by being sent to the College of Surgeons for the purposes of the clinical examination; on their return the limbs were firmly fixed in plaster splints and did well. The union was evidently accelerated by the manipulations of the candidates. 178 FRACTURES OF THE UPPER HALF OF THE BODY, ETC. will remain, it often happens that in the course of years, elboAV joints deformed so that the ordinary landmarks have been lost, recover a freedom of movement Avell nigh perfect. splinting. If the common angular splint be used, it should be placed on the inside of the limb, and must be Avell padded ; the hinge joint (which all these splints should have) should be first firmly fixed with the two pieces at right angles to each other. The forearm piece should extend to the ends of the fingers. The limb must be settled on the splint, with the forearm midway betAveen pronation and supination; bandages and strapping may be used to fix it. If the elbow be very much swollen it may be left uncovered to alloAv of an ice bag being applied, while, on the other hand, it will often be advisable to mould over it an external gutta-percha cap splint, to be secured to the inner one by webbing straps. In many cases an angular trough splint, fashioned out of poroplastic felt, or leather, as previously described, will be Fig. 111.—Moulded Angular Splint for Elbow. the best way of putting up these fractures. (Fig. 111.) For pattern see also Fig. 94. If the oedema after reduction is not excessive, immediate splinting Avith plaster of Paris or silicate of potash is a very good plan, but care must be taken not to run any risk of thus deferring too long passive movement of the joint. passive Jn all cases of fracture into, or near the elbow joint, the movement. . . . . ,.. J. '. necessity for early passive motion must be kept in mind. If a jointed angular splint of the ordinary pattern be used, it should be so far shortened as to alloAv of movement of the wrist and fingers Avithin a few days of the accident: FRACTURES OF THE UPPER HALF OF THE BODY, ETC. 179 after ten days the screw clamp at the elbow joint should be released, and a little later, the limb should once or twice a day be removed from the splint, and flexed and extended. In no joint is the formation of ligamentous adhesions and stiffness through muscular spasm, more readily and insidi- ously set up. If fixation does occur, the joint must be freely moved under an anaesthetic, and this proceeding will probably have to be repeated more than once or twice. Fracture of the olecranon is very troublesome Avhen it is Fracture of the complete, whether it occurs by direct violence or through muscular spasm (if this last ever happens). If, however, as often results from a fall on the elbow, the process is merely chipped, and the triceps muscle still remains attached to the ulna, the actual fracture needs little attention, and the arm may be flexed and put up in a trough splint as in an ordinary case of injury to the elbow. Whether the splinter unites or not will matter little. But if the fracture involves a separation of the triceps attachment, there is a great risk of permanent loss of the power of extension. The fragment to Avhich the tendon is attached is drawn up the back of the arm, and it is difficult to keep it down close to its proper position. Still, if the arm be kept on an anterior splint, moderately, but not extremely extended, these fractures commonly unite well enough, though by ligamentous tissue; something, too, but we think, not very much, may be done by endeavouring to bring the fragment down with strapping, as in fractures of the patella, Avhich these cases in many ways resemble. The common "broken arm" occurs in consequence of Fractures of the direct violence ; as a rule both bones are broken, somev/here about the middle, and there is often a good deal of displace- ment. This, however, is readily reduced by manipulation, and no further restraint is required than that Avhich two straight splints properly padded, and a sling Avill afford. The splints should be placed, one on the front, Avhich should be long enough to reach from the elbows to the tips of the fingers, and the other on the back of the forearm, reaching to the wrist only. The forearm itself must be flexed and placed midway betAveen pronation and supination, with the thumb upwards. It is not at all necessary to place a small pad between the radius and ulna, but occasionally there is a tendency towards a sagging of the ulnar fragments in the middle, which may easily be remedied by a very small wooden splint placed between the other tAvo, along the sub- cutaneous edge of that bone, The fracture is often rather 180 FRACTURES OF THE UPPER HALF (IF THE BODY, ETC. sIoav in uniting, a fact which may facilitate the correction of a faulty position. These fractures of both bones of the forearm do not lend themselves kindly to the immediate treatment by plaster of Paris, for the fragments require more frequent inspection than in most other fractures of common ociurrence. The shaft of either of the bones of the forearm may be broken separately, and in most cases there "will be little difficulty in keeping the fragments in position with splints similar to those used when both the radius and the ulna are broken. But if the radius be broken about the point of insertion of the pronator redii teres, the fragment may pro- ject forwards, requiring careful padding of the palmar splint, and flexion of the elbow beyond a right angle. coiies' fracture. In Colles' fracture, numerous plans and mechanical con- trivances have been devised to disengage the impacted fragments of the radius, and to replace the hand in the natural position. We believe, hoAvever, that feAv, if any of them, in ordinary hands, will be found so efficient as the more simple and straightforward way by manual extension, adduction of, and pronation ("Tug, twist, and turn," Jones). The detailed surgical anatomy of this fracture may be found in any work on Systematic Surgery, so that it will only be necessary here to remind the reader that the lesion consists of a fracture of the radius, or more rarely of a separation of its lower epiphysis, at a point not more than an inch and a half above the wrist joint, with some impac- tion of the shaft into the separated end; and further, that it almost ahvays results from a fall on the outstretched palm. The impaction, therefore, will always be in direct relation to the violence of the shock. ^auction ?f To unlock the impacted fragments and othenvise reduce the deformity. . , . . . .\ ^ the deformity, it aviII be necessary to make forcible exten- sion, and at the same time to powerfully pronate and ad duct the hand toAvards the ulnar side. This is most readily effected while an assistant makes counter extension, by hooking his elbow round that of the patient. Given a sufficient force, in all ordinary cases, the limb must come into good position. Pistol splint. It is still very generally held that this adduction must not only be made for the reduction of the deformity, but must be maintained during the Avhole time the fracture is uniting. For this purpose the common pistcl-shaped splint is devised, to Avhich, Avhen it has been padded, the palmar surface and front of the arm is bandaged while extension is FRACTURES OF THE UPPER HALF OF THE BODY, ETC. 181 kept up, thus securing both this object and that of adduc- tion. A short wooden splint is then laid along the dorsal aspect of the arm as far as the Avrist. Tavo pistol splints are sometimes used, but this is a needlessly clumsy fashion, and in this country it is rare to find the pistol applied to the dorsal surface, although this Avas advised by ^Nelaton. More simple still is the method commonly employed at Two straight St. Bartholomew's and other London hospitals, with equally SB good results, namely, the employment of two straight split.ts, back and front. These should be very smoothly and firmly padded, and should reach from just below the bend of the elboAV to the ends of the fingers, and should be wide enough to overlap the Avidth of the aim, and of the hand at the knuckles, not counting the thumb. The anterior splint should first be taken up and placed ready to be adjusted to the limb. The deformity is then reduced by extension and adduction, and while this extension is still kept up, the limb is laid on the splint, palm doAvmvards, Avith the hand only slightly adducted. A soft wedge-shaped pad of lint is then placed on the back of the hand, the thick end being at the wrist, and the other ending at the knuckles ; the dorsal splint is then put on, and both are firmly grasped at both ends by the assistant, so as to hold the limb betAveen them in position. Tavo or three strips of strapping will serve best to hold the splints together, and are perfectly safe if the splints are of the proper v idth. They are then finally secured by a roller bandage, and the limb is slung. The object of the dorsal pad is to prevent the risk of damage to the prominent and ill-nourished parts at the back of the hand ; it is an important precaution, as slough- ing may, and does not infrequently, occur there very insidiously. Fig. 112 shows diagrammatically the way in FlG. 112.—Post lien of Hand and Arm after Guiles' Fracture on Straight or Pistol Splint, 182 FRACTURES OF THE UPPER HALF OF THE BODY, ETC. Early move- ment of fingers, Moulded splints. Macleod's splints. which the hand and forearm should lie either on a pistol splint Avith a moderate curve, or on a straight one. In three days the fracture should be looked at, to sec that the reduction is complete, and the hand in a satisfactory condition, and at the end of the first week the palmar splint should be shortened to the clefts of the fingers, and these latter moved, first passively, then actively. In ten days both splints should be shortened nearly down to the wrist, and in a fortnight, passive movement of the wrist should be begun. From this time the joint must be gradually brought into working order, though a light palmar splint should generally be Avorn until the end of the fourth or fifth Aveek. Union never fails, and very rarely indeed is delayed.* Moulded splints of various patterns have naturally been used in the treatment of this fracture, either from the first, or in the later stages, and though we do not think that, taking the cases all round, this method is quite so suitable as the use of wooden splints for hospital cases, still there can be no doubt that the plan of treatment is a very good one. A very good pattern and material for a moulded splint is the one made of poroplastic felt which has been described by Professor G. H. B. Macleod, and which is figured here (Fig. 113).t Fig. 113. -Macleod's Splints for Colles' Fracture (the Palmar Splint is not shoivn). * Mr. Robert Jones, of Liverpool, in a recent exhaustive paper on this subject, says that if the fracture be thoroughly reduced early passive movements or shortening of the splints are both un- necessary, and harmful as eading to increased production of callus. He advises that, after reduction, the forearm, hand and fingers should be kept splinted for a full five weeks. (Analysis of 105 cases of Colles' fracture. Liverpool Mcdico-Chirurg. Journal, July, 1885). f British Medical Journal, Vol. II. 1878, p. 79, FRACTURES OF THE UPPER HALF OF THE BODY, ETC. 183 The splinting is effected by tAvo pieces of the felt, the one, an oblong, about 10-in. by 5-in. Avith a corner cut out of it (so that the thumb is left partly free) is warmed and moulded to the wrist and back of the hand while the parts are held in good position by an assistant, and the second and smaller piece is fitted to the front of the Avrist to oppose the tendency to the fonvard projection of the radius. Another plan for the reduction of the displacement caused Carr's splints. by this fracture depends upon the extension which bending of the fingers will effect upon the lower end of the fractured radius. The splints Avhich are used for this purpose are known as Carr's splints, and their application Avill be suf- ficiently explained by the illustration (Fig. 114). Fig. 114.—Carr's Splints for Colles' Fracture. Gordon's splints (Fig. 115) again, aim at the reduction of oordon's the displacement peculiar to Colles' fracture, by a combina-splints' tion of palmar, ulnar, and dorsal splints. The application of this apparatus also, will be understood from the figure. In London this method of treatment has not been often used; its especial merit would seem to be the freedom of the fingers for passive or active movement from the first. The other fractures Avhich may occur about the Avrist other fractures hardly call for special notice. They must be splinted and about the Wl'istl treated on general principles. FlG. 115.—Gordon's Splints for Col tea' Fracture, 184 FRACTURES OF THK UPPER HALF OF THE BODY, ETC. Of the meta- Fractures of the phalanges of the fingers are not generally difficult to maintain in good position. Broken nietricarpal bones, however, often project on the dorsal surface very aAvkwardly, and from the thinness of the skin the surgeon rightly hesitates about applying much direct pressure. The best way of reducing this displacement is to lay the fore- arm and hand on a palmar splint, to Avhich a pad of the size and shape of an ordinary roller bandage (Avhich itself is Avhat is generally used) has been fastened so that the fingers may be completely and securely flexed over it. The combined extension and support thus afforded will keep the fragments in good position. of the thumb. Fractures of the thumb, especially those of the first phalanx, are rather common in boxing, or in machine accidents, and from the nature of the injury are often compound, complicated by necrosis, disease of the articula- tion, etc. A simple fracture is easily enough set, and in most cases a moulded splint of gutta-percha will be the best way to fix the fragments; felt may also be used, or, with a little care, a neat spica of the thumb, made with a narroAv bandage well loaded with plaster of Paris, will prove a very efficient support. The fragments are sometimes rather sIoav in uniting ; if delayed union be threatened the bones should be very rigidly encased. Fractured The justifiability ot any active and immediate treatment of serious fracture of the spinal column is still a vexed question; it may be said, hoAvever, that evidence is accu- mulating year by year which goes to strengthen the position of those Avho hold that the condition of mixed fracture and dislocation Avhich results from severe spinal injury, and Avhich is accompanied by deformity and paralysis, may sometimes be rightly subjected, soon after the accident, to such active manipulation and extension as may seem calcu- lated to replace the dislocated bones or fragments.* is not serioCusria '^e treatment 0I those cases of spinal fracture, in which injured. the cord escapes serious injury, and which may almost per- fectly recover, resolves itself into a question of the kind and amount of support the injured column will require. This Avill not differ materially from that commonly adopted in cases of spinal caries, Avhich will be discussed in a later chapter. Where there is merely a breaking off of some of the spinous or lateral processes, little or no special treat- * §ce for examples, Lancet, Vol. II., 1882, pp. 619 and 658 fractures of the uppkr half of the body, etc. 185 ment is called for. The muscles of the back will certainly be stiff for many days or weeks, but this must not be mistaken for the rigidity which is a symptom of true spinal mischief. Best, properly maintained, will be all that is. required, and the fragments may be left almost to them- selves. If, hoAvever, the spinal canal itself be broken, the symp- when the cord toms of paralysis arising from the necessary injury to the y cord, rather than from the fracture of the bones, will call for attention; the amount of paralysis will of course vary with the situation of the fracture, and the chief distinctions between fractures in the different regions are sufficiently laid down in all surgical text books. The precautions Avhich must be borne in mind in the Transport. transport of these patients have already been considered. Once brought home or to the hospital, the first point to bear in mind is the prevention of bed sores (q.v.), which in Bed sores. these cases may form with astonishing rapidity. If possible, the patient should be placed on a large Avater bed from the first, and in any case all the precautions mentioned later under this head must be most strictly observed. The urine and faeces very often give trouble from the other _ beginning; as a rule there is retention of the former and comp incontinence of the latter, but exceptions are frequent. For the incontinence, incessant Avatchfulness, the use of draAv- sheets, charcoal, marine tow, and other nursing appliances will be required, and for the former, regular catheterisation, with the softest and cleanest instruments possible. But all care will probably soon prove ineffectual to prevent vesical catarrh, alkalinity of the urine, and all the troubles attendant upon this condition ; these must be combated by washing out the bladder. Alkalies and other internal remedies may also be given. A Ioav form of congestion of the lungs is very apt to be set up. It is best met by change of position, if the case will allow of it, but too often it will run its course un- checked. Sandbags placed along the trunk, neck, etc., Avill be found the best means of immobilizing the spine in the neighbourhood of the fracture. Hopeless as the majority of these cases are, still all hope should not be given up, for instances occur in which repair of the spinal column, and return in Avhole, or in part, of the functional activity of the cord take place, and in which power over the sphincters and the limbs returns, so that after long periods of help- lessness the patients are enabled, aided at first by proper 186 fractures of the upper Half Of the body, eio. support, to resume a somewhat active life. The most pro- mising cases are those Avhose } aralysis is limited, and can be localised in the loAver parts of the cord, or avIio present the symptoms of limited hsemorrhage in the spinal canal as being the real cause of the paralysis, by mechanical pres- sure of the clot, the cord itself being only indirectly injured. fractures oF the LoWeR Half oF the body, etc. 18? CHAPTER XIII. Of Fractures of the Pelvis and Lower Extremity, and of their setting. Fractures of the pelvis are generally "run over" cases, Fractures of and vary greatly in severity; their diagnosis is often obscure, and the fact of the patient being able to walk after such an accident does not exclude the possibility of this injury having happened. Little can or need be done in these cases beyond confinement to bed, and the application of a broad belt, or strip of adhesive strapping, round the pelvis. The thighs should be tied together and the knees bent, and supported on pillows. If the sacrum or coccyx be injured, a circular or horse-shoe cushion will be required, or the parts may have to be replaced by manipulation within the rectum, the subsequent formation of hard faeces being prevented by laxatives. In cases of serious injury, the condition of the bladder, the urethra, and the rectum, will be the most important points calling for attention. Where the pelvic arch has been thoroughly crushed, the accident is usually fatal from shock immediately after the accident, or the later results of extraArasation of urine, profuse suppuration, necrosis of - the pelvic fragments, the development of pyaemia, or the like; but in other cases the urethra,may be torn, or there may be retention of urine through nervous shock or injury (short of rupture) of the bladder. The procedure in the former case is considered later (vide rupture of the urethra), but if the retention be only due to temporary paralysis of Retention of the coats of the bladder, the catheter should not be im- mediately used, inasmuch as hot fomentations, or a poultice, placed over the suprapubic region will often cause the bladder Avails to recover their poAver of contraction. If the urine be not passed naturally in a feAv hours, then it must be drawn off with a soft catheter. It Avill be better in all cases to employ enemata once a day, to prevent straining during any action of the bowels, and they will be absolutely necessary if the damage has been at all severe. It appears then, that with the exception of the necessary 188 FRACTURES of the lower HALF OF the body, etc. Of the ncok of the femur. into two chief classes 1. In which union is to be tried for, and treatment of symptoms caused by shock", or bruising, or some more serious injury to the bladder, urethra, or rectum, cases of fracture of the pelvis, are cither so hopeless that little can be done, or so favourable that little nr/ds to be. In the neighbourhood of the hip joint, the femur may be broken in various Avays. Thus the symptoms will be Avidely different according as to Avhether the fracture occurs to an adult or to an aged person—from direct or from ind . cct violence- Avithin, or Avithout, the capsule—Avith impaction, or Avithout it. But in practice all cases Avill fall under one May be divided of tAvo headings—those, namely, in Avhich an attempt should be made to secure a bony, or at least a firm union, and those in which such an attempt would either involve a risk to the patient's life, or Avould be obviously hopeless. The rule commonly given is that intra-capsular fractures occur to aged people, and that in them bony union is not to be expected or tried for, Avhile the exact reverse in all respects is the case for extra-capsular ones. We believe, hoAvever, that this generalization is too dogmatic, and that all fractures about the hip joint, Avhich occur in consequence of an adequate injury (as opposed to a nearly spontaneous snapping across of the bone), should be treated as if union were to be expected, except those which happen to patients who are constitutionally aged, or the subjects of severe chronic bronchitis Avith emphysema, or cardiac incom- petence, or some other condition Avhich renders lying down dangerous or impossible. On the other hand, fractures, primarily due to the degenerative changes of old age, as those happening from a sudden tAvist in bed, a step from an unexpected stair, or the like, or Avhich occur in people Avhose heart and lungs, under ordinary conditions, are barely competent, must be so managed that the accident shall be attended Avith as little extra risk to life as possible, but with a clear understanding that disablement must remain. It is true that among the cases in the first class there will be some in which failure of union will unavoidably occur; but Mr. Hutchinson and others* have clearly shoAvn that the old belief that union of intra-capsular fractures was a practical impossibility is founded on error, and if the cases are properly selected, no risk to life or other harm will result from attempts to obtain this result. 2. In which it is not. * See Illustrations on Clinical Surgery ; Fasciculus XI., Churchill, FRACTURES OF THE LOWER HALF OF THE BODY, ETC, 189 Nor does mere length of years necessarily preclude union; age must be measured by the power of recovery yet re- tained by the tissues. Supposing the case to be one of those in which a useful Treatment for union seems to be possible, and in which it should be tried for (as in the usual extra-capsular fracture in an adult), a long splint, generally of the pattern known as "Ferguson's" or "Liston's" (Figs. 116, 117) Avill almost always be neces- sary. If one plan is to be advocated before all others we FlG. 116.—Ferguson's Long Splint. should advise the use of one of these splints, combined Avith extension by a stirrup and weight and with counter-exten- sion by raising the foot of the bed, in precisely the same FlG. 117.—Liston's Splint. manner as will be presently described for fractures of the shaft of the femur (q.v.); but if the shortening be but slight (not more, say, than about half an inch), the long splint alone may be sufficient. In all cases great care must be taken to correct the eversion, Avhich is even more marked in fractures of the neck than in fracture of the shaft. For this reason treatment by extension alone is unwise, although it has been recommended. Our objections to a perineal band as a means of exten- sion are given later, and apply Avith equal force to this as to other fractures. The patient must lie quite flat, the merest apology for a pillow being alloAved for the head. The splint should be kept on for five or six Aveeks, and if at the end of that time union has not taken place, the attempt had better be given up, unless the case be one in Avhich the union should be confidently expected. In any case the patient should have a firm spica of gum and chalk, plaster of Paris, or of some 190 FRACTURES OF THE LOWER HALF OF THE BODY, ETC. other stiff material put on, or a moulded felt splint of the pattern of Fig. 118 (the shape of which is given in Fig. 94, Fig. 118.— Moulded Splint for Hip and Thigh. No. 1), and should then begin to get about; the stiffness of the joint and surrounding parts will have to be treated by Treatment passive movement and shampooing. If the case be one in when no union 1 • r • 1 , i / • r • . is expected. which no union can be expected (as in most cases of intra- capsular fracture in old people), or in which the patient is a bad subject for prolonged lying doAvn, it will be advisable to let her (for it is chiefly among women that this accident happens) stay in bed, propped up with pillows, if necessary, until the first shock of the injury and the worst of the muscular bruising have passed away, Avhen a spica bandage, or moulded splint, may be put on as in the former case. The patient must then begin to learn to get about on crutches, and may eventually come to manage pretty well, although of course there is permanent lameness. shaonck.r °f ^he snocl< 0I the accident is often in feeble people severe, out of proportion to the actual damage to the tissues, and great care may be required to prevent an immediately fatal issue. The bladder, also, will often not act for some time, calling for the application of hot flannels to the abdomen, or use of the catheter. of the shaft of Except in children, the force required to break the shaft tne lemur, j? ±1 x * -i i . • , * of the femur is very great, and the injury to the soft parts correspondingly severe. Failure, or delay of union is also not uncommon. in the middle Taking first the most common variety of this fracture, that namely in which the shaft is broken somewhere about its middle, from direct violence, we find that there pre FRACTURES OF THE LOWER HALF OF THE BODY, ETC. 191 several Avays m which the limb may be put up. The The three. ?"">■ largest group of methods is that Avhich involves the use of ™ Liston's long splint (Fig. 117), the purpose of which is threefold—to fix the thigh fragments in a straight line, to produce extension from the leg arid foot, and to serve as a 1. a girder rigid girder, lying along the trunk as well as the limb, so som'^extenSou. as to make the body inflexible in all its length. In some few cases the application of such a splint is sufficient by itself, but in most it is found that the distort- ing action of the poAverful thigh muscles is too great to be overcome Avithout some further extension, and the employ- ment of counter-extension as well. The use of the stirrup and weight, introduced first for 2- Further .... r tii- 1 extension as by extension in hip disease, was soon applied to fractures, and stirrup and remains the most efficient way of overcoming muscular weie spasm. The combined extension of the splint and stirrup Avould, hoAvever, especially in those cases in Avhich its necessity Avas most imperative, result in a gradual pulling doAvn of the patient's body to the foot of the bed, if some provision for counter-extension were not made. Until lately the usual Avay s. And counter of effecting this was by means of a "perineal band" or extenS1011, padded strap, which was passed round the crutch, and then both ends were fastened, either to the head of the bedstead, which was most efficient, or to the top of the long splint, which was most usual. It is now recognised that there are many objections to this band; it is difficult to keep it clean, or to maintain proper extension by its means Avithout running the risk of making sores, and it is probable that its days are numbered. Fortunately a much easier method of counter-extension as by raising is at hand, namely, by raising the foot of the bed Avith two blocks of wood eight to ten inches high placed below the castors, and by taking away everything, except the smallest pillow, from under the patient's head. This slight head- downwards incline makes a very effectual counter-extension, the aveight of the body being the passive agent: and pro- vided that the thoracic organs are healthy, the position is well borne after a short time, even by those accustomed to sleep Avith their heads well raised. The combination of the long splint, the stirrup and weight, j^*"8* lan of and the raising of the foot of the bid, seems, therefore, to be setting. the best general way of setting these fractures, and the application of the splint and other details must now be described. 192 FRACTURES OF THE LOAVER HALF OF THE BODY, ETC. Cho>'ce of splint. Application of Btirrup. Many points will require attention in order to ensure success in putting up a fractured thigh by the combined means above mentioned. The first thing to be done is to measure the distance from the axilla to the outer malleolus on the uninjured side, and to select a Liston's splint of such a length that the outer ankle bone corresponds to the hole cut for it, Avhen its upper end fits exactly into the top of the axilla. This is very important for the extension, for if too long there will be SAvelling and numbness of the arm, and if too short it will not be efficient. A foot piece is often added to this splint, but this will interfere Avith the proper position of the foot; a flat horizontal cross-piece, however, so fastened to the under edge of the loAver end of the splint, that it keeps it upright as it lies on the bed, is very useful (or a metal foot, as shown in Fig. 116, may be attached to the splint). The end of the splint must be deeply notched, as shown in the figure, for the bandage, and should then be very carefully padded. The patient lying in bed will probably have the leg much rotated outwards, and the thigh shortened and deformed. AVith as little disturbance of the limb as possible, a flannel or domette roller should be applied firmly to the leg and foot, reaching to just below the knee.* Over this the stirrup must be put on, thus :—A piece of Avood about a quarter of an inch thick is taken (it should be square and the width of the ankle at the malleoli), and placed in the middle of a broad strip of strong strapping; this Avood forms the foot piece of the stirrup, and the broad strip is fastened to it by some more strapping wrapped round it. The side strips of the stirrup are then warmed and adjusted to the tibial and fibular sides of the leg over the flannel bandage, so that the foot piece is quite parallel to the sole of the foot: it is then firmly fastened on by overlapping strips of strapping, put on obliquely, as shown in Fig. 119, from the ankle upwards. A roller bandage may be put over all, but jhis is not generally necessary, t A neater and more comfortable, but a more expensive Avay, is to use strips of white basil leather, spread with * The stirrup is sometimes put directly on to the skin without ill effects, but this is, we believe, running an unnecessary risk thoueh it be but a slight one. ' a t The side pieces of the stirrup must be kept from sticking to the malleoli by guarding the adhesive surfaces, for two or three inches at the ankle, with two bits of the plaster of the same width nut L.cc to face with the side pieces. ' * FRACTURES OF THE LOWER HALF OF THE BODY, ETC. 193 some adhesive plaster. These are put on in the same way as the strapping, and look very workmanlike. The leather strapping is especially useful in stirrups for hip disease Fig. 119.—Stirrup and Weight Adjusted to Leg. (q.v.) where it often happens that the branny, ill-nourished skin breaks down under the pressure of the rigid linen. In extremely tender cases, even chamois leather strips may be used. Fig. 119 shows an ordinary stirrup and weight, attached to the leg before the splint is applied. The stirrup being adjusted, the long splint must be Fig. 120.—Method of Attachment of Long Splint and Stirrup for Fractured Thigh. fastened to the body, thigh, leg, and foot (Fig. 120), in a manner of which the folloAving may be taken as a general description. The foot of the bed must be raised on blocks, and all Application of pillows be taken away from the head. The patient thus l u sp mt' lying absolutely flat, one assistant grasps the thigh just above the knee and makes extension there, Avith internal 13 194 FRACTURES OF THE LOWER HALF OF THE BODY, ETC. rotation. Another assistant takes hold of the foot and ankle, and keeps the leg as much turned inwards as the thigh. These manipulations must be performed with the splint lying alongside, and as close as possible to the limb. importance of The inward rotation is of great importance, and its neglect rotttTon. one of the commonest causes of bad position. It is very generally thought that the natural position of the loAver extremity is to have the foot turned outAvards, but this is an error. It is true that by education the foot has acquired a slight external twist during Avalking and standing, but if anyone with properly formed legs, be laid flat on the back, Avith the legs free, it Avill appear at once that the natural position of rest is to have the knees rolled slightly inwards and a very little flexed, Avith the feet in a position of slight equino-varus. This, then, the natural position, is the one Avhich should be aimed at in placing a case of broken thigh on the long splint. While the extension is being kept up, the splint must be adjusted and bandaged to the limb. If the length be right the small hole near the foot will just receive the outer malleolus, while the upper end just avoids pressure on the vessels and nerves at the top of the axilla. In fastening this splint the direction of the bandage should always be from Avithout inwards, or the opposite of the Avay enjoined by the orthodox. Unless this rule be observed, the tendency of the foot and leg to roll outAvards will be increased. In bandaging the foot and ankle, the inner malleolus, the heel and the skin over the tendon Achillis must be carefully looked to, and extra padding applied Avherever there seems a chance of soreness. Fixing the heel. 'r}ie principal difficulty is to get a good grip of the heel, and yet not to bind it too tight. The best Avay is to take a turn or tAvo round the ankle alone (not with the splint) and then to go round in a figure of 8, over the heel, inner ankle and side of the foot, passing the bandage each time into one of the deep notches cut in the end of the splint. The foot fastened, the leg Avith the stirrup is easily bandaged to the splint up to the knee, or over that joint and the end of . he lower third of the thigh as seems best. t'jc "ippoit of The thigh itself may be treated in several ways. If the displacement be slight so that it can be overcome by simple extension, it Avill be sufficient to place a broad and short Avooden splint along the back of the thigh, reaching from the gluteal fold to the popliteal space. The bandage should then be continued on round the thigh and the loin' and FRACTURES OF THE LOAVER HALF OF THE BODY, ETC. 195 short splints, as high as the fork of the legs Avill allow, where it may stop, or be continued into a spica of the pelvis, although this is not often necessary. But if the fracture be at all a severe one additional support is required for the thigh, and this may be given by adding top and inner straight splints to the back, and long outer ones. All four may then be bandaged together, or what is better, may be fastened by webbing straps. A still hotter hold is sometimes got by cutting out a piece of " kcttleholder " splinting, or felt or gutta-percha of a size and shape sufficient to encircle the front and inside of the thigh, and fastening this, Avith the back splint as before, to the outer splint by webbing straps. This upper splint should extend from the anterior iliac spine to the level of the top of the patella, and must be cut obliquely along its upper edge so as to be parallel with Poupart's ligament. As has been said, a spica is not often required, but Attachment of Avhether it be used or no, the long splint must be fastened Sf lint to trunk to the trunk as Avell as to the limb. This may be done with a broad bandage (flannel is best), passing round the thorax from the tenth to the second or third rib, or by broad belts, Avith several buckles, which are made for the purpose. It only now remains to fasten the weight to the stirrup, weighting the and to adjust the pulley at the end of the bed. The first is stirrup" easily done by boring a hole in the Avooden stirrup-end, passing a piece of stout blind cord through it, and securing by a knot. The most convenient Aveight to use is a shot tin. They are generally sold Avith the measure of the weight of shot Avhich may be put in them, stamped outside. A common arrangement for the pulley can be seen in Figs. 119 or 120, but there are many patterns, all about equally good. No distinct rule can be given for the Aveight, but cases are rare Avhich want more than 10 or less than 4 lbs., and the right amount will be the least that will produce ex- tension. In all cases, however, some time will be required to exhaust the muscular spasm, perhaps even forty-eight hours, so that a weight should not be hastily condemned as insufficient. The weight and pulley should be frequently looked to, for the cord may jam, or yet more often, the long splint may get imbedded in the bedclothes or mattress, so that no ordinary Aveight Avould be of the least use. Lastly, and in vieAv of the frequency Avith Avhich this rule is forgotten, it may be repeated that the patient ought to lie 19G FRACTURES OF THE LOWER HALF OF THE Li'HY, ETC. as nearly as possible flat in bed Avith the head Ioav for at least the first fortnight. other methods Only confusion Avould result from giving in corresponding of treatment, j^ji tne numerous and various other plans which have been advocated, and most of them are in no way calculated to succeed Avhere the combined stirrup and long splint plan Avould fail. We will, hoAvever, shortly describe one or tAvo methods Avhich are found useful in cases out of the common Double inclined run. The first of these is that of the double inclined plane (Fig. 121). This is particularly useful in fractures close by the knee, or where, as often happens in these fractures, there has been a T* shaped splitting of the bone across and downwards betAveen the condyles, into the knee joint, Fig. 121.—Double Inclined Plane for Fractured Femur. through the impact of the patella, as has been described by ]\Jr. Willett.* In these cases, and in some others, no firm bandage or mechanical support can be borne by the injured knee, but extension can easily be made by laying the knee over the angle of a double inclined plane, and a good position is almost ahvays readily thus attained. The angle should be the most obtuse Avhich will secure the desired reduction, and the splint should ahvays have a firm foot piece fixed at a right angle. Generally the limb lies so quietly upon the plane, that only very moderately firm bandaging is A\ranted (often a flannel roller suffices). In winter, one drawback to this plan is that it makes rather a cold bed. frrPupne For fractures quite high up, a combination of the fore- going splint with a stirrup and weight fastened to the loAver thigh fragment, has been advocated. In some awkward * St, Bartholomew's Hospital Reports, Vol. X., p. 329, et seq. FRACTURES OF THE LOAVER HALF OF THE BODY, ETC. 197 cases it might be successful, but it must always be mechani- cally difficult to arrange. The stirrup and Aveight alone, or The stirrup Avithout the long splint, but with the bed-foot raised, may only" no doubt sometimes be sufficient, but Ave doubt whether it is ever right to forego the great additional security of the splint, for the sake of a little more simplicity or a little trouble saved. On the other hand, not a feAv fractures, with but little The long splint deformity, can be set in very good position Avith no other only' arrangement for extension or counter-extension, than that afforded by the long splint alone. The method of the perineal band has already been spoken The perineal of unfavourably; it only remains to be pointed out that even if it were a powerful means of counter-extension, still all the indications for its employment may be as Avell met by the method of raising the foot of the bed. A better splint than the simple Liston's Avill be often Macewen's found in the long outside splint Avith a foot piece and back sp in ' piece running up to the gluteal fold. This splint is made as in Fig. 122, but the outside splint varies in length according as to whether it is required for the thigh bone, or knee joint or leg. It requires to be carefully padded, and the pad should either be made thicker behind the ankle, to support the tendo Achillis and leave the point of heel unpressed upon, or the floor of the splint in that situation may be cut away as an alternative. This splint is generally called " Macewen's " splint, and has been largely used by that surgeon and others after osteotomy in the neighbourhood of the knee joint, etc., and in fractures of the thigh or leg. Fig. 122.—Macewen's Splint. The limb, if fractured, should be bandaged and laid on the splint, then the foot should be adjusted against the foot piece, and the Avhole leg and thigh bandaged on, under extension and with slight internal rotation, the bandage running from Avithout inwards. If required, strapping, plaster of Paris, etc, may be used. In adults, the leverage of the fragments of this long bone Piaster or^ ^ is "-cnerally held to be too great to render treatment by later stages. 198 FRACTURES OF THE LOAVER HALF OF THE l'.ODY, ETC. fixing the limb in an immovable bandage, directly after the fracture has happened (such as in a plaster of Faris case) safe enough to be advisable,* But in almost all cases, in London, the practice is observed of allowing the later stages of consolidation, i.e., after five or six weeks, to be com- pleted Avhile the patient gets about on crutches, with the limb firmly supported in a gum and chalk, silicate, or plaster of Paris splint. The line of treatment to be observed in delayed union is precisely the same as that laid doAvn in the case of the humerus. The condition is not very uncommon, but is rarer than in fractures of that bone. in infants. Fractures of the thigh in infants and children. It was not very long ago held by some surgeons that in infants, fractures of the femur might in many cases be left alone to unite of themselves as best they would.f This negative treatment, however, is now, we believe, generally abandoned, and certainly any surgeon who has much to do with children, will see in his out-patient room, cases enough of over-looked fractures in which this treatment has been unwittingly carried out, and of the distorted limbs arising therefrom, to cause him to doubt greatly if it is ever advisable to follow it deliberately. why less Still, in several ways the fracture of. this bone in infants may be treated much more simply than in the case of youths or adults. In the former it is almost certain that a complete snap across of the bone, with rupture of the periosteum hardly ever occurs, and though a mixed break and bend of the bone is common enough, a very slight support will be sufficient to keep it straight and no shorten- ing should result. A short back, or outside splint, secured with adhesive strapping, or a moulded felt splint, or plaster of Paris case, Avhich may with advantage be painted with shellac varnish for cleanliness, should all do about equally well. in children. For children of a larger growth, the special points to be attended to are cleanliness, and the prevention of general * Mr. Cotterell however has recently advocated for adults the immediate application of a plaster case for the whole limb. This is to be put on while the patient is partly suspended from a modifi- cation of Sayre's tripod, and partly supports himself on the sound leg. Extension is made by a footpiece which can be raised or lowered by adjusting screws, and counter extension by chest and perineal bands attached by pulleys to the tripod. (Vide " Treatment of Common Injuries to Limbs," H. K. Lewis, 1885.) t Vide " Holmes' Surgical Diseases of Children." FRACTURES OF THE LOWER HALF OF THE BODY, ETC. 199 restless movement of the whole body. For these reasons a very favourite Avay of putting up broken thighs in children (for example, of five years old) is to put long splints on splints for both both legs, passing the body bandage round both. Often no kgs' stirrup or counter-extension is wanted. A " Bryant's" splint, as described under " hip disease," does exceedingly well for this purpose, as does Sieveking's splint, figured in Bryant's or Maw's catalogue. In both of these there is a connection spiintsmB's between the splints, and arrangements for extension if desired. Another very good Avay is to suspend the thigh vertically by a stirrup and weight attached to the leg, and vertical stirrup passing over a pulley fixed above the middle of the bed. The advantages of this plan are that it is very easy to keep the child clean, for the leg (or both legs, if it seems best), may be thus slung safely up out of harm's way, and the perineum can easily be got at. Up to eight years of age it will also generally be safe to immediate put up the fracture immediately, in a plaster case, or a felt encasmg- or other moulded splint, and even if it be at first put up with a long splint, three or four weeks at the outside will be long enough to keep the patient in bed. In infants or children there should be little or no shorten- shortening to ing, but in grown up people it is extremely rare to get this e exBect^d- result. Careful measurement Avill almost always show about half an inch, even in the best cases. But this is no real hindrance to perfect recovery ; indeed, a full inch will not necessarily cause a limp, the back and pelvis accommodating themselves thereto. It is coming to be more and more recognised that, Fracture of the generally speaking, the displacement of the fragments in pJ" e fracture of the patella is due rather to distention of the knee-joint by blood, or by inflammatory products, than to tonic contraction of the quadriceps extensor muscle (although this may also bear a part in the deformity), and every year sees a larger number of successful cases reported, in which Recent plans of , . . e. . . , -, ± . , ■ , treatment. the joint has been aspirated, or tapped, as an immediate treatment for the accident. Indeed, a step further is noAv being taken, and surgeons are making vigorous efforts to attain to what has hitherto seemed to be beyond their grasp, namely, bony union in all cases, Avhether the fracture be produced by muscular action, or by direct violence. Not only have the edges of patellar fragments which have failed to unite, been cut doAvn on, freshened, and Avired together Avith success, but the same procedure has been carried out in recent cases of fracture, the advantages of 200 FRACTURES OF THE LOAVER HALF OF THE BODY, ETC. thus securing close, and it is hoped, bony union, having been held to outAveigh the risks of a free opening of the knee-joint. common causes But whatever may be the future general treatment, the of failure. present belief is not seriously combated, that most fractures of the patella do well enough, and many very well indeed, Avithout any such heroic measures. But the fracture is a very common one, and among the many cases there are a feAv in which the result is anything but satisfactory. Some of the reasons for this are not far to seek. In the first place there is no doubt that one great cause of failure is the effusion of blood and serum into the joint, and the inflammator}' condition Avhich is often set up. Not only are the fragments themselves thus widely separated, but the condition of the parts is one very ill adapted for the formation of firm bands of adhesion between them. What- ever, therefore, may be the particular way in Avhich the fragments are to be fixed, no pains must be spared to keep the knee-joint quiet, and to promote absorption. Ice bags are extremely useful, as are evaporating lotions and the like. But the softening and disorganising action of intra- articular tension is very great, and in these fractures, if this reaches a high grade, and if external remedies do not reduce the effusion within about 48 hours, there can be Aspiration. little doubt that the wisest thing to do, is to aspirate the joint.* The place selected is generally on the inner side, a little above the middle of the patella, and the operation must be repeated if necessary. Simple aspiration, however, frequently fails to remove the whole of the blood Avhich has been extravasated into the joint and become clotted. It is, therefore, often advis- WashinK out able thoroughly to wash out the joint, Avhich can easily be the joint. , i 1 • ,i • n i • i i done by having the aspirator fitted with a tAvo-way cock, as in a stomach pump. In this way the joint can be alter- nately injected and emptied without AvithdraAving the cannula, and Avithout any risk of the entry of air, a thing to be especially guarded against. Boracic acid or some other non-poisonous antiseptic lotion should be employed. A yet more common cause of failure is due to the efforts to approximate the fragments being made in a wrong manner. In an ordinary case, and provided the effusion be not very great, it is not difficult in several different ways to bring the fragments together, so that they are apparently * For the use of aspirating apparatus see the Chapter on Minor Surgical Operations. FRACTURES OF THE LOWER HALF OP THE BODY, ETC. 201 in close apposition ; but, in reality, unless this closeness Risks of trying has been produced Avith but little" strain, there will be a ippolmon.086" buckling up of the parts, Avith the result that Avhile the upper edges of the fragments are almost, or quite touching, the surfaces are elsewhere distinctly apart. In consequence of this, the bone unites at a very disadvantageous angle, and though perhaps the patient is discharged from the hospital Avith a good looking knee, any attempt to Avork will produce separation of the fragments, and the ligament v\rhen it once begins to yield, Avill get Aveaker and Aveaker, till the patient is condemned to a back-splint for life, or to the risks of a serious operation, or, it may be, to both. It Avill be better in such a case, as soon as it is found that the fragments will not come together except with con- siderable force, to be content Avith a moderate pull, Avhich will allow the broken edges to be opposite and parallel to each other, though it may be at a little distance. The ligamentous band will be many times stronger than in the former case. Indeed it seems almost certain that the efficiency of a limb after fracture of the patella does not depend so much upon the nearness of the fragments, but is in direct relation to the strength of the ligamentous union. In the first place many cases will do very well if the limb Treatment of be bandaged to a light back splint, and the foot and leg simp e well raised. As the SAvelling goes down the fragments will come closer and closer, although they will never be quite together, and in two or three weeks a long moulded knee- splint may be put on, made carefully of felt or leather, and, for heavy patients, stiffened up the back with a piece of iron or steel, rivetted on (Fig. 123). (See also p. 133.) Fig. 123.—Moulded Back Splint for Knee. 202 FRACTURES OF THE LOWER HALF OF THE BODY, IliC. The patient may now begin to get about on crutches, but must be very careful not to fall again. At the end of tAvo months he should be able to walk with a stiff leg, with only the support of a stick, but the splint must be kept on for at least three months. It may then be left off at night, but no efforts should be made to flex the joint until six months have elapsed from the fracture, and even then the joint must be brought into work very gradually indeed. We have been thus particular in describing the after treatment, because it is not uncommon, and is very dis- heartening, to find that patients whose patellae have, to all appearance, united very well and firmly, have yielded to the temptation of leaving off the splint too soon, or of changing it for some more attractive but inefficient inven- tion of an instrument maker, and in consequence have found, to their cost, that the tendinous union has begun to stretch ; and the fragments once on the move, may continue to separate, till a thin useless band, some three or four inches long, is all that remains of what should be as strong as the tendon of the gastrocnemius or quadriceps extensor. Treatment by Although many of these cases will do well Avith simply a back splint if the foot and leg are well raised, the general practice is to fashion some form of bandage and splint by which the fragments may be approximated, and certainly, so long as the "buckling up" we have spoken of is avoided, such contrivances arc very often useful, and can hardly ever do harm—but in all cases, and Avhatever the apparatus used, the foot and leg must be raised. One common way is to lay the leg on'a back splint (Fig. 124), hollowed out above and below for the thigh and leg. Fig. 124.—Fracture of the Patella treated by a simple Back Splint and Strapping. The leg and splint should be raised, and the patient FRACTURES OF THE LOWER HALF OF THE BODY, ETC. 203 should be directed to sit up ; it will then generally be found easy to bring down the upper fragment with strips of adhesive strapping, as shoAvn in the figure. The loAver piece of the patella must then be brought up as near to the upper one as can be managed in a similar fashion, the strips crossing each other at the sides. Instead of strapping, a bandage may be used, and in this use of the case it will be necessary to have a couple of studs or hooks in each side of the splint, about six inches apart, on either side of the middle line, to keep the turns of the bandage from shifting Again, instead of the studs there may be pegs Avhich can of pegs. be screwed round, and the bandage thus be tightened like a violin string, when it requires it; and it will be found that all kinds of bandages Avill require readjusting, in one way or another, every few days. Another good way of bringing the fragments together on of gutta-percha the splint is to mould tAvo gutta-percha caps to the frag-caps" merits, of a horse-shoe shape, and then to approximate them instead of taking the pull directly on the fragments. Or a method which is still more secure from slipping is of crescents of to adjust tAvo stout broad and crescentic pieces of adhesive s ,apping- strapping to the leg and the thigh, beloAv and above the fragments. The horns of these crescents are then prolonged by other strips, or by Avhipcord, so that they can be brought together by fastening these ends to studs in the splint, or, as recommended by the late Mr. Callender, to an arrange- ment of pulleys and weights, or indiarubber springs. The indiarubber roller bandage, commonly knoAvn as of indiarubber "Fsmarch's," if applied in the same manner as the ordinary bandage and fastened round the studs, will at first bring the fragments most forcibly together, but it cannot be depended on, and needs constant readjustment; the same remark applies to woven indiarubber bandages. Another, and simpler splint, is one shaped bke the fore- a more simple going, but having a deep notch cut on either side of the knee. Strips of adhesive plaster are then passed above and below the two respective fragments alternately, and their ends fastened beneath the notch. The successive strips approach each other in the middle until they nearly, or quite, cover the joint. It Avill be seen that this method of treatment does not differ in any essentials from the fore- going, but it makes a more thorough compression of the joint. But even with a plain back splint, a figure of 8 bandage ^^ 204 FRACTURES OF THE LOWER HALF OF THE BODY, ETC. may easily be so applied to the limb that a considerable amount of approximation of the fragments may be pro- duced, AAdth the only drawback that it must be frequently looked to and adjusted. piaster case. In cases Avhere the effusion into the joint is small in quantity, or aspiration has been successfully carried out, the limb may be at once put up in a plaster of Paris case, extending from the upper part of the thigh nearly down to the ankle. The patient should be kept in bed for at least a week. Bony union. By any of the foregoing methods of treatment firm fibrous union is usually obtained, but surgeons are becoming more and more anxious to get firm bony union between the fragments. One or two methods of attempting this may here be mentioned. The method of cutting doAvn and Aviring the fragments has already been alluded to, but other and simpler means often attain the same end, without the danger which attends every operation performed on tissues whose vitality has been impaired by injury. Malsaigne's hooks. Application. Fig. 125.—Malgaigne's Hooks. Malgaigne's hooks, for example, will in certain cases be found perfectly efficient for this purpose, provided always that due regard be paid to antiseptics in their employment. The instrument itself must be sterilised by boiling, and one or tAvo other points have to be especially attended to:— (1) The leg and thigh should be firmly fixed on a patellar splint, and it is often advisable to use a Liston's long splint as well, so as to prevent any movement of the entire limb. (2) After thorough cleansing of the knee, minute punc- tures should be made Avith a tenotome at the proper sites for the reception of the four hooks, the tAvo smaller over the loAver, the two larger over the upper fragment; and if the skin be draAvn slightly upwards in making the upper Fractures of the loaver Half of the body, etc. 205 punctures, there Avill be less chance of a fold of skin being pinched up when the hooks are approximated. (3) In screAving the hooks together care should be taken that there is no tilting of the fragments. If the fragments cannot be brought into apposition immediately, their com- plete approximation may be accomplished by an occasional turn of the screw in the few folloAving days. (4) Iodoform or boracic poAvder should be freely sprin- kled over the sites of the punctures, and renewed daily. It is well also to have the limb freely exposed, and not covered by bed clothes. It is often advisable to delay the insertion of the hooks for eight or ten days after the occurrence of the fracture, as by this time the tissues will have recovered from the immediate effects of the injury, and the subsidence of swelling alloAvs of better and easier approximation of the fragments. Another method of approximating the fragments is by steel pins means of two stout steel pins, as recommended by Mayo Kobson. Bonnet pins are suitable for the purpose, one being passed through the ligamentum patella?, and the other through the quadriceps tendon, exactly at the point Avhere these structures join the bone. The pins are then drawn closer together by a stout silk ligature passed around them and over the front of the knee in a figure of 8. The same precautions as to splinting and asepsis should be taken as in using Malgaigne's hooks. Before resorting to either of these plans, it is necessary to remove all fluid from the joint by aspiration. The hooks or pins should be removed at the end of a month, and the limb should then be put up in plaster for tAvo months more. The legs, according to statistics, are the most subject of Fractures of the all limbs to be broken, and there are all sorts and kinds and degrees of injury which come under this heading. Putting aside, hoAvever, the different varieties of Pott's fracture, Ave shall find practically, that for the purposes of setting, simple fractures of the legs may be classed under tAvo or three headings at the most. Moreover, from this point of vieAV, Ave shall not have to consider Avhether one or both of the bones are involved, save that in bad fractures, both tibia and fibula are generally found to be gone, while in less severe cases, the fibula is more often broken by itself than the tibia Broken legs, then, may be dh ided into— 206 fractures of the lower HALF OF the body, etc. The different (1) Slight cases, requiring generally a moulded support only, such as a plaster of Paris, or a gum and chalk splint, Avhich may be put on immediately, or after a very short time. (2) Moderately severe cases, where for a fortnight or three weeks some regular splinting may be required, but Avhich easily come into good position, and— (3) Severe, and very severe cases, requiring the best skill and attention of the surgeon, for the replacement of the fragments, and their maintenance in proper position during the process of union. All three kinds may be due to direct or indirect violence, and the seat of fracture may be in either the upper, middle, or lower third ; but if in the upper, which is the rarest, it is generally due to a direct blow. Fractures in the lower third are the most frequent ot all. slight fractures, (i) Slight fractures. It is not at all unusual for a sudden twist, or a moderate degree of direct violence to produce a fracture of one (generally the fibula), or perhaps of both bones of the leg, Avith hardly any displacement, and often without complete disablement. Practically, these cases are not more severe than a sprain, and are recovered from at least as quickly. As there is little or no displacement, any measures which will secure absolute rest, will be sufficient for good recovery. The limb may be put up at once in a plaster of Paris case,* care being taken that the toes are not alloAved to point. (Vide infra.) Or the limb maybe alloAved to remain unsplinted, but steadied between sand bags, or may be lightly bandaged to a Cline's splint, the limb lying on its outer side, and with some evaporating lotion over the seat of fracture. If the limb be not put up in the plaster of Paris immediately, there will be no choice but to wait for the SAvelling, which will develop in an hour or two, to go down, before the stiff case can be applied. No weight should be borne on the limb for about a month. Moderately, (2) Moderately severe fractures. By these Ave mean cases fractures. in which the injury is more severe than in the foregoing, but still ones which do not require the same rigid and care- ful restraint as in the folloAving class. We have here a * Whenever the term "plaster of Paris" is used in this section, it must be taken to mean any of the materials for making stiff cases which the surgeon may prefer. And by a "Cline's" splint is meant the common wooden side splint for the foot and leg, with a hole cut out for the malleolus. A grave objection to this splint is that the foot piece is not at a right angle. FRACTURES OF THE LOWER HALF OF THE BODY, ETC. 207 number of methods of treatment to choose from. The most common course, and one which generally does avcII enough, is to lay the limb on a Cline's splint (or some similar kind) on its outer side, Avith the knee flexed, and to bandage it there firmly. The leg thus splinted, may remain someAvhat raised on a pilloAv, for a fortnight or three Aveeks, and it may then be put up in plaster of Paris. But for such cases the practice is becoming more and immediate .. r. , .1 i• 1 • treatment with more common, to immediately set and encase the limb in piaster of Paris, some form of moulded splint, adjusted hoAvever Avith more e °" attention to position than Avas necessary in the slighter injuries just mentioned. This plan of treatment undoubt- edly gives very good results in skilful hands, and effects a great economy of the beds in hospital accident Avards. At the same time the responsibility of the surgeon is somewhat increased, because if the fracture be badly put up at first, it may happen that an opportunity for rectifying the position will never occur. In all cases if this treatment be adopted, the encasing must be performed as soon as possible after the accident has happened, and before sAvelling comes on. Any of the materials out of Avhich moulded splints are fashioned and which have been before described under that head, may be made to serve the purpose, but by most surgeons plaster of Paris will be the material chosen for the manufacture of the case, in consequence of the quickness with which it sets. This may be used in the form of a Bavarian splint, or the ordinary muslin bandages may be employed. Recently the method of immediate splinting described by Mr. Croft (Med. Chir. Trans, vol. lxiv., 1881), or some modification of it, has come into A'ery general use, as it has all the advantages of the Bavarian splint in the Avay of being able to be opened for inspection of the limb, and is yet much simpler. Each splint (for the leg tAvo Avill be required) consists of tAvo layers of house flannel. The inner layer, Avhich is generally moistened with Avarm Avater, is applied to the limb, while the outer one is thoroughly soaked in plaster of Paris cream and put on over it. Both layers are then moulded to the limb Avhile the surgeon holds it in position. Muslin bandages are then rolled on so as to thoroughly shape the splints and to bind them together. The turns of the bandage adhere to the plaster, but as the interval betAveen the various splint pieces is spanned by the muslin only, this can be cut up for exam- ination of the limb along the upper interval, while it serves 208 FRACTURES OF THE LOWER HALF OF THE BODY, ETC. as a hinge at the lower. In the case of fractures of the leg, the pattern for the pieces of flannel, as in the case of the Bavarian splint (see p. 138), can be got from the flattened out stocking of the patient. Inside and outside splints will here be required, and they must be cut of such a size that they will not meet in front or behind for about half-an-inch. This plan of splinting can be adopted in many different forms of injury, and to various parts of the body. While the case is being applied, the limb must be most carefully held in position (preferably by the responsible surgeon), for upon this the Avhole success of the treatment will depend. After the case has set it will generally be advisable for the patient to remain in bed with the limb raised, for at least the first Aveek; but in any event the period of confinement to bed will be much shorter than upon the old plan. Other fractures in this class are some- times best treated by the back splint and swing cradle, to be presently described. severe (3) Sere re, -and very severe fractures. By such terms are fractures. described all those in Avhich the soft parts have been more damaged than in the preceding ones ; in which the muscular spasm and the deformity are well marked and persistent; in Avhich comminution is frequently present, and where in any case great care will be required to keep the fragments in position, and to restore the limb to its proper symmetry. Compound fractures will be described more particularly later, but it may here be mentioned that no fracture becomes compound secondarily through sloughing of the skin so often as that of the leg, for the sharp tibial shin tries sorely the vitality of the skin which is stretched so tightly over it. Blebs also more frequently give trouble here than elseAvhere. In these severe cases there is ahvays a tendency to an over-lapping and over-riding of the fragments. It is, there- fore, necessary so to fix the limb by splinting, that extension as Avell as immobility is secured, and this must be done Avithout strangulation. Methods of Many Avays and many splints have been devised for splinting. setting these severe fractures uniformly. Only tAvo methods will be described here in detail as being the most uniformly applicable in the majority of cases. First method. The first plan consists in putting the limb up upon a back splint and Avith side splints, and swinging the box thus formed, from a cradle. Fig. 126 represents a leg thus put up, and although it really is a simple method enough, FRACTURES OF THE LOWER HALF OF THE BODY, ETC. 209 still there are many small points Avhich must be attended to. FlG. 126.—Fractured Leg put up with Back and Side Splints and Swung. (The side splint is drawn short, so as to show the foot in position.) 1. The Splint. This is the kind knoAvn as " Xeville's The back back splint," and consists of a plain piece of iron, with cross pieces for the leather bands, by Avhich it is SAvung; it should be perforated along the sides to allow of the pad being sewn on, and bent up below to form a foot-piece • it has as Avell, lesser curves for the sAvell of the calf and the bend of the knee. In choosing the splint for a given case, the important points to look to are— (a) It should be fully broad enough, lest the bandage or side splints should too tightly compress the leg. (b) The foot-piece should be bent up quite at right angles to the leg one. (c) The length from the foot to the bend for the knee should correspond to that of the sound leg. (d) The thigh-piece should be long enough to enable the bandage to take a firm hold of it. (e) The bend at the knee must not be less than 160°.* 2. The padding of the back splint must be firm and even, and especially smooth about the heel, Avhere the possibility of a sore being formed must be kept in mind. 3. The side splints must be Avell padded, and should be The side simple, straight, Avooden ones, reaching from just above the sp mts* knee to the edge of the foot-piece. At the foot there should be a short broad strap and buckle, which serves to fasten * These splints are always made too straight at the knee ; for- tunately they are easily bent. 210 FRACTURES OF THE LOAA'ER HALF OF THE BODY, ETC. the tAvo together, the strap passing just beloAv and round the foot-piece. (This strap is often omitted.) The swing 4. The swing cradle.—-All fractures bad enough to require careful back splinting are bad enough to be swung, ^c^- lect of this is a frequent cause of bad position. The simplest plan is to pass leather straps through the slits in the cross piece of the splint, and sling it to the cradle, as shoAvn in the figure. The apparatus being ready, the limb must be fastened to the back splint; the Avhole difficulty of obtaining a good position, lies in the necessity for keeping up extension, and a slight amount of imvard rotation Avhile this fixation is effected. In difficult cases, or where there is much spasm or pain, an anaesthetic should be given, and its action pushed to complete flaccitlity of the muscles. Method of One assistant should noAv grasp the limb about the knee, extension. and rolling it slightly imvards, must be prepared to make counter-extension when required. The surgeon then taking hold of the foot and ankle, will generally be able, by making extension to get the limb into its proper position.' Sometimes flexion of the knee or other manoeuvres will be required, but we have never seen anything but harm come of the practice of dividing the tendon Achillis, as is some- times recommended. While the limb is thus extended, it must be settled on the splint, and fastened to it, and great care must be taken to keep the plantar surface of the heel Avell against the foot- piece, with the foot turned slightly imvards, and the holloAv above the insertion of the tendon Achillis into the os calcis, properly supported. No point in the setting of the fracture is more important than this, as will be understood from Avhat has been said before about the disaster of a sore heel. The readiest road to security in this respect is to have a store of small pads at hand, from Avhich those can be chosen which will best support the hollow beneath the tendon, so that the point of the heel is free of, or only just touches, the splint. This "fitting" of the foot and ankle finished, and a final look given to see that the upper bend of the splint corres- ponds to the knee, the limb, still held extended in position, is settled upon the rest of the splint. If a second assistant be at hand, to him may be entrusted the task of fastening the limb to the splint Avhile the surgeon and the first one keep up the extension. But if, as often happens, one person only be available, the foot must be held by him FRACTURES OF THE LOWER HALF OF THE BODY, ETC. 211 Avith one hand while the first feAv turns of bandage or strapping are made with the other. In any case the limb must be fastened to the splint very carefully, the heel must be kept down and the foot straight, while very possibly the skin has been bruised, and certainly all the parts are tender. In many cases one or two strips of adhesive strapping may be applied Avith great advantage round .the foot and ankle, great care being taken that they do not strangulate the part, the risk of which is lessened if they are applied Avith a piece of lint between their surfaces and the skin. In the same way it is advisable to pass a piece of broad strapping round the thigh and the splint upon Avhich it lies. But Avhether strapping be used first or no, the foot and ankle must.in every case be firmly bandaged to the splint, and then the upper part of the leg, the knee, and the loAver third of the thigh must be fixed in the samp. wav. No rule can be given as to the extent to which the bandage from the foot should be carried up the limb, but it is generally brought up to the vicinity of the fracture, but never over it. This done, in ordinary cases the limb will noAv be fixed in its proper position, and needs only to have the side splints adjusted and to be SAvung, as shown in the figure. But very often some additional support is required, and further measures have to be adopted to maintain position. Thus one of the fragments may persistently rise, and project dangerously near the skin, or the foot may rotate outwards, defying the action of bandage or strapping; or the heel may be constantly coming aAvay from the foot-piece; or, as very commonly happens, there may be a boAving outwards or inwards of the fragments, Avhich simple extension does not overcome. Directions for such conditions obviously cannot be given in any very precise form; nothing "will remedy the pulling aAvay of the heel from the foot-piece, except an entire replacement of the limb on the splint, nevertheless this will have to be done, for great discredit Avill accrue to the sur- geon if the patient gets up from his bed with the foot pointed so that the heel can in no way reach the ground. One of the ends of the broken tibia frequently presses upAvards beneath the skin, partially or completely over- riding the other. For this condition much may be done by judicious pressure Avith a pad, placed not immediately over, but near to the projecting end; in some cases raising the foot, in others bending the knee to remedy the deformity. 212 FRACTURKS OF THE LOAVER HALF OF THE BODY, ETC. Gutta-percha caps, etc. Starching the bandage. Period of union. The second method of splinting. Pott's fracture. These projections and lateral tAvists or rotations of the foot may often be very Avell corrected by caps, moulded to the leg and splints, of felt or gutta-percha, the latter being preferable as it takes a more exact shape. Thus round the foot and ankle, round the middle of the leg, or round the upper third of the leg and knee, a piece of gutta-percha sheeting can be moulded so as to clasp the parts. When fastened by one or tAvo webbing straps they will hold very firmly. It is generally Avorth while to rub some starch paste into the bandages Avhich hold the limb to the splint; the opera- tion takes only a minute or tAvo, and the gain in neatness is great; moreover, it saves labour in the long run, for many patients, not children only, will pull their bandages about as soon as they can turn themselves in bed, but they Avill not disturb their folds so readily if these are stiff with starch. Finally, all severe fractures of the leg will require con- stant supervision, especially during the first fortnight or three weeks. The limb should be looked at every day to see that the splint sAvings clear, that the heel is down, and that there is no complaint of soreness, while the surgeon must not hesitate to take the apparatus off and resettle it, if there be any indication that the position is not satis- factory. Fractures of both bones of the leg of ordinary severity require to be kept up about five weeks; in many, a shorter, in a few, a much longer time will have to elapse before they can be put up in a plaster of Paris or some other moulded case, when the patient may begin to go about on crutches. The other good general plan of setting fractures of the legs Avhich are too severe to admit of an immediate enclosure in a plaster splint, is to employ a splint of the pattern given on page 197, Avell padded, and of such proportions that the outside piece goes up to just above the brim of the pelvis, and the back piece to just past the middle of the popliteal space, the measurements being taken as for the sound leg, Avith the foot against the foot-piece. Reckoning for the padding the splints must be cut of the increasing widths Avhich av ill alloAv the bandage to grip the foot and leg below the seat of fracture, and the knee and thigh above by passing round the limb and splint, but Avithout any stran- gulation. All the different fractures of the leg bones near the ankle FRACTURES OF THE LoAVKR HALF OF THE BODY, ETC. 213 joint, the majority of Avhich are not difficult to manage, and indeed form the great bulk of our first division of broken legs, are not included under the heading of Pott's fracture. These as we have said may generally be put up in silicate or plaster of Paris, either immediately, or after a week or so, and gh'e little trouble as to maintenance of position, or in any other Avay. It is unfortunate that these fractures should be so often confounded Avith the fracture described by Percival Pott from Avhich he himself suffered; for this latter is one of the most serious in its deformity and difficulty in setting, Avhich is knoAvn in surgery. In- deed, it may be doubted Avhether a true Pott's fracture is ever so perfectly recovered from, that the movements of the ankle are quite free, and no deformity is noticeable. The injury itself consists in a combined fracture and dis- xature of the location, occasioned by indirect violence. The fibula gives Avay (often through a slip on to the side of the foot) from H to Sh inches from the outer malleolus, and the inner malleolus is either separated from the tibial shaft, or the internal lateral ligament is torn across. In either case the foot is dislocated outAvards, so that the sole is nearly vertical. Moreover, the tibia and fibula are almost ahvays forcibly torn asunder to a greater or less extent, and from the Avidening of the front of the ankle thus caused, the tension of the skin is extreme. For this reason the deform- ity at the joint, and at the seat of fracture, must be rectified as soon as possible. If the case be seen before much swelling has come on, no Treatment by line of treatment is more satisfactory than a promptp as e envelopment in a plaster of Paris case, the foot being most carefully held in position the Avhile. But this treatment is only possible Avhen the patient is seen soon, and attended to quickly, and AAThen a moderate amount of extension and manipulation Avill bring the limb into fair position. In many cases the SAvelling is very great, and comes on almost at once, while the foot, although it may be held in good position so long as extension is kept up, returns persistently to its external tAvist when this is relaxed, because the sup- port of the fibula is destroyed. One Avay of meeting these conditions, which is very Avuh a back commonly practised, and Avhich often gives good results, is sp 1E to put up the fracture Avith a back splint and swing cradle exactly as has just been described for those higher up the leg, only giving still greater attention to the fixing of the foot to the splint, so as to get the sole flat against the foot- 214 FRACTURES OF THE LOAVER HALF OF THE BODY, FTC. piece. Then, by means of the side splints, Avith extra small pads put in where they are needed, the tendency of the foot to twist outAvards may be overcome. with A simple Cline's side splint Avill never succeed in keeping spimt! re a limb thus fractured in good position ; but the side splint devised by Dupuytren, if properly put on according to that surgeon's directions, is a method of setting so simple and efficient, that it should be used much oftener than it seems to be at present. The essential points to be noticed are shown in F;g. 127. The splint, a simple straight wooden one, is fastened to the leg, which should be laid on its inner Fig. 127.—Dupuytren's Splint for Pott's Fracture. side with the knee flexed. The pad, which is wedge-shaped, and about 2| inches thick at its base, is so adjusted that the thick end is underneath the malleolus when the thin one lies beneath the knee. The limb is fastened to the splint, above and below, by a few turns of bandage. At the knee, these should only extend a little way down the leg, or the fibula will be pressed inwards; and below, the foot alone should be fastened to the splint. If the bandage be carried up over the malleolus, almost all the good effect of remedying the dislocation by forcible inversion is lost. Fractures of the No particular directions are required for fractures of the foot!8 ° * e bones of the foot. They generally occur in crushes of the part, and the fracture is but part of the general injury. If other conditions allow of it, the best treatment in most cases is a plaster of Paris or silicate case. Compound Fractures. compound The points in which the treatment of compound fractures differs from the foregoing directions are points of surgery rather than of surgical handicraft. Questions such as whether a bad compound dislocation may rightly be saved, whether protruding ends of bone should be cut off, search made for wounded vessels, and so on, are not ones which can be discussed here. The additional details, therefore, of the management and manipulation of fractures, which FRACTURES OF THE LOAVER HALF OF THE BODY, FTC. 215 are entailed on the surgeon by their being, or becoming compound, may be very briefly considered. Fraetures are, not infrequently, clinically simple, although May heal like there exists a skin and flesh wound communicating Avith the simp e fracture ; in these, if the limb be put up in the ordinary fashion, Avith some simple dressing on the AAround, the repair Avill run its usual course without any additional trouble, the wound closing up straightAvay, either because the rent in the tissues has been so narrow that its sides have immediately come together, or because there has been an efficient and timely sealing up of the wound by effused blood and lymph, without any inflammatory process. Such a fracture has plainly never been really compound, "Sealing" the A . wound. and the classic rule of treatment Avas that when in a frac- tured limb there is a Avound of only moderate size which may lead doAvn to the bone, but from Avhich there is little or no bleeding, this wound should not be opened up or disturbed in any Avay, but should be covered with some simple dressing and alloAved to close of itself if it will. This "sealing" may be helped or imitated with a small piece of lint, soaked in collodion. A still better plan, hoAvever, is to dress the Avound accord- Treatment by ing to the Listerian or some other aseptic plan, with every metnoas.ep K precaution. A day or two Avill settle the question as to Avhether the fracture is going to convert itself into a truly simple one, or Avhether the Avound will follow that course of aseptic, but slow, repair, which is characteristic of com- pound fractures treated on the Listerian plan. But although a modified Listerism is here recommended in the cases of small Avounds with doubtful communication Avith the fracture, for all fractures Avhich are obviously or probably compound, there is no question but that the safest line of conduct is to treat them on the most uncom- promising antiseptic principles. This dressing in its details Avill be described in a follow- ing chapter, and the account will apply in every particular to the procedure in the case of fractures. The main special points are the difficulty of getting thorough drainage of the deeper parts, and the uncertainty which is often felt as to whether the fragments are in good position, under the necessarily voluminous folds of gauze or avooI. In these eases it "will often be found that some part of a splint which is essential for the support of the fracture, comes in the Avay of the Avound or of the dressing over it; if so, the splint must there be interrupted, that is, the portion which 216 FRACTURES OF THE LOAVER HALF OF THE BODY, ETC. is in the way must be removed, and iron rods carried across the interval, to connect the upper and lower remaining parts. These rods must be strongly riveted and bent out- wards in a convenient curve. (See for example, fig. 142.) No cases are more tedious, or call for more close attention than those compound fractures, Avhich run a septic course. A daily Avatch must be kept for bagging or buiroAving of pus, for necrosis of the ends of the bones, or for some other of the host of complications Avhich may at any time be sprung upon the surgeon. But, as Ave have said, the consideration of the surgery of these points must be looked for elseAvhere. Or sprains. 217 CHAPTER XIV, Of Sprains. A SPRAIN is a form of inflammation Avhich may be either Sprains— acute or chronic. It arises from a sudden tAvist or wrench, by which the capsule and ligaments of a joint, or the fascial structures in its neighbourhood have been stretched or torn. Sprains vary infinitely in their severity, both in pain, and in the extent and duration of the disablement, but it may be taken that they are severe or slight, in direct relation to the extent of mechanical damage done to the fibrous tissues about the sprained articulation. We shall here chiefly consider severe sprains. These always occur unexpectedly, and call for prompt treatment, for the time the joint will take to recover will depend greatly on the measures which are taken imme- diately after the injury. If a sprained joint be seen soon after the twist, there will Their have been no time for the development of inflammation, treatment6 It is then in many cases possible to prevent this action May be coming on at all, by firm, even, compression, and absolute a or e fixation of the joint. The principles of the treatment understood, the details may be varied. Thus for a badly sprained knee, the best course Avould be to put the patient to bed, to apply a Martin's bandage, or a Avet roller, firmly, and then to fix the limb on a Xevill's or Mclntyre's back splint, and to swing it from a cradle with an ice bag resting on the joint; so also, an ankle might be treated in some- Avhat the same way Avith a wet bandage and a back iron splint, but it would be even better to get a firm elastic compression by layers of cotton avooI, and careful bandag- ing, and then to put up the joint straightway in plaster of Paris. The limb should be kept for a fortnight or three weeks in this stiff case, and will then require passive move- ment, shampooing, etc., as described below. The A'alue of this " abortive " treatment of severe sprains when the cannot be overrated, but for it to succeed, the injury must u^ua'fcourle. be taken in hand at once. When pain, heat, redness, and 218 OF SPRAINS. swelling, the cardinal signs of inflammation, have once come on, a someAvhat different line must be taken. Though it may be sometimes better to lay the joint simply on a pillow, it is still generally advisable that it should be sup- ported, and if pressure can be borne, a wet roller or a The acute stage. Martin's bandage is often very serviceable. An ice bag, too, is a most salutary remedy, but it must be remembered that the joint is now inflamed and Avill bear only very gentle handling. Cold affusions, as from an irrigation apparatus, or a tap, or evaporating lotions may be applied. Sometimes, on the other hand, water as hot as can be borne,* or hot fomentations, or bran poultices are better, while if the inflammation be very severe, leeches (say half- a-dozen for a knee) are very useful. The chronic The duration of the acute stage of a sprain varies, and the condition only gradually passes off, leaving the joint weak and puffy, and susceptible to slight injuries, or apt to become painful with changes of the weather, etc. This condition of chronic sprain requires the most varied treat- ment in different cases, or in the same case at different times. At first it is often necessary to insist upon a splint, but this, if kept on too long, will lead to adhesions and stiffness. So too, the support of a bandage or strapping may be required for the atonic capillaries and veins, but the pressure causes wasting of the muscles if persevered with unduly. In the later stages of the case all the surgeon's efforts should be directed to the getting the joint back again into working order. Cold and hot douches, shampooing and passive motion may be required, and if there be much thickening the joint may be strapped (v. Figs. 79, 80) with an iodine or mercurial plaster. But in cases of severe sprain the recovery is often very sIoav. Adhesions. In spite of all precautions, it will happen every now and again that joints Avhich have been badly sprained (and the same holds good for dislocations), become fixed by internal or external adhesions, or by both, while the difficulty of movement is increased by muscular contraction. These cases give great employment to "bone setters," who are often very skilful in freeing the hampered movements. If a joint be free from heat and tenderness on pressure, no hesitation need be felt in forcibly breaking doAvn the adhesions, either by taking the muscles of the limb by • This is the remedy generally used by professional acrobats. OF SPRAINS. 219 surprise, or, what is generally better, by free flexion and extension under an anaesthetic. The presence of subjective signs of pain need also be no Pain not a bar to bar to this forcible passive motion, provided the objective adhe^iSns^°wn signs of inflammation are absent, for most fixed joints become neuralgic. Even in chronic inflammations it is not always wise to keep the joint fixed, but the discrimination of the cases which should, from those which should not be so treated, often involves very nice points of surgery. In addition to the employment of douches and shampoo- use of the gai- ing for the reduction of the thickening and puffiness which vamc cuirent- follow on a sprain, the effect of the constant (galvanic) current is so striking that it should be especially mentioned. The tendons get loose in their synoArial sheaths, inflam- matory exudations disappear, and even callous bone itself appears to be rapidly absorbed under this treatment. The current may be conveniently supplied by, say 10 to 20 Le- clanche's cells, the negative electrode being formed of a plate of zinc covered with flannel, which can be so bent as to Avrap round the joint. Slight sprains do not generally require splinting, but they slight sprains. may often be cut short by very hot water, or by the firm pressure of a wet roller bandage, Avhich will be found the best treatment for the casualty room, or by massage Avell applied. A Martin's bandage is also frequently used. When heat and SAvelling have come on, if a firm Avct bandage can be borne, it is still the best treatment in most cases; if not, evaporating lotions, irrigation, or hot fomen- tations may be applied. Lastly, in certain cases there can be no question but that walking off a forcible movement, Avith kneading of a sprained joint in its spiam" acute stage, and perseverance in its use, will sometimes cut the sprain short, that, in fact, it is true that a sprain can be walked off. The difficulty is to recognise the cases in Avhich this method may safely be advised, so that the surgeon may be able to promise prompt recovery as the reAvard for present suffering, for the necessary manipulations are always painful. Experience alone will enable the surgeon to do this, and any rules Avould be misleading. One warning, hoAvever, may not be out of place, namely, that in the early treatment of twists of the knee joint, it is hardly possible to be too cautious, and in all cases Avhere there is effusion, rest, and a back splint should be insisted on. This Avill be a convenient place to mention a form of internal strain internal sprain of the knee, which appears to be due to ° lhe knee' 220 OF SPRAINS. some displacement of one of the semilunar cartilage;?, generally the inner one. The usual history of the injury is that the patient, during some sudden rotatory movement of the body, feels an acute pain in the knee, while the joint becomes incapable of full extension, though it can be flexed, symptoms. and Avill allow of no A\reight being borne on it. Often the patient falls to the ground as if he had been shot. Soon, tenderness and signs of effusion into the joint come on, and these are generally out of all proportion to the very slight twist which has been the cause. Sometimes these symp- toms disappear as quickly as they arose, after some slight movement; sometimes they obstinately remain as a chronic synovitis. If the joint be examined, it will be found that where the internal cartilage comes nearest to the surface (Avhere, indeed, it is almost subcutaneous), there will be a spot of Treatment. acute tenderness, and probably a little SAvelling. If this be found, the remedy is easy, and striking in its effect. Taking hold of the limb above the ankle with one hand (the patient lying or sitting) the knee should be strongly flexed, while the thumb of the other hand presses the cartilage imvards. Then, without warning, the limb should be jerked into extension, the pressure being kept up the while. In most cases, even at the first attempt, the cartil- age Avill slip back into its place,- and the patient will be able to extend the knee with great relief, but sometimes the manoeuvre will have to be repeated two or three times. After manage- The cause removed, the pain and effusion quickly dis- appear. It is wise, hoAvever, to rest the joint for a few days, and to Avear a woven or elastic felt bandage, or a laced kneecap. Unfortunately, Avhen once this derangement has happened, it is very apt to recur, and there are many who do not feel themselves safe to undertake such forms of exercise as running, jumping, or dancing, lest they should be suddenly disabled. Many also learn how to put their joints right again for themselves. Much may be done by shampooing, the douche, and judicious support, to brace up the relaxed ligaments, and lessen the liability to the accident, acting on the same principles as in cases of chronic external sprain; but repeated dislocation is apt to lead to a chronic arthritis, and to distortion of the cartilage. This condition may call for an intra-articular operation for refixing the cartilage or remoAring it. carina5elo°se ^e symPtoms which arise when a true loose cartilage OF SPRAINS. 221 (usually originating as a pedunculated growth from a fringe of the synovial membrane) gets nipped between the joint surfaces, are almost identical with those we have described, except that there is not usually any limitation of extension. A patient who exhibits the signs of having a loose cartilage should be advised to seek adA'ice immediately, if at any time the vagrant body should present itself so as to be felt from the outside. If this occurs, every effort should be made Avith strapping, etc., to prevent its slipping back into the depths of the joint until the performance of some planned operation for its removal can be considered. If the fibro-cartilaginous body is felt loose underneath the skin and apparently lying aAvay from its point of exit from the joint cavity, the best Avay is to spear it Avith a sharp tenaculum, and cut it out under strictly aseptic con- ditions ; but if there be good reason to believe that there is. a loose body in the joint, and it cannot be felt in the outlying parts, then it may very probably be right to open the joint and search for it, but this should not be done without due consideration, and except at a time when the joint is quiet. 222 OF INCISED WOUNDS, FTC. SECTION IV. OF WOUNDS, ULCERS, BURNS, Etc. CHAPTER XV. Of the Dressing of Accidental Incised "Wounds. Of incised wounds- general principles. Conditions essential for healing. In the present chapter we propose to consider the general principles of dressing wounds, and the ways in which they are in practice dressed. We shall first take those Avhich may be properly called cuts or incised wounds, large or small, in which a quick healing is to be desired, and should generally be attainable, and we shall consider the rules as to their Avashing, closing, and draining, Avhich are founded on the laws of cleanly surgery. Some of the general ways of "dressing," that is, of covering or protecting these wounds Avill now therefore be described, Avhile in the folloAving chapter the methods will be considered in detail of a more scientific treatment of wounds. In the succeeding chapters of the section, the manage- ment of bruised Avounds, of special forms of wounds (as gun-shot wounds, etc.); and later still burns, ulcers, etc., will be discussed. For any wound to heal Avell, the following conditions must be fulfilled :— (1) The wound must be cleansed, and kept clean. (2) The divided tissues must be accurately readjusted and retained in position. (3) The parts must be kept at rest. (4) All effused fluids must be able to escape, and must be taken up on escaping. The primary blood effusion must be arrested completely, and the Avound, in almost all cases, must be covered and protected by some dressing material. of incised wounds, etc. 223 1. The cleansing of the wound. This will be necessary, even when it has been inflicted ^unane the Avith a perfectly clean instrument, lest blood clots remain in it. For ordinary cases, the thoroughness Avith Avhich the washing is performed is more important than the fluid which is employed. A lotion of carbolic acid (1 in 40 to 1 in 100), or of Condy's fluid, or of perchloride of mercury (1 part in 2000), are about the best to use. If there be any suspicion that septic or poisonous matter has been introduced into the incision (e.g., in a dissection wound), it should be thoroughly swabbed or syringed out with a 1 in 20 carbolic lotion, or one of chloride of zinc, in the proportion of 40 grains to the ounce, or of perchloride of mercury of the strength of about 1 part in 1000. The process of cleansing, of itself tends greatly to check the Arrest of capillary oozing, and hsemorrhage from other sources must 00zmg* be thoroughly arrested before any attempt is made to close the wound. It must be understood that the foregoing applies especi- ally to the cases of incised wounds which occur in the casualty room practice of a hospital, or under similar conditions elsewhere. When wounds are inflicted, as in operations, by a surgeon, Avith deliberate intention they may, and should, be aseptic from the first, and not merely either fairly clean, or of various degrees of foulness. In such no efforts should be spared to maintain this aseptic condition throughout the healing, after some one of the plans described in the folloAving chapter. But in casualty room practice, at least at the present time, this is hardly possible; on the other hand it is practically found that accidental wounds, inflicted upon healthy persons will often heal without suppuration after a thoroughly honest cleans- ing, Avithout special antiseptic precautions, if only rest and drainage are provided for. It goes Avithout saying that all foreign bodies must be Removal of removed from accidental wounds, and in vieAv of recentforeign bodies- discoveries as to the connection of the earth-bacillus Avith tetanus, ordinary mud and earth must be got rid of entirely. If the earth has literally been ground into the wound, the best plan is to place the patient under an anaesthetic, and having washed away the more loosely adherent dirt, to scrub the wound with an ordinary nail brush. Although the rule is broken every day, there is no question but that one of the greatest causes of failure of repair is the continuance of bleeding within a closed wound. 224 OF Inctsed wounds. ETC. The actual bringing together of its sides does, no doubt, often effectually check further capillary bleeding, but it should not be trusted to do so, if it is in any way con venient to leave the wound open until this has quite stopped. The time to seize, if possible, for closure of the wound is when the lymph poured out from the lymphatic spaces is acquiring a plasticity or stickiness, which can be readily appreciated by the finger, and which gives to the wound surfaces a glazed appearance. ' 2. The adjustment and closure of the wound. Adjustment of (A) Of its deeper parts. With the exception of the parts wound; (a) of which are necessarily separated by the presence of drainage eeper parts, ^j^ ^he a(]justment and replacement of the diA ided tissues must be carried out throughout the Avhole extent of the wound, and if possible, as perfectly in its deeper parts as on the skin surface; for upon this the manner of healing, as well as the appearance Avhen whole, will greatly depend. But the means at our disposal for keeping the deeper parts together after replacing them, are somewhat imperfect. In most cases the support and pressure afforded by pads and bandages put on outside the wound are trusted to keep the sides together, and if these will suffice, so much the better. But in many instances, and especially in plastic operations, it is necessary to fix the parts more securely, either by sutures, passed far beloAv the surface (deep sutures), or by needles or hare-lip pins passed at a similar depth, or by what are knoAvn as "buried sutures," by means of which periosteum may be joined to periosteum, fascia to fascia (and finally, if necessary, skin to skin by an external stitch). These buried sutures are used especially in antiseptic sur- gery, and are designed to obviate the use of drainage tubes. They must be made of catgut or fine silk. Deep sutures. Deep Sutures. If the depths of the Avound haAre to be kept together in this Avay, it must be because there is a tendency for the parts to separate. There will, therefore, be tension on the sutures, and unless some precautions are Their principle, taken they will speedily cut out. All the contrivances which have been devised to prevent this have for their object that the sutures shall pull upon an area of skin at the margin of the wound, Avhich is shielded in some way from the direct pressure of the Avire or thread. For this purpose, the suture, which is passed through the Avound at the depth desired, enters and emerges from the skin at a little distance from its edge, and is then fastened to a niece of quill or catheter, or passed through a perforated ivory of incised wounds, etc. 225 cylinder, or piece of sheet lead or zinc cut to the requisite size, or shaped as a stud or button. The illustration (Fig. 12 S) will sIioav Avithout further words the general principle of these fastenings, of which the details may be modified in many ways. The suture employed is almost always made of stout silver wire, but in special cases thick chromicised catgut may be used. The suture may be passed with a common needle, or Avith one of the numerous patterns of handled ones, or, in some cases, very conveniently with the tubular needle devised by Mr. T. Smith (Fig. 129) for operations about the palate or perineum. FlG. 128.—Fludration of some forms of Deep and Superficial Suture, and of the Fastening of Drainage Tubes (after MacCormac). (The attachment'of the thread to the tube is imperfectly shown.) _ If short needles be used it will be convenient, and some- times necessary, to use some kind of holder. For needles of the ordinary kinds a pair of Spencer Wells' forceps (Fig. 18) does very well, and forceps on the same principle with their jaws shielded with lead or copper are also used. Recently an ingenious holder, to be used with especial " sabre shaped" needles, but which will also do for most 15 7150�291730043�5 226 OF incised wounds, etc /^^ rv, r^= q. Fig. 129.—Tubular Self-Feeding Necdhs. other ones, has been* devised by Dr. Hagedorn, and is here figured. (Figs. 130, 131.) Fig. 130.—Dr. Hagedorn's Needle Holder. N°-& Use of leaden shields and buttons, Fig. 131.—Needles for Dr. Hagedorn's Needle Holder. For most of the cases Avhere deep sutures are required, of incised wounds, etc. 227 the best shield for practical use is a piece of sheet lead. It is sold in strips, ready perforated, but is best cut out with scissors to the shape required in each instance. A piece may be laid along each side of the wound, from a ^in. to £in. away from its edges; holes may then be bored in it to correspond to the number and distance apart of the sutures. The suture having been passed through the strips, the two ends are simply tAvisted together so as to close the depths of the Avound. The twists should be to one side, and lying upon the metal strip, as shown in the figure. Instead of using one long piece of shielding metal for each side of the wound, a rounded piece like a trouser button is very commonly cut out for each suture (also shoAvn in Fig. 128), or pieces of lead, of this form, are to be had ready made Avith two studs on them, round Avhich the wire may be twisted. These are convenient enough, but are in no way better, and in some respects not so good as the plan first described. Another good plan is to secure the wire after it has been passed, whateAer shield has been used, by closing a split shot (like those used in angling, but rather larger) over it. Deep sutures are easier to remove than to put in, for a Their removal. pair of scissors placed between the skin and the shield on one side will be able to cut the Avire short off there, and then it can be draAvn out from the other side. No rules can here be given as to the time of their remoAal; this must he settled in each case at the surgeon's discretion, but in the great majority of cases their tenure is only possible for a day or tAvo, much less that is, than in the case of superficial stitches. Hare-lip pins are steel pins Avhich may be passed across Hare-hp pins. the depth of a Avound, entering the skin a little aAvay from the edge on one side, and coming out at a corresponding distance on the other. Silk or Avorsted (the latter is to be preferred), is tAvisted over the protruding ends, so as to bring not only the deeper parts, but the skin surfaces into apposition. The point and head of the pin are then nipped off" Avith a pair of cutting pliers, made for the purpose. Tavo little bits of lint should be put underneath the ends. No method brings all the parts of a Avound better together than the use of hare-lip pins, but there are not many parts of the body Avhere they can very conveniently be employed; their name tells when and where they are most commonly used. They Avould be resorted to much more frequently Avere it not for the fact that unless they are removed in 228 OF INCISED WOUNDS, ETC. Must be removed early. Superficial sutures. Suture materials. Number of sutures, and time of removal. from 36 to 48 hours, they will begin to cause ulceration, which Avill leave very obvious scars (this risk may l>c diminished by having them gilt or silvered). They must in any case be removed as early as possible, and this especially, A\'hen they connect the tender tissues of infants. They must not be zc///alraAvn, but draAvn thrmigh, by seizing the end off Avhich the point has been nipped, and making steady traction with rotation in the axis of the pin, but Avithout Avorking it from side to side. If possible, the silk or worsted threads, matted together with blood, should be left as a scab over the Avound, after the pin has been taken out. (B) Closure of the lips of the wound. Superficial sutures are for the accurate adjustment of the diAided skin surface, and of the tissues near it; in most Avounds they are the only ones required. No strict rule can be laid doAvn as to the depth at which they should be passed, but it is often convenient, as has been said before (p. 28), to put them deep enough to arrest bleeding from vessels in the cut edges of the wound. Wire, silvered, or of silver, silk, catgut, and occasionally horsehair, are the materials chiefly used for sutures, and of these, general preference must be given to silver wire. Silk and horsehair are used principally for Avounds about the face, or in abdominal surgery, and catgut, Avhich should ahvays be chromicised, is especially useful in cases where it is desired that the parts shall not have to be disturbed for their removal, as in many antiseptic dressings. Catgut sutures, hoAvever, are not quite trustworthy; they stretch, and are apt to be absorbed too soon ; silkAvorm gut is now largely used instead, and is not open to these objections. Whatever be the thread used, the interrupted suture is almost the only one practically employed.* Each point is secured separately, by tAvisting, if it is of Avire, or by tying in reef knots in other cases. Thin Avire also may often be tied. In any case, the twist or knot should be at one side, and not over the line of the Avound (Fig. 128). The actual skin surfaces should, if possible, be brought together exact- ly, but it is better that the edges should be a little everted than inverted. A little inversion is often overlooked at the time of adjustment, and the result is an unsightly depression. The number of sutures must be just as many as Avill clo-e * The continuous suture, frequently used, however, is now getting to be morg OF INCISED WOUNDS, ETC. 229 the wound throughout; fewer will not do, and more are needless foreign bodies. So long as stitches are not doing harm, there is no limit to the time they may be kept in, but as soon as there is any tension, or area of inflammation around them, they art better away, lest they should be retaining discharges. Silk sutures require only to be snipped and removed with forceps, but wire ones should always have the little hook Avhich will be found at the end which is to be pulled through the wound, carefully straightened out or cut off*. No more needless pain can well be inflicted than that caused by neglect of this small precaution. Adhesive strapping may be used to relieve tension which closure by Avould otherwise be borne by the sutures alone, or may be b rappmg" the sole means employed to close a Avound. In either case, care must be taken to avoid puckering, and the best way to do this is by cutting the strips as shown in Fig. 79 and des- cribed on page 118. If the adjustment be carefully made, there is no better way of closing a Avound. The widely diffused support of the plaster is extremely useful, but no wound, except very small and clean cuts, should ever be completely closed over with strapping; a drop of pus thus shut in may Avork very great mischief. The use of serrefines, or other mechanical contrivances for the closure of Avounds, is noAv practically abandoned, and there only remains to be mentioned a mode of closing small wounds, especially about the face, by collodion; the collodion. ordinary, or the flexible kind may be painted over the Avound or applied upon a piece of lint, and by its contrac- tion a close apposition may frequently be attained. 3. Arrangements for rest, i.e., for retaining the Avound sur- Best.—its faces in apposition. It is not necessary to enlarge on the imP°rtanc< importance of this point. It will be understood that a. Avound can hardly heal unless it be kept at rest, and also that the means of securing this rest must vary with every case. In the case of Avounds of the extremities, the end desired can generally be attained by splints, interrupted if neces- sary, and slings and other contrivances may be brought into use, the limb being placed in the position which causes least tension on the edges of the Avound. Moulded splints are especially useful in fixing the parts about a wound, and this necessity for rest must ahvays be kept in mind in considering the firmness with Avhich a wounded part should be bandaged, 230 OF INCISED AVOUNDS, ETO. Drainage of the 4. Arrangements for the ready escape and absorption of all exuded fluids, and for the covering and protection of the wound. The means to be adopted to secure the fulfil ment of these conditions, include the different Avays in which Avounds may be drained, and the several "dressings" that maybe put on them. There will be in all cases some fluid exudation, Avhether a wound has been closed before the bleeding has stopped or no, and provision must be made for its escape, except in Avounds Avhich are at once small and perfectly healthy. Kinds of drain- The materials generally used for drainage are, indiarubber age materials. Cubing of different sizes, flexible tubes of coiled up wire, tubes of decalcified bone, and Avisps of horsehair, or catgut; but almost anything of the nature of a tube or a thread, if it be in itself unirritating, may be placed in a wound to facilitate the escape of the discharges. Drainage must As the Avhole object of a drain is to prevent fluid re- bottoru? l e maining Avithin a Avound, no exception can be made to the rule that all surgical cavities are to be drained from the bottom. The place of exit for the drain should therefore! be the most dependent part of the A\'ound, unless, as is often advisable, a separate aperture is made for the tube alone. Often, too, it is necessary to pass the drain right across the cavity, either by making it enter the Avound at one end and leave it at the other, as may be done in amputations of the limbs, or of the breast; or by making apertures, and counter apertures, as in some methods of paracentesis thoracis (q.v.). Horsehair, s'lk, If horsehair be used as a drain (and for wounds A\ith but iams. ij^jg djscharge it is very useful, especially in sinuses, where it can be laid right along), some 20 or 30 hairs must be cut of equal length and tied together at each end. Catgut, silk, thread, or strips of gutta-percha tissue or of oiled silk, flat or tAvisted up, are all in constant use for drains. Rigid silver tubes, retained by an expanding spring have been devised, but have no extensive use ; indeed it would be easy to make a long list of contrivances for drainage Avhich have been brought forward and abandoned Avithin the last few ^'ears. Drainage tubes Coming to drainage tubes proper, glass ones have been kinds. almost exclusively used in abdominal surgery, as for the drainage of the peritoneum in ovariotomy ; the advantages and drawbacks of the material can easily be understood. One great disadvantage of coiled wire drainage tubes is that the granulations are apt to sprout between the interstices of the coils. Tubes made from small bones, OF INCISED WOUNDS, ETC. 231 decalcified by hydrochloric acid, and thus rendered absorbable, have lately been introduced by Professor Neuber, and are now extensively used in this country, and decalcified chicken bones have been employed by Macewen. They are especially intended for wounds treated on the Listerian plan, for it is intended that they shall be gradually absorbed in the wound. Up to the present time, experience goes to shoAv that they often behave as is desired, but that the rate of their absorption is capricious, and is apt to be sometimes extremely delayed, and sometimes too quick. But the drainage material Avhich Avill probably be for long Rubber tubing. in most general use, is indiarubber tubing, of Avhich special kinds are made, of various sizes, and perforated at frequent intervals. The points to be kept in mind as to the drainage of a Avound by indiarubber tubing are, (1) the requisite size of the tube, (2) the mode of introducing it, (3) the keeping it in its place, (4) the occasions of its AvithdraAval for cleansing or shortening ; and, finally, the time Avhen it may be per- manently discarded. All drains are foreign bodies, and, ipso facto, hurtful. The size. tube, therefore, must be as small as Avill freely carry off the discharges. No general rule can be laid down as to the mode of in- introduction. sertion of the tube. It may be put in before or after the Avound is sutured, and a probe or director, or the special instrument devised by Sir Joseph Lister may be used. Forceps of the ordinary kind are objectionable, as they disturb the tissues. The tube is apt to accidentally slip in or out; this may be Retention. prevented by threading a common needle with silk or thread, and passing it through the tube Avail (see Fig. 128), from J to i an inch from its end. The ends of the silk may be left about two inches long, and fixed to the skin surface by a little bit of strapping. A safety pin may be put across the aperture of the tube, or some form of shield may be'employed. For the same reason that the tube should be as small as withdrawal or will be efficient, it should be removed as soon as it is safe S101tenms- to do so ; and if it cannot be AvithdraAvn altogether, it should be shortened up from day to day. But it is impossible to lay doAvn any strict rules ; in such a case as an amputation of a limb, or of a breast, healing by first intention, the tube may be removed on the second or third 232 OF INCISED WOUNDS, ETC. day, Avhile in a chronic abscess, the tube may have to be left in for months ; but in any case it is a safe rule to follow, that every time the dressing of the Avound is changed, the tube must be taken out and syringed through with carbolic lotion. may\e di? en- ^n cases °f accidental Avounds a drainage tube is usually sed with. required, but in many operations it is possible to do Avithout one, in those, for example, where the incisions have passed through healthy structures. Here, if all bleeding be stopped before the wound is closed, and firm, equable pressure be applied, not only by the dressings, but also during the time that they are being put on, it will be found that healing will take place perfectly. There are many advantages in being able to dispense with a drainage tube, and amongst them by no means the least, both as regards disturbance of the wound and the comfort of the patient, is the greatly lessened need for changing the dressings. A tube is in itself irritating and affords a space into which leakage of serum must, and will, take place. Its presence may also lead to the formation of a troublesome sinus which materially delays the healing. In cases where it is not thought desirable to close the wound entirely, one angle may be left open, so that any discharge may find a ready means of escape. The covering of Although Ave are using the term "the dressing of " dressing" wounds " in its larger meaning, to include all the details of proper. ^g management, " surgical dressing " is a phrase generally used in a more contracted sense, to express the materials and medicaments which are put over a wound to cover and protect it, and to forAvard its healing. These may be conveniently divided into dry, watery, and oily dressings. The main The medications used may have for their purpose the pre- dicting ° vention of decomposition, or the maintenance of simple materials. cleanliness, or some stimulation of the wound ; or a cool, a warm, or a moist atmosphere may be desired, or simple greasiness of the surface. But whatever be the nature of the dressing, it must before all fulfil the indications of cleanliness, and absorption of the discharges. Modern Just as in former times it was believed that a simple fracture could not unite, unless healing sah-es of various kinds were applied to the skin, so even up to the present day, many seem to find it difficult to remember, that the nature of wounds is to heal, and that nothing applied to a wound can of itself heal it, though many things can be done £o retard or prevent the healing process. In fact, the results. OF INCISED AVOUNDS, ETC. 233 now desired, are almost absolutely negative ones, such as the avoidance of movement, of irritation, or of tension, the removal of discharges, and the like. But, while it is every day more recognised that the best way to dress a wound is to "severely let it alone;" in most cases some kind of application Avill be required, and the nature of the dressing does in many cases affect the course of the repair. Thus granulations will often become large and flabby under carbolic; oil, and again, small and prone to bleed, under the use of chloride of zinc. A choice, there- fore, has to be exercised, but experience alone will give the poAver of judicious selection. For the purposes of description, some classification of classification ot wound dressings must be adopted, and the following may probably be found convenient. We shall first divide them into dry, Avatery, and oily dressings, and then arrange the drugs and materials used under each head, according as to Avhether they are chosen because they are non-irritant, anodyne, antiseptic or stimulating. Simple scabbing. In a healthy atmosphere, even large f>ry dressJ?~s-[r amputation wounds will heal Avell if they are simply 1- y sca lug" exposed to the air Avith no dressing whatever upon them. The effused blood and lymph form a crust, under Avhich repair progresses, and if care be taken that no discharges are retained, the results of this almost absolute neglect of the Avound are very good, especially in the country, as in cottage hospitals. But the method is not generally adopted, because of various inconveniences, of which the chief is, that no support is afforded to the limb generally, or to the deeper parts of the wound in particular, Avhere the pressure of a bandage or pad is often very desirable. But this objection does not apply to the dressing by dry 2. By dry absorbent pads, a plan especially advocated by Professor absoibent pads' Gamgee. The principles of this method are " dry and in- frequent dressings, immobility and pressure."* A great many different materials have been used for pads in this form of dressing, and, sometimes one, sometimes another, Avill ansAver best. What is Avanted is a proper firmness, combined with elasticity, so that a moderate re- straining pressure is kept on the Avound. At the same time the material must be absorbent, to provide for the infrequency of dressing. Pads of lint, of salicylic avooI, or cushions of ♦"The Trinity of Healing." Gamgee. Lancet, February, 1876, p. 887. See also Professor Garngee's larger work on " Tlie Healing of Wounds." 234 OF INCISED WOUNDS, ETC. the one lined Avith the other, marine toAV, or lint, or oakum, boracic lint, tenax, saAvdust bags, Avood avooI, carbolic gauze, and sponges, have been used, and many more. Of all these, the best for general use, seems to be the salicylic avooI, made into a pad, and covered Avith gauze, but sometimes sponges will be found very useful; thus they may be applied to either side of an amputation wound, or placed in the axilla after amputation of the breast. A wound dressed on this plan must have its edges, and if necessary its deeper parts, adjusted with the appropriate sutures, and provision must be made for its drainage; secondly, the mechanical fixation of the neighbouring parts should be secured by moulded splints, or plaster of Paris bandages, or similar contrivances for the fulfilment of the indication of immobility; and thirdly, the parts immediately concerned in the Avound must be covered, and lightly but firmly pressed upon by the ab- sorbent pads, secured by bandages. If the discharges from a wound thus treated are only moderate in amount, there will be no necessity to change the dressings for some days, and no method gives better results in the case of large healthy wounds. other dry Other forms of dry dressings there are Avhich have proved valuable in the hands of those Avho advocate them, such as the dry earth plan, etc., and layers of dry boracic lint, fastened on with a carbolized gauze bandage, will often be found to give as good results as any of the most complex methods. A dry anodyne dressing of opium powder and poAvdered bark in equal quantities is sometimes used in cases of pain- ful cancerous ulceration. It may be dusted on the parts, and covered over Avith layers of boracic lint or tenax. iodoform. Iodoform in powder, besides being largely used in recent developments of antiseptic dressings (vide Chap, xvi.) and for venereal and syphilitic sores (q.v.), is now often employed as a dressing to incised Avounds, being freely dusted on the part, underneath Avhatever other dressing may be chosen. A small dredger, such as is used for Keating's insect powder, or a pepper castor, is a convenient receptacle for it. It may also be used as an ointment mixed with vaseline, or as an ethereal solution, Avhich, painted on, leaves it as a thin pellicle, upon the eAraporation of the ether. wet dressings. Wet dressings. This class of application is a very large one, and comprehends all lotions, tinctures, hot or cold compresses, and poultices; every dressing in short, by means of which the surface of wounds may be kept moist. OE incised Wounds, etc 235 In the great majority of cases, the moistening fluid is applied by soaking pads or strips of lint in it. Before all other wet applications, must be placed the Water dressing. common " water dressing." This simply consists in the covering of the Avound with a few layers of lint moistened with water, or with a weak watery lotion, renewing the moisture Avhen necessary. Very often it will be found that wounds heal more kindly under this treatment than under any other. In order to check the too rapid drying of the lint, a piece of oiled silk, or gutta-percha tissue, may be put over it, but this must be smaller all round than the lint, or the dressing will be changed from a cool and moist, into a Avarm and steamy one, in fact into a poultice. Watery lotions are generally applied in the same Avay as Watery lotions, the simple Avater dressing, but they may also be useful for irrigation or immersion. The following are examples of the lotions Avhich are used in the dressing of ordinary wounds. Some are simply non- irritant, others are stimulant, or antiseptic, or anodyne, but no regular gradation is possible. The strengths of the preparations are given in the formulary at the end of the book. Lotions of Permanganate of Potash (Condy's Chloride of Zinc Fluid) Chlorinated Soda Carbolic Acid Liq. Chlor. Perchloride of Mercury Iodine Bomcic Acid Liq. Carbonis Detergens Sub-Acetate of Lead (Goulard Sanitas Water) Terebene Sulphate of Zinc Chloralum Chlorate of Potash Sub-Acetate of Lead with Opium Alum Belladonna Nitrate of Silver It will, of course, be understood that many of these lotions may be used in several different strengths, and for other purposes than for dressing incised Avounds. Irrigation, is a form of Avet dressing Avhich is sometimes irrigation. used for clean Avounds, especially Avhen they are near joints, but it is much more often adopted for foul or sloughing ulcers, under Avhich head it is again mentioned. Its great drawback is the risk to the patient of catching cold from the exposure, which can hardly be avoided. To set up an irrigation apparatus, all that is required is an arrangement by Avhich a constant drip of Avater, or of some lotion, can be made to fall upon the Avound, as shoAvn 236 OE INCISED WOUNDS, ETC. in Fig. 132. This may be done by suspending a vessel over the wound, properly fitted with a tap and india-rubber Fig. 132.—Methods of Irrigation. tubing, or the tube may be allowed to act as a syphon. In either case the difficulty is to get the drip to be sufficiently slow, and quite as good a plan, is the simpler one of hanging one or two strips of lint from a vessel supported above the wound. The fluid is evenly distributed, drop by drop, by the strips which act as syphons by the capillary attraction of their fibres (see Fig. 132). It will be necessary to put some pin or basin beneath the Avounded part, and the bed must be kept dry with water-proofing; but there is always some slopping, and the patient had better lie in blankets. immersion. Plain water, Condy, carbolic, boracic, or iodine lotions, are the fluids most frequently used for irrigation, and although, if this treatment be continued for many days, the granulations are apt to become sodden, no dressing will more efficiently clean a avouik! ; immersion of the wounded part in a bath of warm carbolic, or Condy, for many hours, is often also extremely beneficial. Poultices. A poultice is noAv rarely seen in the surgical wards of a hospital, or in any place where the practices of cleanly surgery are observed ; and if any attempt be made to maintain a truly aseptic standard in the methods adopted for the treatment of Avounds, the use of a fermen- table decomposable mass of bread crumb or crushed linseed, which constitutes the old-fashioned poultice, becomes impossible. InAhe medical Avards this kind of application of warmth Of incised wounds, Etc. 237 and moisture is not open to the same objection, and among the out-patients in the treatment of the sores and Avhitlows and similar casualties of daily life, it is hardly likely that they will ever really go out of use. Crushed linseed meal, or stale bread crumbs, are the chief materials used, Avhile the addition of an eighth part of charcoal powder forms the ordinary charcoal poultice, a very common appli- cation to foetid wounds.* The indications Avhich call for a poultice, may be met, compresses of though perhaps not quite so well, by water dressing, com- ?w£ 3P°nsi0 pletely covered Avith gutta-percha tissue, or oiled silk, or by spongio-piline, cut to the requisite shape, and soaked in either hot or cold water. To such an application the term " a compress " is applied. Certain alcoholic tinctures, generally freely diluted, are Tinctures. in common use as wet dressings. Of these, Friar's Balsam (Tinctura Benzoinae Co.) should be mentioned as an admir- able stimulant for wounds wlrich are slow to heal. It is applied by soaking pads, or strips of lint, in the tincture, and is probably the best of the preparations of aromatic gum resins. Whether the tincture of arnica has any especially benefi- cial action on bruises, contused wounds, and the like, beyond that of the spirit it contains, is doubted by many, yet it would be singular if so widespread a belief as that which prevails as to its virtues, were quite groundless. It is, hoAvever, certain that even very weak lotions made with this tincture will sometimes create quite an extraordinary amount of irritation, Avhich may run on into true erysipelas ; and the drug certainly possesses no merits to compensate for the drawbacks of such a risk. Tincture of iodine, freely diluted, is often used as an antiseptic and stimulant application ; it makes an admirable irrigating fluid, especially for foul wounds. Coming noAv to the oily dressings and ointments ; olive oil, ony dressings. pure and simple, Avould be largely used, on account of its absolutely non-irritant qualities, Avere it not so apt to become rancid ; but when carbolic acid is added to it, it forms an application to wounds Avhich is universally appreciated. Carbolised oil usually contains one part of the acid to 40 of carbolic oil. oil, but other proportions may be found more useful in * Charcoal in powder, is perhaps the most powerful disinfectant and deodoriser known; used as a poultice this property is greatly impaired. The methods of making poultices and. fomentations, are explained later. 238 OE incised wounds, etc. special cases. In the proportion of 1 in 15 or 1 in 20, it loAvers local sensibility Avithout having the escharotic pro- perties of the pure acid or its stronger solutions. It is generally used by soaking pads or strips of lint in it. The Eucalyptus on. oil of eucalyptus, thymol, or terebene may also be mixed Avith olive oil, and used in precisely the same way as the carbolised oil. They are all good dressings, although they have not yet been shown to be in any way superior to carbolic oil : any of them, the eucalyptus oil especially, may be used Avhen carbolic acid is contra-indicated. All these dressings, if continued for long, are apt to make the granulations large and flabby ; they should then be changed for some astringent lotion, such as a solution of sulphate or chloride of zinc. castor oil Castor oil is rarely applied externally, except in injuries to the eye, where its viscidity and blandness make it very useful. ointments. Ointments of various kinds are largely employed as dress- ings for wounds, especially in the later stages of their healing. Some are chosen for this purpose because they are non-irritant, as the ung. simplex, or ung. spermaceti, or because they have more or less stimulant properties, as the ung. zinci oxydi., or the ung. hydrarg. nitroxydi, diluted with an equal quantity of vaseline or lard. For others the reader is referred to the text books on therapeutics. Vaseline. Vaseline, though in no sense an oily material, may con- veniently be classed with them. It is a clean and bland dressing, and serves also as a basis to which various drugs may be added, so that they can be applied as ointments. Some of these will be mentioned under the headings of the dressings of ulcers, bed sores, syphilitic sores, etc. Speaking generally, ointments are most conveniently applied by spreading them on lint or on old rags. of antiseptic dressings, etc. 239 CHAPTER XVI. Of the Antiseptic Dressings of Wounds, and the Aseptic Precautions of Operative Surgery. Since this chapter was written it has been already necessary to almost wholly re-write it once for the Second Edition. It is now necessary to recognise the still further recent developments of the practice of treating by aseptic or antiseptic methods all wounds inflicted by surgeons. The alterations seem to eoi.cern details rather than principles, and more particularly to concern the question as to whether absolute " Listerism " be indeed the best way of destroying, or inhibiting the development of bacteria in a wound. Moreover, it seems to be the growing opinion, that in order to prevent septic changes and their absorption, it is not so essential to render the contact of germ elements with living tissues impossible, or to destroy thum if they are already present, as it has been hitherto believed to be ; and it has further been shown to be much more difficult to effect that destruction in healthy living tissues, than in artificial cultivation fluids. But, on the other hand, the opinion is fast gaining ground that a . wound will run a perfectly aseptic course, if bacterian development be inhibited only. The practical conclusion seems to be that the elaborate precau- tions which have been taken to secure this complete protection of wounds from the presence of germs, or their immediate destruction, if there, are very difficult to effect, and are also unnecessary, pro- vided that the wounded tissues be maintained in such a condition that their development is made inqiossible. The antagonism again, that healthy living tissues present to the energy and action of bacteria is more fully recognised. Thus, while the value of antiseptic dressings in preventing septic absorption is as much allowed as ever, the opinion is gaining ground that these results may be obtained in more simple ways than heretofore, and faith is again being more placed in the capacity of healthy tissues in a wound to heal aseptically and to be unaffected by germ elements in their neighbourhood, provided that they are so treated as to be kept in health throughout. This tendency to simplicity has especially shown itself in the abandonment of the spray, and the substitution of irrigation, either throughout the operation, or towards its termination, the antiseptic fluids used being carbolic acid (1 in 40), or perchloride of mercury (1 in 1000). In all other details of immersion of instruments, sponges, etc., the proceedings are the same as in a strict Listerian dressing, and the wound is dressed with carbolic or corrosive sublimate gauze, salicylic wool, or with iodoform freely sprinkled over the wound, and then covered with the gauze or wool; the rules for drainage being according to ordinary surgical principles. 240 of antiseptic dressings, etc. The Antiseptic Method of Lister. drSseinan Descriptions of the germ theory of disease, and the other arguments by which Professor Lister seeks to place on a scientific basis the proceedings Avhich have for their object absolute purity of the surfaces of Avounds, and of everything that may come in contact, thereAvith, may readily be found by all Avho desire to inform themselves on these points,* and we have here only to state, as shortly as may be, how the necessary details of the Listerian method should be carried out. At first sight these may seem very numerous, minute, and difficult to remember, but as a fact if it be conceded that the surgeon or dresser himself believes in the reasonableness and necessity of all the precautions, these details will be carried out as matters of routine, Avithout fear of any being forgotten. Many of the points Avhich are very important or essential to the success of the Listerian dressing, are yet common to it and to other forms of cleanly surgery, and as such, are de- scribed under the head of the general treatment of wounds. Drainage, for example, and the employment of animal liga- tures, are essential points in several methods of dressing wounds, other than the Listerian plan, although the recogni- tion of their importance is largely due to Professor Lister's advocacy. Perfect asepsis. A Avound may be considered to have run a perfectly aseptic course, Avhen there is throughout its healing, no fever, and no suppuration. It is desired to secure this by the Listerian dressing, and all cases in Avhich, after antiseptic precautions have been taken, traumatic fever, or profuse suppuration, or both, develop, must be regarded as failures, hoAvever well the patient may recover. On the other hand, wounds both large and deep will often under good hygienic conditions, heal without suppuration, indeed perfectly aseptically, although these special precautions have not been taken. The necessary it is obvious that the Listerian method, Avhen it is applied precautions. . ' 1 I to operation Avounds, starts under far more favourable con- ditions than in the case of accidental injuries ; but in both instances the same end is desired, and much the same means are taken to attain it. These means are,-all of them, taken so as to ensure absolute purity, and the absence of germ elements, and they may * See for example Sir \V. McCormack's "Antiseptic Surgery." Smith, Elder & Co. 1880; or Mr. W. Watson Cheyne's work on the same subject. 1882. OF ANTISEPTIC DRESSINGS, ETC. 241 be considered under the following heads :—purity (1) of the air; (2) of the Avound and of the parts adjoining; (3) of all instruments, bandages, and other things which can come into contact with the wound; (4) of the persons of all concerned in its dressing. Moreover, this method is concerned not only with the dressing of the wound in an absolutely cleanly fashion, but with the maintenance of it in this condition. Purity of the air surrounding the wound. Purity of the This is attained by making a spray of steam, or of air, air> loaded with carbolic acid, which must envelop the hands of the operator and assistant, and all the parts about the wound. Fig. 133.—Steam Spray Producer. parts would be lengthy, a minute's inspection will enable 16 242 of antiseptic dressings, etc. any intelligent person thoroughly to understand its working. A full sized spray will use up about 12 oz. of water, and a someAvhat larger quantity of the acid solution, in an hour, if one nozzle alone be used. The strength of the carbolic solution in the reservoir should be 1 in 20. The folloAving are the chief points to be borne in mind in the management of the spray :— The lamp. The trimming of the lamp must be looked to carefully, and care taken that there is spirit enough to last half as long again as the spray is expected to be rc<|iiired. The water. The Avater should be put into the boiler nearly boiling, or much time will be Avasted; it should never be alloAved to boil aAvay. As soon as the necessary pressure of steam is produced, the lamp should be turned clown, so that the flame is just enough to maintain an efficient spray. The safety valve should not be loaded beyond the minimum pressure, in all ordinary cases, to avoid straining the boiler. The tube, up Avhich the carbolic passes, should have a metal "T" piece at the lower end, into the cross pieces of which two small pieces of sponge should be placed, to prevent any grit passing up and clogging the nozzle. The carbolic The reservoir should be watched to see that the supply does not run short, and care should ahvays be taken that there be no settlement of undissolved acid at the bottom, as may happen in badly made solutions. In cold weather a little gain in the warmth of the spray may be attained by Avarming the acid solution. The spray must be so placed that it shall not play on the face of the patient, and must be at that distance Avhich will allow the finest part of the steam cloud to envelop the wound. If, by any mischance, the spray ceases to diffuse the acid, it becomes bluish, and less noisy. The wound must then be immediately covered up Avith a pad of soaked carbolic gauze, or with a large carbolised sponge, which should be kept ready to hand. If either the steam or acid nozzle gets choked, it must be cleared by passing a fine Avire, never a pin, doAvn it. The lamp should be turned out directly the spray ceases to be used, and the boiler emptied. purity of the Purity of the instruments. instruments. An iustruments and needles should be got ready before- hand, and these together with the drainage tubes, ligatures, OF antiseptic dressings, etc. 243 and everything Avith Avhich the wound may have to be touched must be placed in shallow pans and covered Avith a 1 in 20 solution of carbolic acid. Unless this be done, there will always be a risk of something being snatched up in a hurry, before it has been passed through the solution, but both this precaution, and the habit of placing the instruments in the solution in the intervals of their use, will soon be automatically carried out by any surgeon Avho means to be thorough. Sponges may safely be employed if they be kept perfectly of the sponges. clean, but those used for antiseptic dressings should be kept apart from those in ordinary use, in a closed vessel filled Avith a 1 in 20 carbolic acid solution. After use they should be Avashed in water, and then in a solution of washing soda, and replaced in the vessel. During an operation or a dressing they should be cleansed in a 1 in 40 solution, as required. Purity of the persons of the dressers and surgeons. of the In addition to ordinary washing, the hands of every one hanas,°etc. Avho may be required to touch the patient should be thoroughly rinsed in carbolic acid, about 1 in 40, and if at any time during the dressing the hands come in contact Avith material Avhich has not been carbolised, they should again be put in the solution. It is generally convenient for the surgeon or dresser to wear over the sleeves a pair of gauntlets or cutis, Avhich may conveniently be made of the pink waterproof material, described on page 245. This Avill protect the coat-sleeve from the soaking spray, and its smooth surface is easily kept aseptic. Purity of the wound and adjacent parts. of the wound This is in great part secured by the spray, but other pre- parts!diacent cautions are needful. The edges and neighbourhood of an accidental wound, or the skin surface where an operation wound is about to be made, must be Avashed, or rather scrubbed, with the 1 in 20 or 1 in 30 carbolic solution. If hairs are groAving over or near the part, they must be cut close or shaved. The other parts of the limb or trunk should be protected from the spray by macintosh sheeting,* and a very effectual " cordon " of aseptic material may use- fully be made, by disposing a toAvel, or towels wrung out of 1 in 40 solution, around the parts concerned in the oper- ation or the dressing. * Waterproof sheeting must also be used to protect the neigh- bouring blankets or clothes from the spray. 244 OF ANTISEPTIC dressings, etc. The details of the arrest of bleeding, the drainage, and the application of sutures, are those which have been already described. Forcipressure or torsion may be freely employed, and a silk ligature may be used if the occasion calls for it, but eitgut is the material which will most commonly be employed. The general rule as to the desirability of arrest- ing all haemorrhage before the wound is closed, applies with equal force to antiseptic wounds as to others, for though a blood clot, lying in the cavity of such a wound, may cer- tainly become organised, or at least be replaced by organised tissue, its presence is-to be avoided if possible. The wound having been closed, and the drainage tube adjusted, a final syringing Avith 1 in 20 carbolic solution should always be performed, and that so thoroughly, that the whole of the wound cavity is distended and all blood clots washed away. The covering or Whatever the wound may have been, it should be now septfe'wounds.1' absolutely aseptic, and the next point to consider is hoAv it is to be " dressed," that is, covered up, so that the changes which it Avill go through from this time, until it is com- pletely healed, may be performed in an absolutely healthy fashion, Avithout fever, suppuration, or pain. In a chemi- cally pure atmosphere, this would be attained without further precautions, and even in good country air, operation and other Avounds will run an aseptic course with any simple dressing. But in hospital wards, and in most dAvellings, precautions must be taken to prevent the germ laden air from coming into contact Avith the wound, or with whatever in the way of discharge may be coming from it, unless it has been previously purified. The use of the This is the rcdionale of the gauze dressing of Listerian wounds, and it is founded on the same reasoning as the preservation of putrescible fluids from decomposition in test tubes, by inserting pledgets of cotton wool into the mouths of the tubes, the fluids being at the time free from anything which can set up septic changes. Details of the Over the wound itself is first placed a strip of green oiled silk, made impermeable to moisture by copal varnish, and then coated with a thin layer of dextrine. This "protective" keeps the edges of the Avound from being irritated by the gauze. The end of the drainage tube should come through a hole cut in it; the silk must be soaked in a 1 in 40 car- bolic acid solution before application. Preparation of The dressing Avhich is applied next, is a very loosely woven "gauze" or muslin, unbleached, and saturated in a mixture of carbolic acid, resin, and paraffin, in the propor- OF antiseptic dressings, etc. 245 tion of one part of the acid to four of each of the other ingredients. The resin makes the muslin someAvhat sticky, and this greatly adds to the firmness of the dressing. This gauze is used in the form of pads, rollers, and of loosely crumpled up pieces, which serve to fill up crevices, and to absorb discharges, and which is called " gauze waste." Over the protective there is generally placed a pad moistened with 1 in 40 carbolic acid solution; this serves for firm, even pressure on the wound. Over and around the pad a sufficient quantity of gauze Avaste must then be disposed, especially about the lower parts of the Avound, the amount varying according to the amount of discharge Avhich is expected. A feAv turns of a gauze roller may conveniently be used to fix these internal layers of the dressing, and if a firm pressure be wanted, as very generally happens, it should noAv be applied. Then a large square, or shaped piece, eight or twelve layers thick, is placed over the whole, and bandaged on with another roller as firmly as is necessary. Between the outermost layer of this piece and all the The water- rest, a piece of pink waterproof sheeting is placed Avith the pro° ng" smooth face towards the wound ; it should be a little smaller all round than the gauze. Its use is to prevent the dis- charge coming into contact with the air Avhen it has soaked through all the layers. The waterproofing should be sponged with 1 in 40 carbolic before it is placed between the gauze layers. This outer piece must be large enough to well overlap the inner gauze dressings, and to serve as a general wrapper over all. The spray should not be turned off until this outer piece has been applied, Avhen the dressing may be considered finished, so far as the antiseptic measures are concerned. The steps to be taken at the future dressings are precisely Re-dressing. the same as for the original one. The spray must be turned on directly the outer bandages are loosened, and all the precautions for cleanliness of hands, instruments, etc., must be as rigidly carried out. It is impossible to lay doAvn rules as to the time of re- Time of. dressing. Some cases may be left for weeks, indeed, until the wound is completely healed, Avhile others will require to be dressed daily. Other things being equal, the period depends upon the amount of discharge, for as soon as there are signs of this coming near the surface, the time for fresh 246 OF antiseptic dressings, etc. dressing has come, though a little delay may safely bo alloAved if additional external layers of gauze are imme- diately put on. Any circumstance which arouses a suspicion that things are going Avrong, such as undue pain, or a high temperature, Avill call for prompt re-dressing. The wound Avill be known to be aseptic, by the absence of smell, or of any discolor- ation of the silver sutures, or of the oiled silk; its edges should present a quiet, inactive appearance, and there should be very little tenderness anywhere. The discharge should be serous, or in recent cases, blood stained, moderate in amount, and freely discharged through the tubes. In re-dressing, the skin surface around the Avound should be lightly sponged with 1 in 40 carbolic solution, and gentle pressure made to ascertain that there is no bagging of dis- charge. The drainage tube should be taken out, syringed through Avith 1 in 20 carbolic and replaced (being shortened if necessary). The Avound should not be syringed through, as this will only separate parts which are adhering. If at any time the wound becomes in the least offensive, or freely suppurates, antiseptic precautions may be said to have failed, and may be discarded at once for more simple measures. Modifications of Modifications of the Listerian plan.—At the commencement the Listerian r 1 • 1 1 • r i plan. of this chapter we have given some account ot the recent methods of antiseptic dressing Avhich have so far departed from the original plan that they cannot be rightly called " modifications " of the Listerian dressing. The neAV anti- septic materials used in these dressings are chiefly solutions of corrosive sublimate, in strengths of from 1 part in 800 to 1 in 2000, corrosive sublimate gauze, or wood avooI, moss, oakum, etc., similarly impregnated, iodoform powder, or iodoform gauze. But all of these, with the exception perhaps of iodoform poAvder, are used for dressings other- wise strictly Listerian. Again, with regard to the spray, some surgeons have abandoned it Avhile retaining all other precautions, while others only turn it on at the conclusion of an operation and while the dressings are being applied. Some surgeons syringe the Avound out with a carbolic solution at each time of dressing, as a matter of routine. Carbolised ointments should also be mentioned as being used in antiseptic dressings, in the form of Professor Lister's " carbolic cream," or as a mixture of the acid Avith vaseline, and a dry carbolised atmosphere has been attempted in two or three different ways, but hitherto Avithout practical success. OF antiseptic DRESSINGS, etc. 247 Other substances have been substituted for carbolic acid Thymol. in the spray. The chief of these is thymol, a not distant chemical ally of carbolic acid. Gauze bandages may also readily be impregnated with it. The antiseptic properties of this substance are certainly inferior to carbolic acid, and its thyme-like smell soon becomes annoying. Salicylic acid has not been used in the spray, but in salicylic acia salicylic wool avc have a material, little, if at all inferior to ' . carbolic gauze as an antiseptic, and Avhich, mechanically, has in some respects distinct advantages. Salicylic avooI is an absorbent wool (i.e., cotton, from which all grease has been removed by alkalies), which having been soaked in an alcoholic solution of the acid, and then dried, retains it within its meshes in crystals. In many instances the avooI may be entirely substituted for the gauze, the Avhole dressing simply consisting of a sufficient quantity of the avooI placed over the wound, and covered with a bandage; but most commonly the wool is used with the gauze, supplying the place of the gauze Avaste, in filling up interstices and corners. Care must be taken to shake it about as little as possible-, for the acid particles are peculiarly irritating to the nostrils and throats of the bystanders, and it should be cut, not torn. This acid can also be employed to impregnate jute, a much cheaper material, and 1 part dissolves in about 10 of alcohol. The strongest Avatery solution, 1 part in 300, is a good antiseptic lotion for Avashing out abscesses, etc., but is not so powerful as carbolic acid. In consequence of the expense of the gauze, felt and tow carhoiic tow, are also largely used on the Continent; they are impreg- nated Avith carbolic acid in the same way as, but hold even more than, the gauze. On the other hand, a more com- fortable and much more expensive gauze is manufactured by carefully bleaching and softening the coarse muslin commonly employed, before it is impregnated with the acid. But the tAvo antiseptics Avhich are noAv most used in the Mercuric preparation of dressings, are (1) sal-alembroth (a double ieSblllgi salt of perchloride of mercury and ammonium chloride); and (2) the double cyanide of mercury and zinc. Sal- alembroth gauze contains 1 per cent., and the avooI 2 per cent., the mercuric zinc dressings about 3 per cent, of the salt; the former are coloured blue and the latter violet, the colouring matter not only rendering the material easily recognizable, but also serves, in the case of the mercuric zinc, to fix the salt in the dressings. The disadvantage of 248 OF antiseptic dressings, etc. the alembroth preparations is that the discharges from the wound readily dissolve the salt, and soaking in the dress- ings take up a larger and larger amount, until the solution may become strong enough to cause vesication of the skin. In using either dressing a layer of gauze, which has been wrung out of 1 in 2000 mercuric chloride or carbolic solution, is first applied ; over this several layers of dry gauze, and finally, a plentiful covering of wool. The folloAving substances may also be used as dressings or Avashes for Avounds, Avhich in other respects have been treated on the Listerian plan, and may keep them in an aseptic condition, but none, as far as Ave know at present, are as certain to do so as the carbolic or corrosive sublimate gauze or the salicylic wool. carbolised oil (1) Lint soaked in 1 in 20 to 1 in 40 carbolic oil, as recommended in the ordinary dressing of Avounds. This is sometimes useful in plugging wounds, as in operations for caries or necrosis. Boracio acid. (2) Preparations of boracic acid, (a) Boracic lotion, a saturated Avatery solution (about 4 per cent.) is odourless and non-irritant; it is generally tinted pink with litmus to distinguish it from plain water. It has been used in the spray for operations, but more commonly for throat affec- tions, (b) Boracic lint, this contains nearly its own weight of the crystals of the acid, incorporated by soaking the lint in a boiling saturated solution, and drying. It is also generally coloured pink. This material is also largely used in ordinary non-Listerian dressing, (c) Boracic ointments. Mixtures of the acid AAdth wax or vaseline are aseptic and non-irritant. The former is made of 10 parts of the acid, 10 of Avhite wax, and 20 parts each of almond oil and paraffin. The vaseline ointment is a 5 to 10 per cent. mixture. Borogiyceride. Borogiyceride, introduced by Professor Barff as a means of preserving meat from decomposition, AA^as soon employed in • antiseptic surgery.* It is a semi-solid substance, like half- melted stearine, and is soluble in water. A 5 per cent. solution is generally used, both to Avash the wound and to saturate lint for dressings, but it mixes also with vaseline as an ointment. Eucalyptus oil. Eucalyptus oil is a good antiseptic, and is recommended by Prof. Listerf to be used Avhen carbolic acid is not advisable. * For a full account of its use, by Mr. Barwell, see British Medical Journal, 1882, Vol. II., p. 362; also p. 371. f See Lancet, January, 1881, p. 828. OF ANTISEPTIC DRESSINGS, ETC. 249 An antiseptic gauze may be made with a mixture of 1 part of the oil, and 3 parts each of dammar and paraffin; or a mixture of dammar and the oil may be used with lint. It also mixes with olive oil. The folloAving substances need only be enumerated as other ami possessing distinct antiseptic properties, and having a more septlcs- or less extended employment for that end :—Acetate of alumina, oil of turpentine, naphthalin, sugar. (2oO OF DRESSING OF BRUISED AND PtNUTURED WO ENDS, CHAPTER XVII. Wounds Continued. The digestion of the wound. Its nature and extent. Importance of the relief of tension. OF THE DRESSING OF BRUISED AND PUNCTURED WOUNDS, AND OF CERTAIN SPECIAL KINDS OF WOUNDS. Of the Dressing of Bruised Wounds. All wounds may, but bruised wounds must go through certain phases of inflammation ending in suppurative granu- lations. The accepted pathology of this process is to be found in all recent text books, but no modern word ex- presses it so well as the old-fashioned phrase of the digestion of the wound. As soon as this is accomplished, and not till then, the wound " cleans " and begins to heal; and if this old word were more often in our thoughts and mouths, we should more rarely see wounds with bruised and inflamed edges coerced into contact, but never into union. The extent of this "digestion" varies from that condition Avhen the edges of the wound just fail to unite by first intention, but quiet down, clean, and take on a healing action Avithin a couple of days, to that which occurs when for a considerable area round the wound the tissues have been bruised to death, and must separate as sloughs before any healing can take place. As soon as this process is finished, A\diether the merest pellicle of lymph, or a large slough, has been thrown off, the wound presents few difficulties in the Avay of its dress- ing, and any of the plans or materials before mentioned may be used. All the precautions of drainage and cleanli- ness must be rigidly carried out, for though the protective poAver of granulation tissue against septic poisoning is very great, blood poisons may yet be absorbed through it. It is, therefore, in their earliest stages that bruised AArounds present special points in their dressing; in these injuries the internal tension which is sure to develop in the tissues in the immediate neighbourhood of the Avound, must be diminished in every possible Avay; moreover, as the Avhole process is an inflammatory one, and may be septic as AND OF CERTAIN SPECIAL KINDS OF WOUNDS. 2-">l well, the cleansing of the Avound, and the removal of all discharges by drainage, etc., must be carefully attended to. A bruised or torn wound should never be tightly closed Bruised wounds up, and this not only because the edges will not unite, but ciosed.be tlghtly because the dragging together of tissues of doubtful vitality must still further reduce their chance of recovery. The wounded parts should be replaced and supported in a gentle fashion, by strapping or bandaging. If sutures are put in they must serve for support rather than for readjustment, Avhile in small Avounds Avhere there has been no tearing off of flaps of tissue, it is often best to leave the wound entirely open. In all cases, unless the Avound be left open, it must be Must be drained even more carefully than a clean cut, and Avhatever be the dressing Avhich is applied, it must be of a kind that will keep doAvn the SAvelling and tension, prevent fcetor, and hasten the separation of the sloughs, if any have formed. For these ends poultices and Avater dressings, the former Their dressing. especially, frequently changed, are very useful. If the wounds become foul, charcoal poultices, or Condy's Management fluid, or terebene, or any of the deodorising dressings when ceL1 ' already mentioned may be used. In such cases, too, irri- gation finds its best application, and a foul gangrenous wound will often become sAvcet in an hour or tAvo under a trickling stream of carbolic or Condy's fluid. In other cases, lint soaked in carbolic oil will suit best. If the discharge be very profuse it should be taken up with pads of absorbent cotton-Avool (the salicylic avooI is the best), or of Avood avooI, or, as recommended by Surgeon-Major Porter, bags of muslin, filled with fresh red pine saAvdust, may be placed beneath or around the wound. Another good Avay of cleaning a foul Avound or ulcer is to alloAv the carbolic spray to play upon it for an hour or two. All the arrangements for the support and approximation of the edges of the Avound must be carefully Avatched lest they should become a cause of tension, and therefore of destruction of vitality. Stitches must be promptly cut, and strapping removed, almost before there are any indications for such relief. Sometimes, but rarely, the congested area around a rse of incisions . , . . • • . 1 i • •.. • to relieve bruised wound requires incisions to be made in it, as is so tension. frequently the case in erysipelas (q.v.) for the effectual relief of tension. Punctured wounds, though often very difficult to manage, ^nctmred call for no lengthy consideration. The great point to bear *' 252 OF DRESSING OF BRUISED AND PUNCTURED WOUNDS, in mind, and the great difficulty to combat, is to prevent discharges from being shut up in the depths of the wound by a premature closure of the superficial parts. The drain- age of these wounds is often a very troublesome matter, because it should be done from the bottom, and the mistake of inserting a drainage tube through the puncture, so that the place of exit for the pus is the highest part of the wound, must be carefully avoided.* of certain Of certain special wounds. special wounds. rrii . • 1 n 1 • i Ihe particular wounds we are now about to consider have, some of them, been before mentioned from the vieAV- point of the arrest of bleeding, so that this complication must, for our present purpose, be excluded ; nor, again, shall we consider those Avounds which are inflicted in the course of major surgical operations. Scalp wounds. Scalp WOUnds. These are very generally bruised wounds, although in consequence pf the way in which the tissues of the scalp are stretched over the calvaria, they almost ahvays look like incised ones, even if they be produced by the bluntest of instruments or missiles. sutures may be It used to be laid down as an inflexible rule that sutures should never be put into scalp Avounds, partly because their edges so very generally fail to unite, but principally from the risks of the bagging of pent-up discharges inside the wound thus closed. It is now recognised that these risks are better avoided by proper drainage, and that the tissues of the scalp are so Avell nourished that not only in clean cuts, but also Avhen the parts have been split upon the skull by a blunt instrument, the edges may yet unite by first intention if they be accurately brought together, and tension be carefully guarded against. But drainage from the bottom is here an absolute neces- sity for safety, and it may often happen (as when the scalp is much torn) that the lowest part of the cut itself is not the bottom of the cavity of the wound. In such a case, the best plan is to make a puncture big enough to admit a drainage tube through the scalp tissues at the lowest point of their detachment, so that the Avound cavity may be tapped at its very bottom. The edges of the flap are best adjusted by points of silver suture, but it is even more important to give support to the Avhole of the * Much may often be done, by attention to the position of the patient, to aid the drainage of punctured, and of otber wounds. AND OF CKUTAIN SPECIAL KINDS OF WOUNDS. 253 portion of scalp Avhic h is detached. This may be done by pads of lint or of absorbent cotton avooI, or sometimes a flat sponge will be found to give just the firm elastic kind of pressure required. These wounds must ahA^ays be Avatched carefully, and Pan*eri». of the Avhole head should be daily examined for that kind of bogginess. oedema Avhich is knoAvn as "bogginess." The sutures must be taken out, and the adhesions broken doAvn if there be any collection of pus. (ienerally the thermometer will give an early Avarning of collecting matter. AVith regard to the dressings, no Avounds are better fitted Actual dressing. for the antiseptic method, either with the gauze or salicylic wool, or both. If the plan is to succeed thoroughly, the head must be shaved for some distance around the wound. For ordinary dressings, of which carbolic oil or simple Avater dressing is probably the best, it will only be requisite to shave or clip the hair in the neighbourhood. If sloughing takes place (Avhich is rare), boracic fomen- sloughing. tations Avill generally be the best dressing, but irrigation is sometimes to be preferred. A superficial necrosis of the skull often occurs in connec- Necrosis. tion Avith scalp Avounds. The bone may separate as a scale of sequestrum, but more commonly the dead Avhite patch of bare bone Avhich is at first exposed, becomes more and more encroached upon by granulations, and is eaten up, so to speak, by them, almost insensibly. Cuts of the ear. The special point about these wounds is cuts of the ear. that the vitality of these parts is very good, so that torn pieces, hoAvever nearly detached, should almost always be replaced. Every care should be taken to prevent future deformity. If the cartilage be torn, sutures should not be passed through it and the skin together, but cartilage must be seAvn to cartilage, and skin to skin. The Avhole organ must be kept warm 1 >y < otton wool. Cut throat. This may be among the most serious of all Cu* throat. wounds, even to being immediately fatal, or may be abso- lutely trivial. It is almost ahvays suicidal or homicidal. Apart from the question of ha-morrhage, the especial The especi.v i <• .i l ^ • -l a, l 1 • • dangers. dangers of these Avounds are, primarily, the possible injury to the air or food passage, or to both ; and, secondly, the danger of pus tracking doAvn Avithin the compartments of the Cervical fascia, involving the pericardium or pleura, or leading to septic poisoning. In self-inflicted Avounds, fortunately, OAving to an appar- injury toj;he ently innate tendency of the suicide to attack his "pomum au pas 254 OF DRESSING OF BRUISED AND PUNCTURED WOUND *, Adami" in preference to any more vital part, the respiratory tract escapes more often than might have been expected. When it is injured, the knife or razor almost always divides the thyrohyoid membrane, so that the rima glottidis is exposed, Avhile the epiglottis is frequently cut aAvay from its attachments. The cartilages of the larynx themselves will resist almost any cutting, and from anatomical reasons it folloAvs than any division of the tracheal tube, or of the crico-thyroid membrane, is accompanied by such injury to the great vessels that the bleeding quickly causes death. In most cases, therefore, the larynx is more often exposed than entered, when the pharynx is laid open, but sometimes a downAvard direction of the cut exposes the top of the larynx alone, Avhile in others the oesophagus may be laid open behind the opened larynx. In all rhese cases the proper performance of breathing and swallowing will be greatly interfered Avith. Eisks of If, on examination of the Avound, there seems to be guarded ' general laying open of the pharynx and larynx, and the chink of the glottis be freely exposed, oedema of the latter is practically certain to come on, and its effects had better be anticipated and combated by inserting a full-sized laryngotomy tube through the crico-thyroid space, carrying out all the precautions of steam inhalation, etc., which will be described under the head of the operation of tracheotomy. If, however, the exposure of the glottis be slight, the mem- brane being rather " nicked" than divided, the patient should be anxiously watched, the steam inhalation and the instruments for tracheotomy being ready at hand, so that they can be used at once if sudden dyspnoea occur. Administration When the pharynx is Avounded, food, Avhen swallowed, may escape by the wound, and may also set up irritation of the larynx. Both these complications are very hurtful, so that it becomes necessary to get the food past the wound in By stomach the oesophagus. For this purpose a very soft stomach pump pump. tube may be sometimes successfully introduced by the mouth, and the pump, or a length of tubing fitted Avith a funnel, employed. (Vide use of stomach pump.) By catheter But a better plan is to pass a large soft catheter into the nostril e pharynx through the nose. Introduced in this way, the tube will lie at the back of the food passage and little, or no spasm will be set up by its insertion. The catheter should then be connected Avith a tube and funnel, and in this way liquid food may safely, and indeed easily, be given. Prognosis. The prognosis in the cases of bad cut throat which we AND OF CERTAIN SPECIAL KINDS OF WOUNDS. 255 have been considering, is always unfavourable, for, apart from the injury itself, there -is, very generally, a complete absence of any desire to get well. Nevertheless cases apparently hopeless do sometimes recover. AAThether the air or food passages be wounded or no, the Position of position of the head is important—it should ahvays be kept head- bent downAvards, so that the edges of the wound may come together. Two or three patterns of bandages have been devised for this purpose. We believe that no restraint is ever required, and that patients will always naturally, and of themselves, keep their heads forward, to avoid opening the wound, unless delirium be present, in which case any form of bandage would almost certainly fail. Sutures may be employed in cases of clean cut wounds use of sutures. not implicating the air passage, but care must be taken to provide free drainage, and watch must be kept for the formation of pus, on account of the tendency of the latter to burrow amongst the planes of the cervical fascia. Sutures should not be used Avhen the edges of the wound are jagged and bruised, and the same rule is to be enforced after wounds involving the trachea or oesophagus. It may be absolutely necessary, however, to apply sutures to trachea or oesophagus should there be much separation of the parts after deep wounds inflicted in them. Strict antiseptic pre- cautions should be observed in dressing all wounds. AVhether septic absorption occurs or no, a low form of Pneumonia. pneumonia is very apt to develop, and is very often fatal. A stimulant treatment generally, with alcohol, will be, as a rule, required, and in suicidal cases a careful Avatch must be kept upon the patient. Wounds of the buttocks. A very aAvkAvard wound is some- wounds of the times inflicted upon the buttocks by the fracture of a uttocks' chamber utensil whilst it is sat upon. This almost always happens to hea\y women. Such an injury, or indeed any Avound of that part is very apt to take on unhealthy action, as Avounds in loose fat will do anywhere in the body; they will rarely heal by first intention, and care must be taken that the discharges are alloAved to have a very free exit. Wounds into joint cavities. AVith the exception of the wounds into smallest joints, and sometimes even in them, any Avound by g0U1 which the interior of a joint is exposed is a very serious occurrence, and even Avhen the injury at the outset may seem to be only the most trivial cut, it may Avell happen Are always that in the end there Avill result a destruction of the joint, sei'wus' or a loss of the limb, or it may be of the life. 256 OF DRESSING OF BRUISED AND PUNCTURED WOl'NDS, May be divided into— 1. Simple wounds of joints. Dangers oJ probing. Treatment. AArounds into joints may be divided practically into two classes. Under the first heading fall those cases in Avhich the wound is a small one, or the injury in itself unimpor- tant, only being serious because a joint is entered. In the second class come all the cases of Avounds Avith disorganisa- tion of the joint structures, laceration of the capsule, free exposure of the cavity, rupture of the ligaments, etc. Simple wounds of joints, i.e., Avhere the joint is just opened, and no more, by an incised avouikI. The first and very important point to bear in mind Avith regard to these injuries is that in cases Avhere there is any doubt as to whether the joint has really been opened, under no circum- stances should any attempt be made to decide the question by probing, or in any other way. More mischief has often been done by an unnecessary use of a probe than by the instrument Avhich inflicted the Avound in the first place, and the only safe rule to follow is that in cases of doubt the joint must be supposed to have been opened, and be treated accordingly. If the Avound be just a simple puncture, in which the fact of the joint being opened has been proved by the escape of a feAv drops of synovia, the limb should immediately be put on a splint, and if the knee or ankle, it should be SAvung from a cradle. An ice bag should be put over the joint, and the wound covered Avith some collodion, or a pad of gauze or lint. If, hoAvever, the wound has more distinctly opened the joint, a decision Avill have to be made betAveen treating it on the general principles of cleanly surgery, or on the Listerian plan. If the latter course be decided on, the same details Avill have to be carried out, as Avill be directly described in the case of disorganising Avounds, and in any case the limb Avill have to be most carefully splinted, and the joint fixed in the position of complete rest, Avhich Avill be in almost all cases, one of slight flexion. If the more general plan of dressing be carried out, the edges of the Avound should be gently draAvn together with strapping or sutures, a small drain inserted into the wound, and water dressing or carbolised lint placed over all, while an ice bag should be kept constantly applied. If the joint should get hot or full, leeches (say six for an adult knee) Avill often prove of great service, and the patient must be kept rigidly on a low diet. Treated in this Avay with good hygienic surroundings or in country air, especially if the patient be a good subject AND OF CERTAIN SPECIAL KINDS OF WOUNDS 257 for recovery from injury, Avounds which have communicated with a joint will often heal up straight aAvay, and no serious synovitis be developed. Nevertheless it is the opinion of most surgeons at the present time that Avounds of joints, except the smallest punctures, are more safely treated on the Listerian plan. But even if we allow that cases occur Avhich may fairly 2. Avhere the be considered to belong to a debatable class, there is no exposed.freely question but that all those in which the joint can in any sense be said to be exposed or to have its investing or lining structures seriously injured, should be treated Avith strict antiseptic precautions. The joint must be thoroughly syringed out with carbolic lotion; provision must be made for the thorough drainage of the joint cavity, if necessary, by counter puncture or incision. In fact, all the details of the dressing described in Chap. xv. must be observed, Avhile, of course, splinting and swinging are as necessary now as ever. If the antiseptic precautions fail of their object, or if they Results of have not been adopted, acute synovitis will surely follow, arthritis!0 This is almost certain to run on to suppuration, and this practically means, at the best, anchylosis; Avhile very pos- sibly a subsequent excision or amputation may become necessary. But we must not here discuss the surgery of traumatic arthritis; Ave hope that enough has been said to impress upon the reader the extreme importance of all Avounds Avhich even by the smallest aperture communicate Avith a joint. Wounds of tendons. Tendons, especially those of the muscles of the hand or Avounds of font, are frequently divided in wounds of the extremities, and the manner in Avhich they will re-unite will depend greatly upon their immediate treatment. The cut ends of the tendons should be draAvn out of their Treatment. sheaths and stitched together by three or four catgut or silk sutures passed through the tendinous substance; their ends may then be cut short. The tendon having been joined, the sheath should then, if possible, be closed with a few points of the finest catgut suture, and the rest of the wound adjusted and drained in the usual fashion. The limb, after dressing, must be placed on a splint in the position which causes least strain on the divided tendons. A flexible tin splint, Avhich can easily be bent to the proper shape, will be found most useful. Inasmuch as the great risk attending these Avounds is the 17 258 OF THE DRESSING OF WOUNDS, ETC. diffuse inflammation which is apt to attack the sheaths of tendons, and which is almost always of an erysipelatous, that is of a septic nature, it will be seen at once that the Listerian dressing has here great advantages, and should be adopted whenever it be possible. But Avith attention to drainage and Avith perfect rest on a proper splint, these cases will often do very Avell with simple water, or oily, or dry absorbent dressings. Even if it is not possible to get the ends of the tendon quite together, they Avill probably join eventually by the formation of an intervening band of firm fibrous tissue, if no acute inflammation disturbs the healing process. wounds of Wounds of nerves. All that has just been written Avith regard to divided tendons will stand for similar injuries to nerves. They must be searched for, joined, and the wound dressed in just the same Avay. There need be no hesitation in passing the sutures through the nerve trunk, but gentle handling, and the finest sutures are required. The sheath of the nerve does not usually call for separate suturing, but great care must be taken to see that the cut ends of the nerve tubes come into contact, or at any rate importance of are brought face to face, Avithout overlapping. If this be ear y union. done soon after the injury, repair of structure and function Avill very probably take place, for nervous tissue resists the effects of injury almost better than any other. Even if an interval of half an inch were to exist betAveen the divided ends, they might eventually come together if no barrier lay between; and it is well known now how nerve trunks will recover their functional activity when re-united, even when the ends have been lying apart for Aveeks or months.* The great enemy to repair is, as Mr. Page has pointed out,f suppuration. * See on the subject, Mr. Page, " On the Immediate Suture of Divided Nerves," British Medical Journal, Vol. II., 1880, p. 347, and Vol. I., 1881, p. 717; and the Author for a case of restoration of functional activity to the ulnar nerve after strangulation for 16 months, due to suppuration of an operation wound [Brain, July, 1885). f Loc. cit. OF GUNSHOT WOUNDS AND BRUISES. 259 CHAPTEK XVIII. Of Gunshot Wounds and Bruises. Gunshot Wounds. These were, at one time, supposed to Gunshot form a class of injuries differing in their pathology from all woun other wounds, and requiring different treatment. They were taken to be essentially poisoned wounds, and the main idea in their dressing was to encourage local inflammatory action and to delay union, until by profuse suppuration the poison (generally supposed to be due to the gunpoAvder), had been completely eliminated. This notion naturally led to a very barbarous system of dressing, and it was not until it was recognised that these were essentially and typically bruised wounds, that more rational plans were adopted. Only the more simple cases of this class of injury, or those in which some immediate treatment is called for, can here be considered as belonging to minor surgery; and with this limitation it will be found that their surgical dressing will not differ much from that of all other contused wounds. The hEemorrhage is generally slight, but whether slight or severe must be arrested on general principles. The next point to consider is Avhether the bullet, or what- ^traction of ever may be the missile employed, be still in the Avound; and if so, whether an attempt should at once be made to extract it. To decide this point an exploration should be made, and if possible, with the finger; and speaking generally, if by this means a foreign body be felt, it can Avithout difficulty be ex- tracted, Avith a pair of ordinary dressing forceps, or Avith ones Forceps. especially made for the purpose, as shoAvn in Figs. 134 or Fig, 134.—Bullet Extracting Forceps. 2G0 OF GUNSHOT WOUNDS AND BRUISES. 135, or with Coxeter's bullet extractor (Fig. 136). Search Fig. 135.—Lucr's Forceps. should also be made for any piece of wadding, cloth, etc., Fig. 136.—Coxeter's Bullet Extraeter. Probing for the which may have been carried in with the missile. If nothing can be felt Avith the finger, then a further examination must be made with a silver probe, or one tipped with porcelain (Nelaton's), Fig. 137, by Avhich the bullet may be detected, Fig. 137.—Nelaton's Probe as in the case of Garibaldi, by the mark of the lead on the porcelain.* In making this examination the patient, must always be placed accurately in the same position as when the wound Avas received, a precaution Avhich is often overlooked. Unless the probe detects the bullet to be in a place Avhence it can easily be extracted, the responsibility of attempting to recover it, or of deciding to leave it alone, should not be left to the dresser, or junior surgeon, nor indeed should the patient be subjected by them to a prolonged, or deep probing. Sometimes a bullet will travel a considerable distance from the original Avound and be found still lying immediately be- neath the skin. Thus a pistol bullet may run almost all round the skull beneath the scalp, or round the thorax in the course of the ribs. In such a case a small incision will allow of its escape ; the track of the ball however will almor.t certainly form a suppurating sinus. Whether the bullet has passed out of the body, or has been removed, or has been left, it is vain to hope that the * Sayre's vertebrated probe is recommended for this purpose, bu$ >ve have never found it at all serviceable, OF GUNSHOT AVOUNDS AND BRUISES, 261 Avound it has caused Avill ever unite by first intention. After a period of inaction, inflammation, Avith suppuration, and more or less sloughing, Avill take place, as in all bruised wounds, and this Avill be succeeded by repair by granulation. The dressing should therefore be light, and great care must Dressing. be taken to keep the Avound clean in every possible Avay. Sometimes fomentations Avill be found to hasten the separation of the sloughs, but as a rule antiseptic dressings Avill be the best to use. Bruises. Whenever capillaries or veins are ruptured in Bruises. or beneath the skin, some variety of bruise is produced. Under this head fall tAvo chief kinds of injuries. In the first there is a general infiltration of the tissues, in the second there is a bag of blood, and speaking generally in the one the capillaries, and in the other a vein of some size, has been ruptured. In either case the great point to keep in mind is, that the effused blood should be left alone, except under one or tAvo quite exceptional conditions. For the common bruise, or infiltration of blood, in the The common vast majority of cases, no special treatment is required. It infiltration of is A'ery doubtful if any external application can appreciably 00d" affect the reabsorption of the effusion, or the course of the dis- coloration, but it is probable that local cold and astringent D^s^"gi^ °°'£. dressings may be meful, if applied early, in limiting the extent of the primary escape of blood. For this purpose diluted tinctures are often used, especially tincture of arnica, or evaporating lotions. The astringent action of strong liq. plumbi subacet. is also very effective, and the actions of cold and astringents may be combined. A still better line of treatment is that by firm, even com- compression pression, but only Avhen it can be applied in time to prevent the infiltration of the tissues taking place. A Avet bandage, smoothly applied, or a Martin's india-rubber roller may in such cases absolutely prevent the development of an ecchymosis. This moderate pressure can never be hurtful, but it must be remembered that the vitality is greatly loAvered in bruised tissues, so that all tight constriction, or unyielding compres- sion, as that of a circular piece of strapping, or the corner of a splint, must be avoided* lest an ulcer should be caused, AA'hich Avould certainly be sIoav to heal. * We often see the effects of pressure in limiting ecchymosis, in cases of sprained ankle, when in taking off the boot, the discolor- ation is found to be sharply limited at the level where the ankle is encircled, 262 OF GUNSHOT WOUNDS AND BRUISF.S. Relief of Severe bruises will often be associated Avith great swelling and tension of the parts. This must be met by position and bandaging ; only in the most extreme cases, Avhen the vitality of the surrounding area of skin is seriously threatened, should the surgeon be tempted to relieve this tension by opera- tive measures. The conditions are just the reverse of those present in inflammation, and an extraordinary degree of stretching Avill be noAV borne by the tissues without their incisions. giving Avay or sloughing. If it becomes absolutely necessary to incise an ecchymosed area, small and numerous punctures should be made, and antiseptic precautions adopted. But it is, Ave repeat, generally bad surgery thus to interfere Avith the natural process of re-absorption. Hematoma. When a fairly large vein is ruptured beneath the skin, a hcematoma, or bag of blood, is the result, and much of what has just been said will apply accurately to its management. The fluctuating swellings thus caused are sometimes very large. Thus the rupture of the saphena vein may cause an effusion which will give a Avave of fluctuation from the knee to the crest of the ilium, and, generally speaking, the blood thus poured out does not coagulate in the same way as if it had escaped from the body: Nothing but tension so extreme that the vitality of the parts is seriously threatened, or the occurrence of suppurative inflammation within the cavity (which is rare), should induce the surgeon to open these bags of blood. Rest, position, local cold, and especially, care- fully regulated pressure, as Avith india-rubber or other bandages, Avill in almost all cases effect their re-absorption. They do, however sometimes suppurate, and sometimes they remain Avith the blood unabsorbed for an indefinite time. In the first case, the tumour must be opened and drained like any other abscess; in the second, when patience has fairly been exhausted, and it is plain that absorption is not going to take place, the fluid must be removed. Sometimes, aspira- tion, or the use of a small trocar and cannula will be sufficient to empty the sac, but in most cases it Avill have to be laid more freely open, and the contents turned out; the operation should be performed antiseptically, and the cavity thoroughly drained, Avhile there should ahvays be pressure put upon its walls to prevent a fresh filling up. Lastly, as in the case of a diffused ecchymosis, sometimes but very rarely, the tension on the tissues bounding a hsematoma may be so great that it must be relieved by in- cision. This procedure should be delayed as long as possible but if it must be done it should be Avith the strictest anti- septic precautions, OF GUNSHOT WOUNDS AND BRUISES. 263 Special bruises. First among these may be mentioned Special bruises hsematoma of the scalp, generally occurring in neAvly born thTscaipT c infants, as one of the accidents of labour, but also as a com- plication of fractures and other injuries to the head. Unless actual death of the skull bone takes place, the blood is in- variably re-absorbed, and incision is never required. The peculiarly deceptive feeling as of a depressed fracture has already been alluded to. Sub-conjunctival ecchymosis is sometimes of importance sub-conjunc- as a diagnostic sign in suspected fracture of the anterior Ecchymosis. fossa of the base of the skull, but it commonly occurs almost spontaneously, as during a paroxysm of whooping cough. It should ahvays be left alone, as it is never in itself a matter of importance, and is generally soon absorbed. So, too; aaith the ordinary "black eye," when the ex- «• Black eye." travasation has once taken place, no application will affect the rainbow-like hues of the discoloration, or make them dis- appear quicker than in their OAvn good time. But the early application of cold, as by an ice bag or an evaporating lotion, or of astringents, and especially of the acetate of lead, may do a good deal to limit the actual escape of blood and serum. Hematocele should also be mentioned as being an extra- Hematocele. vasation of blood into a natural cavity. Whether it occurs spontaneously or in consequence of a Moav, its treatment does not differ from that of other hsematomata. Elevation of the scrotum, cold, and carefully managed compression (see strap- ping the testicle, p. 121), will powerfully aid the absorption of the effused blood, and if these measures should fail, the cavity of the tunica vaginalis- must be opened. If there be reason to believe that its contents are chiefly fluid, a hydro- cele trocar may be used (see treatment of hydrocele), but if the clotted blood cannot thus be removed the cavity must be laid open and allowed to granulate up.* Frostbite. A few cases of this injury occur in this coun- Frostbite. try whenever it is visited by severe weather, generally in ill- fed, ill-clad people, Avhose circulation is enfeebled by priva- tion or organic disease, and although it is in no sense a bruise it may here be shortly considered. The main point to * This proceeding is however an operation belonging rather to the major ones of surgery. In other cases it happens that a condition resembling chronic hydrocele develops after the tapping of a hematocele, and the accumulation of the thin serous fluid may be successfully treated by measures similar to those adopted for th? radical cure of that condition (g.i;.). 2G4 OF GUNSHOT AA'OUNDS AND BRUISES. recollect about this form of gangrene is, that the tissue dies, not when it is frozen, but Avhen it thaAvs, in consequence of the intense capillary congestion then set up. In countries Avhere the accident is common this is Avell knoAvn, and Avhen any part, as the nose or tip of the ear, becomes dead white and loses its sensibility, the custom is to rub it for a long time, but not too vigorously, Avith handfuls of snow. Fol- loAving the same principle, great care must be taken not to thaAv the frozen part too quickly. The patient should be kept in a cold room, and bathed first Avith cold water, and then gently rubbed with the hand till circulation begins to be restored, when there will be much throbbing and feeling of heat, and the extent of the mischief Avill be disclosed. At no time must heat be applied, but the part should be wrapped up in cotton wool. Frostbite from Sometimes a frostbite is produced by the prolonged ap- et er spray. plication of the ether spray, especially if the parts frozen are already in a state of inflammation, and even an ice-bag, sloughing fiom if left on for too long, may produce sloughing. Thus we have known such a bag, left on a hernia for a night, produce extensive destruction by the morning. OF ULCERS OF THE LEGS, VENEREAL SORES, ETC. 2C5 CHAPTER XIX. Of Ulcers, especially Ulcers of the Leg.—Of Venereal Sores, and Syphilitic Ulcerations. Of Ulcers. Every surface wound Avhich is granulating is Dressing of in a sense, an ulcer, and what we have previously stated as ulcers" to the dressing of wounds when the granulation process has once started, will stand equally for that of any healing ulcer, however produced. It is difficult to prevent a healthy sore from closing over ot healthy rapidly, and almost any cleanly form of dressing will serve ulcers' well enough ; still discretion may be exercised. Simple cerate, or zinc ointment, Avill generally be best for small surfaces; lint soaked in carbolised oil, or in carbolic acid, or in some other lotion for large ones. Sometimes under the oil the granulations Avill get large and flabby, and an astringent dressing, as of zinc sulphate or silver nitrate, is called for. Sometimes the edges require to be touched with caustic, or with a crystal of sulphate of copper (blue- stone) and so on. The dressing of healthy ulcers, then, presents little diffi- culty or occasion for remark. On the other hand the * difficulty of getting an unhealthy sore to change its character and take on healing action is often verjT great indeed, and some of the Avays of attempting this we must shortly discuss. It would plainly be useless to try to describe all the kinds of unhealthy ulcers which mav be formed in the various parts of the body, nor need we adopt any especial plan for their classification. The various plans of dressings Avhich ma}' be resorted to Avill be sufficiently described if Ave take tAvo great examples of ulceration for our consideration, namely ulcerated legs, and syphilitic sores. Ulcers of the legs. These are the bane of all out-patient rooms, where those mcers of the who sufler from them form at once the most numerous and leg" the most unsatisfactory class of patients to treat. With the exception of those Avhich depend on some specific taint, or which are the direct result of injury, it may be said that they are all the residt of an imperfect return of the blood from the extremities, either due to varicosity of the veins, to simple 266 OF ULCERS OF THE LEGS, VENEREAL SoilKS, etc. Treatment of the venous stagnation. By bandaging. malnutrition of the tissues, to feebleness of the general cir- culation, or all of these circumstances combined. The treatment must therefore be directed in the first place toAvards this condition of venous stagnation, and secondly, toAvards the improvement of the surface of the sore. By rest in bed. Nothing so well fulfils the first indication, as complete rest in bed, Avith the limb somewhat raised, and in the large majority of cases this treatment alone Avould be sufficient to effect a rapid healing, if only it Avere possible to carry it out. But too often for these patients, to lie in bed would be to starve, and so other means must be resorted to, and the chief of these are, even bandaging, elastic stockings, Martin's rubber bandage, and strapping. Much may be done to prevent the stasis of blood and oedema by means of a firm even roller, applied to the legs as in Fig. 47. The bandage should include the foot, but not the heel, and should be put on every morning before the limb is allowed to hang doAvn, and if the material possess some elasticity, as in the Avoven or elastic felt kinds, so much the better. For obvious reasons it is hardly possible to apply elastic stockings to legs in Avhich the ulcers are large or discharging at all freely; but if this be not the case, a properly fitting stocking often gives an immense relief from pain, and may prove a direct means of cure. The objections inherent to their use mentioned before apply, equally in these cases. Probably feAv improvements in surgery have been the direct cause of relieving suffering, more than the introduction by Dr. Martin of thin indiarubber roller bandages for the treatment of this condition.- These have been before mentioned as being useful in a variety of Avays, but it is in painful ulcers of the legs that their good effect is especially apparent. As a rule, they should not be Avorn in bed, but should be applied like other bandages before the legs hang down in the morning. The bandages must be protected from the discharges by pads of dry lint or cotton wool, and care must be taken that they are not put on too tightly, Avhich may very easily happen from their great elasticity.* The introduction of Martin's bandages will probably cause the proceeding of strapping ulcers, to be less frequently resorted to than formerly, but still in proper cases it is a very valuable treatment. Its principle is the same as the fore- going, namely, of giving support and pressure. * For a full account of these bandages, see British Medical Journal, 1878, Vol. II., pp. 624 and 874. By elastio stockings. By Martin bandages. By strapping. OF ULCERS OF THE LEGS, VENEREAL SORES, ETC. 267 Ordinary adhesive plaster, spread on linen or leather, is generally used ; the surface of the ulcer should be covered Avith a piece of moist boracic lint. The strapping should be cut into strips about an inch Avide, and these must be applied so that they overlap each other, as is described for the strapping of the knee (Fig. 80). The strips should begin at least two inches below the ulcer, and end at least tAvo inches above it. Over the strapping the foot and leg should be firmly bandaged. If this treatment can be borne at all, the relief afforded by the support is very great, but sometimes the veins are ex- tremely varicose and thin walled, and the ulcerated surface is too tender to bear direct pressure. In such cases it is often Avise to apply a strip, three inches broad, round the leg, above the ulcer, to support the column of blood in the dilated veins. Operations for the radical cure of varicose veins are often wisely undertaken in cases of ulcerated legs arising from this cause, but the consideration of these proceedings does not come Avithin the scope of this work. Very much may be done locally to promote the healing of rocai treatment these ulcers, and successfully, provided the venous stagnation, surface!ceia e< Avhich is their real cause, be first alleviated. Much, too, may be done by proper feeding, and sometimes by medicines, to improve the nutrition of the tissues. The nature of the dressing which will best suit any par- ticular ulcer will depend upon the character of the sore; Avhether it be hsemorrhagic, neuralgic, inflamed, and so on, so that no one line of treatment can be laid down as generally applicable. We propose here to give examples of what may be done for the chief kinds of ulcers met Avith in the outpatient room, it being understood that the dressings are examples only. By "common chronic" ulcers we mean those in which common the edges and discharge are fairly healthy and in which c romc granulations are present. There is little difficulty in getting these to heal if the venous stagnation be prevented. Oint- ments, such as vaseline, zinc ointment, ung. hydrarg. nitroxidi, diluted with lard or vaseline, or carbolised, or eucalyptus oil, and many other dressings may be used. All these dressings should be changed frequently, and the sore kept very clean, weak carbolic or Condy being used for washing. Almost the most hopeless kind of ulceration is that "Cold" ulcers, irregular, shalloAV, pale, dry form, known as a "cold" ulcer. 268 OF ULCERS OF THE LEGS, VKXKltEAL SOUKS, ETC. They are generally large, quite devoid of granulations, in- sensitive to touch, with little or no discharge or evidence of inflammation. It is this last fact that tempts the surgeon to despair, and unless the surface of the ulcer can in some Avay be stirred into action, no healing can take place. To this Blistering. end it was an old practice to apply a blister over the whole surface, and although this remedy is noAv old fashioned, it caustics. might Avell be revived in suitable cases. A solution of chloride of zinc (10 grains to the 5J), or of nitrate of silver (from 10 to 20 grains to the 5J), or the solid lunar caustic, are the stimulants most commonly used. When the ulcer has once been roused into action and granulation has com- menced, the process must be maintained by milder stimulating dressings, as the Friar's balsam, the balsam of Peru, the ung. hydrarg. nitroxidi dil., the diluted tincture of iodine, or by one of the astringent lotions as that of the sulphate of Warmth. zinc or copper. It is especially important that the ulcer and the limb should be kept Avarm. This is best effected by cotton wool; occasionally a very hot linseed poultice, to which a little mustard flour may be added, Avill prove a very useful stimulant. It is in this form of ulcer that strapping is most beneficial. Flabby ulcers. Allied to the "cold" ulcers are those which are not devoid of granulations or action, but in which the whole process of ulceration or repair is Aveak. They may spread to a large size, with pale flabby granulations, a Avatery discharge, and very frequently Avith their edges extensively undermined. These also must be stirred into action, and this can gene- May be treated rally be done somewhat more readily than in the case of the hke cold ones. cqj * oneg^ ^y tne uge 0f similar stimulant dressings. In addition to the dressings, hoAvever, it is necessary here to trim off the undermined edges with scissors, and if the granulations are very flabby, it is Avise to get rid of them altogether by scraping the surface of the ulcer, and thus starting afresh. Sometimes a very useful stimulus is given Use of sheet- to these sores by covering them with a piece of sheet lead, such as is used for packing tea, cut out to the right size. A rather active chemical action is set up, and the metal is quickly eroded, the stimulating effect being probably due to the action of lead sulphide in the nascent state, upon the surface of the sore. inflamed ulcers. An inflamed ulcer is ahA^ays a spreading one, and on that account alone the process should be cut short as quickly as possible. Their sharp cut, angry edges, painfulness, and dirty discharge, make a mistake in their diagnosis almost iin- OF ULCERS OF THE LEGS, VENEREAL SORES, ETC. 269 possible. Confinement to bed is now, not desirable only, but necessary. The limb must always be raised, and irrigation (see Fig. 132) is probably the best of all dressings. Water dressing (weak carbolic acid or Condy being used) and poultices are also very useful. These ulcers are generally foul, and pass by insensible gradations into the kind next to be considered. That worst kind of sloughing ulcer, sloughing phagedsena, sloughing or will be considered later, but any ulcer may, under certain conditions, take on a sloughing action. Sometimes the rate and character of the destruction are so rapid, that it is advis- able to cut it short by the application of nitric acid, or the actual cautery (see Sloughing Phagedaena). As rule, how- ever, it is sufficient to treat the case as one of severe inflamed ulcer, with the addition of those measures rendered necessary by its foetid character. Charcoal, or sometimes yeast poul- tices are generally preferable to irrigation, at any rate, at first. The limb may be kept in a bath of Condy or carbolic acid for an hour or tAvo, and in any case these lotions, or the lotion of chlorinated soda or the like must be very freely used. Terebene and " Sanitas" are also good applications, as is also iodoform in certain cases. The management of those ulcers, the granulations of Hemorrhagic which have a marked tendency to bleed, has been already discussed (p. 44), and need not be further considered. This is the case too, Avith those which erode the walls of varicose veins (see p. 32). Pain is not usually a prominent symptom in ulcers on the Neuralgic legs, but sometimes they entail an inordinate amount of suffering. These neuralgic ulcers are generally small, with small granulations. The relief of the pain they cause is often very difficult, and sometimes almost hopeless. Of local anodynes, the most generally successful is a concentrated Anodynes. carbolised oil, say, 1 in 20 to 1 in 12, or the glycerine of carbolic acid may be used, or the same acid, pure. A lotion of the nitrate of silver, grs. v—5j is also often effective, as is sometimes the solid lunar caustic. In other cases opium, or its alkaloid may be used in the form of poppyhead fomentations, or the powdered crude opium may be dusted over the sore. Care must be exercised in this case that only a limited quantity is used, or poisonous symptoms may develop from absorption.* * It is perhaps more correct to say that these cases should always be watched, for it seems that there exists in some people a suscepti- bility to opium poisoning by the local absorption of even very small doses. 270 of ulcers oF The legs, venereal sores, etc. Division of nerve. Pressure. Of certain special treat- ments. Electricity. Incision. Solutions of cocaine, morphia and chloral may also be used as local applications, on lint, or in the form of the hand spray. Preparations of belladonna are also sometimes of service. Iodoform is frequently of service in alleviating the pain of simple ulcers, as it is to a more marked extent in the specific forms (q.v.). If the pain can be distinctly localized to one spot, it is probably seated in one nerve filament. The late Mr. Hilton has shown that it may be quite abolished by making an in- cision through the granulations, so as to divide the nerve thread, and these are the most fortunate of all cases for treatment.* In other cases the pain is due to a general neuralgic tendency, and these may be benefited by con- stitutional treatment, such as quinine, iron, etc. Lastly, the pain of a neuralgic ulcer may often be relieved by moderately firm pressure. Thus strapping, or Martin's bandage, are appropriate modes of treatment for these as for other forms ot ulcers. The elastic compression exercised by a sponge bandaged or strapped over the granulations has been recom- mended. The following lines of treatment have all had more or less success in fitting cases, but we here rather mention than ad- vocate them. The electrolytic effects of a weak galvanic current have certainly a stimulating action on chronic ulcers, but the ap- plication is not very easy, and the same good results may probably all be attained in more convenient ways. The cur- rent might be applied direct from an ordinary gahranic bat- tery, as from two pint Leclanche cells, one electrode being placed a little distance from the ulcer, Avhile the other (which is best fashioned out of a piece of sheet zinc or lead) should be placed over it. The current should be maintained for several hours. Another way is to connect tAvo plates of zinc and silver by a piece of insulated Avire, and to apply the zinc or the silver platet over the ulcer, and the other one elseA\diere, say on the opposite side of the leg, or on another ulcer, if more than one exists. Incisions made through the margins of the ulcer into the subcutaneous tissue have been advised. Their good effects are probably due to the alteration of the vascular and nervous * This will be again alluded to apropos the treatment of painful ulcer or fissure of the anus. t Authorities differ as to whether the positive or the negative pole is the more efficient. OF Ulcers of the legs, Venereal sores, etc. 271 supply thus caused. Again, incisions, crucial or multiple, are sometimes made through the bases of cold ulcers, especi- ally of those which are adherent by inflammatory exudation to the underlying tissues.* Excision of the whole ulcerated surface, Avith or Avithout Excision. attempting to close the edges of the wound thus formed, is a rational and often successful treatment for very severe and obstinate cases. Both the actual and the galvanic cautery have been em- cautery. ployed on the same principle as the application of a blister or lunar caustic, namely, in order to start afresh, and it is hoped, with more healthy granulation tissue, after the sloughs caused by the cautery have separated. In addition to the occasional use of a carbolic or Condy continuous bath, the limb may be submerged continuously for days (Hutchinson). This treatment Avill be referred to again under the head of " sloughing phagedsena." Ulcers may also be "sealed " by covering them over with "Sealing." Avhite wax, or lastly, for deeply excaA^ated indolent ulcers, the cavity may be filled up with the powdered carbonate of iron, and the whole strapped up. Doubts have been expressed as to the Avisdom of healing old chronic ulcers of the leg of many years' standing ; it has been suggested that they sometimes acquire a certain status among the secreting or excreting organs of the body, a re- spectability, as it were, and that though their presence may be a discomfort, their departure Avould be a disaster, from the extra Avork Avhich would then be thrown on other organs, chiefly, we suppose, upon the kidneys. We Avill not venture upon a positive denial of this some- what bizarre theory, but we believe that any ulcer which can be made to heal should be encouraged so to do. The question of skin and sponge-grafting will be considered in the next section under " Burns and Scalds;" but it may here be said that in any form of ulcer, skin grafting can never be successful unless the surface of the sore be covered with healthy granulations. OF THE DRESSING OF VENEREAL SORES, ETC. We here consider the chief Avays of dressing the initial syphilitic sores, lesion of syphilis, i.e., the true syphilitic or infecting sore, * See " Clinical Lecture on Adherent Ulcers," by Mr. Hardie, Lancet, May 17, 1884. 272 OF THE DRESSING OF VENEREAL SORES, ETC. a« it mcst commonly presents itself, the later syphilitic ul or- ations, and the common soft, non-infecting, or suppurative sore, often called chancroid. The treatment of constitutional syphilis does not come Avithin our scope any more than that of any other of the exanthemata. Excision, etc. The question of early excision or cauterization of the initial sore, can hardly be more than alluded to. There is the high authority of Mr. Hutchinson and of most French authors for its performance, if it seems possible (and certainly it ought to be so sometimes), to prevent lymphatic absorption, Avhile on the other hand, such authorities as Berkeley Hill and Cooper consider that the evidence of this possibility is very doubtful.* It may, at any rate, be said that if an abrasion be detected within a few hours of an impure connection, it will be quite justifiable to cauterize with fuming nitric acid, or with Ricord's paste (acid, sulph. fort, and charcoal, q.s.), or with the Pacquelin's, or the actual cautery. Excision, unless a large Avound be made, can do no more than the acid or the cautery, and is in other ways very objectionable, Avhile from the milder caustics, such as the nitrate of silver, no efficient protection can be expected. But in the vast majority of < ases, the time for any attempt to confine the sore to its local action has l6ng since passed by when attention is seriously attracted to it. Local treatment The local dressing of the ordinary infecting sore Avhich sypthmt[c1sore. runs its course AAathout complications, is generally simple enough. The sore itself, and the surrounding parts must be kept scrupulously clean, bathed several times a day, and un- less the foreskin be very short, it will be Avise in all cases to keep a piece of lint between it and the balanus. For the sore itself, black-wash, iodoform, and yellow-wash stand before all other preparations, and any one of the three is suitable for most cases. Biack-wash. The black-wash (lotio nigra, lot. hydrarg. suboxid.), pre- pared by adding 15 grains of calomel to 5 oz. of lime water, may be used to wash the sore; also the dressing may consist of a piece of lint soaked in the lotion, and covered if necessary Avith gutta-percha tissue. The mercurial suboxide is very heavy, and it is better to add some mucilage to the lotion so as to suspend the powder as much as possible. iodoform. Iodoform. This is one of the most useful of all local dress- ings, and the way in which specific sores take on a healing * See " Syphilis," 2nd Ed., 1881, p. 76. OF THE DRESSING OF VENEREAL SORES, ETC. 273 action under it, is very striking. Unfortunately its strong and unmistakable odour is very difficult to hide, and one practical drawback to its employment is that the significance of its smell is now getting to be recognised by the public, so that patients naturally object to the risk of detection. Iodoform may be used in the form of a very fine powder (the common samples are too coarse) simply dusted upon the sore. This is a very good Avay if the ulcer be a small one, and especially if it be well covered by the foreskin. The smallest possible quantity should be taken up with a quill and applied, great care being taken not to scatter even a grain about. The powder is not so apt to scatter if the neighbouring parts have been smeared with vaseline or zinc ointment. Another good Avay of using the drug is as an ointment, mixed with vaseline in various proportions, from 20 to 60 grs. to the Jj> or as a paste (Gerrard),* Avhich can be moulded into a wafer form Avith the fingers or Avith a piece of wood. It may also be used in the form of a liniment, made by adding 1 ounce of the oil of eucalyptus and 5 ounces of olive oil to 1| drms. of the iodoform poAvder. Lastly, it is soluble in ether, and thus Avill dry as a thin pellicle over the surface of the sore, if an ethereal solution be painted on it. The yellow wash (lotio flava, lot. hydrarg. perox.), is used Yellow wash. precisely as the black Avash, but is more actively stimulant. As soon as the surface of the sore has lost its specific character, and is beginning to granulate, a weak stimulating lotion, as that of the sulphate of zinc, or of the subacetate of lead, zinc ointment, or some other simple dressing will be all that is required. The induration must not be ex- pected to disappear for some time after the surface is healed. In feeble constitutions, or through neglect of cleanliness, suppurating . , .. , .-..,. i r i venereal sores. infecting or true syphilitic sores may become freely sup- purating ulcers Avith more or less loss of tissue. The requisite dressings for the sore in this state do not differ from those of the non-infecting chancre, Avhich is usually a simple suppurating sore, but Avhich may become an ulcer Mix. 13 Iodoform paste :— Iodoform 3j Wood charcoal 3 ij Glycerine of starch 3ij Glycerine 5j Oil of lavender nixx 274 OF THE DRESSING OF VENEREAL SORES, ETC. Their dressing. Suppurative sores with loss of substance. Venereal sores may become phagedenic. Often require cauterization. Constitutional treatment. Local dressing during healing. with well marked loss of substance, or, in extreme cases, may run on into sloughing phagedsena. The best treatment at first for any suppurating sore, Avhether infective or not, in the absence of deep ulceration, is the ordinary Avater dressing, changed every feAV hours. If there be any foulness, Condy's fluid or Aveak carbolic acid should be substituted for the water. Under this dressing the sore, if it be a simple one, Avill soon subside and take on a healing action, or, if infecting, will soon manifest the characteristic Hunterian induration. For all specific sores, the solution of tartarated iron (about grs. x to gj of Avater) forms a very good application, except in the early stages of the ordinary infecting sore. It may be used for the common suppurating soft sore at any time, and is believed by many to suit these better than lotio nigra, or iodoform. If the ulceration be deep, the patient should be kept in bed, and (in the case of male patients) the penis should be supported. Frequent Avarm fomentations and poultices are often found to be better than water dressings. Iodoform is useful also in this condition ; it may be dusted on the ulcer, and a poultice placed over all. The destructive course of true sloughing phagedena is seen noAvhere more strikingly than in the genital organs, both male and female. In broken down constitutions, or in patients profoundly unhealthy, any venereal sore may take on a sloughing action, Avhich once set up, seems to run riot in the loose tissues of these parts. It is essential to arrest this destructive inflammation as soon as possible, and if absolute rest, fomentations, and poultices fail to do so, it is best to lose no time, but at once co apply the fuming nitric acid, or the thermo-cautery, or Bicord's paste, to the edges and base of the ulcer. A charcoal or yeast poultice should then be applied, and the parts bathed constantly with Condy, carbolic, or chlorinated soda lotions. In very severe cases, and sometimes the destruction is very wide spread, the continuous bath advocated by Mr. Hutchin- son produces very striking effects. In all these cases a generous diet, and stimulant treatment will be required. Preparations of quinine, or the liquid extract of bark, carbonate of ammonia, and chlorate of potash, are the chief drugs employed ; alcohol will probably have to be given in full quantities. As soon as the excavated ulcer begins to clean, and the sloughs to separate, iodoform, or the solution of tartarated OF THE DRESSING OF VENEREAL SORES, ETC. 275 iron, or of boracic acid, are often very useful applications ; but, speaking generally, any weak stimulating lotion will do for the dressing. At this time the possibility of haemorrhage Risk of from eroded vessels must be kept in view. This may occur haemorrhaee- anyAvhere if the destruction has been deep, but is more frequent Avhen the phagedamic action has extended to, or has occurred in the glands of the groin or their neighbourhood (virulent bubo). All that has been said as to the dressing of these specific sores applies equally whether they occur in men or Avomen, save that in the latter the dressing is generally more difficult to manage, and that indolent infective sores, Avhen they occur high up in the vagina, are very apt to be overlooked. The ulcers which result from the breaking down of syphi- Later syphilitic litic deposits in the skin or the tissues beneath, or as the result of other specific inflammatory processes, only differ from ordinary ulcers in their dressing in one or tAvo points, and it is only with their dressing that we have here to do. The surgeon's efforts are in all cases directed towards the Must lose their t ° fj1 ,. , ... i-i sp'cine charac disappearance ot those peculiar characteristics which cause ter before they these ulcers to be called specific. When once these are lost, can heaL and the sore assumes an ordinary appearance, it rapidly heals. The fcetor, the sharp cut edges, the dirty base, and the sanious discharge, must be replaced by healthy granulations, bevelled off edges, and the secretion of laudable pus; and to effect this, in all cases constitutional as well as local treat- ment is called for. It is this that makes it so necessary to recognise these ulcers. Nothing is more common than to see some obstinate ulceration baffle for months or years all efforts to heal it over, and then to find it disappearing from day to day, almost from hour to hour, as soon as full doses of iodide of potassium are administered. On the other hand, although attention must be given to the condition of the circulation in the part, this is not so urgently demanded as in the case of simple ulcers. The first importance of constitutional treatment being understood, by proper local dressing the rate of healing may be greatly increased. So long as the sore has any specific character, so long must the dressings be anti-syphilitic. The preparations of iodo- form, black wash, various mercurial ointments, especially the ung. hydrarg. oxid. rub., calomel and vaseline, or the ung. hyd. subchlor. may all be used Avith advantage, with many more. The acid nitrate, or the bicyanide of mercury may 276 OF THE DRESSING OF VENEREAL SORES, ETC. be used as a caustic for warts, fissures, or mucous tubercles, as in the mouth ; as may also be the mercuric perchloride in a strong solution (say 24 grs. to 3J). In the formulary at the end of this book will be found the composition of the chief mercurial, and other anti-syphilitic applications in common use. OF ERYSIPELATOUS INFLAMMATION, ETC. 277 CHAPTER XX. Of Certain Special Inflammations. In this chapter we propose to review in the first place the chief points which arise in connection with the dressing of parts affected with any of the various forms of erj'sipelatous inflammation. We shall then discuss the management of boils and carbuncles, and the ways in which "bedsores" may be prevented, and hoAv they should be treated when they have occurred. Lastly, we shall consider the treatment of the condition which is known by the name of sloughing phagedsena, or hospital gangrene. Of cutaneous erysipelas. £^ltsajne°us The local applications in the cutaneous forms of erysipelas Local are directed towards limiting the extent of the inflammation, app lcatl0ns' or diminishing the tension of the skin. Fomentations and poultices of various kinds, or the Fomentations, powder of starch, flour, or zinc oxide, are the applications powders!' most commonly used, m eariv ann slight cases, collodion collodion. painted on the part sometimes ansAvers very well, but the belief that the spread of the area of inflammation may be checked by a line of nitrate of silver painted round the margin, seems to be fallacious. The preparations of lead, especially of the acetate, are Acetate of lead. very useful, either in the form of the ordinary " lotio plumbi," or in a more concentrated solution, say 5j—51'j liq. plumbi subacet. fort., to §j of water. Another preparation of lead has lately been strongly white lead advocated, and with good reason, namely white lead paint as pa" ordinarily used by house-painters. This is no doubt chiefly an oleate of lead,* but it certainly seems as if in many cases it exerted a specific influence on the inflammation. The paint is simply laid on with a brush, and the parts covered with cotton wool. In cutaneous erysipelas large incisions are never called Punctures. for, but it is often wise to promote the escape of serum and to relieve the tension of the cuticle by numerous small * A "linimentum plumbi sublactatis" is prepared by Messrs. Wilson & Co , and appears to have the same action as the paint. 278 OF erysipelatous inflammation, etc. Phlegmonoi s erysipelas. Value of incisions. Poultices and other dressings Constitutional treatment. Bark and iron. Stimulants. Sloughing phagedsena. Cauterization, Method of. punctures, or "stabs," with the point of a sharp scalpel. This is especially the case in situations where the cellular tissue is loose, as in the eyelids. In phlegmonous erysipelas, or in cellulitis, on the contrary the value of incisions made freely and early in the course of the inflammation, is perhaps the most important point to bear in mind in the surgical management of the case. Whenever there is brawny tension, and still more, whenever there is any " boggy " feeling, incisions extending into the cellular tissue beneath the skin should be promptly made, and will afford great relief. The bleeding from them is generally free at first, unless the parts are already slough- ing, and should not be immediately checked. If it does not stop of itself in a short time, a little pressure is all that will be necessary. Poultices will, as a rule, be found the best application for these forms of erysipelas ; but irrigation and immersion in baths of Condy, or of carbolic lotion, are also very useful, and in all cases the inflamed parts should be raised if pos- sible. The reader may be reminded of the importance of con- stitutional treatment in all these diffuse inflammations, and especially of the usefulness of the preparations of bark and iron ; and of stimulant drugs, such as the carbonate of ammonia. Alcohol, too, will generally be required, and opium in some form or other may be indicated. Reference has been made at different times to that peculiarly destructive and rapidly spreading ulcerative inflammation known by the name of sloughing phagedcena, or hospital gangrene. This condition is now much less frequently met with than it was even a few years ago, but when it shows itself it must be dealt with promptly, for unless checked in its course it will not spare blood vessels or any other tissues. In some few cases, cleanliness and constitutional treat- ment are sufficient for its arrest, but very frequently it is necessary to use some form of cautery, or caustic, and of these the actual cautery, and the fuming nitric acid are the best. The latter is most conveniently applied with a small mop of cotton wool, tAAdsted round a splinter of wood. The sloughs themselves should be first cut away (not pulled) as nearly as may be down to the line of the spreading inflam- mation, and then the whole space or cavity thus formed should be mopped out with the acid, or seared over with OF ERYSIPELATOUS INFLAMMATION, ETC. 279 the thermocautery of Pacquelin. If this treatment is suc- cessful, it will be seen that the sharp cut edges of the ulcer- ation no longer spread from hour to hour, but gradually lose their angry look, and take on a healing action under the sloughs produced by the cautery. To forAvard the separation of these sloughs, and to prevent fcetor, charcoal, in poAvder or as a poultice, or linseed or yeast poultices are the most usual dressings, Avith frequent fomentations of Avarm Condy, or carbolic lotions; but another very important line of treatment must not be omitted—that advocated by Mr. Hutchinson* and others, of immersing the patient in a bath for many hours contin- continuous uously. The temperature must of course be kept up to immersion' about that of the body, and under these conditions it is certain that the spread of inflammation has been arrested in extremely formidable cases, Avhere all other methods of treatment have failed. As soon as the ulceration begins to take on a more healthy action, some more stimulant form of dressing Avill be found useful in the place of the poultices, such as the balsam of Peru, or Friar's balsam, terebene, eucalyptus oil, etc. Iodoform, in powder, or as an ointment is a most valuable application in any of the stages of the inflammation. In England, at the present time, examples of true slough- Generally met i " i i , •, i , • . • with in syphi- ing phagedsena are rarely met Avith except in connection uuc cases. with syphilis, in the form that is, of syphilitic ulcerations which take on this destructive action in consequence of the miserable state of nutrition of the patient. In these cases then, the diet must be a generous one, and stimulants will be required in full doses. Opium also is very valuable. A special kind of phagedsenic ulceration is knoAvn as Noma, or noma, or when it occurs, as is usual, about the mouth, cancium ons- cancrum oris. In its pathology it appears to be almost identical with sloughing phagedsena, as it is in its treatment. It is especially a disease of children, and is characterised by the peculiar dryness of the slough, Avhich looks more like an eschar, and by the rapidity of its destruction. It is often almost painless, and may be accompanied by singularly little constitutional disturbance until quite late in the progress of the case.f It is frequently a sequel of diphtheria, scarlatina, etc., * Medical Times and Gazette, 1862, Vol. I., p. 8. + This, the true " cancrum oris," must not be confounded with that common ulceration of the mucous membrane of the mouth, which is frequently met with in ill-nourished children. 280 OF ERYSIPELATOUS INFLAMMATION, ETC. but it seems as often to attack children to all appearance healthy and well-nourished, as those who show signs of malnutrition. Mode of com- AVhenever there appears, in children, in the substance of the cheeks, or on the vulva, a dusky induration, with a dry central slough, the case should be looked upon Avith sus- picion, and if it shows any tendency to spread, there is no question but that the right course is to remove the gan- its arrest. grenous tissue at once, and to apply nitric acid, or some other form of cautery, freely. importance of One common cause of death in these cases is the poison- washfng, etc. ous effect of the putrid discharges when these have been swallowed. It is impossible to prevent this altogether, but very much may be done by extremely frequent washing out with such lotions as the chlorate of potash, chlorinated soda, or of dilute liq. chlori. Chlorate of potash should also be freely given internally.* Passing over the rare forms of gangrenous inflammation, malignant pustule, malignant facial erysipelas, or facial carbuncle, etc., a word or two may be said as to the dress- ing of boils and carbuncles. of boils. When a boil is seen early, and especially if it be of the " blind" Arariety, attempts may very properly be made to Their abortion, abort the process of its maturation. A pointed stick of lunar caustic may be held against its centre for about a minute, and the injection of one or two drops of pure carbolic acid into the centre of the inflammation by means of a hypodermic syringe is stated to be very successful. In the majority of cases, however, a boil once started will run its course, and all that can be done is to hasten its matura- Their dressing, tion. Poultices and water dressings do not appear to suit this kind of inflammation so well as they do most others. Boils seem to do best when they are merely protected from pressure, and perhaps the best dressing for them is the opium plaster (E. opii), spread upon a piece of soft chamois leather, in the centre of which a small hole may be cut. When suppuration has evidently occurred, a crucial in- cision followed by warm fomentations, Avill hasten the separation of the central slough or " core." of carbuncles. The practical questions which arise in the dressing of carbuncles are, first, whether or no the inflamed part should * Or any of the sprays which are so useful in diphtheritic cases, as of the boracic, or sulphurous acids, or of Banitas, may be em- ployed. OF ERYSIPELATOUS INFLAMMATION, ETC. 281 be incised, and secondly, the consideration of the best external application during the first stages of braAvny indu- ration, and in the later ones of separation of the sloughs. Authorities differ widely as to the theoretical wisdom of of their incising carbuncles, but there can be no doubt that the m practice is far less general than it used to be. The question probably resolves itself into one of tension. In carbuncular inflammations, as elsewhere, if the local tension is itself strangulating the tissues and shortening their life, this ought to be relieved by incision, and tissues may in this way be saved which Avould otherwise die. On the other hand a routine slicing into every carbuncle would be only a needless cruelty. If incisions are decided on they should be made sufficient once for all for the relief, for few things are more trying to patients than the daily repetition of such operations. The common plan is to make bold crucial cuts right Method of its . c . * i performance. through the inflamed mass, down to its base. Another Avay is to make the incisions subcutaneously, slipping a long narrow bladed knife into the base of the carbuncle, and severing its connection with subjacent parts, and then dividing or quartering without further injury to the skin.* With regard to the dressing, at first, poultices or water dressings, with frequent fomentations, will be best; later, when the sloughs are separating, and the suppuration is fully established, some of the stimulant resins, such as Friar's balsam, balsam of Peru, terebene, etc., will hasten the process. But septic absorption may take place and death from Excision. septicaemia or pysemia, and this is a strong argument in favour of a more radical treatment, such as excision of the carbuncle. If the patient be placed under an anaesthetic and the diseased tissues be removed by scraping Avith a Volkmann's spoon and the indurated skin cut away, a wound will be left AArhich will speedily become covered with healthy granulations, and healing take place in a much shorter time than would have been the case if the sloughs had been allowed to separate. This method also cuts short the severe pain which is so prominent a symptom in carbuncle. Carbuncles so frequently occur in persons who are broken constitutional i? i . . i p. • treatment. down constitutionally, that these cases often require very * The hsemorrhage from these incisions is sometimes very profuse, and may be a source of danger in patients who are already much enfeebled. 282 OF ERYSIPELATOUS INFLAMMATION, ETC*. Urine to be examined. Of bed-sores. How best guarded against. The bed. Change of position. careful and generous general treatment.- An especial ex- amination should ahvays be made to ascertain if sugar be present in the urine. The same precaution should be taken in cases of obstinate and successive crops of boils. Experience alone as to what bed-sores may become if neglected will enable the student to realise the extraordinary amount of destruction which this form of ulceration from pressure can cause, or the rapidity Avith which it spreads, or the insidiousness of its commencement. It is also very necessary for every surgeon and every nurse to understand that with the exception of certain paralytic cases, bed-sores are almost always preventable, and, Avhen present, are as a rule, standing evidence of neglect or mismanagement. But, though we will not qualify this assertion further, it must be allowed that sometimes it is extremely hard to prevent soreness, as, for example, in a case of hip disease with extreme emaciation, contraction of both legs, and suppura- tion. Sometimes, again, tissues have such a Ioav vitality that it seems as if the least touch Avould produce a slough; still with incessant watchfulness, Avith the exception of the paralytic cases Ave have mentioned, bed-sores can be pre- vented, although once begun they are very hard indeed to arrest or to heal In warding off the formation of bed-sores, attention must be specially directed to the following points :— I. The bed must, in all cases, be smoothly made, elastic, and soft; a spring mattress is often a great help, and water cushions may be used for the buttocks, etc. But in cases where there is a Avell marked tendency to soreness there is nothing like a complete water bed.* In filling one of these beds, care must be taken to have the water properly warmed, and not to put in more than will just support the patient. II. In every possible way continuous pressure must be avoided upon the parts which are liable to become sore, such as the sacrum, trochanters, ischial tuberosities, heels, occi- put, elboAvs, or the spines of the scapulae. Taking every precaution (when precaution is needed, as in fractures; against doing local harm by movement, in some Avay or other it must be managed that the patient shall shift his points of pressure upon the bed, lying noAv a little Ioav, noAv a little high; first with the head to one side, next day turned slightly over (for the least shift is as efficient as a * In private nursing it is well to recollect that these can be hired. OF ERYSIPELATOUS INFLAMMATION, ETC. 283 great one) to the other; a pillow may be put under the knees one day and omitted the next, etc. III. Something may be done to improve the nutrition of Local the skin by bathing with stimulant lotions (whiskey, or aP^lications' brandy and water is a common application). Starch or violet powder should be freely used, and if the tendency to soreness appears imminent, the part, Avhich Avill be a bony prominence, should be covered with a protective adhesive plaster spread upon chamois leather or felt. Nowadays in hospitals or Avhere skilled nursing has been employed from the first, such precautions as we have mentioned will be sufficient to prevent soreness altogether, or at the worst to limit it to a superficial excoriation. The cases we meet with where true ulceration is present, are those Avhere there has been previous neglect of nursing care, through ignorance or poverty. Such cases are not infrequent among those who come at Modes of last to be hospital in-patients, and whatever the nature of aheady^formed the original illness may be, the bedsores will count heavily against recovery. These ulcerations are indeed very hard to dress ; they present the characters of deep foul sloughing ulcers, not generally painful, but tending to destroy all the soft parts between the skin and the bone, and often compli- cated by necrosis of the bone itself. The great point then is to remove all pressure, and to get the ulcer to begin to clean. Charcoal, or yeast poultices, with frequent fomentations, and if possible, immersion in baths of warm Condy or car- bolic lotions Avill be the best treatment at first, and after wards when the sloughs clean off, stimulant resins, such as tinctura benzoinse co., balsam of Peru, etc., will suit Avell. Very much Avill depend upon Avhether there is improve- ment of the constitutional condition, or the reverse. If there be general recovery, local recovery is often extremely rapid when once it is started. 284 BURNS AND SCALDS. CHAPTER XXI. Burns and Scalds. Burns and For the purposes of the dressing of these injuries it will be convenient to divide them into burns which are (1) im- The two main portant by reason of their extent and position, and (2) im- portant by reason of the depth of tissues destroyed. To the first class belong all extensive scalds or burns, especially those occurring on the chest, abdomen, or head; to the second, burns, or more rarely, scalds, wherever they may occur, in which the whole depth of the skin has been destroyed, so that on healing, a contractile cicatrix is the result. AcfaiVurn"" -^- ^urns w scalds important from their extent and position. Primary shock. No class of injury produces such grave depression of all the functions of life, such profound " shock," in comparison with the actual damage to the tissues, as does a large burn or scald. This depression occurs wherever the injury may be situated, and is in direct relation to its superficial extent; but it is especially marked if the chest or abdomen be burnt, and is more profound in children than in adults. It may moreover be aggravated by exposure, or diminished by protection from the air, to a very marked extent. This primary shock is often very prolonged, a;.d when it passes off is apt to be succeeded by a congestion of internal organs, as of the lungs, intestines, cerebral meninges, kidneys, etc.; or later still, the patient may have to go through an exhaustive process of suppuration. Times of The periods of greatest risk to life in these cases are, greatest ns o ^rs^ (jurj[ng the feAv hours immediately succeeding the injury, when it may be doubtful if the patient can rally from the primary shock ; and after that, during the period of internal congestion or inflammation, which rarely extends beyond the first fortnight; during this time a low form of pneumonia, ulceration of the intestines (especially of the duodenum), peritonitis, or cerebral meningitis with serous effusion, thrombosis, or hsemorrhage into the substance of the brain, or beneath the arachnoid, may, any of them take place. It is in this stage, too, that intussusception of a BURNS AND SCALDS. 285 portion of the small intestines is said to be liable to take place. The best treatment and dressing for severe superficial Treatment. burns in the first instance will generally depend on the resources which are nearest to hand, for the air must be The immediate excluded from the burn as quickly as possible, and it should dressins- be covered with some light non-conducting material. Fatal damage may be done in a few moments by exposing a badly burnt chest or abdomen to the air before anything is ready to cover it; but oil or flour, or poAvdered whiting, or cotton wool, are materials which are in such common use, that any one of them can be readily applied in an emer- gency.* The clothes must, therefore, be cut away from the burnt surface with the utmost care, so as not to further damage the tissues beneath, and over and around the wound, flour or whiting should immediately be thickly dredged, or olive oil freely poured, and then the whole part should be wrapped in cotton wool. While this is being done, and aftenvards, attention must Management of be given to the condition of shock, which will generally be shock. present. The patient must be kept Avarm, and should lie with the head low. Hot water bottles, etc., may be used, and ether, or sal volatile administered. If the collapse be profound, a mustard plaster may be placed over the heart, the feet put in very hot water, or ether injected hypo- dermically. (See chapter on " Shock " for further details as to the treatment of extreme cases of this condition.) When a bad burn has once been dressed, if shock be pre- sent, the surgeon should not be in a hurry to change the extemporised dressings for applications Avhich may be in themselves more suitable, but the patient should if possible be left alone so far as dressing is concerned, until the state of collapse has passed off. In tAventv-four hours, however, The later and .-,•, A n 1 i i " j.i i i more deliberate it wul generally be necessary to redress the burn, and noAv dressing. (or in the first instance, if skilled assistance and proper materials have been procured) it must be done with the greatest care. If the burn be extensive, it is almost always best to perform the first tAvo or three dressings under an anaesthetic, not only because the burnt surface is exqui- sitely tender, but on account of the nervous shock of the exposure. The fresh dressings should always be got ready before the * Soap suds, or treacle, may also be mentioned as useful domestic applications. 286 BURNS AND SCALDS. burn is uncovered. The ones generally used for burns in their early stages are—(1) "Carron " oil,* i.e., a mixture of oil and lime Avater in equal parts. (Linseed oil Avas origin- ally employed, but olive oil is cleaner.) (2) Carbolised oil. (3) A saturated solution of common Avashing soda. Any of these may be applied by means of soaked strips of lint; and layers of cotton wool should ahvays be placed over the strips. The soda solution generally gives the greatest relief to the pain, but the Carron oil is also a very bland and sooth- ing dressing. The objection to both is that the prevalent discharges very soon become foul, and for this reason Ave prefer, in most cases, the carbolised oil. As a rule the 1 in 40 strength is sufficient, but, for very painful surfaces, the anaesthetic effect of 1 in 20 solution is sometimes very striking. Whatever may be in contact with the burn should not be pulled, but washed aAvay Avith a stream of lukeAvarm Condy" or carbolic lotion from a syringe, and the surface should be cleansed in the same way. It is often Avise if the burn be extensive, to cleanse and dress one part of it, before un- covering the rest, and the fresh dressings should always be put on as quickly as may be consistent Avith cleanliness. Small blisters may be snipped, and the serum soaked up with blotting paper, but in large ones the skin had better be cut away Avith sharp scissors. Listerian dress- A mode of dressing which is not commonly employed, mgs or urns. ^^ wnjch has much to recommend it, particularly if the discharges be offensive, is to use the carbolic spray, as in Listerian dressings, and then over the carbolised oil lint to place a covering of salicylic wool, or carbolised gauze. other dressings. The following dressings are also useful in many cases :— a. The lotion of chlorinated soda (P. B.), especially if there be fcetor. b. A mixture of chalk, or whiting, olive oil, and vinegar, in about equal parts. c. Whiting and water. d. Olive oil and litharge (which form a kind of soap by chemical action). e. A solution of about gj of yellow soap to a pint of water has sometimes a decided anodyne action. Exclusion of Air may be strictly excluded from the burnt surface in two ways. Firstly, by continuous immersion of the injured * So called from its employment in the Carron iron foundry works. BtitNS AND SCALDS. 28? part in a Condy or carbolic bath, and secondly, by sealing the surface with flexible collodion. This ansAvers admirably for small burns, but for these only. Granulations spring up over the surface of a burn with Granulation of great rapidity, and as soon as this occurs the sore may be burns" considered in the light of a healthy and healing ulcer, though one, it may be, of large extent. All, therefore, that has been before written as to the management and dressings of these sores will stand for granulating burns. Skin grafting. skin grafting. This process may here be conveniently described, as it is most frequently employed for the large granulating surfaces of burns, especially where contraction is to be feared. There can be no doubt that fragments of epidermis, or even epidermal scales from the horny layer only, when applied to, and retained upon, the surface of healthy granu- lations, do form little cicatricial foci, Avhich may hasten the ultimate covering in of the sore, and diminish that draAving together of the edges which is so apt to occur in the healing. Whatever the process may essentially be, and it is very obscure, it is not a transplantation, or even a "grafting" proper, for the implanted tissue is non-vascular. It is often difficult to estimate the real gain, even of sue- Question of its cessful grafting, but upon the Avhole it has hardly realised Va the promise it held out at the time of its introduction, for the islands of cicatricial tissue are very apt to disappear after they have been formed, and the quality of the cicatrix is often indifferent. To obtain any success in skin grafting, the granulating Method of surface must be typically healthy. Given a good soil, it is gra tlng" only necessary to plant a number of pieces of detached epidermis, the smaller the better, upon it, and to fix them there without disturbance for not less than two days. The grafts should only include the horny and Malpighian layers of the epidermis, and may be snipped oft' Avith ordinary curved scissors, or with the special ones (Fig. 138), devised for that purpose. Fig. 138.—Skin Grafting Scissors. 283 feURNS AND SCALDS. The grafts should not be handled, but should be imme- diately placed, the dermal side dowmvards, upon the granu- lating surface, which must itself be cleansed and dried beforehand. The grafts should then be covered with small pieces of gold beater's skin, or gutta percha tissue, or isinglass plaster, or a 1 per cent, ointment of the zinco- mercuric cyanide may be spread on linen and applied under a blue wool dressing. Transplantation Mr. Clement Lucas (Lancet, October, 1884, p. 586) re- commends the use of the skin, removed in circumcising children, for supplying grafts to large granulating surfaces, especially those left after extensive burns. The skin of the prepuce removed by circumcision from children with phimosis is peculiarly adapted for transplantation, on account of its suppleness, thinness, and vascularity. The time which may elapse between the removal of the skin from the pre- puce and its use as grafts to a wound, may safely extend from half an hour to an hour, during which time it should be kept in warm boracic lotion. Or a piece of skin may be removed from some other part of the body, usually the inner side of the arm or thigh. If the wound be small and it is intended to cover it entirely, the procedure will be as follows : The part from which the skin is to be taken is thoroughly cleansed, and if necessary, shaved. The size and shape required should then be marked out and the piece dissected off, care being taken that no fat is left on .the under surface. The graft is then transferred to the wound, and may be fixed with a few sutures. Thiersch has introduced a modification of skin grafting in which long strips of thin skin are employed. These strips are about an inch in breadth and consist of the superficial layers only ; they should be shaved off' with a very sharp instrument, such as a razor. The tAvo last methods are also applicable to recent wounds, care being taken that all bleeding has ceased before the grafts are applied. Syphilis has been communicated by skin grafts, and the patient ought to provide his own graft. Inasmuch as the surface of the burn or ulcer when grafted must be left undisturbed for a couple of days, it is con- venient to cover it all up in salicylic wool, or boracic lint, which will hinder it becoming foul. A good number of grafts should be planted at one time, say, about one for every square inch of burnt surface, for the probability is that many will fail to take. A successful plant will be BURNS AND SCALDS. 289 known when the part is uncovered, by the presence of a whitish pearly spot, which will increase from day to day, and will soon evidently be an island of cicatrised tissue. Other plans of grafting, such as the dusting of epithelial scrapings over the wound, have not held their ground. Sponge grafting. Sponge This proceeding, introduced by Dr. Hamilton,* has also graftmg hardly justified, at present, its initial promise. Boughly speaking, the process may be said to depend on the tendency of granulations to sprout in the direction of least resistance, and to insinuate themselves into the interstices of any sup- porting frameAvork. It is asserted that if this frameAvork be itself absorbable, the sprouting granulations Avill cicatrise. Sponge grafting is performed as folloAvs : Pieces of fine Turkey sponge are soaked, first in dilute nitrohydrochloric acid to remove the silex, etc., then in liquor potassse, and then in 1 in 20 carbolic acid solution. The pieces are then placed upon the granulating surface, and the Avhole dressed Avith Listerian precautions. The sponge adheres to the surface of the Avound, and then becomes gradually filled with granula- tion tissue, bleeding freely when pricked. It is said that the sponge tissue proper now gradually melts away, and that the mass of organised tissue Avhich replaces it, quickly skins over. That a piece of sponge will fill Avith granulations if it be kept upon a Avound is certain, but the replacement of the sponge tissue by an organised material which quickly cica- trises, has yet to be proved to take place. In any case the process is a sIoav one, and it has been found very difficult to keep the sponge thus filled with soft granulations from becoming foul. II. Burns, important through the depths of tissue destroyed, of deep burns. Those burns Avhich destroy muscle, tendon, and bone, are of those de- either immediately fatal, as in most cases Avhen the trunk fimbs^fta is involved, or, if in the limbs, produce practically the same condition as that of gangrene. As to the general management of such cases, nothing further need be said than that they require the same treat- ment in the first instance, as the milder kinds of burns, both for the shock, and the local injury. But burns frequently are inflicted, of Avhich the appear- ot large bums • i • t«> it r j.1 J. i i destroying the ance at first sight is not different at all trom that ot the thickness of the skin. * See Medical Times and Gazette, February, 1881, p. 577; and Lancet, February, 1881, p. 1,0571 J9 290 BURNS AND SCALD3. large superficial injuries we have been considering, and which indeed may be quite as large, and attended with as important a degree of shock. Nevertheless, in all the later stages of repair, this class of burns, those namely where the whole thickness of the true skin has been destroyed, follows a very different course from the superficial ones, and one harder to treat. TfhthCe°scarCtion -^ot tnat these hums are slower to heal than the other ones; indeed if they are left alone, they will close over more quickly, by dragging the margins together towards the centre ; but it is in this contraction of the edges, and in the fact that the process of shrinking does not cease even when the sore is closed over, that the especial difficulty of these cases consists, and the dresser will assuredly find himself on the horns of a dilemma, for either he must, by fixing the parts to prevent contraction, greatly retard their healing; or if he alloAv the edges of the burn to come together, anyhow they will, he will quite certainly be accessory to the development of deformity, while for his consolation he has only the knowledge, that let him try his best, the con- traction will almost certainly beat him in the end. In so far as the actual dressing of the injury is concerned, the similar applications to those mentioned for more super- ficial burns will be appropriate. The contraction begins very insidiously, but becomes more and more marked, and stubborn as the case goes on; as has been said, it does not cease with the covering over of the sore surface, but for months, or years, bands of con- tracting tissue will form in the ribbed and furrowed scar The effect of this contraction shows worst when the face, or neck, or the flexor aspect of any large joint is involved, and most surgical text books have representations, not at all exaggerated, of the deformity Avhich may thus happen. Prevention or To combat this misfortune is very difficult, and the dresser diminution of P, .. , i • • i *_ . • e the contraction, may often wisely make up his mind to a certain amount of undeserved blame in any event. Much may, and should be done by steadily and patiently splinting, or fixing the part in some way or other, and by willingly exchanging for a quick, a very slow healing. So, too, the effect of the patient, daily, application of the solid nitrate of silver, should not be forgotten. Something may perhaps be done too by skin grafting. But probably more effectual improvement can be attained after the burn has healed by stretching the cicatrix, othtr°mampu? tnan during the healing. Though it has been several times lation of the pointed out, it is still often forgotten that this contracting BURNS AND SCALDS. 291 scar tissue is as distensile as it is contractile, if it be properly manipulated, and that by patient handling a rigid tendinous band may be converted into a supple elastic one. The results of prolonged stretching, kneading and shampooing the scars of burns are as satisfactory as those of plastic operations for the same end are disappointing. An anaesthetic is sometimes desirable upon the early occasions of kneading and stretching, and the progress of the extension should be slow and gradual. Care must also be taken not to tear through the superficial cicatrix and thus to cause a wound. A little oil may be used to rub into the scar during the manipulation. This way of treating a con- tracted cicatrix is too often neglected in favour of more tempting but far less satisfactory plastic operations, and even if the latter be deemed necessary the preliminary kneading will have greatly improved the nutrition of the parts concerned. These plastic operations themselves consist chiefly in the making of V shaped incisions and dissecting up flaps, and in the subcutaneous division of the tendinous bands. Scalds or burns of the larynx and pharynx present such scalds and especial features that they must be mentioned separately. la'rV'nV'and They are produced generally by drinking scalding liquids, Pharyi}X- and are thus far more frequent in children than in more sensible adults. (The habit of teaching children to drink out of the spout of a kettle will account for more scalds of these parts than all other causes put together.) But breathing hot air, as in a fire, may produce the same effects, and practically the action of any chemical caustic is the same in this situation as that of the thermal ones. Scalds of the pharynx itself are not usually very serious, unless the consequent oedema of the tongue and fauces reaches a very high degree ; but when the scald extends further doAvn, so as to affect the rima glottidis, and the oesophagus, there is both an immediate and remote risk of complications. The remote one is that the scald of the gullet may cause a contracting cicatrix, and thus become itself a simple stricture, or that the cicatrix may be the seat of a new growth, and thus develop into a malignant one. But it is with the immediate risk of suffocation through calling for oedema of the larynx th;it we have here to do. These cases tracheotoD1 are ahvays full of anxiety, and require very prompt treat- ment. If, shortly after the accident, there be a distinct difficulty of breathing, from obstruction, the safest plan will be not to wait for more urgent symptoms, but at once to 292 BURNS AND SCALDS. perform laryngotomy, or in young children, a high tracheo- tomy, and then to treat the case Avith a warm moistened atmosphere, and in all other respects, as if it were a case of diphtheria or croup, in which the operation has been called for. But often there is a deceitful calm for some hours, and we may be tempted to think that the larynx has escaped altogether, when suddenly the most urgent dyspnoea may be developed. Whenever, therefore, inspection of the mouth and throat shows that a scalding fluid, or a corrosive liquid has passed down it, the patient must be carefully watched, made to breathe a steamy atmosphere, and the surgeon should be ready himself, and have his instruments in readiness, to open the windpipe if necessary. OF HIP DISEASE, ETC. 293 SECTION V. OF CASES REQUIRING PROLONGED OR MECHANICAL TREATMENT. CHAPTER XXII. Or Hip Disease. There are certain surgical cases in Avhich deformity is a prominent feature, which are so common, and require such patient and prolonged treatment, that every student of surgery should understand the principles of their mechan- ical and general management. The most important of these are the usual forms of hip disease, of lateral and angular spinal curvature, of club foot, contracted knee, and bandy-leg. In describing, as Ave propose to do, in this section, the ordinary proceedings for the treatment of these conditions, Ave shall confine ourselves to the manual operations and shall not discuss their pathology or treatment in other respects. For our purpose the following different divisions of hip HiP disease. disease may roughly be made :— JJf1? divisicma Usual lines of treatment. (Bed-stirrup and weight (for rest). Spica ; long splint; Bryant's splint. Counter-irritation. Bed stirrup and weight (for deformity). Bryant's splint. Thomas's splint. Moulded splint, (2) Chronic hip disease, with tendency to deformity, and frequently with abscess or sinus forma viotL 291 OF hip disease, etc. 'Stirrup and aveight; loag (3) The same condition after splint. the deformity has been- Bryant's splint. treated by osteotomy. Thomas's splint. Moulded splint. (4) The same condition after I the diseased joint has-! Ditto. been excised. [ i.—acute hip disease. Acute hip In all the acute forms of hip disease, the surgeon's efforts are directed towards subduing the inflammation, so that suppuration shall not occur, and towards preventing defor- mity. If these ends are to be obtained, the joint must be kept at rest, and the limb kept in extension. The main The muscles about the hip are the chief agents in keeping obiects of • > • jt o treatment. up irritation, and causing the deformity of flexion and abduction, and it is because muscular spasm can be better controlled by steady traction than by any other means, that the use of the stirrup and weight is so general in these cases; for although the plan was first introduced with the idea that an actual separation of the inflamed joint surfaces was thus obtained, it is now generally held that this does not take place. The most common plan of treatment is to put the patient to bed in the supine position, Avith the head low; with a stirrup and weight attached to the limb, and passing over a Fig. 139.-—Stirrup and Weight in position. pulley (Fig. 139); and with the foot of the bed raised, ag OF fflP DISEASE, ETC. 295 described for fractures of the femur, under which heading the method of putting on the stirrup and Aveight will be found. The bed should resemble a fracture bed in all respects, The bed. particularly in smoothness and absence of sagging. The amount of weight will vary in every case, and may be The weight. anything betAveen 3 and 12 lbs. It must be the smallest that will keep the limb at rest, but it must be sufficient for this, or it yyill simply act as a stimulus to the contracting muscles, and be actively harmful. It often takes some days for the spasm of the muscles to be exhausted. The direction of the pull of the stirrup. The pull upon the Direction of limb in these acute cases may generally be made in a pul1" straight line from the first, but sometimes it is necessary to make it first in a line Avith the deformity, as in the chronic cases mentioned later. This is essentially a children's disease, and for this reason importance of it is often difficult at first to secure the continuous supine lying flat' position with the head low. AY hen children have once learnt that rest means ease, they will lie flat and still enough, crying only Avhen they are moved, or when the weight is lifted from the leg. But at first it is often neces- sary to fasten a child down, and this can easily be done, as shown in the figure (Fig. 140), by a sort of harness of Fig. 140.—Method of Fastening Down a Child in Bed. webbing by means of Avhich the shoulders and chest are attached to the bedstead, or to a thin piece of Avood running across underneath the mattress. Some form of counter-irritation is generally combined counter- with this treatment by rest. The tincture or liniment of irnUti011 296 OF HIP DISEASE, ETC. iodine, and blisters, Avhich may be kept open with savine ointment if desired, are the most common irritants used. Occasionally, Avhen great pain is present, the actual cautery is applied, usually behind the great trochanter; but this treatment is more adapted to chronic than to acute joint mischief. other plans of \ye naVe assumed that, at the present time, the usual treatment. . , i i i , • , • •• treatment ot a case of undoubted hip disease in its early and acute stage, is to procure rest and good position, by the use of the stirrup and Aveight, the raised bed foot, and the other expedients Ave have just considered. But it will be easily understood that there are many other ways of treating acute hip disease, and some of the more important of these we will now mention. stirrup plus the 1. By the stirrup and weight, combined with the long ong sp mt. Splin^ adjusted as for fractures of the femur. This is very useful in cases Avhere there is great pain, and where the limb becomes so ill nourished that it is unable to sustain properly without assistance the requisite pull on the stir- rup.* Long splint 2. By the long splint alone. If this plan be adopted, the splint should have a foot-piece; it is not often advisable. Moulded splint, 3. By fixation of the joint, by a plaster of Paris or silicate spica, or by a moulded splint; this is a sufficiently effective treatment for slight inflammatory conditions of the hip joint, but it is not so satisfactory in the acute period of genuine hip disease. In the treatment of the convalescent stage, the support thus afforded may be of great value. Thomas's 4. By Thomas's splint. This splint Avill be considered in detail immediately, and from the quotations which we shall give from the inventor's own description, it will be seen that, in his opinion, it may be applied to the patient in any stage of the disease, including the earliest and most acute one, when confinement to bed is imperative. The general opinion, hoAvever, is that his form of splint is not convenient for fixing the limb in the early stages of hip disease, or so long as the patient is absolutely confined to bed. Bryant's spii. t. 5. By Bryants Splint (Figs. 141, 142). This is a most valuable splint for many stages and forms of hip disease, or of fractures about the hip, etc., and may here be con- * If the stirrup and weight are required for a long time, especially if there be much wasting of the limb, some of the pull should be mad: from above the knee ; for that joint may suffer, or the upper epiphysis of the tibia may become separated from the shaft, in consequence of the constant traction, or plaster spica. splint. OF HIP DISEASE, ETC. 297 veniently described, though it is more extensively used in chronic suppurative cases, or after excision, or osteotomy. Fig. 141.—Bryant's Splint, Its appearance and application are sufficiently explained in the figures. In Fig. 142, it will be seen that extension Fig. 142.—Bryant's Splint applied. is made with a pulley and weight fastened to the foot piece, and this will be found better than, the india-rubber springs in Fig. 141. In the cases we are noAV considering, i.e., cases of early hip disease, there will generally be no shortening, so that the tAvo foot pieces should be at the same level. It is always Avise to put on flannel bandages round the legs before fastening them Avith the ordinary roller to the splint. The interrupted part should be opposite the great trochanter, and a broad flannel roller will be found the best for fasten- ing the trunk to the two splints between which it lies. The great advantage of this apparatus is that the patient its uses. can be readily lifted, or turned right over, or on to one side, the splints Avhich run on either side being so firmly braced together above and below that the trunk and limbs are perfectly rigid, Avhile the parallelism of the legs is well maintained. 6. A splint of the form of St. Andrew's cross has been st. Andrews r cross. 298 OF HIP DISEASE, ETC. Simple lving in bed with legs tied together (children only). Value of anaesthetics. advocated, but has not come into general use, and forms of parallel long splints other than Bryant's, but on much the same principle, are employed. 7. Finally, many cases of incipient or sub-acute inflam- mation of the hip j.-.iut in children, Avhich, if allowed to drift on, might lead to destructive changes, may be effi- ciently treated without any splints, or other mechanical contrivances, by strict confinement to bed, the movement of the legs being sufficiently restrained by tying them together. Counter-irritation or other local measures, may of course be also employed. The valuable aid which anaesthetics afford in some cases of acute hip disease in their early stages must also be men- tioned. It not unfrequently happens that the muscular spasm, and consequent deformity, appear to be out of all proportion to the other signs of inflammation about the joint, and the stirrup and weight fail to produce rest by extension. As soon, however, as the patient is anaesthetised, the limb comes doAvn readily, and it is often wise to fix it then and there in good position on a Bryant's or Sieveking's splint—or to a simple long splint, while the spasm has been thus temporarily abolished.* Chronic hip disease. (1) Deformity without anchv losis or suppu ration. II.—CHRONIC OR OLD STANDING FORMS OF HIP DISEASE. The treatment of these cases is always to a large extent mechanical, but Avill differ in accordance Avith the presence or absence of suppuration, or of bony anchylosis. It may be taken for granted that some degree of deformity will in all cases be present. (1.) Quiet, or old disease, without suppuration or bony anchylosis. \Ye will take first the most common form, where the active symptoms have subsided, in great part or entirely, and where the limb has been alloAved to fall into a condition of flexion and abduction, so that it can only be used for progression, by a bending and tilting of the spine and * It is not rare for the subjects of hysterical neuromimesis to simulate the contraction of the limb and other symptoms of genuine hip disease. If such a patient be put under chloroform, the symp- toms due to muscular contraction will of course disappear. But they will disappear also in cases of genuine joint mischief, if this be only commencing. Cases of real joint disease may thus be put down "only hysterical" because the suspected articulation, usually ex- quisitely tender, has been found to move with freedom when the patient was anaesthetised. OF HIP DISEASE, ETC. 299 pelvis, which is generally at once aided and confirmed by the use of a high boot. In the cases we are now consider- ing there is no bony anchylosis, and suppuration has either terminated or has been absent throughout. In these cases the general plan of treatment is to keep the patient lying doAvn, and to try, by means of the stirrup and weight, to pull the limb gradually straight, the weight employed being generally greater than in acute cases. The foot of the bed should also be more raised.* Unless the case be a very simple one, it will be found Lordosis. that the limb apparently lies straight enough directly the weight is put on ; but if the hand be now placed below the lumbar spines it will be seen that they form an arch to an its cause extent corresponding to the deformity. The appearance of improvement is therefore quite deceptive, and the weight is doing little or no good. It must always be kept in mind that, for the apparatus to be of any avail in reducing defor- mity, no lordosis must be allowed, that is, the back must be in contact Avith the bed all along. The only way to secure this is to make the " pull" of the stirrup almost in the direction of the flexion of the femur, and of its adduc- tion as well, unless this latter be slight. This may most How remedied. readily be done by attaching the pulley-block to a standard placed at the end of the bed, so that it may be raised or lowered (Fig. 143). The standard also may be shifted laterally. Fig. 143.—Diagram of Pulley and Weight making traction in direction of deformity. It is best during the first week of treatment to make no attempt at reduction of the deformity, but simply to get the parts at rest, and to abolish muscular spasm, by making traction in the direction which the femur assumes when the * This treatment may be sometimes combined with that of for- cible straightening under an anaesthetic, to be mentioned directly. 300 OF HIP DISEASE, ETC. spine is flat on the bed. Then inch by inch, and very gradually, the limb may be abducted and extended. When the extension has done its Avork, if the parts are quiet and free from pain, a spica of plaster of Paris, silicate, etc., or a felt or leather moulded splint (Fig. 118) may be put on, and the patient may begin to get about on crutches, or Thomas's treatment may be begun. Thomas's Thomas's splint. The mechanical principles on which many cases of hip disease may be successfully treated Avith little or no confinement to bed, are fully explained and advocated by Mr. H. 0. Thomas, in his book on this sub- ject,* and although many surgeons may be little disposed to agree Avith his doctrines in their entirety, there can be no doubt that the extent to which his splint has come into general use, marks a distinct advance in the treatment of this disease. its objects. The objects of Mr. Thomas's splint are, first, to secure rest, and to avoid friction, by means of posterior fixation of the hip joint, together with the trunk, thigh, and leg; and secondly, to allow the weight of the limb gradually to remedy the deformity, in the place of a more active form of extension. Inasmuch as we find ourselves unable to accept Mr. Thomas's views, as to the applicability of his treatment to all stages of the disease, while at the same time we consider that in the later periods it is extremely valuable, we have thought it best to give, slightly condensed, his own account of the fitting on of his splint. It will be seen that if success is to be obtained much personal care and attention must be given by the surgeon. Mr. Thomas's Account of his Splint, t We will suppose the patient, cet. ten, with right hip joint disease. The surgeon requests him to stand on the left limb, and proceeds to measure him for the instrument. A block, or several if necessary, is placed under the sole of his right foot, until the sound limb is raised sufficiently to allow the spine to resume its natural form. Now he takes a long, flat piece of malleable iron, one inch by a quarter for an adult, and three-quarters of an inch by three-sixteenths for children, and long enough to extend from the lower angle of the shoulder-blade in a perpendicular line downwards over the lumbar region, across the pelvis slightly external, but close to, the posterior superior spinous process of the ilium, and to the prominence of the buttock, along the course of the sciatic nerve, to a point slightly * " Diseases of hip, knee, and ankle joints." Liverpool, 1876. t Loc. Cit. pp. 28—42. OF HIP DISEASE, ETC. 301 external to the centre of the extremity of the calf of the leg. The iron must be modelled to this track to avoid excoriations. The lumbar portion of the upright must be invariably almost a plane surface, and rotated on its axis in the direction of the arrows (Pigs. 144, 145) more or less in proportion to the plumpness of the patient. This iron forms the upright portion. It is very necessary that it should come below the knee, to enable the surgeon to fix this joint. Then measure round the chest, a little below the axilla, deducting, in the case of an adult, four inches from the chest circumference. This latter will be the measure for the upper cross piece, which is made from a piece of hoop iron, one and a half inches, by one eighth of an inch. The hoop is firmly joined to the top of the upright with a rivet at one third of its length from the end next to the diseased side. (Pig. 144). It is important to give the upper crescent this oval shape, to assist in arresting the machine from rotating from its position behind the body, and thus producing inversion of the limb. Fig. 144.—Single Tfomas's Splint. FlG. 145.— Section of Trunk and Limbs at level of the half circles of the Splint. Another strip of hoop metal, three quarters of an inch by one eighth of an inch, and in length two thirds of the circumfeience of the thigh, is fastened to the upright, at a position from one to two inches below the fold of the buttock ; then another piece of metal of like strength, equal to half the circumference of the leg at the calf, is firmly riveted to the lower extremity of the upright. The short portion of the top half circle is next to the diseased 302 OF HIP DISEASE, ETC. side, with a space intervening, while the long portion must be closely fitted to the sound side. If the machine should tend to rotate from the disused side, then daily contract the long wing of the crescents, and expand the short ones. In applying the instrument with two uprights (Pig. 146), care should be taken to measure the distance between the tip of right and left posterior spinous processes, and then to set the uprights parallel and apart one inch more than such measurement, or it cannot be tolerated by the patient. The two uprights should be connected by a cross-bar when practicable, which is not possible when the double instrument is used for reduction of deformities; when used it will be found useful for the attendant to grasp in nursing. The instrument is now ready to be padded and covered. The former is conveniently done with boiler felt, the latter with basil leather. Fig. 146.—Double Thomas's Splint. It will often occur that some slight alteration will be demanded, at some period during the progress of the case, and if it is one attended with much deformity, the surgeon will; for a few weeks, occasionally have to alter the curves of the appliance. This modi- fication he should be prepared to perform himself, with wrenches. The patient being placed in the machine, the upper circle round the chest is closed with a strap and buckle, and the limb is bound with flannel from the calf upwards beyond the small crescent. ' Should the instrument rotate towards the diseased side, and so become a side splint, the surgeon should contract the longest wing of the upper crescent, and expand the shorter one ; or if the instru- ment does not rotate, yet the stem is not over the prominence of the buttock and well behind the thigh, then the upright requires more twisting. 6F HIP DISEASE, ETC. D03 It is very desirable that the patient should be confined to bed for the period at the commencement of the treatment. This prelimin- ary reclination I have never noticed to injure the general health, but invariably improves the patient's condition, and shortens the acute stage. The surgeon being satisfied that suppuration has been avoided during the first stage of the mechanical treatment, permits the patient to proceed on to the second stage. He is then allowed to go about with the assistance of crutches, the frame is continued, and an iron patten at least four inches in depth is placed under the shoe of the sound limb (Fig. 147). These must be worn day and night until the limb is well atrophied around the great trochanter, the outline of which should be more discernible than that of the sounr1 side. Fig. 147.—Thomas's Splint applied—front view. Fig. US.—Thomas's Splint applied—back view. (Reduced from Mr. Thomas's book.) Now we come to the third stage. The patient takes off the 304 Of hip Disease, etc. framework in bed and replaces it during the day, still using the crutch and patten for a certain period. We now arrive at the fourth stage. The patient totally discards the frame, and uses the crutch and patten only. These he sets aside after the surgeon is well satisfied with regard to the per- manence of the cure. If the case does not progress to the satis- faction of the surgeon, some of these stages must necessarily be prolonged. The weight of the lower extremity is equal to reducing any angular deformity of the hip or knee joint, not resulting from true anchylosis, and is capable also in some degree of diminishing any shortening, should absorption of the head of the bono occur, pro- vided a suitable mechanical arrangement be applied, and continued during a sufficient period. The splint ought to be applied at once, whatever be the stage of the disease. Forcible flexion, extension, tenotomy, or chloroform, are to be avoided as unnecessary. In the presence of my method these operations are undesirable, though they were essential at one time. Even should the deformity be an extreme one, no violence must he attempted; the limb should be gently persuaded to come back from the erring position, and as it assents, the wrenches should be used to alter the hip instrument towards the normal line. From this account it will be seen that Mr. Thomas advocates his splint and plan of treatment in all stages of the disease. For the reasons we have already stated, we believe that its great value will be found in the treatment of subacute and subsiding cases, with only a moderate amount of deformity. The advantages gained by not having to confine the patient to bed are here very great, and most certainly, if the splint fit properly, and be well looked after, the weight of the limb does, in practice, act as a most efficient agent in the reduction of the deformity. We have found that a piece of leaden gas tubing, flattened out, acts better for the modelling rod, than the malleable iron Mr. Thomas advises. The flexibility of the lumbar spine is always very great, and is especially marked in children; the patten should, therefore, be in them not only relatively, but ibsolutely as high, or higher, than is necessary for adult patients. Forcible Forcible straightening of the limb, the patient being stiaijj 1 e. under an anaesthetic, Avith tenotomy, where necessary, is sometimes a very successful treatment. It is only applic- able to those cases in whkh the inflammatory mischief has passed aAvay, leaving contraction of the muscles and adhe- sions about the joint. It may not be possible to bring the limb quite down at one operation, but the improvement must be maintained to its full extent by putting on a Bryant's splint, or a common OF HIP DISEASE, ETC. 305 long splint, before the effect of the anaesthetic has passed. Later on a moulded felt splint, or a plaster spica may be applied. If any tendons require to be divided, they will probably be those of the adductor longus or the tensor fasciae femoris. The operation is in all cases quite simple. (2.) Cases which have run on to suppuration, in which excision <2>. Hip disease ' ii ' With EIDSCGSS is not considered adrisable. formation. These cases differ very widely among themselves. In some, the disease runs a favourable course to consolidation, its duration not being much affected by the abscess forma- tion ; in others the formation of pus is the first chapter in a history of hectic fever, and of steady exhaustion. In the chief practical points, the manipulative manage- ment of this class does not generall}T differ from that of the one Avhich has just been considered, and the choice of the line on which the treatment is to be carried out must be made on general surgical principles. The risk of bed sores must be kept in mind if confinement ganger of to bed be decided upon. These are apt to occur in severe cases during the treatment by the stirrup and weight, unless great care be taken. If there be any tendency to their formation, it will hardly be possible to carry out this plan of treatment efficiently, but the patient may be put into a Bryant's splint in the prone position (see treatment after excision), or in the ordinary fashion, or may lie on a softer bed, or on a Avater cushion, in a Thomas's splint very carefully fitted. In extreme cases of emaciation the temptation is great to Tendency to n ii ii ,i . .i V i i- flexion of limbs allow the legs to be draAvn up, so that the body may lie over to one side more easily, but the limbs must never be allowed to assume this position if it can in any way be prevented. With regard to the abscess itself, Avhen it becomes Treatment of necessary to evacuate the pus, aspiration should in most cases first be employed, and may be repeated, for it some- times happens that after the abscess cavity has filled once or tAvice, suppuration ceases. If it does not, sooner or later the cavity must be thoroughly drained. A sufficient opening at the most- dependent part, and counter openings being made, a piece of drainage tube, or a wisp of horsehair may be passed right through, or two pieces of tube may be used. It is then easy to wash out the cavity Avith Condy, or carbolic, or iodine, or Avith any lotion that may be ordered. (See the treatment of abscesses, in the section on Minor Surgery.) The opening and subsequent dressing is commonly per- 20 306 OF HIP DISEASE, ETC. When osteo- tomy has been performed. When the joint has been excised. Bryant's splint. Regulation of the traction. Other splints, etc. formed with strict antiseptic precautions. The absorbent salicylic avooI Avill be found very useful here if there be much discharge, and it is often wise to put a certain amount of elastic pressure OArer the abscess walls, as Avith a Martin's bandage arranged in a figure of 8, particularly when the patient is beginning to get about. (3.) Cases in which division of the neck of the femur has been performed. Supposing the operation of osteotomy of the femoral neck to have been successfully performed, the deformity will not be cured Avithout the most careful after treatment. An interrupted long splint, or a Bryant's (Avhich is better), is generally used at first, and later, a Thomas's, or a moulded one. The stirrup and Aveight are sometimes, but more rarely, used, but the after management of these operation cases will vary Avith the individual practice of the operating surgeon. (4.) Cases in which excision of the joint has been performed, The same remarks apply here as to the preceding class, save that osteotomies are performed as a rule, on well- nourished, healthy subjects, while cases calling for excision are often much exhausted by irritative fever and suppu- ration. Of all the splints, we believe the best to be certainly Bryant's (see Figs. 141, 142). It has this advantage over others that, if desired, the patient can be put into it in the prone position; this is often very useful for cleanliness, especially soon after the excision, in children, or if there be a tendency to bed sores. It is easy to exert too much traction on the limb after excision, and care must be taken to maintain the proper amount of shortening, neither alloAving the shaft to slip up and irritate the pelvis, nor to be pulled down so that the interval at the site of the excision is too wide to be filled up in the course of consolidation. If a plain long splint be used, it must have a sufficient interruption and a foot piece. This splint may be combined with a stirrup and weight, as in fractures of the femur (q.v.), or the stirrup may be used alone, in Avhich case there is the risk of over extension Avhich has just been mentioned. In the later stages of consolidation, a Thomas's splint is very useful, and later still, a spica of plaster of Paris, or a moulded splint. OF THE "JACKET " TREATMENT IN SPINAL DISEASE. 307 CHAPTER XXIII. Of the "Jacket" Treatment in Spinal Disease. Of the Application of Jackets in Spinal Cases. Since the introduction of the jacket treatment of spinal General disease, numbers of these cases have been rescued from the consideratic hands of the instrument makers, or from a confinement, both irksome and demoralising, to the bed or couch. Nowadays, every surgeon is expected to know how to put on a plaster or felt jacket, and every dresser should acquire the knoAvledge of a mode of treatment which has produced such important changes of practice. This is not the place to discuss the pathology and treat- ment of spinal cases, but at the same time it should be under- stood that the early stages of the disease are generally, if not always, best treated by strict recumbency, and that not all cases of true spinal disease are suitable for the jacket at any stage. A jacket, placed on a patient who does not require one, is actively harmful, hampering respiration and groAvth, and depriving muscles and joints of their power of movement and development.* Especially among the unfit cases may be mentioned those unfit cases. rickety spines so common in quite young children, and cases of simple lateral curvature, due to laxity of ligamentous structures, where the deformity has not produced noteworthy visceral displacement and is not associated with other diseases, such as paralysis. But when all the unfit cases are excluded, there will still remain such a very large class of patients for whom a jacket is by far the readiest, cheapest, and most appropriate treat- ment, that its application should not be allowed to become a speciality, but should be understood by all general surgeons. The tAvo kinds of jackets which we shall particularly describe are made respectively of plaster of Paris and poro- plastic felt, but the principle may be carried out in other materials, such as leather, gutta-percha, or paraffin. * See the Author's paper on this subject in the " Proceedings of The International Medical Congress," 1882, Section, Diseases of Children. 308 OF THE "jack in" treatment in spinal diseask. The end desired is to immobilize the spine about the scat of the disease, and to fix the Avhole spine in the best position possible, that is, with as little curvature and rotation of the vertebral sections as the extent and stage of the disease will allow.* The necessary To do this by means of any splint or case, moulded to the conditions. ■ bod^ it is 0kvjous that ft must De fitted (1) while the trunk is as much extended as it may, or rather as it ought, to be ; (2) with the thorax in the position of inspiration ; (3) Avith FiO. 149.—Suspension (partial) by Tripod and Pulleys. * If the disease he high up, as in the cervical spine, the vertebrae can hardly themselves be fixed, but the manner of supporting the head will be described directly (see " Jury Masts "). OF THE "JACKET" TREATMENT IN SPINAL DISEASE. 309 all bony prominences protected ; (4) with a good hold on the pelvis to serve as the basis of support. It must also be as light as is compatible with strength, and be loose enough over the abdomen to allow of moderate distension by food or flatus. The extension of the trunk may be attained by Dr. Sayre's Extension of method of suspension, or, in the case of children, by simply the trunk' holding them up Avith the hands in the armpits, or by the inclined plane ; this latter, hoAvever, cannot be used for the ordinary plaster case. Of these three methods, the suspension from the tripod re- By suspension. quires the most care. As shown in the figure (Fig. 149), the patient can be suspended with the feet just off ov just on the ground—in England the general practice, with Avhich Ave thoroughly agree, is not to swing the patient clear of the ground—by means of straps and padded slings, Avhich pass round the head and beneath the axillae, and are attached to a crossbar, itself connected Avith a cord passing over a system of multiplying pulleys. By means of this cord, partial or complete suspension may be attained by the patient him- self, or by an assistant, with a very moderate amount of force. In severe cases, or if there be any loss of power in the legs, the patient may conveniently sit under the crossbar, inside the tripod, and have the slings adjusted. The objections to the suspension apparatus are, that in objections to • • » • • tliis method children it is alarming and fatiguing, and even for adults it is generally a trying ordeal. For most cases it is no doubt safe enough, but delicate patients must be watched lest faintness comes on, and if the consolidation of the vertebrae be only in its early stages it is impossible to be too careful not to inflict damage by forcible extension. Unfortunately, it is difficult to estimate the force which is being employed, owing to the multiplying pulleys. Speaking generally, hoAvever, it maybe said that for adults, if the ordinary plaster case is to be applied, gentle suspen- sion from the tripod, in the standing or sitting position, will be best; but that for young children, suspension by an assistant with the hands in the armpits is much to be pre- ferred. The simple inclined plane, Avith the arms thrown over the The inclined head and grasping a bar, is even a better and safer Avay of plane" producing extension in the position of inspiration. This position cannot be maintained Avhile a bandage is being rolled on the trunk, so that it will not do for an ordinary plaster 310 OF THE "JACKET" TREATMENT IN SPINAL DISEASE. Inspiratory position. The protection of prominences The hold on the pelvis. Application of plaster jacket in ordinary manner. The jersey. case ; but for the poroplastic jacket, or for a modification of the plaster one to be presently described, it has much to recommend it. The inspiratory position of the chest-Avails is secured by the raising of the hands, if the inclined plane be used, and this is the case also Avith the tripod, if the patient be self-sus- pended ; if not, the hands may be raised to grasp the legs of the support, but the management of this is often a difficulty. In holding up children by the hands in the axillae, it is easy to maintain the desired position of the arms and chest-walls. The protection of prominences is most important. Not only the angle at the curvature of the spine, if one be present, but any other projection Avhich seems in the least likely to be rubbed, must be protected by pads placed on either side, or around, but not over it. The pads are best made of toAV, covered Avith old table linen, and are placed in position next to the skin. Careful moulding of the case to all irregulari- ties, by pressing and squeezing it into shape before it sets, will also prevent chafing. The hold on the pelvis is very important, and its neglect is the most common cause of failure of the treatment. If the case merely encloses the trunk as in a barrel, there is no relief afforded in the way of support of the weight of the head and upper extremities, nor is the rotation of the spine at all prevented. The requisite grip is easily secured by taking care to bring the bandage, or the felt, at least 1^ inches beloAv the iliac crest, and to mould the case to the prominence of that bone. We will pass noAv from the consideration of the general principles of the jacket treatment, to a description of the actual application of the common plaster jacket, of its modi- fications, and of the poro-plastic jacket. We will take first the case of an application of the jacket in the ordinary manner. A time should be chosen not less than two hours after a meal, if possible upon a dry day, and there should be a fire in the room in which the operation is about to be performed. A firm horse hair mattress should be laid on the floor near the fire, ready to place the patient upon as soon as the jacket is adapted. The patient is then stripped, and the cinglet or jersey A\diich is to go under the jacket, and Avhich should be of a kind specially made for the purpose, is slipped on, and the tags for the shoulders tied, or fastened with safety pins (on no account must an ordinary pin be used anywhere in these cases). The pads must then be adjusted to protect the OF THE "JACKET " TREATMENT IN SPINAL DISEASE. 31-1 angular curve, when necessary, as it almost ahvays is. If the abdomen be unusually retracted,, it is Avise to place a temporary pad to bring up the circumference of the jacket there, to its normal size. The permanent pads at the back The pads. or elseAvhere should be fastened to the cinglet Avith a stitch or two, after they have been carefully adjusted. The bottom of this garment is then fastened, back and front together, betAveen the thighs with a safety pin. All is ready iioav for suspension. In the case of a child, The suspension. as we have said, this is best performed by an assistant plac- ing his hands in the axillae, so as to grasp the arms at their highest point. The child can thus easily be held Avith the shoulders well throAvn back and Avith the toes just touching the ground. But if suspension by straps and pulleys is to be employed, the patient must have the head and shoulder slings of the tripod adjusted so as to give an equal pull upon every part, as seen in figure No 149. The straps of all the slings, and of the chin and occiput supports, can be altered to suit different patients, and too much care cannot be taken to get the support exactly right before applying the bandage. As a general rule, the patient stands for the suspension ; but if there be great Aveakness, or any paralysis, or simply if* it be found more comfortable, a seat without a back ^a rotary music-stool does best) may be placed beneath the tripod. When the slings have once been adjusted, the actual x'aising should not be made until everything is ready for the application of the bandage, and in our opinion it is never advisable to swing the patient quite clear of the ground or stool. The general manipulation of rolling on a plaster of Paris bandage has already been described, and this particular form does not differ in any essential point. Six or eight freshly-rubbed muslin bandages Avill be re- Application of quired, and both they and a small quantity of loose plaster the bandaees- should be put into an oven for about an hour before they are wanted. In moistening the bandages, a large basin of warm water should be used ; as soon as one is ready, it is taken out and another is put in the Avater, Avhile the surgeon rapidly rolls the first on to the trunk of the patient, alloAving the bandage to take pretty much its OAvn course, but endeavour- ing to work generally in figures of 8, the upper loop encir- cling the chest and the loAver one grasping the pelvis. The bandage must on no account be draAvn upon, but merely rolled on. When the first is finished the second is taken out of the water and a third one put in, and so on. As a rule, 312 OF THE "JACKET" TREATMENT IN SPINAL DISEASE. for a child of eight years of age, four bandages will be enough to make a jacket three layers thick everywhere, and four layers in the parts that most require strength. For an adult, six will generally be necessary. While the bandages are being rolled on, an assistant should rub in additional loose plaster Avith the hand, moisten- ing it as is required ; and when the bandages are all put on, the whole jacket must be Avorked over with moistened plaster, Avell rubbed in, until the surface has a uniform greasy feeling. The prominences of the pelvic crest, the spine, etc., must iioav be moulded before the plaster sets. All this must be done very quickly, for the position is a fatiguing one. In most cases it is wise to have one assistant Avhose Avhole care it is to Avatch the patient, and to look after the suspension. If in the process of applying the jacket, any symptoms of embarrassment, either to the breathing or circulation appear, the patient must be promptly let down. When the application is finished, some patients, if there be Removal from no great discomfort, may be left partly suspended for about ten minutes while the jacket begins to set, but as a rule it is Fig. 150.—Plaster of Paris Jacket applied. advisable to remove them from the apparatus as soon as pos- sible, and lay them flat on the mattress, placed ready on the floor near a fire. The removal must be made with great care, so as to avoid any cracking of the case. Hot water OF THE "JACKET" TREATMENT IN SPINAL DISEASE. 313 bottles, or hot bricks, laid near the case Avill hasten its dry- ing, especially in damp weather. As a rule the patient had better remain still for three or four hours Avhile the case is setting. It will then probably require a little trimming and cutting away in the armpits, etc., Avhich can conveniently be done with a sharp knife. The safety-pin in the perineum, and the stomach pad, when present, can be removed as soon as the patient is laid down. Figure 150 is drawn from a case of angular curvature of ordinary severity, in Avhich a plaster case had been applied. Modifications of the above method. (1.) It is sometimes advisable to especially strengthen the Modifications back, or one side of the case, when there is a great tendency to yield, or Avhen the patient is unusually heavy. If this be Metal strips. done by increasing the amount of bandage, the case is apt to be made too heavy, but a very good way is to work into the plaster, strips of tinned iron about half an inch wide, with holes roughly punched in them to make the plaster hold better. These are laid along the jacket as it is being made, and are incorporated Avithin its folds. (2.) One great drawback of this jacket treatment is the changing impossibility of getting at the skin to wash it, or of cleans- ]acket' et0< ing the cinglet, and, among the poor, there is great difficulty in avoiding the presence of vermin. If only one cinglet be used, it cannot be changed without making a new jacket. There are two ways in which this difficulty may be par- tially overcome. The first, recommended by Mr. Keetley, consists in laying tAvo clean handkerchiefs or napkins, back and front, betAveen the cinglet and the skin (and of course inside the pads) before the jacket is applied. When these have to be changed, this is easily done by pinning a clean napkin to the lower edge of the soiled one, Avhich should project a little below the plaster jacket; then, by pulling the latter out at its upper end, the new folloAvs the old one and lies in its place. The other Avay is on the same principle, and is Mr. Oxley's device. Tavo cinglets, inrtead of one, are worn throughout the treatment (the pads being fastened to the outer one only). The outer one adheres to the plaster, and forms part of the case, but the inner one can be removed by pulling it off, over the head and shoulders, after having tacked a clean one to its loAver edge all round. (3.) A more important modification is due to Dr. Walker, Mifcat°on°wh?i€ lying down. 314 OF THE "JACKET" TREATMENT IN SPINAL DlsEASil. of Peterborough,* by means of which the swing may be dispensed Avith, and a plaster jacket be put on while the patient lies flat, or better still, extended on an inclined plane, Avith the hands raised backwards above the head, and grasping a bar. To carry out this plan it is necessary to retard the setting of the plaster. This is effected by soaking the muslin bandages into the interstices of which the plaster has been rubbed in the ordinary way, in a mixture of mucilage and water (about 1 oz. to a pint of Avater). When the roller bandages have been thoroughly moistened, they are cut into lengths sufficient to go round the body of the patient, and to overlap some inches in front. The several lengths are then arranged on the inclined plane so as to form a series of overlapping strips, in sufficient number to secure a three or fourfold thickness everyAvhere. The cinglet having been put on, and the pads adjusted, the patient is placed in the extended position, over the strips of bandage, which are then taken up, one by one, and their ends crossed over the front of the chest and abdomen, like one loop and a bit of a figure of 8. If they have been pro- perly placed, it will be found that in this manner a Avell- fitting jacket of a somewhat hour-glass shape will be made, expanding above for the upper part of the thorax, and beloAv to take a hold of the pelvis. The patient should be allowed to lie still until the case sets, which it will do in three or four hours, f The time occupied in the actual application of this jacket will generally be a good deal less than in the case of the ordinary one, but even if this were not so, the saving of fatigue, and the other advantages incident on the doing away of the necessity for suspension, are sufficient to make this plan a very valuable one in many cases. On the other hand, it Avould be quite easy to make the jacket by means of short over-lapping strips instead of the long roller bandage, Avhile the patient Avas suspended in the tripod, if it Avere so desired, but this does not seem to have come into practice. * See British Medical Journal, 1879, Vol. I., p. 305. Also a Clinical Lecture, by Mr. Furneaux Jordan, Lancet, 1880, Vol. I p. 905. t Mr. Furneaux Jordan (loc. cit.) uses instead of a number of strips, three or four wide "compound" ones, each of six or eight thicknesses of muslin and plaster, or of three or four layers of honey- comb toweling and plaster. In either case the number of layers seems excessive, if there be a proper amount of plaster incorporated. Of the "jacket" treatment in spinal Disease. 315 (4.) Mr. Davy has adopted for some time past, and has Mr. Davy's plan. fully described a plan of " hammock extension," face doAvn- Avards, for the purpose of putting on a plaster jacket, for a description of which the reader is referred to his paper.* Suggestions have often been made of slitting up the jacket in front, and sometimes of making a hinge behind, so that it may be removable, but in practice this has not been found to be successful. When the prominence of the angular curvature is the seat Trap doors. of an ulcer, it is not generally wise to put on a jacket at all, but it is sometimes advisable to cut trap doors for this con- dition, or opposite the opening of discharging sinuses or abscesses. Poroplastic jackets. The moulding of resinous felt into a spinal jacket does not Poroplastic differ in its main principles from the moulding of thatjackets- material for other splints, but the large amount of felt em- ployed, together with the great rapidity with which it sets, makes a certain amount of practice necessary in order to be able to fit a case of spinal curvature properly. A well-fitted poroplastic jacket is often an admirable Their method of treatment. It is not much more than half the advantages' weight of a plaster one, is porous, so that the action of the skin is but little interfered with, and it can be removed Fig. 151.—Poroplastic Felt Jacket. altogether, or Avidely loosened, at frequent intervals, for the purposes of cleanliness, although it will not long stand being taken off every night, as is sometimes advised. These jackets are sold roughly blocked out (Fig. 151) in a • British Medical Journal, 1880, Vol. I., p. 959. 31G of the "jacket" treatment in SPINAL DISEASE. sufficient number of sizes, and of three qualities, of Avhich the tAvo more expensive are about equally good, though the dearer one is rather the lighter of the two. The third and coarsest quality is not here recommended. The jackets are fitted A\dth the necessary straps and buckles and eyelet holes, and lately an additional improve- ment has been to leave unstiffened the felt correspond- ing to the front iliac spines, and (in Avomen) to the breasts, as shoAvn in the figure. Other parts may also be left unstiffened as required, as over tender prominent ribs, or spinous processes. Fitting by A jacket of about the right size having been chosen, it means of a cast. mug^ ^g accurately fitted to the body of the patient, while the position of extension is maintained. One way of doing this is to take a plaster cast of the trunk, and block the jacket upon-that instead of upon the body. This is a plan very generally f olloAved by instrument makers, and has this advantage, that any number of jackets can be moulded in the future without further trouble to the patient. But the first cast is difficult to make, except by a professional modeller, and generally speaking, the position of extension is not well maintained.* A cast, however, would be absolutely necessary if leather were used instead of felt. By the tripod. But the general practice is either to suspend the patient from the tripod, or to procure the extension, and the inspiratory position, by means of an inclined plane. As we have said before, we consider the latter is, in ordinary cases, to be preferred. By the inclined In either case, the fitting of the cinglet and pads is just the p ane" same as if the plaster jacket Avere about to be made, and if the tripod be used, the head and shoulders are adjusted exactly as has been before described. If the plan of the in- clined plane be chosen, the patient lies down on it, and, raising the arms above the head, catches hold of some bar or support. The best inclined plane is the simplest, namely, a board about tAvo feet Avide, and Avith an inclination of about tAvo feet in six. There must be no foot-piece, nor any pilloAV for the head. * The Author has recently made a cast of the inside of an old jacket serve as the model on which a new one ould be blocked, and found that it answered the purpose very well; all that was required was to pour plaster of the consistency of cream into the jacket standing on a board, as into a bucket, the straps being buckled to close it in front. If a layer of paper be pasted inside there will be no ad- herence of the cast to the felt mould, or, better still, the mould may be oiled. OF THE "JACKET" TREATMENT IN SPINAL DISEASE. 317 The same method of softening the jacket can be employed softening the in either case. This can be done very well in a good-sized ]a oven at the ordinary cooking heat, in Avhich the jacket should be suspended from some support, such as a surgical cradle ; in the kitchen it must hang free, and must not touch the sides anyAAdiere or °ven' it will burn ; it must also be Avell moistened, and a pan of water should be placed on the floor of the oven. But upon this plan it will be necessary to bring the patient in a special to the oven, i.e., in most cases, into the kitchen, and it is s eam c am e naturally more convenient to bring the oven to the patient. This may be done by using a specially contrived steam chamber, sold or let out by instrument makers, and Avhich consists of an iron cylinder Avith a double bottom, into Avhich an oil stove-lamp, a spirit-lamp, or a gas-jet, is put. A pan of water stands Avithin the cylinder, Avhich has a tight-fitting lid. The lamp quickly generates the steam, and there should be Application oi heat enough to thoroughly soften the jacket in three or four the ;iacket, minutes. It is then ready for application and must be at once and as quickly as possible put on. According to the description of Mr. SAvain,* the patient being suspended from the tripod, an assistant (a\ ho is advised to have gloves on) quickly draAvs, first the Avaist-strap and buckle together, then the pelvic ones, and lastly those about the breast, the responsible surgeon the Avhile moulding and kneading the felt to the prominences of spine and other parts. This is a good plan to folloAv, but a better, is to have ready cut, six or eight lengths of broad, stout bandage stuff, then, whether the patient be suspended or be lying on the inclined plane, the jacket can be quickly slipped on and the sides brought round into position, care being taken that the softened parts of the felt correspond to the hips and breasts, and that the buckles come opposite the straps. The lengths of bandage are then quickly passed round and knotted in front by the assistant, while the surgeon brings the sides accurately forward, and moulds them as he does so. The waist bandage is tied first, then those for the hips ; the breast ones next, and then intermediate ones as may be required. In this Avay all fumbling Avith hot buckles and straps is avoided, the jacket is easily put on before it can set, and a closer, more accurate fit is attained. The jacket sets too firmly in a minute or tAvo for any further moulding to be done, but it is not really strong for • Lancet, 26th June, 1880. 318 OF THE "JACKET'* TREATMENT IN SPINAL DISEASE. about half an hour, so the patient must lie still for that time, if on the plane, or may remain semi-suspended if this can be borne, or as in the case of the plaster, may be carefully re- leased from the tripod and laid flat on a mattress, this time not close to a fire. AVhen the felt has set, the bandages may be cast off, and the straps and buckles closed. These will very likely require some adjustment, and for this reason it is often wiser to mould the jacket before the straps and buckles are soavii on. Trimming, etc. The jacket itself will almost certainly have to be cut aA\-ay somewhere, or slightly altered, and this may be done in one of two ways, as may seem best; namely, with a hot iron, which will re-soften parts that do not quite fit, or by dissolv- ing out of the felt, the resin, with spirits of wine sufficiently to make it much more pliable. This is often a very good plan for such parts as the arm-pits. Re-appiication If the jacket be a failure, or if, as ought to happen in the of the jacket. - . .« - -. ° . progress ot a case, it seems as if a further improvement were Fig. 152.—Poroplastic Jacket applied. possible, the case must be slipped off and re-softened in the steam chamber, unless it be badly cracked, or be worn out. In Fig. 152 is shown a felt jacket, moulded to an adult 802802 OF THE "JACKET" TREATMENT IN SPINAL DISEASE. 319 case of bad lateral curvature. In this case a similar jacket had been worn for several years. Methods of support in Cervical caries—Jury masts. Jury mast. When the seat of the spinal disease is in the cervical region, it is obvious that no jacket can, of itself, fix the vertebrae. In acute cases it is generally necessary to make the patient lie absolutely flat, with the head fixed with pilloAvs or sand bags. But there are many stages in the disease, in which it is both safe and advisable to allow the patient to get about, provided that in some way or another the weight of the head and neck can be taken off the diseased \ ertebrre and thrown elseAvhere. This may be done by various patterns of steel instruments ; these Ave cannot here discuss, but the simple plan known as the "jury mast" system is very generally efficient, and can be carried out by any surgeon or dresser. Its main features can be seen in the accompanying figure. (Fig. 153). It consists of a light plaster jacket, from Avhich Fig. 153.—Jury Mast applied. springs the mast itself, Avhich is a light bar, Avith a joint for Shape of mast. the adjustment of its length, arching overhead, and having a cross-yard about 5 inches long, from Avhich hang straps to support the head from the chin and occiput. 320 OF THE "JACKET" TREATMENT IN SPINAL DISEASE. The mast is forked beloAv, so as not to press upon the vertebral spines, and has attached to it thin strips of tinned iron, with pierced rough holes; these go round the body and are worked into the plaster jacket. Fitting ana In fitting the mast, the iron bar should first be bent Avith appica on. wrenches to the right shape, and then tempered. The exact height may be afterwards adjusted. The jacket may be put on with, or without, suspension, as may seem best, but if the tripod be used, the greatest possible care must be taken not to put too much strain on the vertebrae of the neck. The plaster jacket must be as light as will fix the mast, Avhich with the cross strips, is imbedded in its substance, having layers of plaster both above and beneath the iron. As soon as the jacket is set, the straps may be adjusted, and the length so fixed that the bar is just clear of the head, when the latter is supported to the extent which gives greatest relief. This height will have to be altered from time to time. Although this apparatus Avould be almost insupportable to people in health, it can be Avorn Avith comfort in cases of cervical caries, where the relief it affords is often very great. The curve of the mast in Fig. 154 is hardly bent enough to the shape of the head and neck. OF THE "JACKET" TREATMENT IN SPINAL DISEASE. 321 The Author has recently applied the mechanical principle of the jury mast to cases of caries of the upper dorsal spines, with good results. In certain forms of this disease the angular deformity is of such a nature that the shoulder girdle and upper part of the chest drop more and more forward until the hands rest upon the knees (see Fig. 155). This deformity continues to increase even when the active carious process has been arrested, for there is no tendency to any compensatory lordosis lower down in the healthy parts of the spine, as occurs in many other varieties of dorsal caries. FlG. 155.—Jury Mast for upper Dorsal Caries before the Bands are fastened. No form of jacket will of itself give the requisite support, but if a jury mast be attached over the last eight dorsal and the lumbar vertebrae by means of a light plaster case, as in the case of cervical disease, and if it be bent opposite the angular deformity so that the upper free part overhangs the 2] 322 OF THE "JACKET " TREATMENT IN SPINAL DISEASE. spine above this angle, stopping short at the back of the head, as shoAvn in the figure, it will their be easy to sling up the drooping chest and shoulders to tAvo cross-bars pivoted on this free part by means of a couple of padded axillary bands, and a broad Avebbing strap. The figures 155, 156, illustrate this arrangement before and after the bands are tightened up. The webbing chest support is best fastened by seAving short tin strips to it, (indicated by dotted lines in the figure 156) and attaching these to the jacket by a turn or two of plaster bandage. Fig. 156.—Jury Mast, etc., as in Fig. 155, after the Bands are fastened up to the Cross Pieces. In other cases a light felt jacket may be used instead of the plaster one. There must always be a good hold taken of the pelvis. Eeturning to the question of support in cervical disease, in addition to the jury mast plan one or tAvo others should here be mentioned. Thus Mr. Furneaux Jordan (loc. cit. OF THE "JACKET" TREATMENT IN SPINAL DISEASE. '5TA p. 299) has recommended a plaster support which fixes the whole spinal column, absolutely preventing rotation, and which, therefore, should be more suitable than the ordinary method, for caries of the two first cervical vertebras. The apparatus essentially consists of a plaster of Paris figure of 8; the upper loop embraces the forehead and sides of the head, the decussation is at the seat of the disease at the back of the neck, and the lower loop encircles the root of the neck; the ends of the bandage which has formed the 8, are then attached over the front of the chest to a light plaster jacket. Fig. 157.—Furneaux Jordan's support for high cervical caries. The method of application is as follows: The patient must lie on a flat, hard couch or table, with the arms raised over the head. The head itself must either be steadied by an assistant, or (as advised in Mr. Jordan's original paper) extended by a Aveight and pulley. In either case, pads of cotton avoqI or lint must first be placed over 324 OF THE "JACKET" TREATMENT IN SPINAL DISEASE. the ears, at the back of the neck, and over the collar bones, and these must be secured by a flannel figure of 8 bandage, put on in the same Avay as the plaster bandage will be, which is to lie over it, and a cinglet is to be Avorn over the body. Extension may generally be dispensed with, but if it is to be employed a chin and occiput sling must be made by adjusting an ordinary four-tailed bandage below those parts, or attaching two strips of adhesive strapping in a similar fashion. In either case the ends of the sling must be brought together over the head and attached to a cord, which, passing over a pillow at the head of the couch, has there a weight of 3 or 4 lbs. attached to it (Fig. 158). Fig. 158.—Furneaux Jordan's arrangement for extension of head. A strip of household flannel, two inches and a half wide, and of sufficient length, is soaked in a basin of plaster of Paris cream. The centre of it is then applied to the patient's forehead, and the ends are brought round from before, backAvards on either side over the ears to the back of the head; the two ends are crossed there over each other, and are then continued forwards over the front of the root of the neck, and either approach or cross each other again upon the sternum. Another strip of flannel soaked in plaster must then be put round the chest over the ends of the figure of 8 bandage. A second and third bandage are then applied to the head and neck as before, and enough flannel strips are put round the chest to make a light jacket for the thorax, into Avhich the strips are firmly incorporated. OF THE "JACKET" TREATMENT IN SPINAL DISEASE. 325 If .the chin and occiput sling has been used, it can now be cut aAvay. Mr. Walsham, in a paper read before the Medical Society* advised the use of a poroplastic jacket and collar combined. Dr. Fleming, lastly, has invented an india-rubber inflating Fig. 159.—Dr. Fleming's India-rubber Inflating Bag.\ bag (Fig. 159) which Avhen adjusted over a broad stiff collar of felt," and distended Avith air, supports the head, and extends the neck. * Brit. Med. Journal, 1885, Vol. I, p. 701. t Vide The Glasgow Medical Journal, May, 1884. 326 OF GENU VALGUM, TALIPES OF THE FOOT, ETC. Genu valgum or knock-knee. CHAPTER XXIV. Of Genu Valgum, Talipes of the Foot, etc Of Genu Valgum or Knock-Knee. Putting aside those cases in which some operation about the femur, or about the knee joint seems to be advisable, much may be done by a patient use of the simplest forms of splints; in very young children especially, quite as much, and probably more, than can be eflccted by the most expensive forms of instruments. Treatment by gimple splin s. Fig. 160.—Splints for Genu Valgum. (The strapping or webbing is not sufficiently broad in this cut.) For most cases, two outside splints of a simple pattern, as those which are shoAvn in the figure (Fig. 160) will be of genu valgum, talipes of the foot, etc. 327 found quite efficient. These may be fastened on by webbing straps, or by broad strips of strapping. In either case one strap, or strip of plaster, must ahvays go over the knee. Long, thick stockings had best be worn beneath the splints, or a flannel bandage may be applied instead; a calico bandage may be put on over all if the webbing or strapping fails to fix the splint firmly enough. In bad cases, or ones Avhich are quickly getting Avorse, it is best to Avear the splints continuously, only taking them off night and morning for readjustment. But in slight cases, or in those Avhich are on the road to recovery, free movement in bed may be alloAved, and the splints put on the first thing every morning. Another plan, is to put up the legs in light plaster of By piaster of Paris cases, stiffened if necessary by a wooden splint on the ails" outside. While the plaster bandages are being put on, the knock-knee must be forcibly straightened as much as it will bear. The neAv position of the limb will be retained by the splint, and Avhen this has been worn a short time (say three weeks), it may be taken off, and a further forcible straight- ening effected and retained in the same manner. Valgus of the knee is often associated with that of the foot. Which may be the cause, and which the effect, is a much disputed point; but in any case both conditions must be attended to. Bandy (or bowed) legs, curvature of the tibia, etc.—Simple Bandy legs. bandy leg, or general outAvard curvature of the tibiae, inasmuch as it is nearly the reverse of knock-knee, may be Avell treated on just the same lines, the splints being put on the inside instead of the outside of the legs. This condition yields to treatment more readily than valgus of the knee. The curved tibiae which occur as a consequence of rickets, Rickety curva- are noAv far more frequently treated by section of the bones with a saw or a chisel, than formerly was the case. It seems to be established, that if it be properly performed, the operation is practically free from danger; and although the ultimate results upon the groAvth and nutrition of the bones can hardly be determined absolutely at this time, all the evidence points to there being no important disturbance of these processes. But the number of rickety legs which can be improved Treatment by or cured by proper splinting, will ahvays be very large as sp in mg" compared Avith those in which osteotomy is at all called for, and common light wooden splints are infinitely preferable to " irons " of any kind. 328 OF GENU VALGUM, TALIPES OF THE FOOT, ETC. '. When the >atient is not to walk at all. The length and method of attachment of these splints will depend a good deal upon the stage of the disease, and upon the age of the patient. In the acute stage of the rickets, and especially if the children are quite young and are only just beginning to " feel their feet," it is best to keep them from bearing any of their Aveight, often increased by a tumid belly, and a heavy head, upon the yielding leg and thigh bones. In this case the splints had better be Avorn day and night, ahvays being adjusted morning and evening. They must be well padded, and should extend three or four inches below the foot, being attached by bandages or webbing straps, and generally to the inside of the limb. If this length does not succeed in keeping the child off its feet, they may be made of different lengths, and if this fails, the legs must be tied together, or some such plan as was described in the chapter on hip disease, must be adopted. (See Fig. 140.) But if the rachitis be not acute nor the curvature very great, it is generally wise to allow the child to run about, the splint extending to the bottom of the foot only (Fig. 161). Ing is permitted. Fig. 161.—Simple Splint for Bandy-leg, attached. As a rule, Avebbing straps and buckles are here better than strapping or bandaging. A broad strap should always go round the place of greatest curvature. As a rule, these splints are best put on the inside of the leg, but there are frequent exceptions, and it is often advisable to change about from one side to the other to avoid sores over the malleoli, etc. As the improvement continues, and the bones consolidate, the splints may be left off at night and finally abandoned altogether. Treatment by Here, as in the case of knock-knee, plaster of Paris can piasterof Paris. be very usefu}ly employed. The best Avay is to attach a Avooden splint so as to keep up a constant straightening force Avhen it is fixed by the plaster. The case should be OF GENU VALGUM, TALIPES OF THE FOOT, ETC. 329 as light as possible, so as not to interfere with the nourish- ment of the limb.* Of Club Foot. Club foot. The different kinds of club foot are very numerous, and the cases of each variety of the deformity, differ very much among themselves in the extent to Avhich they are amenable to treatment, and as to whether one plan of treatment or another is the more suitable. Without entering into the pathology of the condition, classification of the folloAving forms of club foot may be taken to be those with Avhich the house surgeon and surgical dresser may expect to have to do. I.—Slight forms of Weak Ankle and Flat Foot. Varus. Valgus. H. Varus + equinus or VI. More severe forms of cams (generally + both) and valgus and calcaneo-valgus, equinus only, with little dis- not paralytic. placement of bones and not requiring tenotomy. III. Varus + equinus + VII. Valgus -f- calcaneus, cams, requiring tenotomy, paralytic. division of fasciae, etc., (bones not permanently displaced or deformed). IV. Equinus only, requir- VIII. Calcaneus only, par- ing tenotomy. alytic, or due to non-union V. Varus + equinus + of the tendo Achillis after cams, with marked bony division. distortion, not curable by tenotomy, splinting, etc. (treatment belongs to major surgery). I. Sli'tht forms of Avhat is generally called "weak ankle slight forms of J , -i»i-i • i /• won.!!1 anklp are very common in children ; sometimes the foot turns imvards as a persistent condition resembling the slight varus Avith Avhich all infants are born; but more commonly, the tendency to a slight valgus, Avith a flattening of the arch of the foot, and a little slip fonvards of the astragalus over the ridge of the sustentaculum tali. In either of these conditions the aim should be to brace * As a preventive measure against bowed legs, and other infantile deformities, the usefulness of the old-fashioned " go-cart" should not be forgotten. The modern perambulator is in many respects a change for the worse. weak ankle. 330 OF GENU VALGUM, TALIPES OF THE FOOT, ETC. up the ligaments and muscles as much as possible, and to this end shampooing, bathing Avith salt and Avater, galvanism and other measures to improve the nutrition of the parts, are all good, Avhile anything in the shape of irons, Avhich cripple the limb under the pretence of keeping it straight, is bad. The legs should be kept Avarm, and light shoes, not boots, be worn.* oblique heels. In these slight cases a good deal may be done by alter- ations in the pattern of boots Avhich are otherAvise of the ordinary kind ; thus the heels of the shoes may be cut obliquely, so as to slope, in the case of the valgus foot, backAvards and outwards across the sole; in the varus form, in the reverse direction, an angle of about 45 degs. being a good general direction. The boot sole as well as the heel may also be made thicker on the one side than on the other, so as to thro~" the foot over in the direction opposite to that in which it naturally turns. valgus pad for Another expedient is only used for valgus, and consists in fixing a pad or plate under the sole of the foot, in the shoe, so as to support the plantar arch. One pattern of such a pad is shoAvn in Fig. 162, and another and a better form in Fig. 163, where an india-rubber pad is shown by itself, and also in the position in which it should be attached to the inside of the boot so as to support the instep. Fig. 162.— Valgus Sole-plate. varus,generally II. Not quite so common as this condition, but still very Tquinu'synot01 frequently met with, are those varus club feet, which are ation.rmg °per" almost always associated with a contraction of the plantar fascia, and with some degree of equinus, but in which the whole deformity is slight, and yields to treatment without the division of any structures. The beginning and the end of the successful treatment of these cases is patience, and, again, patience, in the keeping * We believe that the best kind of shoe in these cases is that known as the " Flexura," the special feature of which consists in the working of a metal spring into the sole. OF GENU VALGUM, TALIPES OF THE FOOT, ETC. 331 of Avhatever contrivance may be selected, properly adjustec to the foot and legs; and the same may be said of uncon- firmed cases of simple equinus. anie treatment as more severe Fig. 163.—India-rubber Valgus Pad, in position and separately. It will not, hoAvever, be necessary to distinguish or Requires & describe the various plans for the remedy of this grade, the__. separately from those for the third one, where the tendons oplrauon'' call for division, for practically the whole treatment of the former is identical Avith the after treatment of the latter degree of club foot, Avhich is now to be considered. III. Talipes varus and equino-varus, both of which con- Varus and ditions are generally associated with plantar contraction, eQuinovarus may be from the first, and, if neglected, will in all cases become, complicated Avith such an amount of contraction of the tendo Achillis and of the tendons of the anterior and posterior tibial muscles, etc., that division of some of these structures will be necessary before the deformity can be remedied. It is, hoAvever, often desirable to carry out a preliminary course of splinting, etc. In the chapter on Minor Operations we shall refer to tenotomy, although only very briefly. As a rule these operations present little difficulty, yet some cases are troublesome, and all require practice to do neatly. For- tunately, this is one of the few operations Avhich can be done on the dead body, owing to rigor mortis, with a rather 332 OF GENU VALGUM, TALIPES OF THE FOOT, ETC. Tenotomy only one step towards cure. The choice of plans. By a stiff straight splint. By a flexible metal splint. close imitation of the conditions during life, so that every student should have abundant opportunities of acquiring the necessary skill. The mistake is too commonly made of supposing that the tenotomy once performed, the club foot is cured ; on the contrary, the division of the tendons should only be regarded as a necessary preliminary to the real curative treatment of the deformity. We Avill suppose then that the necessary tenotomies have been performed, or that none have been required, and that in the former case the foot has been alloAved to remain undisturbed for three or four days.* One of the folloAving lines of treatment should be chosen. (1.) Persistent splinting with stiff, straight splints. (2.) Persistent splinting with a stout but flexible metal splint. (3.) With some form of Scarpa's or Adam's shoe. (4.) With a plaster case. (5.) By a combination of flexible metal Avith plaster. Any of these plans, in proper hands, will succeed, if the case be favourable; on the Avhole, we believe No. 5 to be the most, and No. 3 (the shoe) the least satisfactory, but it would be quite improper to dogmatise. 1. By a stiff straight splint. A Avell padded wooden one is the best to use, not broader than the leg, and long enough to reach from the knee to below the foot. The limb should be attached to it either by bandages, or strapping, or by webbing straps, or by a combination of these. For very young children, strapping applied over a flannel bandage is best. The splints should be taken off and readjusted at least once every tAventy-four hours, and when they are off, the opportunity may be used for shampooing, galvanism, etc. This direction must be taken to apply to all other remov- able apparatus to be presently mentioned. 2. By a flexible meted splint. A cure of the club foot can be effected by means of a stiff splint, but a more comfortable plan in most cases, is to use straight metal splints, flexible enough to be easily moulded, and sufficiently stiff to retain the shape to which they may be bent. By their use the * Although some surgeons advise the immediate fixing of the foot in good position after tenotomy by plaster of Paris, and although, no doubt, good results may follow this practice, still it is attended by a certain risk of non-union of the tendon. OF GENU VALGUM, TALIPES OF THE FOOT, ETC. 333 deformity may be gradually corrected, as shown in the figure (Fig. 164). The splints should be put on over Fig. 164.— Use of Flexible Metal Splint (diagrammatic). flannel bandages, and strapping or webbing, etc., used as before. These also have to be taken off at intervals, as was directed for the stiff splints. 3. A shoe, Scarpa's or some modification of it, is still By a Scarpa's largely employed (though not quite so generally as hereto-shoe* fore), more especially in the later stages of the treatment. In Figs. 165, 166 a good form of shoe and the mode of its application are shown, and no further description is called for. In all the varieties of this instrument, expense is a great draAvback, and it is absolutely essential to have the shoe of the right size. The principle of the shoe treatment, is to adjust the Principle of the angles of the instrument to those of the deformity, and shoe treatme,lt' then, after fastening the foot and leg firmly into it by Figs. 165, 1GG.—Adam's modification of Scarpa's Shoe. 334 OF GENU VALGUM, TALIPES OF THE FOOT, ETC. straps, to gradually brin-i the parts into posit'on by turning day by day, but Aery slightly, the rack and pinion hinges, or other contrivances for'altering the direction of the sole (varus), and the angle of the foot (equinus). These shoes will have to be readjusted very frequently, and the flannel bandage, which should ahvays be put on the limb under the shoe, taken off, so that the slightest commencement of a sore may be observed; these are very apt to form, especially over the heel. care of the The greatest practical difficulty in this method, is the keeping the heel down into its place in the shoe. Unless this be done, every turn of the rack and pinion will only lift it a little more, and no good will be effected. This is a very common oversight, and is of itself a sufficient reason for fre- quent readjustment. It Avill be gathered from the above that the treatment by Scarpa's shoes is a troublesome one, and though success will often repay the daily care required, it will never be a favoured method with hospital dressers. with a piaster 4. A plan of treatment which is noAV coming into very general use, is to put up the foot and ankle in a plaster of Paris case, while the foot is held in as good position as possible. If tenotomy has been performed, the limb may be put up immediately after the operation, or three or four days allowed to elapse. piaster case 5. But a better plan than the sinr le plaster case is the splint. modification shoAvn in Figs. 167, 168, for a knoAvledge of which the author is indebted to Mr. Churchill. The splinting is performed in the following Avay : a piece of broad webbing is cut of a length sufficient to go round the foot at the instep, and its ends are sewn together. A flannel bandage having been applied to the foot and leg, this webbing band is slipped over the foot. A strip of tinned iron, a half or three-quarters of an inch wide, and a little longer than the patient's leg, is then bent round the sole of the foot as shown in Fig. 167. The strips must have holes punched roughly, to allow of the lower end being seAvn to the Avebbing, and to enable the plaster to hold better. When the strip is adjusted, it can be used as a lever to straighten the foot, by being held along the leg, as shown in the figure, and then must be fixed in this position by a plaster of Paris bandage, AAdiich may be quite light. In this way there is a constant spring on the foot, to force it out- wards in the right direction. OF GENU VALGUM, TALIPES OF THE FOOT, ETC. 335 Having now discussed the management of the different degrees of club-foot of the various types which are amenable Fig. 167.—Plaster and Flexible Metal Splint combined (First Position). Fig. 168.—Plaster and Flexible Metal Splint combined (Second Position). to mechanical treatment, with or without tenotomy, we shall be able to consider the remaining kinds and degrees of talipes Avhich are mentioned in the list on page 329, much more briefly, for some should be treated on the same principles as the foregoing, and others, especially those which are due to distinct paralysis, are hardly capable of any improvement. IV. Cases of confirmed equinus without any other defor- of equinus only mity are not very common, but are not difficult to treat, tenotomy. The tendo Achillis having been divided, the foot and leg may be put in a Scarpa's shoe after an interval of a few 336 OF GENU VALGUM, TALIPES OF THE FOOT, ETC. days, and the heel gradually brought doAvn, or a flexible splint may be applied to the inner or the outer side of the limb, so as to produce the same result. It is not advisable to fix the foot in the proper position by means of plaster of Paris at once, lest the tendon should fail to unite. of varus, etc., Y. When the bones of the tarsus are so distorted and deformity. °ay ill-developed that by no ordinary division of the soft struc- tures can the sole of the foot be brought flat, or nearly flat to the ground, the removal by operation of a wedge-shaped portion of the tarsal arch has been practised with success. The operation itself is a severe one, but the after manage- ment of the case, does not differ materially from that of slighter deformities in which tenotomy has been performed. This treatment, of course, is only to be adopted Avhen all milder measures are obv:ously hopeless, or when they have been tried and have failed. Valgus and cai- VI. Valgus and calcaneo-valgus—too severe to be classi- not paralytic, fied as simple flat foot—but Avhich are not paralytic, are rare. They must be treated on the same general principles as grades II. and III. of varus club foot, which have been described. of valgus, and VII. But in the great majority of cases, high degrees of calcaneo-valgus, , iii ii9 /. due to paralysis, valgus and calcaneo-valgus are caused by some form of spinal degeneration (usually by infantile paralysis). Very little can be done here by the surgeon, beyond the adoption of general measures to maintain the nutrition of the muscles affected, and to prevent the increase of deformity. These cases, moreover, differ so Avidely one from another, that general directions can be of little use. But we may say that tenotomy is almost always to be avoided. Micaneuf, VHI- Something, hoAveA-er, can be done mechanically, for paralytic or cases of simple calcaneus, even if it be due to paralvsis, and through non- ,•„ •<• . 1 1 • /- , i r '•,',.•. union of tendo still more it the cause be a non-union of the cut ends of the tendo Achillis, after its division by the surgeon, or as the result of injury.* tSldon?1 In tliese non-Paraiytic cascs> it is often feasible to unite the ends by a planned operation; but putting aside this procedure, whatever the cause of the calcaneus may be, a useful artificial tendon may often be made by attaching an elastic spring to the heel of the boot below, and to a metal hoop encircling the calf above, Avhich is riveted to an * The possibility of non-union, is a strong argument against dividing this tendon in cases of fractures of the leg, when it is° diffi- cult to get the fragments into good position. OF GENU VALGUM, TALIPES OF THE FOOT, ETC. 337 upright, hinged at the ankle and springing from the sole of the boot. Much of the ordinary work of the calf muscles may be supplied by such an arrangement, which any instrument maker can easily construct. The spring itself is best made of three or four lengths of woven elastic, such as is used for garters. Twisted toes. Twisted toes. The dresser will sometimes have his ingenuity taxed by cases where one toe, generally the middle one, persistently bends down betAveen its neighbours, and is compressed by them. These toes are very obstinate, and often exhaust the patience of the surgeon. Some form of glove for the three toes concerned, AA-hich must be stiff enough to hold them straight, combined Avith very roomy boots, will be generally found the best treatment. Hallex Valgus. The great toe is frequently deflected or Haiiex valgus twisted outwards, displacing the other toes, or riding over or under them. This deformity is generally due to bunion, or to some inflammatory enlargement of the parts concerned in the metacarpo-phalangeal articulation. It is generally progressive, and is a common cause of ingrown toe-nail (q.v.). Belief may often be afforded, by protecting the prominent joint from pressure, by attention to the shape of the boot, and by the use of a pad of adhesive felt, as in the case of corns, but the condition is difficult to cure except by the radical method of excision of the joint, or the removal of a wedge from the metacarpal bone as recommended by Mr. Arthur Barker. But moderately severe cases may be suc- FiG. 169.—Dr. Spitta's Splint for Hallex Valgus. cessfully treated by a splint, such as is shown in Fig. 169, invented by Dr. Spitta.* It will be seen that the correction * Brit. Med. Journal, 1885, Vol. I„ p. 1110. 22 338 OF GENU VALGUM, TALIPES OF THE FOOT, ETC. of the deformity depends upon the action of a rack and pinion. Another and cheaper apparatus is described by Dr. Nealet as being an old device. It consists of a tin plate cut to the natural shape of the foot, and riveted to a cork sole. Slots are then cut in this, in such places that the toes can be retained in their proper positions by tapes passed between them. t Brit. Med. Journal, 1885, Vol. I., p. 1205. OF SURGICAL EMERGENCIES. 339 SECTION VI. OF CERTAIN EMERGENCIES, SURGICAL AND GENERAL. CHAPTER XXV. Of Surgical Emergencies, and Especially of the Retention and Extravasation of Urine. In any large general hospital it is a matter of almost daily General experience that cases of disease or injury present themselves considei in Avhich the condition of affairs is such that immediate action must be taken; and it will sometimes happen that it is not possible for the resident medical officer to obtain the attendance of one of the visiting staff sufficiently quickly to be of any use. The experience that a house surgeon acquires during his term of office as to the management of these " cases of emergency " forms perhaps the most valuable part of his training—for many other qualities besides theoretical or book-learnt knowledge are called into play—readiness, tact, firmness, self-restraint, and self-confidence, every quality that enables a man to take the lead, to govern, and to direct, may have to be shown, and shoAvn at a moment's notice.* * We have some apprehension, lest, in this, and the preceding chapter more especially, we may seem to unduly consider questions concerning major surgery. But what is here written has been deemed necessary for the explanation of the practical measures we advise. It must however be most clearly understood that in all matters of treatment the house surgeon's place is the second one, and that his chief work consists in the carrying out of the instructions of his senior. It is quite impossible to draw any line within which he may feel free to exercise his own responsibility, for the rules at different hospitals vary, and much will depend upon the length of service and 340 OF surgical emergencies. The emergencies that we propose to deal with in this present section are those which commonly occur in hospital casualty practice. Many of them are strictly surgical, such as the retention of urine, but Ave shall not confine ourselves to these, but will endeavour to include in our list the majority of those conditions of urgency, Avhich may rightly claim im- mediate attention at the hands of a qualified medical officer ; but it must be understood that we shall here consider only the measures to be taken for the relief of the urgent con- dition, not those which may be advisable for the treatment of whatever disease may be its cause. Division of the We shall take first those surgical emergencies which arise subject. from the retention, or the extravasation of urine, from in- testinal obstruction and the like, and in the two subsequent chapters we shall discuss those urgent conditions caused by some general disease, such as the occurrence of fits, and the appropriate management of cases of poisoning, drowning, etc. surgical . Surgical Emergencies. i^ec^aefkfnds. The strictly surgical emergencies which we have to con- sider are those which arise from obstruction, by disease or injury,to the passage of urine, or from intestinal obstruction, commonly caused by the strangulation of a hernial pro- trusion. Retention of Cases of obstruction to the flow of urine, "retention cases" as they are termed, form a class which probably gives house surgeons more anxiety than any other, and certainly no sub- division of surgical practice can show a worse record of damage done through careless or ignorant treatment. In considering this question we shall confine ourselves personal experience of the particular officer; for example, in a case of retention of urine, with a practically impassable stricture, a house surgeon, recently appointed, should not proceed beyond a fair attempt at catheterisation before he sends for help, while another who has served a year or more, may be justified in going on to aspiration of the bladder. Still, to the following rule there can be no exception :—In all cases of doubt the house surgeon must send for the visiting surgeon at once, and if the case be urgent he can but do his best in the meantime. adopting curative or temporizing measures, whichever seems to him to be right. We have discussed some measures which border upon major sur- gery, such, for example, as deep perineal incisions, chiefly because they are the logical sequence of the failure of less severe proceedings, and in order that the junior surgeon should not feel as if with these failures the end of all resources had been arrived at, although the operative steps themselves are most frequently undertaken upon the advice and under the direction of his senior. urine. OF surgical emergencies. 341 strictly to the fact of the retention, leaving alone the means, operative or otherAvise, which the visiting surgeon may adopt for the cure or alleviation of its cause. We may take first, as an illustrative case of retention, one From stricture which is very common in hospital practice, namely, Avhere a Wlt spasm- patient, the subject of a long-standing stricture, suddenly, in consequence of alcoholic excess or of exposure to cold, is attacked by additional congestion and spasm of the urethra, sufficient to produce complete retention, Avhereby in a few hours his sufferings become so great that he must be relieved without delay. In such a case no one line of treatment is to be recom- mended to the exclusion of all others, but the surgeon's decision must be founded on what he can learn of the previous history of the disease. If he find that the patient is a regular " stricture case," in in chron'c, but the habit of passing a catheter on himself, or of having it stricture.' frequently passed, the probability is that no great difficulty Avill be encountered in introducing a silver or flexible instrument, and the attempt may rightly be made to give instant relief in this way. But suppose that, on the contrary, no noteworthy difficulty when spasm is has been experienced by the patient previous to the reten- tion, and that the urine has hitherto been passed in a fairly full stream 1 Here we probably have to do with a case of stricture, insidiously contracting, in which spasm is playing a more important part than the organic constriction. For this reason it will be wise (although immediate catheteri- sation is frequently performed) first to take measures to re- duce the irritability of the urethra. These will often be sufficient of themselves to procure relief, and in any case the condition of the parts will be then much more favour- able for an easy passage of an instrument. The patient should at once be placed in a bath, hot enough to produce general relaxation (of a temperature that is from 102° to 104° Fah.), and must remain in it until the skin acts pro- fusely. If, as often happens, the urine be passed while the patient is in the bath, so much the better, but failing this occurrence, he should lie between blankets, and an enema of starch, or of warm water, with the addition of nT. xx of laudanum or of the liq. opii sedativus may then be given. A hot linseed poultice, to which a little mustard may be added, should be applied to the hypogastrium. In the great majority of cases the patient will now be able to pass his water freely enough to get relief, but if not, the 342 OF SUROIuAL EMERGENCIES. circumstances are much more favourable than before for successful catheterisation, and even supposing that the re- tention still continues obstinate, and that no instrument can be passed, relief can ahvays be given by puncture of the bladder through the rectum, or over the pubes (q.v.)* But in the class of cases we have hitherto considered, this will very rarely indeed be necessary. when the stric- For somewhat different reasons the immediate use of the neglected?6611 catheter should not be resorted to, in those cases where from the history it appears that the stricture has through neglect been alloAved to go on steadily contracting until the canal of the urethra has become almost obliterated, so that a very slight additional congestion is sufficient to produce retention. These cases are very hard to treat, and often require urethrotomy for their permanent cure, but this operation is hardly ever performed for the relief of the retention itself, and should never be by a junior medical officer. In these patients, catheterisation will, even under the most favourable circumstances, be difficult enough, and it is therefore Avise to adopt the measures for the relief of the spasm and congestion, which have just been mentioned, before any attempt is made to pass an instrument. WhateArer the character of the stricture may be, it will sometimes happen that no catheter can be got through it; and supposing that the hot bath, poultices, etc., have failed, and also that a patient trial has been made with the various kinds of catheters, bougies, etc., without success, what is to be done 1 whenliecessary. We advise that the patient be now placed under the in- fluence of an anaesthetic, and that a final attempt be made to pass an instrument. Failing this, the bladder should be aspirated above the pubes with a moderately fine aspirating trocar, in the manner to be aftenvards described. The retention once relieved, opportunity Avill be given for the subsidence of spasms, etc., so that it often happens that the urine is subsequently passed in the natural way, or that an instrument can be got in. In any case time will have been gained for consideration as to the best surgical treatment, and the case will have passed out of the category of emergencies. mi^e^pr^™ We nave hitherto considered those cases only in which tate- the retention has been due partly or entirely to an organic * The details of catheterisation, of puncture of the bladder, etc.. are described later in the section on Minor Surgery. OF SURGICAL EMERGENCIES. 343 stricture of the urethra (for a purely spasmodic stricture, capable of producing serious retention, must be ranked only among the curiosities of surgery, if it ever has really occurred). We come now to a different kind of retention, that, namely, which is caused by an enlargement of the prostate gland, and generally, of its middle lobe. With re- Never to be . ' o . ** t mist&ken for gard to this form, no warning can be too strongly worded as stricture. to the \dtal importance of recognising the cause of the re- tention, and of not mistaking the case for one of stricture to be relieved by catheterisation yvith small metal instru- ments of an ordinary length and curve. Such a warning may seem altogether uncalled for and gratuitous, and so we suppose it should be ; but that it is not, is a matter of commonknoAvledge, and every surgeon sees only too many patients Avhose urethras bear Avitness of hoAv dangerous a weapon a No. 2 or 3 silver catheter is, in ignorant or heedless hands. These cases of enlarged prostate are rarely attacked with Dribbling over- sudden or absolute retention, but very often suffer from a present. m condition hardly less serious, namely, an over-distention and partial paralysis of the bladder AAralls, in Avhich event the organ is only saved from bursting by a constant dribbling or overflow, which brings but little relief. Whenever a patient over the age of 50 or 55 presents him- The general his- i !■ • i i i • i i i i t • • T rv i ■ torv °f the case. self Avith the history that he has had increasing difficulty in emptying the bladder for some time past, and that now he can only pass a few drops after much straining ; and Avhen, in addition, it is found that the bladder (not necessarily large) is obviously full, the case is almost certainly one of retention from enlarged prostate, and an examination should at once be made by the rectum to establish the diagnosis. In the more troublesome of these cases, the paralytic con- dition is the chief agent in the retention; in others there may be temporary congestion of the urinary passages, as in the case of stricture, while, of course, we may have to do with mixed cases of prostatic enlargement and stricture. When the retention is recognised as being due to an The measures enlarged prostate, the immediate relief is not generally diffi-for relief" cult, provided the case has not been already complicated by improper attempts at catheterisation, and there will be, as a rule, little difficulty in passing a full sized instrument (Nos. 10 to 12). This may either be a silver "prostatic catheter," i.e., one Avhich is longer and which has a much bolder curve than the ordinary pattern, or a flexible catheter of the usual form, or 344 OF SURGICAL EMERGENCIES. if the middle lobe should prove unusually difficult to sur- mount, an elbowed one (coud6) may be used, or resort may be had to some of the manoeuvres which will be mentioned apropos of the practice of catheterisation. puncturing the It should very rarely be necessary to puncture the bladder for enlarged prostate. If this has to be done, aspiration above the pubes is to be preferred. After manage- Although the immediate relief of the retention in cases of enlarged prostate is not generally very difficult, the after management is always troublesome. The recurrence of the retention should, if possible, be avoided, the tone of the bladder walls improved, while that low form of cystitis, which is almost always present, calls also for treatment. By regularly emptying the bladder with a soft catheter, by washing it out, etc., much may be done for the patient's comfort, but the cause being irremediable, the treatment can only be palliative. Finally, we repeat, that in very many cases we believe the immediate use of the catheter for the relief of retention, to be unwise, and that it will often not be required at all, if proper measures for the diminution of local spasm and congestion are promptly adopted; and further, that it often happens that a patient has eventually to be subjected to the operation of puncture or aspiration of the bladder, who would never have required it but for injudicious attempts to pass instruments upon the first opportunity. Retention from In children it may occasionally happen that a tight phimosis may become inflated and cedematous, and the urine may be unable to escape. In such a case, dilatation with a director and a pair of dressing forceps will secure a temporary and perhaps a permanent relief. (See ' circum- cision,' in Section on Minor Operations.) Retention from Another cause of acute retention also occurs more fre- .caicuius. quently in children than in adults. This is the impaction of a small calculus in the urethra. * In such a case it often happens that the arrest takes place sufficiently near the meatus to enable a fine pair of specially-constructed urethral forceps to seize and remove it. If the fragment lie further back, so that the forceps will not catch it, but where it still can be felt easily through the tissues, a careful incision made absolutely in the middle line, should allow it to be readily removed, and the wound may be expected to heal almost directly. But if it should be lodged near the neck of the bladder, any operation for its removal will be a more serious matter, and one not OF SURGICAL EMERGENCIES. 345 to be reckoned as " Minor Surgery." We will, therefore, only mention that the course commonly advised is to try to push the stone back into the bladder, by passing an instrument, and then to take a favourable time for its removal by cystotomy. It not unf req uently happens that the shock of an operation Retention r • - L • n -r ii ii -i i • • following shock, or of an injury, especially it the abdominal or pelvic viscera operations, etc are concerned, produces an atonic condition of the bladder walls, and therefore a transient retention of urine. So commonly is this the case that almost the first question the surgeon asks at his visit, subsequent to an operation, is, Avhether the urine has been passed. This retention seems to occur as often in women as in men, and is especially occurs in both common in children. In most cases a little patience, and the application of a hot poultice or fomentation to the hypogastrium and perineum, will be folloAved by a natural contraction of the muscular coats of the bladder, but if not, a catheter must be passed before extreme distension takes place. With the exception of this and one other form, retention Hysterical of urine in the female occurs so rarely that we need not women?11 in consider it. The other form we allude to is hysterical retention. This mode of self-torture is not uncommon in severe hysteria, and unless it speedily yield to moral influences may require to be treated by regular catheter- isation, night and morning (which it will be wise to depute to the nurse to perform) until the habit is relinquished.* Of rupture of the urethra and extravasation of urine. Rupture of the There are two main causes for a giving way of the The chief urethral Avails and the occurrence of extravasation of urine. causes' The first is the infliction of some injury to the perineum • the second is due to the gradual weakening, or increasing rottenness of the tube, caused by low inflammatory changes folloAving on an old standing stricture, Avith a more or less complete retention. In both cases the extravasation is strictly a " surgical emergency " and requires prompt and decided treatment. Taking first, the cases of traumatic rupture of the urethra, Traumatic it will be found that these are mostly caused by a heavy urethra.°f the fall on the crutch, or by a kick or blow there, but they may be due to an incised or punctured Avound. The symptoms symptoms. * The condition of the bladder must of course be ascertained by physical examination, whenever there is a report of the urine not having been passed, for it may happen that the condition is one of suppression, not of retention of the secretion. 346 OF SURGICAL EMERGENCIES. pointing to an injury of the urethra, are a constant and ex- treme desire to pass water, Avith inability to do so, or at least only in a feAV drops, while there is a varying amount of haemorrhage from the meatus. There will also be bruising and great tenderness in the perineum. These symptoms will indicate almost certainly that the urethra has been torn, and unless a catheter can be immediately passed, and kept in the bladder, symptoms of extravasation will soon Management if occur. In the first place then, a very gentle and patient palsld" °an be attempt should be made to pass a catheter, using by pre- ference a No. 8 or 9 soft, olivary shaped one, and if this fails, a silver one, taking particular care to keep along the roof of the canal. If a moderate-sized catheter will not pass, a smaller one may be tried, but will probably fail to get through, and the attempt must not be persisted in. In the fortunate event of an instrument having been passed into the bladder, it should be tied in, in the manner to be described later, and the after treatment of the case may be left to the visiting surgeon. The patient will, in most cases, do Avell. And if it can- But very often it is not possible to pass an instrument, and in this case the Avisest thing to do will be to wait for a feAV hours to watch the development of affairs. A poultice may be put over the bladder, and an enema of starch and opium administered. commencement It may be that the obstruction is due to injury short of tion? ravasa" rupture, in which case the urine will presently be passed naturally ; but this is unlikely, and in all probability in a very short time there will be unmistakeable signs of com- mencing extravasation of urine. This will be indicated by increased fulness and tenderness in the perineum, while the bladder becomes steadily more distended. The median Under these circumstances the patient should at once be fncision. put under an anaesthetic, and being placed in the lithotomy position, a deep incision should be made absolutely in the middle line, down to the urethra in the perineum. The opportunity of the anaesthesia may be used for a final attempt at the passage of a catheter. The knife will be found to cut into tissues which have a semi-gelatinous appearance, due to infiltration with urine, which will at once begin to drain aAvay from them, gradually relieving the bladder. No mere surface incision is to be made, but the urethra or its immediate neighbourhood must be thoroughly opened up. OF SURGICAL EMERGENCIES. 34? A median incision made thus early will often be sufficient to prevent further extravasation, but it frequently happens that the patient is not seen until the urine has made its Avay into the scrotum, and may be traced, travelling along the folds of the groin upwards on to the abdomen, its progress being marked by a dusky, brawny, infiltration.* In such a case the only chance of preventing the most Further extensive sloughing, with all the attendant risks of called for. septicaemia, etc., is to make free incisions wherever the tissues are involved. The median one in the perineum should never be omitted, but in addition, the scrotum and penis may have to be incised in two or three places, Avhile the same relief will frequently have to be afforded to the skin of the lower part of the abdomen. In spite of all, however, some sloughing is sure to occur, and this, with the smell caused by the constant escape of urine, generally makes it desirable that the patient should be isolated. The best local application is a large charcoal poultice. Frequent washing and syringing with Condy's fluid, or car- bolic acid lotions, will be called for, and as soon as the patient is able so to do, he should frequently sit in a bath of weak warm Condy. The other fashion in which the urethral walls may give Extravasation way, occurs Avhen a long-standing and neglected stricture stricture!11 °* produces a condition of partial, or (more rarely) of complete retention. A low form of inflammatory softening of the walls of the canal takes place, and distended beyond their power of resistance in that condition, they give way ; the result is a formation of urinary abscesses and extravasation. The symptoms do not differ materially from the traumatic form, save in this, that the extravasation commences as soon as the urethra gives way, Avhereas in the traumatic' cases there is no escape of urine until the patient attempts to pass water. The question of the passage of an instrument should be left Main lines oi to the discretion of the visiting surgeon, for as a rule, the weatment- tissues are not in a condition to allow of successful * The anatomical reasons why the usual traumatic rupture of the urethra in front of the triangular ligament, is followed by extrava- sation into the scrotum and upwards on to the abdomen, but not down towards the thighs, are well known. But cases do sometimes occur of rupture between the layers of the ligament; the urine will then travel in a different direction. See a case reported by the Author in the St. Bartholomew's Hospital Reports, Vol. XIV., 1878, p. ■J.'Ji. 348 OF SURGICAL EMERGENCIES. Prognosis bad. Rupture of the bladder. How caused. Catheter to be passed. catheterisation until the operation of perineal section has been performed, and further damage may easily be done in the attempt. But there must be no hesitation or delay in relieving the extravasation by free incisions, whenever they are required, the one in the middle line of the perineum being, as before, the most important. The prognosis in these cases is almost always unfavourable. From the nature of the disease it follows that the patient is broken doAvn constitutionally; very probably his kidneys are diseased, "surgical kidneys," and the infiltration, suppuration, and sloughing, which result, are apt to bring about a condition of blood poisoning which is very generally fatal. In any case stimulants, such as alcohol, carbonate of ammonia, etc., and a generous diet will be required, while with regard to the local dressing, the management will be similar to that Avhich was advised for traumatic cases. We do not here consider the surgical questions which arise in connection with the urinary fistulae which so often are the result of extravasation, however produced. Rupture of the bladder. This accident is almost always fatal. In the majority of cases it occurs from a direct Woav, or a fall, upon the hypogastrium, when the bladder is over distended, and it is almost always the case that the patient is drunk at the time, a fact Avhich complicates a diagnosis in other respects not generally difficult. In these cases the rupture will be situated in that part of the bladder which is covered by peritoneum. The usual signs of collapse which follow severe abdominal injuries are here Avell marked, and there is in addition, an in- tense desire to pass water, with complete inability to do so, or at most only a few drops mixed with blood are expelled ; nevertheless the bladder remains obviously empty, until the tumefaction due to peritonitis renders a physical examination indecisive. In such a case, all the house surgeon can or need do, pen- ding a decision as to operative interference, is immediately to pass a full-sized, and very soft catheter, well into the bladder, so that the best chance may be given for the escape of urine as soon as it passes from the ureters. It may be that the extravasation will be sufficiently limited to prevent a fatal result, if by good chance the rent involves only such parts of the bladder as are not covered by peritoneum, which, is the more likely to be the case if the injury to the bladder is the result of perforation by the fragment of a fractured pelvis. In these cases of extra-peritoneal injury the OF SURGICAL EMERGENCIES. 349 symptoms are usually much less distinctive. But in any case, further interference can hardly be other than harmful; all questions as to abdominal section, median cystotomy, or any other of the measures Avhich have been advocated for these desperate conditions being, of course, left to the judgment of the visiting surgeon. 350 OF SURGICAL EMERGENCIES. CHAPTER XXVI. Of Hernia and other Forms of Intestinal Obstruction. Rupture with symptoms of obstruction. Reasons for mortality after herniotomy in hospitals. Cases of rupture, Avith symptoms of obstruction more or less marked, are of very frequent occurrence in any large hospital, and the proper discrimination of the different kinds and degrees of this condition is a most difficult and re- sponsible part of a house surgeon's work. It is true that, in London at any rate, the actual herniotomy is usually per- formed by the visiting surgeon, but this may be the simplest part of the whole treatment, while the house surgeon has to decide upon points which are often obscure, such as whether the question of operation ought at once to be raised, or whether taxis should first be tried, and if so, for how long, whether a preliminary bath should be given, and so on. Here the rule which is laid down at the commencement of the preceding chapter most strictly applies, namely, when in doubt send for the visiting surgeon. The death rate of herniotomies in London hospitals is high out of all proportion to the mortality which would attend these operations if only they were performed at the right time. There can be no question but that directly it is recognised that a hernia is strangulated, and that an honest attempt at reduction by taxis has not been effectual, the surgeon should perform herniotomy at once, if a final attempt at the taxis, while the patient is under an anaesthetic, should fail. But all who have any experience of hospital work know how grievously and unaccountably this rule is departed from, and hoAv case after case is admitted with clear symptoms of strangulation, of four or five, or even more, days' standing, where nothing has been done, or worse than that, where the patient has been subjected alternately to castor oil or calomel and colocynth within, and to repeated and strenuous attempts at the taxis without. On inquiry it may be found that this has gone on for days until, almost every possible chance of recovery having been thrown away, the case is sent to the hospital to die, not because, but in spite of, an operation, OF SURGICAL EMERGENCIES. 351 AA'hich, if performed at the right time, would in these days almost always be successful. In considering the rules which should govern the manage- course of a ., ° mi if 'ii -j. i typical case o: ment of these cases, we will take first a typical hospital case, strangulation. in which symptoms of well-marked strangulation have existed, we will suppose, for twenty-four hours, and Avhere the hernia has not been reduced by moderate taxis Avithout the use of an anaesthetic. It Avill, first of all, be important to know if the hernia be one of long standing which has suddenly become much larger, or Avhether this is the occasion of its first appearance, and in the former case, whether or not a truss has been habitually Avorn. These questions bear upon the amount of taxis which it may be safe to employ. Thus, a small hernia, down for the first time, is probably more tightly nipped and requires more tender handling than an old-standing one in which the canal is certainly dilated, and a portion, at any rate, of the gut accustomed to slip to and fro. The house surgeon must then exercise his discretion as to whether a further trial may fairly be made of the taxis, then and there; but as a rule, unless distinct gurgling, or other indications show that the strangulation is very slight, he will be wise if he confines his manipulations to those which are necessary for the ascertaining of the condition of affairs. He must next decide between sending for the visiting surgeon at once, or first trying the effects of a hot bath, to be, perhaps, followed up by an injection of starch and laudanum. The latter is the usual course, and in the case of old standing herniae, where the symptoms are not very urgent, and Avhere there seems a fair chance that the rupture will go back under taxis, after the relaxation produced by the bath and the opium, has much to recommend it. The bath should be hot (102° to 104° Fah.), and the patient should stay in it until there is a slight feeling of faintness. Taxis may then be tried in the bath, but it can be performed more conveniently on the bed, the patient lying betAveen blankets. If the hernia is not yet reducible, but feels as if it " ought to go back," a further relaxation may be produced by an enema of thin starch, with the addition of about xx n\. of laudanum. After this the attempt may be renewed, the patient lying with the head low, the foot of the bed raised, and the buttocks supported on a pillow. If the hernia be not now reduced, no time should be lost in sending for the Aisiting surgeon, and preparing for herniotomy. 352 OF SURGICAL EMERGENCIES. In the case of a very acute strangulation in a rupture down for the first time, opinions are divided as to Avhether it be right to delay the preparations for immediate operation, even for the administration of the bath,*and bearing in mind that the anaesthetic itself Avill produce relaxation, and that if the rupture can be got to go back by taxis at all, the attempt will be as likely to succeed when the patient is on the operation-table, as at any other time, we believe that the safest practice is, not to wait for the bath, but to make a thorough attempt at taxis before proceeding to operate; but each case must be decided on its OAvn merits, and sometimes the one, sometimes the other course will be the Aviser. In the cases Ave have hitherto considered the strangulation has not been supposed to have been of more than twenty- four hours' duration. Unfortunately, a large proportion of hospital cases of strangulated rupture are not sent in until the symptoms have been present for days. In such a case it will always be at any rate doubtful, as to Avhether the intestine can bear even the gentlest taxis, and it may be in a condition in Avhich it Avould not be right to return it into the abdomen, even if it were possible to do so. Here every hour's delay is hurtful, and the house surgeon should im- mediately send for the visiting surgeon, get everything ready for herniotomy, and leave the question of making any at- tempt at reduction by taxis to his senior's discretion and responsibility; of the use of ice-bags, tobacco enemata, nauseants, etc., we will only say that the delay caused by their employment in a case of real strangulation is not justifiable. It may be laid down as a rule that taxis should never be tried AAdien either faecal vomiting or hiccough is present. doubtful But a^ mptures Avhich cannot be returned, or are difficult strangulation, to return, are not strangulated, even though in some cases there be a certain amount of distress and nausea. Clinical experience, not to be learned from books, will alone enable these to be distinguished with certainty, but, although some will remain doubtful until cleared up by the course of events, the house surgeon avjII generally be able to distinguish readily enough, whether strangulation is really present. The cases which require most discretion are those in which at first there are no symptoms indicating that the gut is nipped beyond the fact that it cannot be returned, * See for example (British Medical Journal, ]880, Vol. II., p. 364,) a paper written by my esteemed colleague, Mr. E. Owen in which he condemns the practice altogether. OF SURGICAL EMERGENCIES. 353 and then gradually the case becomes doubtfully, and at last distinctly, one of strangulation. Although in such a case the visiting surgeon will very probably have some difficulty in deciding when to operate, still it is certain that he should be giAen the opportunity of doing so early ; so that the plain duty of the house surgeon is to send for him as soon as any question of the existence of strangulation arises, and it should be remembered that in cases of umbilical herniae of long standing, the symptoms of strangulation are frequently very indefinite. A rupture should never be thought lightly of because it is small; on the contrary, it is the small knuckles of intestine which get most tightly nipped, especially in femoral herniae, and, as Ave have said before, those which suddenly develop in consequence of some strain, are more likely to be very acutely strangulated than long-standing ones. A Avord or tAvo may be said as to the performance of taxis. As to taxis. Whether an anaesthetic be used or no, the leg and trunk must be put into the position Avhich will mechanically relax the margins of the apertures, and the greatest possible gen- tleness should be exercised. This must be specially kept in mind when the patient is under ether or chloroform, when absence of complaints does aAvay Avith one safeguard. The amount of damage Avhich may be done by rough taxis must be seen to be believed. The gut may be ruptured or bruised into gangrene, and the sac. or the more superficial tissues, may be so gravely injured that they will presently slough. Kuptures which are difficult or impossible to reduce, but Ruptures Avhich are not strangulated, can hardly be said to be emer- strangulation. gencies; nevertheless, we may here shortly consider them. Very often a few hours' rest in bed, in the supine position, with the buttocks slightly raised on a pillow, will enable re- duction to be effected, and, in old standing cases especially, the patient should be allowed to try to put the rupture back himself if he can, for he will often succeed when the surgeon would fail. An ice bag applied to the part is noAV a very proper remedy, except in cases of tense incarcerated ruptures, where the vitality of the tissues over the hernia is very feeble. The warm bath, folloAved by a simple enema, or one containing opium as before described, is here also frequently of great service; but in the absence of disquieting symptoms, patience and rest in bed are the great agents for effecting the reduction. 33 354 OF SURGICAL EMERGENCIES. A rupture is sometimes permanently irreducible in whole or part, in Avhich case the only thing to do is to have a truss of a special shape made for its support and protection. Acute intestinal obstructions, due to volvulus, intussuscep- tion, internal strangulation, malignant tumours, etc., involv- ing as they do, questions of abdominal sections, or of other capital proceedings, lie outside the province of the dresser or house surgeon. Prornaccumuia- One Iorm °f intestinal obstruction however, must here be tion of faxes, noticed which occasionally gives rise to symptoms resembling those of volvulus or intussusception, that namely which arises from accumulation of faeces. The obstruction almost always occurs in the upper part of the rectum and in the sigmoid flexure. This condition occurs most commonly in women or in children as a sequel of some severe illness, such as typhoid fever, but examples may be found in patients of either sex, and at any age. Usually a history will be given of habitual constipation, steadily getting more and more difficult to overcome until finally there may have been no relief by the anus for a period to be measured by weeks. In other cases some fasces may have been passed, but the bowel has never been properly unloaded. On examining the patient, it will probably be found that the intestines are greatly distended with flatus, Avhile in the left iliac region, a soft doughy tumour is to be felt, the shape of which may be altered by manipulation, Avhich is generally borne Avell, although it may be that a certain degree of inflammation of the surrounding parts has been set up. In any case distress and nausea will be present, and the symptoms may be sufficiently severe to mask the real nature of the trouble and to make it resemble a case of acute obstruction, due to some mass of new growth in the situation of the sigmoid flexure, or to an intussusception or volvulus of the bowel. A thorough digital examination of the re: turn, ought never to be omitted. The treatment in these cases consists in unloading the sigmoid flexure and rectum as speedily as possible. In the first place all the faecal matter which can be dislodged from the rectum by the finger or a spoon, should be so removed, and masses somewhat higher up may be got at by a scoop or spoon with a longer handle. A peAvter table spoon, bent so as to diminish the Avidth of the boAvl, Avill do. But these masses are frequently very hard, almost stony, and often OF SURGICAL EMERGENCIES. 355 they can hardly be dislodged without previous softening; while those that lie still higher up in the canal are out of reach altogether. The removal of these must be achieved by enemata injected high up into the bowel by means of a long tube.* These injections must be frequently repeated, and it may be necessary to play a stream from an enema upon the hardened collections for a long time. But although the clearing out of the canal may be very trouble- some, we believe it can always be effected by the careful use of a scoop for such masses as may come within reach, and of enemata ; these may be copious ones of warm water, or in more obstinate cases of warm olive oil. Again, to about a pint of the oil an ounce of turpentine may be added. The tube of a stomach pump will do in the absence of a special apparatus for the administration of these enemata. The intestine will be left in a very atonic state for a long time after the faeces have been removed, and a recurrence of the condition must be guarded against by the frequent use of simple or astringent enemata, vegetable or saline purges, and the like. Often much good is effected by shampooing and kneading the abdomen, especially if flatus be the most prominent symptom. Lastly, there are noAv a good many cases on record Avhere the intestinal coats have been successfully stimulated through the abdominal walls by the passage of a poAverful constant current, delivered through electrodes Avith large surfaces. * For the use of the long tube see chap. xxxv. 356 OF GENERAL EMERGENCIES. CHAPTER XXVII. Shock or collapse. Shock from severe injury without haemorrhage. General indications for treatment. Of Emergencies continued—General Eaiergencies, Shock, Fits, etc. We continue in this and the following chapter the con- sideration of the more important conditions Avhich call for immediate relief at the hands of medical men, but especially at the hands of house surgeons, or of medical officers in charge of the casualty departments of hospitals. In the preceding chapter we discussed those surgical emergencies, Avhich had not been previously dealt with under the sections upon fracture or haemorrhage, and there remains now the larger class of general emergencies, such as Collapse, the usual forms of Fits, cases of Drowning, Poison- ing, etc., which although they are in no sense surgical, nevertheless must not be omitted from a work intended principally for hospital dressers and resident medical officers. But it is only with the treatment in the first instance of these various conditions, that avc have here to do. Shock, or Collapse. For a description of this condition, and for its pathology, the reader is referred to the vivid pictures drawn by Mr. Savory,* or by Mr. Page,f or to the article by Mr. C. Moullin.J We have here to consider hoAv best to minimise its duration and severity, and we will take first, cases of shock from severe injury without luemorrhage. " The sIoav, feeble, or almost annihilated pulse, the pallor of the lips, and coldness of the extremities, the mental hebetude, the anaesthesia of the surface, the relaxation of the sphincters, the lessened secretion of the urine, the impaired muscular action,"§ all point to a state of seeming lifelessness, founded on a temporary paresis (a reflex inhibi- tion) of the circulatory system, and it is this apparent lifelessness which gives the clue to the line of treatment. The Aveakened heart can barely keep its OAvn and the * " Holmes' System," Vol. I., p. 377 (1883 edition). t " Injuries of Spine and Spinal Cord," 1883, p. 145. I "International Encyclopaedia of Surgery," Vol. I., p. 357. See also the Hastings Essay, 1882, on "Shock," by Mr. Furneaux Jordan, reprinted in" Surgical Enquiries.?' ' '' § Page, Loc. cit., p. 144. OF GENERAL EMERGENCIES. 357 respiratory centres going, still less the cerebral cortex. The head must therefore be as low, or loAver, than the rest of the body, and artificial respiration must be performed if necessary. The feeble circulation fails to maintain the heat of the body ; so it must be supplied from without. There is a danger of the heart stopping altogether; therefore it must be directly or indirectly stimulated. Lastly, since in these cases of shock Avithout haemorrhage, it has been shown by experiment that one effective cause of the stoppage of the heart, is congestion of its right cavities and of the large thoracic A'eins, the surgeon should look for signs of venous distension in the neck, and if this be present the propriety of opening the right jugular vein may be considered. We have mentioned this possible treatment of shock by venae- section, for the sake of completeness of the clinical picture, and because of the high authority for its performance, but we have never seen, and can hardly imagine, a case in Avhich the indications of congestion Avould justify the house sur- geon in adopting this measure. In practice, the first thing to do Avhen a patient is col- Details of lapsed, is to get him to bed, betAveen the blankets, and Avith the head quite Ioav. Hot-Avater tins, or hot bricks, should then be put in the neighbourhood of the flanks, and betAveen the thighs, care being taken not to scorch the skin, while the patient is too insensitive to complain. The further measures will depend upon the severity of the shock. In slight cases, Avhen the feeble pulse steadily gathers strength and the respiration continues regular and becomes gradually deeper; in fine, AA'hen it is evident that the condition is rather one of a temporary loAvering of vitality than of apparent lifelessness, no further measures can be taken which are so useful as doing nothing Avill be. Rest and warmth, and lying flat, will do all that is Avanted. Cases of a higher grade of severity are those Avhere the patient can be roused to SAvallow, and has a fair respiration and a perceptible pulse, but still, after a little watching, does not appear to be coming round, or may seem to be getting Avorse. (For shock is eminently a relapsing con- dition.) In these cases, sal volatile, ether, alcohol, or some other diffusible stimulant should be given in small doses, frequently repeated, and of these, sal volatile is probably the best. Most cases of shock will fall under one of these tAvo heads, and with ordinary attention, in the absence of other complications, they will do well enough. 358 OF GENERAL EMERGENCIES. Extreme col- lapse. Question of venaesection. Stimulants. Hypodermic injections of ether, etc. But more rarely, cases occur in Avhich the collapse, the lifelessness, is much more profound, and then every exertion will be necessary to prevent the life going out altogether. In these, the respiration will be threatening to stop at every moment, or may actually have stopped, the pulse will be barely, or not at all perceptible at the Avrist, the tempera- ture may be lowered beloAv 90°, and the insensibility pro- found. In such a case (still dealing Avith those in which there has been no important haemorrhage), if there be any turgidity of the veins, it is urged by Mr. Savory* that the right side of the heart will clearly be relieved by bleeding from the external jugular vein, and no one Avho has seen the way in Avhich the cavities of the heart, in the loAver animals, resume their functions upon the relief of distension, can doubt the physiological soundness of this advice. Nevertheless venae- section for shock is very rarely performed, and Ave doubt Avhether in practice there is often found a venous turgidity sufficiently great to strongly suggest the operation. This may be a doubtful point, but there is no doubt at all as to the necessity of other measures. We must not Avait for the natural breathing to stop, before artificial respiration is set up. The head should be placed well beloAv the level of the legs and body; frictional warmth procured by hand rubbing; Avhile the heart may be directly stimulated by a hot mustard plaster, or by a turpentine stupe ; and the diaphragm by faradisation.! As soon as the patient can SAvallow, stimulants should be given, but the risk of choking an insensible person must always be kept in mind. Another method of administering stimulants, however, is noAv coming into general favour, and is of extreme value in these cases, namely by hypoderndc injection. The effect of the hypodermic injection of 30 or 60 drops of ether, or of ether and brandy in equal parts, into the arm, is very striking indeed, and in many cases has undoubtedly saved life; the needle of the syringe should be pushed into the muscle, as "sub-cutaneous" injection of ether is apt to cause a troublesome slough. Stimulant enemata are sometimes very useful. Even in cases of apparently total collapse it should be kept in mind that there may be only " suspended " animation, and it is * Loc. cit., Vol. I. p. 383. t For the details of the performance of artificial respiration, and the application of electricity, see under Drowning a little later. Indeed the measures for resuscitation in either case are very similar, OF GENERAL EMERGENCIES. 359 right to proceed Avith all approved methods of resuscitation before pronouncing the condition to be hopeless. Care must be exercised not to over stimulate Avhen the Keaction after effect of the collapse begins to pass off, and to leave as much as possible to rest and warmth. The collapse will in any case be folloAved by a reactionary period of irritation and generally of fever, and this may be much aggravated by injudicious treatment at the first. In this stage of reaction, opium, or the hypodermic injection of morphia may be administered ; hyoscyamus again is often extremely useful. The general effects of extreme and sudden haemorrhage shock from are recognised as being to a large extent identical with those of true shock ; nor do the two conditions differ gener- ally in their treatment, except Avith regard to the great question of transfusion, which we have considered in an earlier chapter. (See pp. 56, et seq.) Sipicope. Inasmuch as faintness is due to partial cerebral syncope. anaemia, brought on by failure of the heart's action, Avithin certain limits the treatment is the same, Avhether the syn- cope be merely emotional, or be due to some more definite cause, as general exhaustion, cold, haemorrhage, organic disease (especially cardiac valvular incompetence), or a combination of any of these. As an example of the common fainting fit, Ave may take The common that form which occurs most commonly in young Avomen or falnting fit- lads of feeble circulation. Such people, under conditions of bad ventilation, disagreeable sights or smells, fatigue, or of an empty stomach, are liable to attacks of simple syncope. They have a sudden feeling of nausea and giddiness, and fall uncor.scious to the ground. On examination there is found a marked pallor and moistness of the face, shallow but distinct respiration, a pulse just perceptible at the Avrist, and a peculiar fiaccidity of the limbs. The eyelids are half open and the lips parted.* Presently, if let alone, the colour will return to the cheeks, the respiration become deeper and sighing, the eyes Avill open, and consciousness will return. Of a similar nature, but even more transitory, is the purely emotional form, which occurs in perfectly healthy, strong people. Thus, groAvn men often faint on being vaccinated, or at the sight of blood. Although none of these forms of syncope are dangerous, * It may be noticed that as a general rule, men fall down in a faint as if they had been shot; women generally manage to get to a chair or to some support, 360 OF GENERAL EMERGENCIES. it is Avell that the attack should be as short as possible. The great agent in the recovery is an improvement in the cerebral circulation, and the best Avay to effect this is to make the brain the lowest part of the body. The patient must therefore be kept lying doAvn (the position naturally assumed), and in c\ery Avay freedom of respiration and of the circulation must be attained. External stimuli, such as smelling salts (not too strong), the sprinkling of cold Avater on the head, slapping the hands, etc., must be resorted to, but stronger stimulation, as faradisation, is not required. Fainting may often be prevented if the patient be sitting at the time of the attack, by making him lean Avell fonvard, so that the head comes almost between' the knees, and thus receives a good blood supply. Perhaps, too, the aorta is partly compressed by the flexion. Extreme But although the milder kinds of syncope are not alarm- ing, faintness may be a condition of the greatest danger, and is indeed one of the most frequent actual causes of death. We haAre examples of such extreme syncope as an effect in great exhaustion from exposure, or in starvation ; or it may be due to the exhaustive effect of some severe illness.* If these cases be left to themselves, they will often insen- sibly drift onwards into death, and active measures must be taken to prevent this. The actual details of treatment will differ according to the particular cause in each case, but in almost all respects they are identical with those for extreme haemorrhage, or for shock, or for droAvning; namely, lying flat, warmth, stimulation, injection of ether, etc. In addi- tion, in very severe forms of syncope it is often useful to invert the patient, so that the head is the lowest part of the body. This is most conveniently done by placing the legs on a couch, and the head and shoulders on the floor. (This method of resuscitation is called " Nelaton's.") Artificial respiration, faradisation, and auto-transfusion, i.e. emptying of the limbs of blood by hand rubbing and elevation (vide page 56), may all be sometimes required, but actual trans- fusion or venaesection is never indicated in cases of true syncope, due neither to haemorrhage on the one hand nor to suffocation on the other. Hysteria. Of Hysteria as a disease, we here say nothing ; for this penalty Avhich Ave pay for the artificial character of our lives, * Death from chloroform is usually a fatal syncope. See on this point the special chapter on anaesthetics. OF GENERAL EMERGENCIES. 361 appears in such protean forms, that it cannot be considered in any detail, and Ave will only mention what should be done in the case of a common hysterical fit. Although no tAvo of these attacks are alike, there is rarely any difficulty in the diagnosis; indeed it is only Avhen the attack exhibits the more serious characters, of Avhat is termed hystero-epilepsy, that any doubt can arise In ordin- General ary cases the flushed tearful face, the panting breath, the therfitc.ter 0l emotional laughter or sobbing, the jerking movements, not truly convulsive, and the almost invariable termination in a flood of tears, and (though this is naturally not so evident) with a profuse secretion of almost colourless urine ; all these points are characteristic of the hysterical attack, and could not occur in a real fit. Moreover, if there be any doubt, analysis of the symp- Diagnostic toms will show that the condition is a mimicry of graver Slgns" disease, and that there is a "contrariness" in the behaviour of all these patients, which is very characteristic. Try to open the eyes, and they will be screAved up; or the mouth, and the teeth will immediately be clenched; the tongue, however, never being bitten. So, if an effort be made to sit the patient up, she will immediately flop down on the floor, but in doing so will give a further evidence of the nature of the attack, for in falling, even though there be apparently a loss of consciousness, the patient will carefully guard herself against injury. Apparent unconsciousness.is often present, and a kind of anaesthesia, so that needles may be run deeply into fleshy parts without eliciting a sign of pain ; yet both these states are really deceptive. The anaesthesia is the result of an exaltation akin to the ecstasy of a flagellant, and the un- consciousness is only on the surface. In fact, as in the conditions of hypnotism (Avhich in many other respects resembles hysteria), there is quite an abnormal intelligence of surrounding affairs. No hysterical Avoman, though she may be to all appearance profoundly uncor^oCiou;;, would ever allow anyone to cut off her hair. Moreover, Avhile this emotional condition lasts, patients are very completely "en rapport" Avith the state of mind of those around them, and promptly become much worse, or speedily recover, accord- ing to the behaviour of the bystanders. Although we have said that the symptoms are a mimicry Hysteria not of other disease, no greater mistake can be made than to malmeennS' treat these sufferers as malingerers. The illness is real enough, although it is a moral, rather than a physical 362 OF GENERAL EMERGENCIES. ailment; and although the symptoms be not genuine, the object to be attained is to cut the attack as short as pos- sible, and to diminish the chances of its recurrence. On the one hand, the tendency to recur will be increased if the symptoms are treated as if they were signs of a grave mysterious illness, and on the other, the severity of the present attack will very likely be aggravated by harshness or rough treatment. The "bucket of cold water" we believe to be always harmful, but so is the other extreme of profuse sympathy, mixed with restoratives such as sal volatile, or chloric ether, or with comforting glasses of hot brandy and water. General treat- As we have stated before, hysterical people may be quite well trusted not to hurt themselves, so in almost all cases the best thing to do is to leave them alone. Nothing con- duces more to a quick recovery than that the patient shall be convinced that her condition is one which excites no alarm, no pity, and no anger; and bearing in mind how hyper-sensitive these patients are to external conditions, all fussy friends should be rigidly excluded. Indeed, there is no necessity for anyone to remain in attendance, and if the patient be simply laid on her bed at the commencement of an attack, and left to come out of it as soon as she will, nothing better can be done. A mixture of hysterical and alcoholic excitement is not uncommon in hospital casualty rooms. These cases again may be left to themselves or may often be more quickly restored to their right minds by a brisk emetic.* (See Drunkenness, p. 381). Concussion. The unconsciousness which is due to a distinct injury to the head may be of the kind knoAvn as concussion or stun- ning, or it may be due to the compression of some part of the brain by a portion of the skull which has been driven in upon it; or by a collection of blood effused betAveen the brain and its membranes, or the membranes and the bone, or within the brain substance. With regard to the latter of these tAvo forms, as we are considering the question of treatment only, we need not stop to distinguish it from that kind of comatose unconscious- ness which is brought on by an attack of apoplexy, and which is presently to be described. * For the other forms of surgical hysteria, hysteric paralysis, neuromimesis, anorexia, etc., the reader is referred to the article by Mr. Savory in "Holmes' System," or to Sir James Paget's "Clinical Lectures." OF GENERAL EMERGENCIES. 363 The former condition, of concussion or stunning, appears to be a transient abolition of the higher cerebral faculties, brought on by a mechanical shaking up of the brain sub- stance, without the infliction of structural injury. While concussion lasts the unconsciousness is absolute, while many of the symptoms of general shock are present. Vomiting very generally occurs as the condition passes of. It is rare for the stunning to last many minutes, the reported cases of prolonged unconsciousness due to brain concussion being probably due to some definite structural brain lesion. As for the treatment, the points to be recollected are Treatment. almost entirely negative ones. No effort should be made to restore consciousness, but on the contrary, the shaken brain cells should be allowed the most complete repose, and darkness, silence, and such warmth in bed as may be necessary to promote recovery from the shock are indicated. After the actual concussion has passed away, it is always wise to keep the patient quiet, Avith a simple diet, and to avoid excitement and brain Avork, for the remote effects of concussion may be serious, although the immediate stunning may have lasted hardly more than a few seconds. Two great groups of attacks, or states of disease, are Fits. especially designated by the common term of "fits," although as every one knoAvs, the name is applied to many other conditions as Avell. Those two are the apoplectic, and the epileptic state, and the first certainly, and probably both, may be produced by very various causes. As effectual causes of the apoplectic state, we may have causes of the hcemorrhage (the commonest), causing the attack eitherapop ectic stat through brain shock, pressure, or laceration ; urcemia ; acute alcoholism, or the circulation of some other poison in the blood; or rapid serous effusion on the surface of the brain; (the existence of this serous apoplexy is now much ques- tioned), and we also find cases of so called simple apoplexy, in Avhich the exciting cause of the fit cannot be traced with certainty. But the apoplectic state or fit, from Avhichever of these causes it may arise, will present verv much the same symp- toms ; namely, " of loss of consciousness, Avithout failure of the heart's action,"* while, in the vast majority of cases, there will be evidence also of some local cerebral lesion in the shape of convulsive movements, or paralysis, or both, * " Quain's Dictionary of Medicine " (Article on Apoplexy). 364 OF GENERAL EMERGENCIES. A typical apoplectic fit. Its onset. Its develop- ment. Its decline. General management. the paralysis generally remaining after the actual fit has passed ; inasmuch as we have only here to consider the practical management of the patient during the attack, a differential diagnosis is not at all necessary. Taking the case of an apoplectic fit arising from cerebral haemorrhage, its course will be something like the following. After a varying prodromal period, during which there may have been warnings, in the way of mental confusion, giddiness, etc., the fit proper generally comes on quite suddenly, often during some emotion, or some unusual exertion. The prominent symptom is the complete loss of consciousness, but preceding this, there may be a short period of convulsive twitchings of the face or limbs. When consciousness is lost, the patient falls to the ground, the breathing becomes laboured and stertorous, with a flapping in and out of the cheeks, caused by their paralysis, and by that of the soft palate. Commonly one side of the body, and the opposite side of the face and tongue will now be found to be partly convulsed, partly paralysed. As the fit continues, the paralytic symptoms become more developed, and with this there is steadily deepening coma. Reflex is nearly or quite abolished, and the pupils may be widely dilated, or unequal, or small, but are generally fixed, and in any case, do not react to light. The pulse as a rule is full and slow. The larger venous trunks ate often distended. (This is the condition in haemorrhagic cases. In uraemic fits, pallor, and a small pulse are frequently present.) In such a case the coma may get steadily deeper and end in death, without any effort at a rally, in a few hours or days. If this does not happen, after a period so variable that no estimate is possible, there is a gradual lightening of the coma, twitchings cease, and reflex gradually returns. Later, the patient can be partially roused, and then returns to a state of consciousness. This, hoAvever, is rarely at first unclouded, and with it there generally comes the appreciation of permanent paralysis of the limbs or face, and often, aphasia in some one of its forms. The after history of the case is generally one of improvement. Bearing in mind the usual cause of this condition of apoplexy, it Avill be plain that all direct attempts at rousing or restoration of consciousness will not only be futile, but Avill be actively harmful. The first and great point in the treatment will be to get the circulation as quiet, and the heart's action as free from embarrassment as is possible. A OF GENERAL EMERGENCIES. 365 " do nothing " policy is therefore on many points essential; but, except in the more transient and slighter attacks, or on the other hand, in those cases of apoplexie foudroyante, in Avhich death occurs almost immediately, there are certain indications for relief of the cerebral circulation Avhich should, if possible, be fulfilled. There will be little difficulty in recognising whether the Belief of brain case be one in Avhich nothing is required except absolute consestion- rest and quiet watching, or whether more active treatment be called, for. In the latter case, the chief measures are the local application of cold to the head, blood letting, and free purgation. If the head be hot, or the face flushed, it can never be unwise to cut the hair short, and apply an ice bag, or cold water. The question of letting blood should be Aveighed very venisection. carefully, and at the present time it is rarely performed, still there can be no doubt that in cases Avhere the pulse is hard, almost incompressible, and bounding, and when the veins of the head and neck are distinctly full, great relief can be thus afforded. In these cases, a small quantity of blood, rapidly extracted, will give greater relief than a larger quantity more sloAvly taken; so that other things being equal, venaesection of the veins of the neck or arm is the preferable mode, but four or six leeches applied to the temples will often be of great service. Wet cupping,* or the milder proceedings of dry cupping, cupping ana or blistering, at the nape of the neck, should not be omitted bhstei'mg- as means of quickly relieving the cerebral circulation. The object of free purgation is akin to that of bleeding, Purgation. and is similarly indicated, provided the patient can sAvalloAv. The purge must be a drastic one, and very often the best croton on. is croton oil; 1 to 1 ^ drops of it should be rubbed up with bread and given in the form of a pill, or placed upon the back of the tongue. Calomel is also very generally given, in full doses, either calomel. with a purgative such as colocynth. or folloAved by castor oil. Other drastic purges, such as elaiurium or gamboge, are sometimes used. These various measures may rightly be employed in fitting cases, but we repeat that in the majority of cases of apoplexy, the one thing needful in the first place, is to keep the patient still in bed, with the head slightly raised, * For bleeding, leeching, and cupping, see the section on Minor Surgery. 366 OF GENERAL EMERGENCIES. in a dark room, taking particular care that there be no obstruction to the respiration. Epilepsy. The practical management of an Epileptic Fit may be very shortly described. In the epileptic, as in the apoplectic state, the prominent feature is the absolute loss of conscious- ness. The attacks also vary infinitely in their severity and duration, from those cases of petit mcd—in which there is a momentary confusion and loss of consciousness, gone almost before it is felt—to the most violent storms of convulsions, lasting, it may be, a full half hour. The following may be taken as an account of a moderately severe epileptic fit. a typical Quite suddenl}r, or after some subjective premonitions, as epileptic fit. 0£ a creepmg sensation, or travelling Avave of coldness or the like, Avhich is known by the name of an "Aura," the patient becomes unconscious and falls to the ground, often Avith a cry or groan. Almost all the body is then throAvn into a state of tonic convulsion; the respiratory movements are arrested Avith the others, and the patient becomes more or less asphyxiated. The asphyxia, however, seldom becomes extreme, and after a time, shorter than it appears to the lookers on, the tonic contraction passes over into a state of general clonic convulsion, in Avhich the limbs are tossed hither and thither, damage to them being often inflicted. At this stage, too, the tongue may be bitten, or the nails its subsidence, driven into the palms. Gradually, and generally after a very feAV minutes, the convulsive movements quiet down, and a condition resembling coma, but Avhich only in the most severe cases is true coma, follows. Soon this comatose state passes into one more like natural sleep; the asphyxial colour disappears, and as a rule, the patient wakes up Avithin half an hour or an hour, ignorant of what has happened, unless previous experience has taught him to understand the position of affairs. Management In such an attack, nothing ought to be done with the idea of any restoration to consciousness, and all that is called for, is to s:e that during the convulsions the patient does himself no injury, either by tossing his limbs or head about, or by getting into such a position that respiration is interfered Avith. Anything tight about the neck, chest, or care of the abdomen, should be loosened, and especial care should be tongue. taken that the tongue does not get caught between the teeth. If this happens, the jaAvs must be forced open, and a piece of cork, or Avood, or some other suitable wedge inserted to keep them apart. Strenuous efforts at restraint of the convulsions appear OF GENERAL EMERGENCIES. 367 rather to excite them, and are never necessary. As soon as the violence of the fit is over, the quieter the patient is left the better, and if natural sleep folloAvs, it should be en- couraged to last as long as possible. On waking up, if any signs of exhaustion are present, a little soup or beef tea is useful, but no alcohol. The general treatment of the epileptic tendency, the con- sideration of its causation, prophylaxis, and of irregular forms of the disease, such as epileptic mania, homicidal epilepsy, etc., are outside the scope of this work. Epileptic malingering. In hospital practice the house Malingering. surgeon or dresser must be on his guard against being deceived by malingerers, Avho feign to be epileptics in order to obtain admission. The only way to detect them with certainty is to be thoroughly acquainted with the symptoms of the genuine attack. Foaming at the mouth may be simulated by soap, and much "lather" about the lips is in itself suspicious; but the crucial point is the insensibility. In genuine cases this is absolute. Many malingerers are aware of this, and will bear pain inflicted as a test, Avith a fortitude worthy of a better cause, but faradisation judiciously applied can hardly be resisted for more than a few moments. The Convulsions of Infants. The convulsions mi -I-I1P1 it ..of infants. Ihe equal balance ot the cerebral government is, in several causes infants, very easily upset, and convulsive attacks may occur from very slight causes. Worms, teething, intestinal irrita- tion, cerebral irritation, as in rickets, or some local irritation, even that of a pin, may, any of them, be sufficient to bring on an attack. On the other hand, the fit may be an indication of the gravest brain disease, or may stand in the place of the initial rigor which in adults heralds the onset of some acute fever. But the " infantile convulsions " Avhich we here consider, The ordinary are epilepti-form fits, arising as a reflex from such local and oim" temporary causes as we first mentioned, and although they are alarming, are seldom permanently harmful. Taking as an example, the convulsions caused by the irri- tation of the gums during teetjring, Ave shall find that the child, after being hot and fretful for some hours previously, is noticed suddenly to "look queer," or to squint. A general spasm of rigidity then passes over the body, the face becomes pale and set, the eyeballs are turned inwards, and respiration is almost arrested, in consequence of which an asphyxial look quickly develops. This rigidity, however, 368 OF GENERAL EMERGENCIES generally lasts only for a few seconds, and is succeeded by tAvitchings of the face, and other clonic convulsions. These again quickly subside, and the child falls into a sleepy, semi- comatose condition, AAdiich soon becomes a natural sleep. Consciousness is quite abolished during the fit itself. vary greatly in This is an account of a rather severe fit, and they are severity. found of all degrees. Often the whole attack is compressed into a momentary loss of consciousness, with a spasm of rigidity, followed by a little drowsy heaviness. But in all, except the very slightest, the condition is certainly one which must be hurtful to brain action ; the cerebral circu- lation, therefore, should be relieved if possible, and that quickly; such relief can be given most directly and readily by putting the child into a hot bath at once, at as high a temperature as can be borne (say 103° Fah.). If this can be got directly, the child may with advantage be put in clothes and all, and undressed in. the water. It should be immersed up to the neck, and a sponge of cold water may be placed.at the back of the head. Indirectly, too, the bath fulfils several good purposes. The undressing of the child will enable a thorough examin- ation to be made, and will discover if, by any carelessness, there be a pin^ running into the skin, or any other local irritation. Possibly the warmth may hasten the appearance of the rash of some fever, or if there be intestinal colic, this will be relieved. The reader may be reminded of the usefulness of the small operation of lancing the gums, and it may be said that a mercurial purge will, very frequently indeed, greatly improve the condition of affairs. OF DROWNING, AND OTHER FORMS OF SUFFOCATION. 369 CHAPTER XXVIII. Of Drowning, and of some other Forms of Suffocation. In all forms of asphyxia it is important to recollect, first, of asphyxia. that insensibility comes on very soon, some time before the convulsive struggles cease, and is succeeded by a paralysis of all the voluntary muscles, including those of respiration: and secondly, that the heart's action may continue for a long time after the ordinary muscular movements are abolished. The actual cause of death is probably the hyper-distention of the right side of the heart, and it can easily be shown in animals that recovery from asphyxia is possible even after the heart has ceased to beat, if the right heart be rapidly unloaded of its blood by opening the jugular vein. In man, it is very doubtful if such recovery has ever taken place; but it certainly seems that prompt venaesection, although it is very rarely resorted to, offers in extreme cases almost the only chance. It should be remembered, too, that the performance of artificial respiration, to be directly described, in addition to re-oxygenating the blood, also relieves the distention of the right ventricle, by facilitating the passage of the blood through the capillaries of the lungs. It will probably save needless repetition if we here con- sider the steps to be taken with the object of restoring sus- pended animation in ordinary cases of drowning; and taking this account as a typical case of suffocation, to leave it to the reader's common sense to fill in the details of the slight variations which are called for by the different circumstances of other forms. In drowning, several causes are generally present to pro- Drowning. duce a condition of lifelessness, in addition to the asphyxia itself. Thus, shock is often present and may be a very im- portant factor. Exhaustion from long-continued struggling, and the effects of exposure to cold, are also common, and have to be dealt with. Still, the great agent in producing the condition, is suffo- cation, and this must first of all be combated. Supposing, then, that the body of an apparently droAvned Restoration person has been recovered from the water, and that respira- rom ownl «jon is found to have stopped, it may well be that the 24 370 of drowning, and other forms of suffocation. breathing can be set going again by simply making sudden forcible pressure at the pit of the stomach some three or four times, at intervals of three or four seconds ; but should this not be quickly folloAved by respiratory movements, artificial respiration proper should be at once begun.* For this method to be of the least avail, all its details must be carried out regularly and thoroughly ; the object being so far to imitate the natural thoracic and abdominal movements, that air may be sucked into, and squeezed out of, the chest. Artificial respi- The three principal Avays of doing this are known as ration. u Sylvester's," " Marshall Hall's," and " HoAvard's." Sylvester's In Sylvester's method (Figs. 170, 171) the arms are used as levers, acting so as to expand the chest Avails by means of the muscles placed betAveen the limbs and the trunk, the origins of the muscles acting iioav as insertions, and vice versa. Position. The patient should first be laid on his back, and some con- venient support be placed under the shoulders, so that the chest may be throAvn out, and the neck extended, with the head thrown back. (See illustrations.) If this be properly managed, there will not generally be any necessity for the tongue to be drawn out of the mouth, for the larynx will be kept open by the chin being kept well up. But it may Management of sometimes be desirable for an assistant to draAv forward the tongue. tongue, and if so, the best way to hold it, in the absence of proper forceps, is Avith the corner of a handkerchief betAveen the finger and thumb. This is much better than trying to fasten the organ doAvn to the chin Avith an indiarubber band, or running a hair-pin through it, as has been recommended. Everything which in the least confines the neck, or chest, or abdomen, must be loosened, and the mouth and nostrils cleansed from any mud, etc. Should there be any water lying in the pharynx the patient may be turned over on one side to let it run out of the mouth, but no direct attempt should be made to empty the stomach. Performance of These preparations should only occupv a few moments. the movements n., 1 x , , ,. ,J . l ■', n . of respiration, llie surgeon then kneeling at the patients head must take hold of the arms above the Avrists, and carry them well over the head right back as far as they Avill go, as shown in figure 170. The chest-walls aaIH then be expanded, and * It is generally best to do this on the spot, but if a shed or bouse be close at hand, the loss of a few moments may sometimes be risked, in view of other advantages. OF DROWNING, AND OTHER FORMS OF SUFFOCATION. 371 generally air can be heard passing through the glottis. The Fig. 170.—Sylvester's Method. Inspiration. Fig. 171.—Sylvester's Method. Expiration. arms must then be brought doAvn against the sides, and the forearms crossed over the pit of the stomach. Leaning now 372 OF DROWNING, AND OTHER FORMS OF SUFFOCATION. with his weight upon them, the surgeon makes forcible pres- sure upon the abdomen, so as to press up the diaphragm, and this should elicit a distinct grunt from the patient; if it does not, it is doubtful if air has entered the chest cavity at all; the whole process is then repeated. Rate of artificial The rate at which artificial respiration should be made respiration. varies with the age of the patient, and should be about the rate of normal breathing for that age, say, for an adult, 17 times a minute. If recovery be going to take place, generally a very few minutes will be sufficient to restore natural breathing move- ments, and then care must be taken not to interfere with the short gasps with Avhich natural respiration begins ; but the patient must still be carefully watched, for the condition, like that of shock, is one very prone to relapse, and the respiration may fail again after it has been restored. Minor restora- While this principal restorative process is being carried out, other secondary aids to recovery should be attended to. These do not differ greatly from those already described for shock. A warm bath should be prepared, and the dripping clothes exchanged for dry warm blankets. Frictional warmth is a very useful agent, and the extremities and flanks may be energetically rubbed in the direction of the venous circula- tion. The bath, etc. As soon as respiration has been fairly established, the hot bath, if procurable, may be used. The temperature must be high, say 104° Fan., and the time of immersion short. The patient may then be put to bed between blankets, with hot water bottles, and some stimulant, such as hot brandy and water may be given, especially if there be still feebleness of the heart's action, or shivering. Marshall Hail's Marshall Hall's method is generally said to be easier for one person to perform unaided if the patient be heavy, or the operator weak. Whether this be so or not, it is, we believe, certainly less efficient. For its performance, the body is rolled half over from the position of lying on the back, to that of lying on the side, when the arm which is uppermost, is pulled forwards out of the way, and pressure is made on the side of the chest to expel as much air as possible (the expiratory movement). The body is then rolled over on to the back (the inspiratory movement) and these manoeuvres are repeated at the same rate as in Sylvester's method. meS'8 ^r' Howard's "method of direct resuscitation," is des- OF DROAVNING, AND OTHER FORMS OF SUFFOCATION. 373 cribed in the "British Medical Journal," 1881, Vol. I. p. 963. Dr. Howard advocated his method very forcibly on a visit to England some few years ago. It is certainly ener- getic, and has proved itself to be successful, but for some reason it has not made its way to general adoption in this country. The following are his rules of procedure :— 1. Instantly turn patient downwards, with a large firm roll of clothing under stomach and chest. Place one of his arms under his forehead, so as to keep his mouth off the ground. Press with all your weight two or three times, for four or five seconds each time, upon patient's back, so that the water is pressed out of lungs and stomach, and drains freely out of mouth. Then : 2. Quickly turn patient, face upwards, with roll of clothing under back, just below shoulder blades, and make the head hang back as low as possible. Place patient's hands above his head. Kneel with patient's hips between your knees, and fix your elbows firmly against your hips. Now—grasping lower part of patient's naked chest— squeeze his two sides together, pressing gradually forward with all your weight, for about three seconds, until your mouth is nearly over mouth of patient; then, with a push, suddenly jerk yourself back. Rest about three seconds ;—then begin again, repeating these bellows-blowing movements with perfect regularity so that foul air may be pressed out, and pure air be drawn into lungs, about eight or ten times a minute, for, at least, one hour or until patient breathes naturally. Note.—The above directions must be used on the spot, the first instant the patient is taken from the water. A moment's delay— and success may be hopeless. Prevent crowding around patient; plenty of fresh air is important. Be careful not to interrupt the first short natural breaths. If they be long apart, carefully continue between them the bellows-blowing movements as before. After breathing is regular, let patient be rubbed dry :—wrapt in warm blankets—take hot spirits and water in small occasional doses, and then be left to rest and sleep. Dr. Howard claims a superiority for his method for the following reasons:— 1. The direct method alone provides for a thorough preliminary ejectment of fluids from the stomach and thorax. 2. This method alone makes the drainage of the pharynx constant, precluding failure from lodgements there, or suction thence into the trachea. 3. In this method, the usually impracticable task of opening the mouth and pulling forward the tongue is more than superseded by simple position. ' 4. The same position also secures, and in the only way possible, the instant elevation of the epiglottis. 5. The compression by this method is the most complete, and capable of the most delicate adaptations. 6. It is the only method which can be practised by one person, and which by the same person can easily be continued as long as it may be of use. 371 OF DROWNING, AM) OTHER FORMS OF SV FFOCAI ION. other forms of In suffocation by the fumes of charcoal or cake, by the suffocation. cnri,mie acid in brewing vats, or by the choke damp of mining accidents, or in cases of hanging other than those performed by the public executioner, we have examples of suffocation, in all of Avhich the great agent for resuscitation must be artificial respiration. As a rule the conditions are more simple than in drowning, as shock, or exhaustion, or cold, the effects of Avhich in droAvning have to be overcome, is not generally present, but the main principles of treatment remain the same.* We have mentioned already when considering the treat- ment of extreme shock and syncope, most of the other measures which are accessory to artificial respiration in cases of suspended animation, from Avhatever cause arising; but although faradisation has been alluded to on two or three occasions, and Avill be again in connection Avith recovery from some poisons, such as opium, chloral, or prussic acid, the details of the administration of the electric current have not yet been given. We take the following directions from Messrs. Beard and EockAvell's Treatise on Medical and Surgical Electricity.! The faradic current is usually employed, but the inter- rupted galvanic current might answer the purpose. Graduate the current to a strength sufficient to produce vigorous contractions of the muscles of the ball of the thumb. Then press the electrodes firmly over the phrenic nerves, between the sterno-mastoid and scalene muscles; or, put one electrode over one phrenic nerve and the other in the seventh intercostal space. Interrupt the current about three limes a minute, while the assistant presses firmly on the abdomen, pausing occasionally to observe the effect. If no inspiratory movements appear after a number of inter- ruptions, increase the strength of the current. The electrodes must be large, and well moistened. The resuscitation of stillborn infants, though carried out on the same general principles as that of the other cases of * It will be noticed that nothing has been said about insufflation or the use of bellows to blow up the lungs as devised by Richardson, etc. We purposely omit this method, because although in skilful hands the apparatus is very useful, in the vast majority of cases the attempts to use it will only mean loss of time, during which the artificial respiration, which any person can perform, might have been begun. f William Wood and Co., New York, 1881. See also Chap, xxx., On Anaesthetics. OF DROWNING, AND OTHER FORMS OF SUFFOCATION. 37f> suffocation, does not come Avithin the list of emergencies to which we have limited ourselves. Two forms of suffocation must be especially mentioned, Asphyxia frnr. those namely Avhich are due to the lodgement of a foreign inrthenair orS body in the commencement of the oesophagus, or somewhere food Passases- in the larynx or trachea. Commonly enough a piece of hard meat is " bolted," and From a foreign is arrested at the narroAvest part of the oesophagus, namely, oesophagus? at the top. Great distress, and even dangerous symptoms of suffocation, may thus be caused. Sometimes it is possible to reach the lump with the finger, in Avhich case, naturally, the best thing to do is to hook it up. Failing this, the next best, and the more common plan, is to push it gently onAvards. Frequently, too, the lump may be moulded into a more con- venient shape by pressure from the outside of the throat. So soon as the mass passes the commencement of the oesophagus, it may be trusted to go doAvn of itself. A good deal of distress is frequently caused by the From fish sticking in the throat of a fish bone, or some other small pointed or jagged foreign body. If the body be quite soft and flexible, probably the best Avay to get rid of it is to swalloAv a good mouthful of bread, and to drink some Avater ; but if there be any reason to suspect that injury to the lining mucous membrane may thus arise, it must not wil- fully be pushed on, but an effort must be made to ex- tract it. For small bodies, such as a pin, small sharp splinti rs of Pins, splinters bone, and the like, the best instrument to use is a probang ° with bristles (Fig. 172) arranged so that they occupy little Fig. 172.—Expanding Probang. room as it is passed doAvn, but Avhich on its AvithdraAval can The expanding be expanded into a form something like a chimney-sweep'?. probang- brush, in the meshes of which the object may be en- tangled. But if this expedient should fail, or if the foreign body should be larger (and Ave may adduce as the most common examples, a set of false teeth, or coins), it would not be safe to use a probang, and patient attempts must be made to 376 OF DROWNING, AND OTHER FORMS OF SUFFOCATION. Forceps, etc. extract it by means of forceps of especial construction, of Avhich some examples are here given (Figs. 173, 174, 175), or by means of a coin catcher or snare. If the body can Fig. 173.—Pharyngeal Forceps. be touched at all, or its locality made out with the fingers, extraction will generally be easy enough, but if not, it may Fig. 174.—Pharyngeal or Laryngeal Forceps. Fig. 175.—Cross-lever Laryngeal Forceps. be extremely hard to lay hold of, and the greatest patience and skill will be required. OP DROAVNING, AND OTHER FORMS OF SUFFOCATION. 377 If all these attempts should fail, the question of operative measures will have to be raised, but as we do not here propose to discuss these, we have only further to express the opinion that it is bad surgery to try to produce vomiting (as has been recommended) under any circumstances, and also that Emesis not to the dresser or house surgeon should never on his own re- e pi° sponsibility attempt to push onwards into the stomach a foreign body which he has failed to extract, unless that body be of such a shape and nature, as the lump of meat or soft fish bone mentioned before, that its presence there will not be hurtful. When any foreign substance (other than a poison) has Foreign bodies once passed into the stomach, no attempt should be made to in ' e stomac recover it by means of vomiting, nor should purgatives be given. The diet should be of a kind which will give the substance the best chance of being enveloped in pultaceous material, and the stools, of course, should be carefully watched. Under such circumstances, bodies, such as coins, marbles, etc., may be confidently expected to be passed in the course of a few days, and even such irregular bodies as plates for several false teeth, with numerous pointed hooks, have been harmlessly expelled.* It sometimes, but very rarely, happens that the symptoms Body in ceso- of suffocation due to the presence of a foreign body in the oaiigfor ¥v&- cesophagus are so urgent, that before any attempt at ex- cheotomy- traction can be made, it becomes necessary to open the Avindpipe and to insert some stiff tube. In this case the tracheotomy Avill generally have to be made rather low down, but the Avhole subject of the performance of this operation Avill be dealt Avith in Chap, xxxvi. Even more marked is the urgency of the symptoms of Foreign bodies distress or of suffocation, Avhich the presence of a foreign 0r tracheal body in the larynx or trachea occasions. These substances are generally quite small, such as cherry stones, rice grains, small coins, etc. It never happens that they are swallowed into the windpipe, but they get caught in the air passages in consequence of some irregular inspiration, performed while foreign materials are in the mouth or are being SAval- lowed. Thus one of the most distressing examples of the * It is a somewhat curious fact, that very irregular and jagged bodies often pass through the whole length of the alimentary tract, without causing any pain or trouble, until they are within an inch or two of the anus, when they are arrested and may give rise to ulceration and haemorrhage, ischio-rectal suppuration, or other serious mischief. 378 OF DROWNING, AND OTHER FORMS OF SUFFOCATION. accident (which Ave believe indeed has hitherto been in- variably fatal) is the not very uncommon sucking in of the dart of the " puff and dart" toy, an inspiration being made instead of an expiration, Avith the result that the missile passes, head first, doAvn to, and through the larynx, some- times even as far as a secondary bronchus. The consideration of the Avhole question of the treatment of foreign bodies in the air passages Avould lead us too far into general surgery. The questions Avhich arise in such cases, indeed often call for the highest surgical discrimina- tion and courage, nevertheless the accident is most tru'y an emergency, and one Avhich a junior surgeon may be called upon to treat in the first instance, to avert impending suffo- cation.* Tracheotomy He will be called upon to decide whether a tracheo- by the mouth, tomy should be done forthAvith, or whether an attempt should first be made to remove the body by the mouth, and in the majority of cases the former is the line of action which should be folloAved. Attempts to excite vomiting or sneezing, patting on the back, or inversion of the body, are all attended with risk of instant suffocation, and though cases have occurred in Avhich these measures have been successful (notably in the Avell- known case of Mr. Brunei) they are not to be recommended. It does happen, however, not very infrequently, that a foreign body is lodged in the larynx, and excites com- paratively .little irritation there. In such a case, supposing that the house surgeon is moderately skilful in the use of the laryngoscope, he may rightly attempt to remove it, if it can be seen, by means of laryngeal forceps, or by some kind of snare. The forceps shown in Figs. 174 or 175 may be used ; or a still better pattern, the cannula lever forceps of Dr. Mackenzie (Fig. 176), or Durham's flexible forceps. But in most cases all measures for removal will be far more safely undertaken after a laryngotomy or tracheotomy has been performed, and the choice of the operation will depend upon the situation of the body. If it be evidently in the laryngeal folds or pouch, then a free laryngotomy, or in children, laryngo-tracheotomy, should be the chosen operation. If it be in the trachea, or appears to be lodged * We consider here only genuine cases of foreign bodies actually retained in the air passages, not that large class of cases in which an irritating substance is momentarily in contact with the vocal cords and is violently expelled. OF DROWNING, AND OTHER FORMS OF SUFFOCATION. 379 in one of the main bronchi, a tracheotomy, as low down as is convenient, should be performed. «~~-IF =°^ Fig. 176.—Mackenzie's Cannula Forceps. When the opening in the air passages has been made, its Mathi edges should be held open Avith a pair of ordinary retractors, or with Mathieu's three bladed forceps (Fig. 177), or, best leu'i forceps. Fig. 177.—Mathieu's Forceps. (The third blade can be removed if so desired.) of all, with Golding Bird's tracheal dilator (Fig. 178). In Golding Bird's tracheal dilator. FlG. 178.—Golding Bird's Tracheal Dilator. a great many cases this proceeding will be followed by the immediate expulsion of the body, either through the open- ing thus made, or through the larynx, the folds of which are relieved of the acuteness of their spasm j now, also, 3S0 OF DROWNING, AND OTHER FORMS OF SUFFOCATfoN. inveision, slapping of the back, etc., may be safely tried : but if, after a fair opportunity has been given for the expulsion, this does not occur, a full-sized tracheotomy tube, or the dilator before referred to, should be inserted and retained. The risk of asphyxia being now removed, the patient may safely Avait for the chances of the natural expulsion of the body, Avhich often happens, or for more deliberate exploration of the parts by the visiting surgeon, under conditions which the house surgeon has by his prompt tracheotomy made much more favourable for success. Entry of air We may here briefly consider the treatment of entry of into a wounded . , j j • ■ j.t_ i vein. air into a wounded vein in the neck or armpit. This accident is always dangerous and often disastrous. The patient becomes pale, the pulse feeble, and the signs of dyspnoea dc\relop. AVhen the amount of air which is sucked in during inspiration is small, a transitory faintness may be all that is produced, but othenvise the symptoms become most urgent. For their relief it is generally advised that the vessel be at once compressed with the finger and ligatured as soon as possible, while the constitu- tional effects of the accident are combated by artificial respiration, compression of the main A-cssels, and the recumbent position.* Treves, hoAvever, points outf that artificial respiration is not called for, and urges that the first thing to do is to fill the wound with water (this prevents further ingress); then by making firm pressure on the thorax during expimiion, he states that most of the air can generally be expelled from the veins. This effected, a ligature may be put on during expiration. Lastly, if digital pressure be employed at all, he states that the vessel should only be compressed during inspiration. • See "Erichsen's Surgery," 1884, Vol. I., p. 470. t British Medical Journal, 1883, Vol. I., p. 1278. OF THE! TREATMENT OF OASES OF POISONING. SSl CHAPTER XXIX. Of the Treatment of Cases of Poisoning. Of Poisons. We have noAv to consider the measures which General should be taken when some one of the substances which are considerations- commonly used as poisons, or which may be so used, has been taken into the body in sufficient quantity to produce toxic symptoms. The folloAving are the chief of these sub- stances, and we Avill consider them in the order in which they are here given. General Poisons. Irritant Poisons and Caustic. List of common 1. Alcohol. 1. Carbolic ] poisons. lA (Ether.) Oxalic »-i o i i • VAcids. Sulphuric 2. Kerosine oil. 3. Opium. and other J 4. Strychnia. 2. Corrosive sublimate. 5. Belladonna. 3. Arsenic. 6. Prussic acid. 4. Antimony. 6a. (Nitro-benzol.) 5. Phosphorus. 7. Chloral. Poisonou Shell fish. — 6. s Fooc Caustic alkalies. Is. Mushrooms. The general poisons vary too greatly among themselves to admit of any general description, and must be considered separately. Alcoholic poisoning may be conveniently divided into Alcoholic drunkenness and acute alcoholism. The former is not in p01S0ning- itself dangerous, and usually the best course to take with drunken men or AAromen is to leave them to sleep the effects of the alcohol off. Nevertheless, even a moderate grade of Drunkenness, drunkenness may be dangerous in old or feeble people, with o^ danger degenerated tissues and Aveak circulation, for it may be the cause of a grave cerebral disturbance (generally of the nature of an apoplexy), or of a failure of the heart's action. The latter event must be particularly guarded against in cold Aveather, for, in consequence of the dilated condition of the arterioles of the skin, drunken people lose heat very quickly. Care must be taken, therefore, in thus 382 OF THE TREATMENT OF CASES OF POISONING. leaving drunkards alone, that their conditions are such that there is no chance of their getting dangerously cold. Use of emetics. It often happens in the casualty department, that it is de- sirable to make a patient sober as soon as possible. For this purpose nothing is more effectual than a brisk emetic. Sulphate of zinc, sulphate of copper, or tartar emetic may be used in sufficient doses.* If the patient be violent, or refuses the draught, it may be given Avith the stomach pump (the use of which is described later), but in practice it will be found that if the pump has to be used at all, a sufficiently sobering effect will be produced by Avashing the stomach out with tAvo or three pints of warm Avater. In certain cases, a hypodermic injection of one-tenth to one-eighth of a grain of apomorphia may be administered. Although this emetic is generally reserved for graver cases of poisoning (vide infra), still it appears to be perfectly safe. Faraaism. For the common occurrence of a drunken and disorderly person being brought to the hospital, and refusing to give his or .her name and address, farad ism, strong enough to produce painful contraction of the muscles, will generally prove effectual Avhen the proceeding is really worth while. Diagnosis of A short experience will enable the dresser to separate aiconoasm. ordinary cases of drunkenness from other forms of poison- ing, and Ave need not particularise its symptoms. It is undesirable also to attempt a hard and fast differential diagnosis betAveen the higher grades of acute alcoholism, and other grave conditions, but this is for a different reason, namely, because it is noAv not an alternative question, drunk 1 or dying 1 but a positive statement, drunk, and dying. Any patient Avho has SAArallowed enough alcohol to produce symptoms which may be confounded Avith apoplexy or any other severe illness, must be considered to be poisoned, and to be in need of^ careful treatment. Acute alcoholic In these cases of acute alcoholic poisoning, the condition of the circulation and respiration Avill be the best guide as to Avhether the patient may be left to recover from his stupor AAnthout further measures beyond those Avhich are required Use of stomach for keeping him Avarm, or Avhether the stomach pump should pump. ke uge(J. j^ jn most cases it will be best to wash the stomach out with warm Avater, and this should ahvays be done if there be any sign of failure of the heart's action, * An effectual, but a very nauseous draught was, and probably still is, used at St. Bartholomew's, under the name of " half-and- half." It consisted of 30 grains of sulphate of zinc in 3jss of water, added to an equal quantity of house physic (Hst. Sennae Co., P.B.). OF THE TREATMENT OF CASES OF POISONING. 383 or if the breathing be suspiciously shallow. Alcohol may remain for a long time nearly unchanged in the stomach, and should therefore be removed, to prevent further ab- sorption. In extreme cases, artificial respiration may be called for, but these are generally speedily fatal. In acute alcoholic poisoning, as distinguished from simple drunkenness, if the stomach-pump be not at hand, emetics may be used, but as it is undesirable to further irritate the already injured stomach, preference should always be given to the pump if possible. This irritable condition of the stomach should always be kept in mind in the treatment of the case after the acute stage has passed. Intoxication by drinking ether is hardly known in England, intoxication by but is stated by Dr. Richardson to be common in some ether" parts of Ireland. As a result of inhalation, it is of daily occurrence in all hospitals. When it is SAvallowed, its effects nearly resemble those .of alcohol, but the period of excitement is more marked, and that of stupor less so. It is much more rapidly eliminated, so that the whole in- toxication is shorter, and is less poisonous, although Dr. Morshead, of Draperstown (the head-quarters of ether drinkers), has recorded four fatal cases. Its treatment does not differ from that for alcoholic poisoning. Almost the same may be said of a form of poisoning noAv Poisoning by getting more common, namely, by kerosine or some mineral minerals- oil. When this is SAvallowed it produces flushing and excitement, folloAved by droAvsiness. In these cases the major part of the oil is generally \romited spontaneously, but the stomach-pump should in all cases be used, or failing that, an emetic should be given. Poisoning by opium, or by its alkaloids, is very common, Poisoning by and is getting more so, not from any increase of suicide by phinm or mor' this means, but from the numerous instances of inadvertence occurring in the groAving class of people Avho have acquired the habit of administering the drug to themselves. When opium is taken for suicidal purposes, laudanum is generally employed, and it often happens that the suicide swalloAVS a very large quantity. This very frequently leads to failure of the attempt, through the active vomiting Avhich is set up. The symptoms of' opium poisoning are generally distinct The symptoms. enough. The slow shallow respiration, and feeble fluttering pulse, the pallid, almost livid skin, coa ered Avith a cold sweat, the obstinate droAvsiness or profound stupor, and above all, the fixed contracted pupils, are sufficient evidence 384 OF THE TREATMENT OF CASES OF POISONING. of the condition, even Avithout any external, or circum- stantial proofs. The treatment. In this condition the respiratory centre is the part in greatest danger of striking work, and it must be kept going until the poison has been eliminated. By every possible means the patient must be roused, and kept aAvake, generally the best way is to keep him walking about. supported, if necessary, on either side,* while by shouting, slappi ig the face or chest Avith a Avet towel, etc., every effort must be made to prevent a relapse into torpor. The nitrite of amyl may be inhaled Avith advantage, and it is very im- portant that the patient be kept Avarm. If there be any reason to suspect that there may be some of the poison still remaining in the stomach, the pump should be used, or an emetic given, and after that, strong, hot coffee should be freely drunk. It is often difficult to excite emesis on account of the action of the poison upon the vomiting centre in the medulla as well as upon the stomach walls. Apomorphine acts directly upon this centre, as sulphate of zinc, or mustard and Avater does upon the stomach; if, therefore a brisk irritant emetic, (say 30 grains of sulphate of zinc) does not excite vomit- ing, it will be wise to give subcutaneously 1-10th grain of apomorphine. Any form of emetic is of course useless unless the poison has been taken by the mouth. If, in spite of these efforts, the stupor deepens, and the respiration further fails, the stimulus of faradisation of the diaphragm may be tried; the surgeon must be ready to adopt artificial respiration, and may consider the advisability of administering the only drug Avhich is believed to have an Value of antagonistic action to that of opium,namely atropine. Opinions atrop me. &g ^0 ^Q truth of this antagonism are very contradictory ; some e.g., Dr. Fothergill, holding the fact to be indisputable, while others state that its administration actually intensifies the poisoning. On the whole there seems to be sufficient evidence for the antagonism, to justify the administration of the drug in extreme cases. The most convenient form will be by the hypodermic injection of liq. atropise sulphatis, 4 or 5 Vt[ (uVth to ^Vth grain of the alkaloid) of Avhich might be given for a dose, to be repeated, or slightly in- creased, if the symptoms seem to be improving under it. When improvement has once commenced, it is generally * The Inspector at the nearest police station will usually detail relays of men for this purpose if he be asked ; this will save the hospital porters much labour. OF THE TREATMENT OF CASES OF POISONING. 3S5 continuous. The pupils may remain contracted for a long time, but when the respiration and circulation appear to be well established, and the patient is able to keep himself awake, the best treatment will be Avarmth in bed, Avhen natural sleep will probably soon come on and may be en- couraged. The patient should be Avatched, hoAvever, lest the Risks of respiration should again begin to fail and other symptoms of relapse< poisoning re-develop. Alcoholic stimulants seem to be hurtful in all stages of the poisoning. Strychnia poisoning.—This alkaloid is a common in- strychnia gredient of " vermin powders," " beetle paste," and the like, poisonin?- so that strychnia poisoning by misadventure is rather frequent. The symptoms of this condition can only be mistaken for those of acute tetanus, and this error can hardly be made if attention be carefully given to the case for a short time. The condition is, of course, a " tetanus " in both cases; but in that of the poisoning, the rapid de- velopment and acuteness of the attack, the universality of How aistin- the convulsions, as opposed to the almost invariable spreading feTanua.fr01 from the neck and jaw muscles in the ordinary tetanus, the nearly complete relaxation in the intermittent periods, and the fact that the duration of the Avhole attack is to be measured by hours—all these will enable a diagnosis to be made with almost absolute certainty, although indeed this is of the less importance in that the treatment may be much the same in either case. In strychnia poisoning there is a very short period of abnor- Symptoms. mal restlessness, quickly followed by a general trembling, and then complete opisthotonos, with marked "risus sardonicus," and cyanosis. In half a minute,or a minute, the spasm relaxes, and there is a period of exhaustion and respite, to be suc- ceeded on the slightest irritation, or apparently without any cause, by a similar storm of reflex contraction. If death occurs, it Avill generally be from asphyxia or exhaustion, and Avill very often take place in less than an hour. If the dose has not been a fatal one, the spasms will gradually diminish in frequency and force. In the treatment, the main reliance must be placed upon inhalations of chloro- form, and large and frequently repeated doses of chloral hydrate and bromide of potassium. Xitrite of amyl may be inhaled, "and artificial respiration if possible performed" (Murrell). If by any means the first few hours can be tided over, hopes of recovery may be fairly entertained. If the form in which the poison has been taken be rather a bulky one, as a vermin poison, then in the first instance the 25 386 OF THE TREATMENT OF CASES OF POISONING. stomach pump must be used ; or a brisk emetic, e.g., one of sulphate of zinc, or of mustard and Avater, must be very promptly given ; or ^th of a grain of apomorphia may be injected subcutaneously. Belladonna Belladonna poisoning. This is generally accidental, as from eating the berries of the "Deadly Nightshade" (atropa belladonna), svralloAving lotions containing atropine, symptoms. or through some similar mistake. The symptoms are very characteristic. The pupils are Avidely dilated, and the skin capillaries injected, producing a rash like that of scarlatina. There is much cerebral excitement, the delirium is generally chattering and restless, but may be extremely violent. The mouth is always parched, and the skin very dry. Treatment. Emesis must be produced by the stomach pump, or by sulphate of zinc, etc., or by apomorphine ^o gr., and folloAving this, stimulants in the shape of alcohol or ether, as well as strong tea or coffee, Avhich are also useful from the tannin they contain. Artificial respiration may be necessary in very severe cases, and in others external stimuli, such as douche, faradisation, etc. Both morphia and chloral have an antagonistic action to atropia, but this is in neither case so distinct as that of pilocarpine, \ to \ gr. of which should be injected subcu- taneously, and repeated if saveating be not produced. 5 to 10 ni of a 1 in 20 solution of the alkaloid, or its hydro- chlorate, or 5ij of the tincture of Jaborandi will be the dases required. Retention of urine is common in these cases, calling for the use of the catheter. Prussic acid Prussic acid poisoning. The action of hydro-cyanic acid poisoning. -g g0 jntense that death is often almost instantaneous, or symptoms. there may be just time enough for a cry of agony. Even in less acute cases the symptoms come on within a few minutes. There is first respiratory difficulty, and then a period of violent convulsive movements, Avhich are general throughout the body, but especially affect the expiratory muscles. Vomiting, and involuntary urination and defalcation, occur. This stage is followed by a period of calm, Avith rapidly deepening paralysis and cyanosis. This usually is quickly folloAved by death. In fact the Avhole attack resembles an acute asphyxia, or rather is one, and although treatment is rarely successful, it must be directed toAvards maintaining the action of the respiratory centre in every possible Avay. Treatment. Should there be time for any attempts at restoration, an emetic should be given, or the stomach pump used, if it can OF THE TREATMENT OF CASES OF POISONING. 387 be employed at once, and then ammonia on a handkerchief, as strong as can be borne by the patient, should be inhaled, and other stimulants freely given by the mouth if they can be swalloAved, if not, then brandy and ether should be given hypodermically. Stimulant enemata may also be made use of. Alternate douches of cold and hot water are powerful stimuli to respiration, and strong faradisation should always be applied if possible. Artificial respiration will most prob- ably be called for as soon as the convulsive stage is over, and must be persevered in, although the condition may seem to be almost hopeless. The materials used for prussic acid poisoning are usually either impure bitter almond oil, or the pharmacopceial, or " Scheele's" acid, or some one of the soluble cyanides so largely used by photographers. The only substance Avhich at all resembles it in its action Nitro-benzoi. is nitro-benzoi, or artificial oil of bitter almonds, nor would the treatment of poisoning by the latter differ in any respect. Chloral poisoning. As in the case of opium poisoning, this chloral is generally a poisoning by misadventure, due to the in- P°lsomnS' creasing habit of self-administration of drugs by the laity. The symptoms resemble in great measure those of opium poisoning, but the fixed contraction of the pupils is absent, and the circulation is affected quite as much as is the respiration. In all respects of rousing, emetics, etc., the treatment is Treatment. the same as for opium, and so also Avith regard to effusion, faradisation and artificial respiration. It is even more im- portant than in opium poisoning that warmth should be kept up, and the administration of a pint of hot strong coffee by the rectum will fulfil the indications of Avarmth and stimula- tion. With regard to an antagonist, the most distinct one is strychnia ; 4 u\ of the liq. strychnia? may be injected be- neath the skin, and repeated every 10 to 20 minutes if necessary. The irritant and corrosive poisons may conveniently be irritant and grouped together, for the symptoms of the latter only differ poisons!6 from the former in their greater intensity. Moreover many of the substances in our list, in Aveaker solutions are irritant poisons, and corrosive poisons when concentrated. In most cases the local effects are so marked that any constitutional results of their absorption are unnoticed. The following is the general sequence of events after an General course irritant poison has been swalloAved. There is first a burning irritant poison- 388 OF THE TREATMENT OF CASES OF POISONING. metallic taste in the mouth and throat, and then a sense of intolerable pain referred to the chest, behind the sternum (heartburn). This is folloAved by increasing general ab- dominal pain, so that the legs are draAvn up, as in peritonitis, and the belly becomes tumid. Vomiting is almost invariably present, and there is generally great thirst. If the poison has been taken in a quantity insufficient to cause speedy death, and if it be irritant only, and not corro- sive, the above are the chief symptoms. In the less severe cases these may, Avith appropriate treatment, be subdued ; on the other hand if the dose be a fatal one, the symptoms of irritation will quickly be followed by dyspnoea and increasing collapse, so that the patient looks to be in the algid stage of cholera, and this will continue until death by syncope occurs. in corrosive But if the substance be truly corrosive in its action, such poisoning. . . . J ' as one ot the concentrated mineral acids, the symptoms are even more severe, and run a much more acute course ; it is probable that no recovery has ever taken place after such a poison has been swallowed, so that any quantity has passed into the stomach, although instances are common of great damage to the throat and oesophagus being folloAved by recovery ; or, Ave should rather say, by recovery in the first instance, for generally the consequent cicatrisation has led to contraction and stricture. Local signs in The damage to the lips and throat is the first and most niroat.an prominent symptom, and gives the measure of the extent of the corrosion of the parts loAver down. The corners of the mouth will be marked, and the tongue and palate covered, with a whitish coat of slough, " like a coat of paint," if sul- phuric, or hydrochloric acid, or corrosive sublimate has been used ; or with a yellow stain, in the case of nitric acid. Abdominal In the presence of these signs of corrosion a very few minutes will decide Avhether the poison has been really swallowed. If so, the symptoms Avhich have just been detailed will develop, but more rapidly and more acutely. The stage of collapse is reached more quickly, and there are signs of actual destruction of the viscera. The vomit contains shreds of sloughing mucous membrane, or it may be, casts of Avhole sections of the oesophagus. The abdomen becomes enormous- ly distended with gas. The dyspnoea and dysphagia are both intense, and death usually occurs within a few hours. Treatment. In many respects the treatment of poisoning by irritant or corrosive substances is common to them all; and again, Avith regard to many, there are some particular antidotal drugs, or some especial measures to be taken or avoided, OF THE TREATMENT OF CASES OF POISONING. 389 In the first place, the stomach-pump should be used, unless The stomach there be evidence of such corrosion as to make it probable to be used. that the walls of the oesophagus or stomach are too much T damaged for the tube to be safely passed. Such a case is indeed practically hopeless from the first, unless the damage be confined to the upper part of the canal. The vomiting, Avhich is almost ahvays present, should be encouraged by giving Avarm Avater, and failing the stomach pump, the natural emesis may be encouraged by mustard and water, or by the injection of apomorphia. As soon as the stomach has been relieved of the poison, raw egg albumen, milk, barley Avater, arrowroot, or whatever mucilaginous fluid can be most readily procured, should be given. Egg albumen, raAv, is probably the best of all in all cases, as well as having a special action on corrosive sublimate. Salad oil may generally be given Avith good results, except in the case of phosphorous poisoning. The rest of the general treatment of irritant poisoning will be directed toAvards the symptoms of peritonitis and collapse. The pain must be subdued Avith full doses of opiates. The Avarmth of the body must be maintained, and the other signs of shock combated by such stimulation as the inhalation of ammonia, or nitrite of amyl, the subcutaneous injection of ether and brandy, stimulant enemata, faradisation of the extremities, etc. Morphia by hypodermic injection will also generally be indi atcd. Special points in the treatment of particular irritant and special points r . 1 . of treatment COrrOSlve poisons. for particular I. For irritant and corrosive acids. _ ivr acids. These comprise sulphuric, nitric, hydrochloric, oxalic, and carbolic acids ; the symptoms in the case of the first three will be similar, and in accordance with those results of SAvallowing any corrosive fluid which have just been de- scribed. The acuteness of the symptoms will vary directly with the strength of the solution, and inversely Avith the quantity of food in the stomach. In all, if a strong solution be actually swalloAved, the symptoms will be of the most urgent kind, and will be rapidly fatal if not at once counter- acted, so that time is of the utmost importance. The stomach pump may not safely be used unless the acid has been in quite a dilute solution. The charring in the case of nitric acid is yelloAV, and the vomit possesses a nitrous smell. In sulphuric and hydrochloric acids, the lips and mouth are whitish, and the vomit dark or black, containing charred shreds of mucous membrane. 390 OF THE TREATMENT OF CASES OF POISONIXC The treatment lies in diluting and neutralising the acid as quickly as possible, so that all remedies should themselves be copiously diluted. Lime Avater (the saccharatcd is the best) whiting and water, chalk and water, soap and Avater, ordinary washing soda, or the bicarbonates of soda or potash, or any of the preparations of magnesia, in solution, are all useful alkaline remedies. Some of them will almost certainly be at hand in any given case, and it should always be borne in mind that " the nearest remedy is the best" (Murrell). In addition to alkalies, milk, olive oil, and the other demulcents mentioned above are all useful. Oxalic acid and In poisoning by Oxalic acid or by Stdts of sorrel (the acid salts of sorrel. oxajate 0f potash) the main special point to bear in mind is that the alkaline oxalates are soluble and poisonous, so that chalk, Avhiting, lime Avater, or magnesia must be used to neutralise the acid, and not soda, potash, or ammonia, or the carbonates of any of these. Oxalic acid poisoning is rather common and is frequently suicidal. The symptoms are those already detailed, save that collapse is often disproportionately marked, and that death may be very speedy. carbolic acid. Carbolic acid poisoning is now perhaps the commonest of all forms of poisoning by misadventure, and is also used for the purposes of suicide. Its corrosive action is, in concen- trated solutions, very conspicuous, but the destruction does not extend deeply into the tissues. The mouth and jaws are usually covered Avith a white, leathery pellicle. The symptoms are those of poisoning by any corrosive fluids, but pain is even more intense than in the case of the other acids, while on the other hand the collapse, and other symptoms of the gravest local injury are not so manifest, nor, is the whole course of events after the poison has been taken, so hurried. Treatment. Treatment. The sulphates of magnesia, or soda, in half ounce doses in a tumblerful of Avarm water should be given at once and the stomach Avashed out with warm Avater, or with the same alkaline solution three or four times, half a pint or so of the solution being afterwards left in the stomach. In the absence of the stomach pump, vomiting must be produced by zinc sulphate, mustard and water, ipecacuanha, or the injection of apomorphia. Later on demulcents, such as barley Avater, olive oil, etc., may be given, or an ounce of castor oil. Shock is often very marked and must be treated by frictional warmth, ammonia, etc., as before stated. If there be much restlessness chloral should be given, as there is an antagonism between it and carbolic acid, OF THE TREATMENT OF CASES OF POISONING. 391 The urine is often dark and scanty, and may be suppressed in acute carbolic acid poisoning. The carboluria is then a grave symptom, but it often happens in surgical cases, that carbolic acid, not necessarily used in very large quan- tities, is absorbed and produces a similar inky urine. II. For corrosive sublimate (perchloride of mercury), the For the acid acid nitrate of mercury, etc., albumen in any shape (even cury.° mer" gluten of flour is better than none, but Avhite of egg is best) should be freely given, as an insoluble albuminate is thus formed. Emesis should be encouraged by warm water or mustard and water, if vomiting be not active without such aid. If the solution has been concentrated, the stomach pump must only be used with great care. III. Arsenical ]ioisoning is generally effected by arsenious Arsenical acid (white arsenic), and is frequently given Avith criminal intent. The symptoms do not come on immediately after taking the poison. The vomiting and purging resemble at first an intensely violent bilious attack; afterwards the symptoms are more like acute cholera, and the diagnosis is often obscure. The emesis must be encouraged, and the stomach emptied by the pump. This should be followed up Avith oil, SAvitched eggs, or a mixture of oil and saccharated lime water. Magnesia is also very useful, but the substance which best neutralises the action of arsenic or arsenious acid in solution, is the freshly prepared hydrated peroxide of iron. This can be quickly made by adding half-an-ounce of common carbonate of soda to a fluid ounce of tinct. or liq. ferri perchlor., and filtering. As a substitute, dialysed iron in ounce doses, may be given. If the diagnosis of the acute form of this poisoning is not generally easy, that of chronic arsenical poisoning is ahvays difficult, but this condition does not fall under the heading of emergencies. IV. Poisoning with antimony, in the form of tartar For Antimony. emetic. The symptoms come on soon, and generally the vomiting is so violent that the whole of the poison is soon ejected. If not, the symptoms resemble those of arsenical poisoning, but there is more depression. The treatment is the same as in arsenical poisoning ; but in addition, tannin should be given in the form of Aery strong tea or coffee, or by means of preparations of oak or cinchona bark, or of tannic acid itself. V. Poisoning with phosphorus. This is usually taken in Phosphorous the form of beetle paste, or rat paste, or sometimes by swal- p01s loAving the heads of lucifer matches. In these cases the 392 OF THE TREATMENT OF CASES OF POISONING. symptoms declare themselves quickly after the poison has been taken, and are generally prolonged over days, or it may be Aveeks. The prominent symptoms are great thirst, with heartburn, and violent vomiting, the vomit being phospho- rescent in the dark, and the breath smelling strongly of the poison. Acute and sub- The result will mainly depend on Avhether the vomiting be acute poisoning, ^ft^jgntiy active to prevent an absorption of a really poison- ous amount. If the quantity absorbed be large, the symp- toms remain acute; htematemesis and bloody purging are often present, with cramps, and finally coma. But if only a small, but still poisonous quantity has been taken (say \ to 1 gr.), after the first indications of irritation have passed over, the symptoms usually subside for a day or tAvo, and then the signs of acute atrophy of the liver begin to declare themselves. Then the jaundice deepens, and a comatose, typhoid condition, Avith delirium, generally ends in death in a feAV days, although in some of the milder cases recovery on not to be may take place. The early treatment of the poisoning does not differ from that of other irritants, save that oil, in Avhich phosphorus is soluble, should never be employed Avith the idea of soothing the intestinal mucous membrane. After the stomach has been emptied of its contents either naturally or with the stomach pump, mucilage, magnesia in barley Avater, or similar demulcent fluids may be given. The only drug which seems to have any action in preventing the liver changes, is the French oil of turpentine in full repeated doses of 15 n\ to 5ss. chronic Chronic phosphorous poisoning, phosphorous necrosis, etc., poisoning. cannot here be discussed, as they do not occur as emer- gencies. poisoning by VI. Poisoning by caustic alkalies and their carbonates. aneuh ir'car-es This form of poisoning is rare, but potash or soda lye is Donates. sometimes taken. The symptoms are those of ordinary irri- tant poisoning, except that violent purging is generally a prominent symptom. In the treatment, the question of the use of the stomach-pump must be decided by the amount of caustic destruction. Weak acids, such as vinegar and Avater, or any of the dilute pharmacopceial acids, should always be given. Poisonous Poisonous foods. A form of acute gastro-intestinal irri- f oods. . . J • ,-c i , ... tation, often so severe as to justify the term poisoning, is not Shell fish. infrequent as a result of eating shell fish, especially mussels. In the treatment, an emetic should be given in the first place, and aftenvards a full dose of castor-oil with 20 to 30 n\ of laudanum, chlorodvne, or of some "similar sedative. OF THE TREATMENT OF CASES OF POISONING. 393 This is to be repeated if necessary. Atropia is here also in- dicated, although not so distinctly as in the case of poisoning by muscarin. The manner of administering, and the dose, are the same as in the following case. Mushroom poisoning should not go without mention, al- Mushrooms. though in London cases are rare. Most fungi, edible or inedible, may produce, if improperly cooked, symptoms of a mild degree of irritant poisoning, similar to those which have been mentioned, and which may be treated in a similar Avay. But cases of true muscarin poisoning exhibit a much higher Muscarin grade of toxic symptoms. The fungi which contain muscarin poisomns- or some similar alkaloid are not very numerous in England, the principal one being the fly fungus (amanita muscaria). When the more actively poisonous fungi have been eaten, as a rule great cerebral excitement is caused, in addition to the more strictly irritative effects on the alimentary tract. In the antagonism between muscarin and atropia Ave have Antagonism perhaps the best example of this mode of the physiological Wlth alropia action of drugs. Digitalis also, though in a less degree, is antagonistic to muscarin. Whenever, therefore, the symp- toms of mushroom poisoning are grave, and especially if there be delirium or mania, atropia should be given, say iij to v Viy of the liq. atropiae, by the mouth, or ij m subcutaneously, or as an alternative treatment, full doses of the tincture or infusion of digitalis may be administered. In other respects the treatment should consist in removing the poison from the alimentary tract as soon as possible, by means of emetics, etc., and in allaying the irritation by demulcents.* * For further information as to the treatment of cases of poisoning, the reader is referred to Dr. Murrell's excellent little pocket book (" What to do in cases of Poisoning," H. K. Lewis, 1884), to which also the Author is much indebted. 394 OF THE ADMINISTRATION OF AN.ESTHKTICS. SECTION VII. OF THE ADMINISTRATION OF ANAESTHETICS. By Joseph Mills. Administrator of Ancesthetics to St. Bartholomew's Hospital. CHAPTER XXX. General con- Anesthetics are administered to patients to prevent todvahie°ofas their feeling pain during surgical operations; for the anaesthetics. diminution of pain in labour ; to produce relaxation of muscles, as in reducing dislocations or in setting fractured bones. They are also given to assist the medical man in making a diagnosis, as in obscure abdominal tumours, examinations of diseased joints, or in the detection of malingering. Though it is a great thing to be able to say that patients can in a few minutes be placed in such a profound sleep that they are quite insensitive to pain, and are unconscious, this is not all that can be said in favour of anaesthetics. By their means a patient may be brought to a state of perfect stillness, so that many operations which could not be done before the days of anaesthesia, because of the patient's struggles, are now performed with comparative ease. Again, as the patient does not feel pain, more time can be spent in the performance of the operation, in ligaturing all the smaller vessels and in many of the minor details on which to a great extent its success depends. As there is less difficulty in persuading patients to undergo operations, many more are now performed. To the surgeon, also, it is a great comfort that he can do what is necessary for his patient without giving pain, and without the struggles and screams which were formerly witnessed. The frequent use of anaesthetics in medical and surgical OF THE ADMINISTRATION OF ANESTHETICS. 395 practice renders their administration one of the most impor- tant subjects for investigation. In the hands of those Avell acquainted with their use they are capable of bringing the greatest relief to sufferers, and of facilitating the work of the medical man; but if used carelessly or Avith insufficient knoAvledge of their action, their administration is accom- panied not only by additional anxiety and annoyance to the surgeon, but by the greatest danger to the patient. It is not to be supposed that there is no danger at all when anaesthetics are used by those who are experienced in their employment, for sensibility and life are so closely allied, that a patient cannot be deprived of the one without there being of necessity some risk to the other, but there is no doubt the danger is least Avhen they are given judiciously and by one accustomed to their administration. As any medical man may be called upon at any time to give an anaesthetic, it is highly important that every one should make himself thoroughly acquainted with the best and safest means of administering one, or more, of those commonly in use, so that in any emergency he may be able to produce and maintain anaesthesia, leaving the operator free from all care and anxiety except that which the opera- tion itself entails. Not only must the administrator depend entirely on his own judgment, but he must give to the administration the Avhole of his attention, and must not interest himself in, or in any way assist at, the operation. It is quite possible for the operator to superintend the administration of the anaesthetic, or for the administrator to assist in the operation, provided all be going well, both Avith the operation and the administration, but in the critical part of the operation, in vain does the nervous administrator look for the guidance of the operator, Avho is compelled at this period to devote himself entirely to his OAvn Avork; so, on the other hand, when any difficulty occurs with the anaesthetic, the administrator cannot lend a hand to the operator, and as difficulties in the operation are not un- commonly almost simultaneous Avith alarming symptoms to the patient (for example, a sudden gush of blood, accom- panied by syncope), the operator and the administrator must each be thoroughly competent to take the entire control of his OAvn department. Those who are interested in the history of anaesthesia, History of should read Snow on "Anesthetics," the works of Sir J. an8esthesia Simpson, Vol. IL, and a very interesting account of the 396 OF THE ADMINISTRATION OF AN/ESTHETi('S. modern history, written by Sir James Paget in " The Nineteenth Century," for December, 1879, entitled "Escape from Pain, the History of a Discovery." In 1799, Sir Humphrey Davy produced anaesthesia by himself inhaling nitrous oxide gas, and he recommended its use in surgery. In 1844, Horace Wells, a dentist of Hartford, inhaled the nitrous oxide gas himself, successfully gave it to fourteen or fifteen patients, and then went to exhibit its effects at Boston for extraction of a tooth. " Unfortunately for the experiments," writes Wells, " the bag was withdrawn too soon, and the patient was but partially under its influence Avhen the tooth was extracted. He testified that he experienced some pain, but not as much as usually attends the operation." After witnessing this solitary experiment the audience pronounced it a humbug affair and an im- position. Wells was hissed away, and for a time gave up the profession in disgust. In 1846, Morton, a former pupil of Wells, who was present when he failed to produce complete anaesthesia Avith the gas, applied to him for particulars concerning its manufacture ; for this purpose he was referred to Jackson, a chemist, who advised him that sulphuric ether was more easily obtained, and had much the same effect. Morton proved the efficiency of ether on Eben Frost, for the extraction of a tooth, and then gave it at the Mas- sachusetts hospital to a patient from Avhom Dr. Warren removed a tumour of the neck, on 16th October, 1846 ; this then is really the date of the commencement of the practice of producing anaesthesia for surgical operations. On this side of the Atlantic it was first given by Mr. Robinson to Miss Lonsdale, in the surgery of Dr. Boot, of GoAver Street, for the extraction of a tooth on the 19th of December, 1846. Two days later it was given to two of Mr. Liston's patients at University College Hospital for amputation of the thigh, and for avulsion of the toe nail— and it then came into very general use until the November following, when Sir James Simpson discovered the proper- ties of chloroform, which for a time almost entirely super- seded ether. Though Sir J. Simpson was the first to use pure chloro- form, it had previously been used in the form of " Chloric Ether" (a mixture of chloroform and alcohol) at St. Bartholomew's Hospital, by Sir William LaAvrence and Mr. Holmes Coote. OF THE ADMINISTRATION OF ANESTHETICS 397 The popular notion that anaesthetics, especially chloro- *it subjects for form, are inadmissible in cases of heart disease, is erroneous. anse The only affection of the heart Avhich contra-indicates their use is fatty degeneration, which is extremely difficult to diagnose. And if it be necessary for a patient with fatty disease to undergo an operation he would be as likely to die of the shock of the operation without an anaesthetic as from the anaesthetic, cautiously and properly administered. Patients with slight valvular disease, who are otherwise healthy, take anaesthetics very well. Drunkards and those who habitually indulge in alcohol take them badly. It is impossible to lay too much stress on the importance Preparation of of having a patient properly prepared before an anaesthetic patients- is given; this is of course out of the question in cases of accident or emergency, but, in the majority of cases, is easy enough. ' Care should be taken that the bowels are acting properly, and if necessary, a purgative should be given a day or two beforehand. No food should be taken for four or five hours before the time appointed for the operation. When this is fixed for the early morning, unless the patient be very weak, it is best to give nothing after awakening. When the patient is in such a state as to require constant feeding, a little beef tea with some brandy or champagne may be given three hours before the operation. It is very important that the stomach should be empty at the time an anaesthetic is taken, not only on account of the danger to the patient of being choked by some undigested portion of food being vomited into the pharynx, and at the next inspiration draAvn into the larynx or trachea, and so pro- ducing asphyxia ; but also on account of the faintness, which is so commonly seen both before and after the vomiting. This syncope is generally most marked before the vomiting, after which it frequently passes off, though it may continue for some hours. Vomiting is almost sure to occur if the stomach contains food, and it may, and does sometimes happen Avhen proper preparation has been made. In the former case the vomit- ing lasts much longer, and is accompanied by much greater syncope than in the latter; moreover, patients with loaded stomachs ahvays take an anaesthetic abnormally ; this is most noticeable in children. They are generally a longer time going under the influence, and require a larger quantity of the anaesthetic, and Avhen under, they may, although apparently deeply narcotised, start and cry out at the com- mencement or at any time during the operation, or they 398 OF THE ADMINISTRATION OF ANjESTUK'ITCS. may remain in a state of such deep narcotism that it is impossible to rouse them for perhaps half an hour, during the whole of Avhich time they are in a dangerous state from syncope. choice of And noAv Avith regard to the choice of an anaesthetic. anaesthetic. rrn 1 • •. • 1 i i lhose most commonly in use are nitrous oxide gas, chloror form, ether, and bichloride of methylene. Nitrous oxide is suitable for very short operations only, so that for ordinary surgical cases the choice rests between ether and chloroform, or bichloride of methylene, the last tAvo being similar in action, though some consider less sick- ness is caused by the methylene. «er«us°etner ^r ^ames Simpson says, "As an inhaled anaesthetic agent, chloroform possesses over sulphuric ether the follow- ing adA7antages:— "1. A much less quantity of chloroform than ether is requisite to produce the anaesthetic effect. " 2. Its action is much more rapid and complete, and generally more persistent. " 3. The inhalation and influence of chloroform are far more agreeable and pleasant than that of ether. " 4. Considering the small quantity requisite, as com- pared with ether, the use of chloroform is less expensive. " 5. Its perfume is not unpleasant, but the reverse , and the odour of it does not remain for any length of time obstinately attached to the clothes of the attendant, or exhaling in a disagreeable form from the lungs of the patient, as so frequently happens Avith ether. " 6. Being required in a much less quantity, it is much more portable and transmissible than ether. " 7. No special kind of inhaler or instrument is necessary for its exhibition." With the exception of "2, its action is much more rapid and complete" (improvements in ether inhalers having now rendered the action of ether more rapid and quite as com- plete as chloroform), all the advantages Avhich Simpson claimed for chloroform over ether must be allowed to hold good. Chloroform has even yet another advantage over ether Avhich might have been claimed for it, Avhich is that it does not so greatly irritate the air passages. But ether possesses over chloroform one advantage so great as to more than turn the balance in its favour. Effects of ether p'or whereas ether stimulates, chloroform is apt to depress, action. the heart's action. During the administration of chloroform OF THE ADMINISTRATION OF ANESTHETICS. 399 there is sometimes very alarming syncope, Avhich rarely occurs with ether. From experiments on animals it appears that the heart may be paralysed by chloroform, but not by ether. Then again the vomiting which frequently accompanies the administration of an anaesthetic, as a rule lasts longer after chloroform than after ether. Ether then seems to be the sater, and so snould be used in all suitable cases. The following are the cases in which ether is not recom- chloroform, , , ° when to be pre- mended :--- ferred to ether. 1. Children. 2. Old people. 3. Midwifery. 4. Operations on mouth or nose. 5. Operations on the eye. 6. Ligature of large arteries. 7. Setting of fractures. 8. Obstructed respiration. 9. Bronchitis. 10. Emphysema. 11. Empyema. 12. Phthisis. 13. Laryngitis. 14. Patients under opium. 15. Advanced kidney disease. (1.) Children under ten or twelve years take chloroform very well; but are readily asphyxiated by ether, and are frightened by the apparatus. (2.) People over sixty or sixty-five years take chloroform well, with little, if any, struggling , but are greatly irritated by ether, especially if, as is frequently the case, there is a tendency to bronchitis. (3.) As the first stages of the inhalation of ether are far more unpleasant than those of chloroform, and as the first stages only are requisite during the pains of labour, chloro- form, which is exceedingly well borne in these cases, is preferable. (4.) As the influence of chloroform lasts longer than that of ether it is preferable for operations on the mouth and nose. In these cases chloroform possesses other advan- tages over ether, in that it may readily be given on a piece of lint, or, better still, through a tube inserted into the mouth or nostril without obstructing the operator; more- over, its administration is not so likely to be accompanied by coughing, nor does it occasion such a Aoav of viscid saliva. These, in operations such as that for cleft palate, are important considerations, for the operator requires the parts to be as still as possible, and it is necessary for him to get a good view without having to be perpetually sponging out saliva from the fauces. 400 OF THE ADMINISTRATION OF ANAESTHETICS. (5.) In operations on the eye, chloroform may be given on lint, Avithout obstructing the light or impeding the operator's hands, as sometimes happens Avith an ether inhaler ; and as its inhalation docs not occasion so much congestion and haemorrhage, it is generally preferred to ether in ophthalmic surgery. (6.) For the ligature of large arteries, such as the subcla- vian, chloroform is preferable, because the veins are so distended during the administration of ether as to render the operation more difficult and more dangerous. (7.) In cases of fracture, Avhich require an anesthetic whilst the parts are being placed in apposition during the time the muscles are relaxed, chloroform is preferable, because patients recover from its effects quietly, the in- » halation of ether being sometimes followed by a state of delirium and struggling which Avould be likely to displace the fractured ends of the bone and necessitate their re- adjustment. (8 to 15.) Patients who are suffering from any obstruction to the respiration, whether the obstruction be in the lungs or in the air passages, from pressure of tumour or abscess on the neck, or from pressure on the diaphragm from rapid distension of the abdomen (as in cases of intestinal obstruc- tion, hernia, etc.), and patients under the influence of opium; not only take ether badly, but its inhalation is likely to be followed in some of these cases by bronchitis or hemoptysis, in others, by a dusky, droAvsy, state, in Avhich the patient may gradually die. Administration Supposing now that chloroform has been chosen as the of chloroform. mogt su^able anesthetic, the folloAving are the general directions for its safe inhalation. a third person Artificial teeth should be removed before any anesthetic present.be is administered ; cases have occurred in Avhich, by becoming detached they have fallen into the pharynx. It is advisable that no anesthetic should be given except in the presence of a third person, because assistance may be required either in restraining any struggling Avhich may occur, or in restoring animation. Moreover, OAving to the extraordinary dreams which sometimes occur during anes: thesia, women have occasionally been induced to bring serious accusations against medical men, Avhich might easily have been disproved had a Avitness been present. The pure chloroform only should be used; Duncan and Flockhart have the reputation of being the best makers. No inhaler is necessary. OF THE ADMINISTRATION OF ANESTHETICS. 401 All that is required is to cut a piece of lint about 12-in. by 6-in., and fold it so as to form a square of 6-in. A chloroform drop bottle Avhich holds one ounce is the most convenient size—a stock bottle containing tAvo or three ounces of chloroform being at hand, if required. The patient should be in the recumbent position, and ?he method of iiii iti ii i inhalation. should have none but light garments on, and these must be loose about the neck and abdomen. It is better for the patient to lie on the back Avhile anesthesia is being pro- duced, even if during the operation he be required to be on the side; because in the former position the administrator has more control over him ; for example, Avhen lying on the side patients sometimes bury the face in the pilloAv so as to prevent a continuance of the administration. The head should not be much raised; as a rule one pillow is better than two; if two are used, the lower one should be placed partly under the shoulders, so as to make a gradual incline, and to prevent the head being tilted forward and thus obstructing the respiration. It is well to commence by sprinkling about five drops of chloroform on the lint, which should be held about two inches from the patient's face, just to allow'him to become accustomed to the vapour. In a few seconds, without removal of the lint, a little more chloroform may be added, and the lint turned so that the wet side may be toAvards the face. When more chloroform is added, the lint should be held tAvo inches from the face, but as the chloroform evaporates it may be gradually approximated, so that at the time when it is necessary to add more chloroform the lint rests on the face; when more chloroform has been added, the lint should be turned and the administration continued as before, the quantity of chloroform sprinkled being slightly increased each time. Care should be taken that the part of the lint Avhich is Avet Avith chloroform be not allowed to touch the face, as it is apt to blister. Of the many different kinds of chloroform inhaler, that inhalers. invented by Clover is the most ingenious and the best, being so constructed as to insure a mixture of 3 to 4 per cent, of chloroform to air, which is said to be the safest proportion. Junker's is also a Aery useful apparatus see p. 416), but the advantages of the lint are cleanliness, simplicity, and the regularity Avith Avhich the vapour can be supplied. At first it is unadvisable for the patient to be held, but Kestraint of when the chloroform begins to take effect and produces ex- pa ien ' e c" citement, it is necessary for him to be restrained sufficiently 26 402 OF THE ADMINISTRATION OF ANESTHETICS. to allow the administration to be continued and to prevent his doing any damage Avith his arms or legs, but it is not necessary, as a rule, to keep him absolutely still; in- deed it is unadvisable, for in most cases the greater the resistance offered to the patient the greater the amount of struggling. Adults struggle most, and men more than women, and the subjects of delirium tremens and drunkards always give great trouble during this stage ; but in any case the struggling is least when the administration is regular and gradual. When an unusual amount of excitement occurs the chloro- form should be continued unless the respiration be impeded, in which case it should be discontinued for a few inspirations. If a sufficient quantity of chloroform be not given during this stage, either the struggling will be unnecessarily prolonged, or some recovery from the effects having taken place, perhaps two or three of these stages Avill be induced in the one ad- ministration. Whilst struggling, the respiration is often very deep ; a full inspiration occurs and there is a long pause be- fore expiration. Care must therefore be taken that the vapour is not given too strong, because as the lungs remain so long filled with the vapour a good deal is absorbed. The muscular excitement generally subsides gradually, and the patient passes into a state of slumber with more or less snoring and relaxation of the muscles. It is well to stop the administration for a few seconds as soon as the patient is under the influence, especially Avhen there has been much struggling, because of the cumulative property of chloroform. Its effects often become more in- tense after its administration has been stopped. This is no doubt due to a portion remaining in the lungs and being afterwards absorbed. Patient when A patient is generally said to be ready for the operation ready for oPer- ^ bg commencecij when touching the inner border of the eyelid or ocular conjunctiva Avith the finger produces no reflex action. In some cases it is necessary that touching the cornea, which is far more sensitive than the sclerotic conjunctiva, should produce no reflex action. But the eye is by no means a certain test, as its sensibility varies so much in different people, and the patient cannot usually be said to be " ready " unless, in addition to the loss of reflex action of the conjunctiva, there be also general re- laxation and more or less snoring. Constantly touching the eye should be avoided while the patient is being got under, for this will to a great extent deprive it of its sensibility, OF THE ADMINISTRATION OF ANESTHETICS. 403 and so lead the administrator to imagine the patient to be more thoroughly narcotised than is really the case. After one eye has been touched several times it is well to try the effect of touching the other. Again, when the patient is under the influence, the chloroform should be frequently applied in small quantities, rather than in larger amounts administered only upon the reappearance of reflex action. If at the commencement of the operation, reflex is found to be still present, the first incision will cause not only move- ments of the limb which is being operated upon, but such deep inspirations that a small quantity of chloroform is sufficient to very soon produce a more profound anesthesia, and a larger dose is both unnecessary and dangerous. During the struggling stage the conjunctiva often becomes condition of slightly congested, assuming again its normal appearance as the eye' the excitement passes off'. In this stage also the pupil is sometimes dilated, but Avhen fully under the influence the pupil is slightly contracted and acts with the light. In very deep narcosis only, such as is sometimes necessary in operations on the more sensitive parts, as the eye, genitals, or anus, does it fail to act with the light. Dilatation of the pupil occurring during thorough narcosis should be regarded as a signal of danger, and the adminis- tration must be stopped. It may be a premonitory symptom of vomiting, or it may be caused by asphyxia, or because the patient is too fully under the influence. When there is much struggling the face generally becomes congested, and sometimes slightly livid. Lividity or pallor may occur at any time during the narcosis, the former being caused by obstruction to the respiration, the latter being a symptom of syncope. Either of these changes in the face is to be regarded as a signal of danger, and the administration should be stopped. The pulse must be carefully A\ratched from the beginning The pulse. to the end of the administration, for though it is possible that in some cases the pulse and respiration simultaneously cease, there is no doubt that very often the first warning of approaching danger is given by the pulse, Avhich, before stopping, gradually becomes Aveaker ; it may be irregular or intermittent for many seconds before any alteration is ob- servable in the respiration. Immediately on the occurrence of any such change in the pulse, the administration must be stopped, and preparation must be made for the application of restorative means. 404 OF TnE ADA1IXISTRATION OF AN ESTHETICS. When for the convenience of the operator the patient is lying upon one side, the radial pulse of that side should not be felt, as the Aveight of the body on the brachial artery is apt to impede or stop the circulation, and give rise to un- necessary alarm. The respiration. The respiration, too, is to be carefully Avatched from the commencement to the end of the administration. It is not sufficient simply to Avatch the movements of the chest walls and abdomen, but it is necessary also to listen to the breath- ing, especially Avhen there is any doubt as to the efficiency of respiration, as the chest walls and abdomen Avill some- times go on moving though no air be entering the lungs. Obstruction to the breathing may take place in the bronchi, trachea, or larynx, from blood, or Aomit. It is most frequent in the pharynx, and is generally caused by the falling back of the tongue, or the approximation of the glottis to the back of the pharynx ; this is due to a faulty position of the head, generally by the head being tilted fonvard and the chin being too near the sternum; sometimes, though rarely, by the head being thrown too far back. It may generally be remedied by a change in the position of the head, by draw- ing the chin forcibly from the sternum, or turning the face to one side to prevent the tongue falling back. If the ob- struction be not at once removed by these means, there should be no delay in seizing the tongue with a pair of dress- ing forceps and dragging it out of the mouth, though such severe treatment is very seldom necessary. Some patients are not able to breathe freely through the nostrils. In these cases, when under an anesthetic, it some- times happens that at each attempt at inspiration the lips are tightly pursed up, or flap together like a valve, entirely preA'enting the entrance of air. This is-very easily remedied by separating the lips, but may cause needless alarm, or even asphyxia, if it be not corrected. Infants, after the completion of the operation for hare-lip, very often are unable to breathe properly unless the Ioavct lip be draAvn doAvn with the finger ; they therefore require careful Avatching during the recovery from chloroform. If alarming symptoms commence with the respiration there is less likelihood of their terminating fatally, provided they are observed immediately on their occurrence, because the respiration may be supplied artificially. syncope. The greatest danger Avhich attends the administration of chloroform is syncope. This may be produced by giving too large a percentage of OF THE ADMINISTRATION OF ANESTHETICS. 405 chloroform to air, or by an over-dose, or by shock from the operation. This shock is very marked Avhen, in the oper- ation for strabismus, the internal rectus is divided, the pulse often intermitting and remaining feeble for some minutes. It is said also that the pulse intermits at the moment the cord is divided in the operation of castration. Syncope may also be caused by the loss of blood during an operation, or it may accompany vomiting. When the face becomes pale and bedewed Avith a cold sweat, the pulse Aveak, slow, or irregular, and the respiration slow and shallow, no matter Avhat the cause of these symptoms may be, the chloroform must be immediarely stopped, and the administrator must be prepared to apply restoratiA c means. Sudden stoppage of the circulation and respiration have been said to occur simultaneously under cbloroform without the slightest warning, but there is no doubt that before stopping, the pulse generally becomes more and more feeble, and then imperceptible ; the respirations for a feAV seconds continue, and then becoming more and more shalloAv, cease also. The following directions for restoring animation Avill be Restoration in found Useful :— Syncope6. Seize the tongue with forceps and draAv it fonvards, taking care in doing so not to depress the chin more than is necessary. Compress the sternum forcibly, allowing it of its own elasticity to expand ; do not wait for the respiration to cease before doing this, for when alarming symptoms are observed it is only by prompt action that these cases can be saved, and by making the respiration more forcible by artificial means in this early stage, the heart may be stimulated. Give directions for the pillow to be removed from beneath By Nelaton's the patient's head, and if, after two or three compressions of method- the chest, matters are improved by this treatment, continue it, if not, give directions for the patient to be suspended by the legs, head downwards, continuing the respiration by placing one hand on the back and the other on the sternum. (This is called Nelaton's method.) Whether in these cases of alarming syncope under chloro- form the heart be over-distended Avith venous blood, Avhich it is too feeble to send on, or whether, through dilatation of the abdominal vessels, the heart not being filled has no blood to send on, cannot here be discussed, nor can any argument be entered into as to Avhether by Nelaton's method of total 406 OF THE ADMINISTRATION OF ANESTHETICS. inversion, the blood is sent direct to a previously anemic brain, or whether it is simply poured from the relaxed abdominal A^essels, through the inferior cava to the anemic heart. But of this there is no doubt, that Nelaton's method of total inversion of the body, combined with artificial respi- ration, is the most efficacious remedy for severe syncope under chloroform. As a rule, the pulse and respiration are immediately improved by this plan, but it frequently happens, that when the patient is replaced in the recumbent position, the pulse and respiration, Avhich have been restored by the inversion, again cease ; it is advisable therefore to be pre- pared again to invert the patient if it appears necessary. ?* restStton.8 Though Nelaton's method appears to be the most effica- cious, there are other remedies which have proved service- able, mention of which must not be omitted, especially as the total inversion of a heavy patient is not always practicable. Sylvester's. Sylvester's method of artificial respiration (vide p. 370)is of great use, and has been successful on many occasions. Before commencing this, or any kind of artificial respiration, the tongue should be drawn fonvard, and held with forceps to prevent its forming an obstruction to the entrance of air. If this does not at once succeed, it, or Howard's plan, should be continued, and if necessary, persevered with for half an hour, or so long as there is any hope of recovery. Faradisation. The faradic current may be applied, one pole being placed at the epigastrium and the other at the right side of the neck, to try to induce the diaphragm to act. The application of the electricity should be discontinued while the chest is being compressed, and applied while the arms are being raised, in order to imitate natural respiration, and also because strong and continued currents appear rather to exhaust, than to restore muscular activity. Ether or brandy may be injected hypodermically. warmth, etc. A hot water bottle may be applied to the feet, and friction to the legs; warm blankets should be thrown over the patient, and an enema of brandy may be given, or brandy may be given by the mouth as soon as swallowing is possible. Some have suggested the opening of windows and doors, dashing cold water on the chest and face, and holding nitrite of amyl to the nostrils; all these remedies may be of avail in slight syncope, but are not to be relied upon in the more alarming cases. As the administrator himself must attend to the artificial OF THE ADMINISTRATION OF ANESTHETICS. 407 respiration, and not neglect it for one moment for any less efficacious remedy, he must let others apply the battery, etc., while he continues the respiration. Protoxide of nitrogen, nitrous oxide, or laughing gas is the Nitrous oxide safest anesthetic to administer, and the pleasantest to inhale. gas" It is generally said to be without taste or smell, but it really has a slightly sweet taste. It may be obtained from its manufacturers, Barth, Coxeter, How stored. or J. H. Parkinson, compressed into the liquid form in iron bottles of various sizes, those which contain 50 gallons and weigh about 6 to 81bs. being the most useful. As the label on each bottle shoAvs its weight, both when full, and when empty, the quantity which any bottle contains at any time may readily be ascertained by Avcighing it. The weight of fifty gallons of gas is 15oz., and this is generally sufficient for about 10 administrations, so that, on an average, each patient takes about 5 gallons by measure, or l|oz. by weight. At one end of the bottle is a screAv, which, if slightly loosened with a hand spanner or foot key, alloAvs the gas to escape at right angles through a nozzle, to Avhich the appa- ratus employed in the administration is to be fastened. Before attaching the apparatus to the nozzle, ascertain that the screw is in good working order, by turning it on and off, for considerable force is sometimes required to start the screAv of a fresh bottle, and then the gas is apt to come out Avith a rush, which may damage the apparatus, if it be attached. If, on turning the screw, the gas does not come out freely, as is often the case in cold weather, a little Avarm water should be poured over the neck and nozzle of the bottle. The apparatus which is generally used, consists of a tube, Apparatus for one end of which is to be attached to the nozzle on the gas of™hTgaslUor bottle, the other is connected with a bag, from Avhich leads another larger tube, ending in a stop-cock, just where it is attached to the face-piece. The face-piece has tAvo valves, which must be of sufficient size to allow free passage of inspired and expired gas. One valve at the attachment of the supply tube allows free entrance of gas to the face-piece at each inspiration, but prevents any exit. The other communicates Avith the air, and through this the expired gas escapes, but no air can be admitted. Running round the edge of the face-piece is a small air bag, or cushion, Avhich readily adapts itself to the shape of the face. 408 OF THE ADMINISTRATION OF ANESTHETICS. For the successful administration of gas it is of the utmost importance to exclude all air ; this is insured by a Avell-constructed apparatus with good valves, and, above all things, by a Avell-fitting face-piece, Avhich must be firmly held upon the patient's face, including both the mouth and the nostrils. its advantages. The nitrous oxide gas is very safe, and, being almost without taste or smell, it is not unpleasant to inhale. Its administration is never accompanied or followed by any distressing symptoms, such as sickness, nausea, or head- . ache; and it is not necessary to make any alteration in diet before or after its inhalation. Unfortunately, however, as it produces asphyxia, it is only suitable for short operations, such as extraction of a tooth, or the opening of an abscess. Details of its Before commencing the administration, all air should be administration. , * ii i i j.i l j.i_ r pressed out ot the bag, and the stop-cock near the face-piece closed ; the bag may then be filled with the gas, and the gas bottle be placed Avithin reach, so that the bag may be replenished when necessary. With nervous patients, it is a good plan to commence by holding the face-piece quite lightly on the face, allowing them at first to breathe air through it, and when they have become accustomed to this, the rest of the apparatus may be attached, care being taken not to press the face-piece too firmly down, until two or three inspirations of gas have been taken. In about one minute, the breathing becomes slightly stertorous and the face congested, when the operation may generally be commenced ; but if the nature of the operation be such that the administration cannot be continued during its performance, it should not be begun until after three or four stertorous inspirations, and slight lividity of the face. If the administration be continued beyond this, very great lividity occurs, Avith spasmodic tAvitching of the muscles, wide dilatation of the pupils, and probably opisthotonos, and in women, paralysis of the sphincter of the urethra. The gas in In giving gas for dental operations, it is necessary before dentistry. commencing the administration to place a small prop at- tached to a string betAveen the teeth to keep the mouth widely open ; it must be placed as far as possible from the teeth about to be extracted, and be firmly fixed so that it is not in the way of the operator. In addition to this, the administrator should be provided with a more poAverful gag, with which he can quickly open the mouth during the anesthesia, should the prop from any cause have been displaced. OF THE ADMINISTRATION OF ANESTHETICS. 409 Care must be taken that the teeth Avhich are extracted are not left in the mouth, as there is great danger of their then getting into the larynx and causing fatal asphyxia. After the completion of the operation it is better not to attempt to arouse the patient; if the prop be still held betAveen the teeth, it may be left thejre until the patient has entirely recovered consciousness. Any difficulty with the respiration is generally at once relieved by one or two forcible compressions of the chest, the recovery from the effects of the gas being very rapid. Faintness is best treated by the recumbent position. The ether which should be used for inhalation is that Ether. which in the Pharmacopoeia is described as pure ether, that is, ether free from alcohol and water, and of the sp. gr. *720 ; or what is much cheaper, and apparently quite as good, the anhydrous ether, made from methylated spirit by Macfarlane and Co., of Edinburgh. It is scarcely necessary to mention its very volatile and in- its administra flammable nature, except as a caution against a lighted candle being held near the patient during its administra- tion. Ether may be given in a toAvel folded into a conical shape to fit the face, or in a felt or leather mask containing a sponge; but when administered in this way it is very Fig. 179.—Clover's Ether Inhaler. disagreeable to the patient, takes a long time to produce sleep, is accompanied by much struggling, is very extravagant, and from the large amount which escapes, is very unpleasant 410 OF THE ADMINISTRATION OF ANESTHETICS. to every one who may be in the room, or, indeed, in the house. clover's appa- The best, simplest, and most economical way of giving ether iatk,nfofe?hear. is by " Clover's Portable Regulating Ether Inhaler," made by Messrs. Mayer and Meltzer (Fig. 179 on previous page). " The object of this instrument is to induce anesthesia, in part by the diminution of oxygen respired, and to regulate the strength of the ether vapour, so that it may with certainty produce the degree of quietude wanted, and yet may not cause coughing or great difficulty of respiration." its construction. Clover's ether inhaler consists of a face-piece with an indicator, which, by rotation, may be made to point to 0, 1, 2, 3, or F. (Fig. 180), on the circumference of a metallic vessel containing fluid ether, and of a bag into and from which, the patient breathes. It is so constructed, that when the indicator is at 0, the expired and inspired air passes to and from the bag, without in any way communicating with the ether chamber. o F Fig. 180.—Place of numbers upon Ether Vessel. If the indicator stands at F, the whole of the air expired passes through the ether vessel into the bag, and at inspira- tion, returns from the bag through the ether vessel. When the indicator is at 2, half of the respired air passes to and from the bag direct; the other half passes through the ether vessel; and so on for the other numbers. The air does not pass through the ether, but simply through the vessel containing it, and this is sufficient to carry off a large amount of its vapour. Having poured into the vessel an ounce and a half, or two ounces of ether (which is about two-thirds of the quantity which the measure supplied with the instrument is capable of holding), and having fixed the different parts of the apparatus together with the indicator at 0, the face-piece Method of adm nistrati n with the inhaler. OF THE ADMINISTRATION OF ANESTHETICS. 411 should be applied lightly to the patient's face; it should be raised slightly during each inspiration, and held more firmly during expiration, until the bag is moderately distended, when it is no longer necessary to raise it. The ether vessel should now be rotated so as to bring the indicator nearer to either of the figures 1. Let us suppose each of the intervals betAveen 0, 1, 2, etc. to be divided into six spaces. It will be found sufficient to rotate the vessel one space at a time. The rotation may be continued during every second or third expiration, unless the patient shows any signs of discomfort, when it is advisable to rotate the vessel back a little. It is necessary to turn on the ether very gradually, or it cannot be freely inhaled. Should the bag become empty, as often occurs if the face-piece be not applied sufficiently firmly during expiration, it should be raised for one inspira- tion, and re-applied in time to catch the expiration. It must be borne in mind, when using this instrument, Need of fresh that so long as it is applied to the face, there being no com- air" munication Avith the external atmosphere, the same air is respired over and over again, so that it is necessary to frequently remove it for an inspiration of fresh air. As a rule, while anesthesia is being induced, an inspiration of air should be admitted every half minute, and Avhen it has been induced, every three or four inspirations from the inhaler should be folloAved by one from the air. Allowance must of course be made for the degree of tolerance of the vapour Avhich exists in different individuals; if the respirations are very shallow, it is well not to increase the vapour quite so frequently as Avhen they are full and forcible, Avhich indicates that no irritation is being produced. Should the patient show any signs of intolerance of the if there be vapour, it is generally sufficient to admit one inspiration of mtolerance- air, and for a time to give the vapour less strong. When given in this way, there is not as a rule any struggling, and if such occurs, it may at once be cut short by admitting one inspiration of air, and then rotating the ether vessel two spaces instead of one. In Avarm weather it is rarely necessary to go much beyond figure 2, or in cold weather, beyond figure 3. After inhaling for two to three minutes the anesthesia is chief indica- complete. There is at first considerable congestion of the thesL?£ au8es face, sometimes slight lividity, which soon passes off on the admission of a little more air. Slight reflex action may be produced by touching the conjunctiva. 412 OF THE ADMINISTRATION OF ANESTHETICS. Continuance of anaesthesia. Clover's gas and ether apparatus. The advantages of the combi.i- ation. The advan'ages of the appa- ratus. The chief indication of complete anesthesia is the deep Snoring. There is sometimes a slight spasmodic tAvitehing of the muscles Avhich is apt to lead the beginner to imagine t hat the patient is not fully under. By giving the vapour more strongly the tAvitching will be found to increase, with, per- haps, spasm of the larynx, lividity, and dilatation of the pupils. But if, on its occurrence, air be admitted more fre- quently, these spasmodic movements soon pass off. When tne patient has been under the influence about two minutes, it will be found that it is not requisite to give the ether vapour so strong to maintain the anesthesia, as it was to induce it, and that the ether vessel may with advantage be rotated backAvards. The longer the anaesthesia is maintained, the less ether is required, and the more frequently should the inhaler be removed to allow inspirations of air. After about ten or fifteen minutes, it will be found necessary to add another half-measure of ether. Any disturbance of pulse or respiration may generally be remedied by diminution or discontinuance of the amount of vapour, and the respiration may often be improved during very profound anesthesia, by drawing the chin away from the sternum. Combined administration of nitrous oxide and ether. It is often said of instruments intended to serve many pur- poses, that they are ill adapted to accomplish any one of these ends satisfactorily, but this saying cannot be applied to Clover's gas and ether inhaler (Fig. 181), Avhich is most in- geniously devised for the administration of these anesthetics, separately or combined. It may be used for the administra- tion of gas alone, or with any desired amount of ether vapour, or for ether alone, or for ether with air, all of which purposes it serves extremely well. The advantages of commencing with gas before giving ether are, that it is less disagreeable to the patient, that total anesthesia is produced in a minute, or a minute and a half without any struggling, that in short cases the recovery is more rapid, less ether having been inhaled, and that it is less likely to be folloAved by sickness. The advantages of this particular inhaler are, that the gas being turned on with the foot, leaves the administrator one hand free with which he may watch the pulse and steady the head, and that after a feAV inhalations of gas, Avithout any re- movals of the face-piece, the ether may gradually be turned on, so that a mixture of gas and ether is inhaled before anesthesia is complete. For although with ordinary inhalers OF THE ADMINISTRATION OF ANESTHETICS. 413 it is possible to give gas until anesthesia is produced, and then to substitute an ether inhaler; no ether having been in- haled during the production of anesthesia it is in many cases impossible in this way to get sufficient ether into the patient to continue the anesthesia of the gas, before partial recovery from its effects have taken place, sufficient ether only having been inhaled to produce struggling. The late Mr. Clover himself preferred keeping the apparatus in a tin box, in one corner of Avhich the gas bottle Fig 181.—Clover's Gas and Ether Apparatus* was fixed ready for use, but the advantage of fixing the gas bottle in a tripod with folding legs is that it enables it to be carried in an ordinary black leather bag, which attracts less attention. The apparatus is made by Messrs. Mayer and Meltzer, and Description of consists of a thin india-rubber bag, at one end connected, and aPParatus * F, Face-piece ; Ke, Regulator; G, India-rubber Bag ; E, Ether Vessel; H, Hook to attach the latter to a strap passing round the administrator's neck; K, Foot-key; R, Gas Rariiier. 414 OF THE ADMINISTRATION OF ANESTHETICS. communicating with the ether vessel, at the other, with the face-piece. Inside the bag there is a flexible tube, indicated by a dotted line in the figure, also connected and communi- cating Avith the ether vessel and face-piece. The communi- cations of the ether vessel Avith the tube and bag may simultaneously be opened or closed, by turning the one stop- cock Avhich is situated at their junction. The communications of the face-piece Avith the bag and tube may be opened and closed by rotating the dial-like regulator, Re. As the communication Avith the tube is opened, that with the bag is closed. By rotating the regulator, the letter G, E, and A, may successively be brought into view. When only the letter G is visible, the face-piece communicates with the bag, and through an expiration valve, Avith the outer air, but not with the tube. When only the letter E is visible (the stop-cock of the ether vessel being open), the face-piece communicates with the tube, through which expired gas or air Avould pass through the ether vessel into the bag ; and at inspiration from the bag it will return through the ether vessel and tube to the face-piece. If this be compared Avith the former description of Clover's portable ether inhaler, it will be seen that except for the intervention of a tube betAveen the face-piece and ether vessel, this is precisely the same action as takes place in the ether inhaler when its indicator is at F. So also, the action of the regulator, Avhen half-way between G and E, is the same as that of the former indicator at 2, Avhen half the air passes direct to the bag, the other half having first to traverse the ether vessel before it can reach the bag. It will be seen that the gas passes direct from the rarifier through a small flexible tube to the bag, and not to the ether vessel, to which, being of metal, this tube is attached for convenience only. when u*ed for When used for gas alone, the regulator is to be turned to gas alone. q ^q face-piece held firmly on the face to prevent admission of air, and sufficient gas turned on with the foot to moderately distend the bag. The expired gas will pass out through the expiration valve on one side of the regulator. For ether after When used for giving ether, preceded by gas, 3 or 4 ozs. of ether must be put into the vessel, Avhich itself must be placed in Avarm water until the thermometer stands at about 08° or 70°. After about six inspirations, administered as if gas only Avere to be given, the stop-cock of the ether vessel OF TIES ADMINISTRATION OF ANESTHETICS. 415 must be turned on, and the regulator gradually rotated towards E. When half way betAveen G and E, the rotation of the dial, which has partly opened the tube and partly closed the bag, will have entirely closed the expira- tion valve, so that the gas must now be turned off with the foot. The rotation of the dial towards E is to be continued after each inspiration until stertor is produced. After two or three such inspirations, it will be found necessary to admit a little air, either by raising the face-piece or by rotating the dial toE A. From this time it is generally advisable to admit one inspiration of air after every four, and in about ten minutes after every two or three inspirations. If the ether be turned on too early, or too strong, it will cause the reflex movement of swallowing, or coughing, and perhaps struggling. If not turned on sufficiently early and freely, the long continuance of the gas generally occasions asphyxia, and spasmodic twitching of the limbs, which necessitates admission of air, and this in the early part of the administration is likely to lead to partial recovery and excitement. It follows then, that although for the patient's comfort it is not desirable for the ether to be turned on very soon, yet, for the successful administration by this method, it must be turned on as early as it can be borne. When used for ether only, the dial should be turned to G ; Por ether oniy: the face-piece should be held firmly during expiration, and slightly raised during inspiration, until the bag has become moderately distended, Avhen the face-piece may be held firmly upon the face, the regulator gradually turned towards E, and the administration proceeded with, as if gas and ether were being given. When used for dental operations, if it be desired to pro- long the effects of the gas by the inhalation of some ether, it will be found that this may be accomplished by turning on ether much later than in ordinary cases, as it is re- quired during the last three or four inspirations only. The shorter time the ether is taken, the less giddiness is felt after recovery, and this is important Avhen patients have shortly to leave the dentist's chair, and very probably his house. Bichloride of Methylene (CH2C1.2) Avas introduced by Dr. Bichloride oi B. W. Richardson in 1867. It is manufactured by Bobbins Methylene' & Co., of Oxford Street. By Sir Spencer Wells it is preferred to chloroform. In 1883, at a discussion in the Paris Academie de Mede- its nature. 416 OF THE ADMINISTRATION OF ANESTHETICS. cine, concerning bichloride of methylene, M. Regnault said he had examined several samples, and found that certain products sold in France under that name were nothing but chloroform ; others coming from England were a mixture of chloroform and methylic alcohol, and he asserted positively that the so-called bichloride of methylene procured from Sir Spencer Wells's proA'ider, contained no trace of bichloride of methylene, though it was sold under that name. It was in fact a mixture of one part of methylic alcohol with four parts of chloroform.* (It should be mentioned that this substance is noAv sold under the name of " methylene," the formula CH2 Cl2 of the former label being omitted.) Fig. 182.—Junker's Inhaler. How best given. This anesthetic may be given with a perforated leather mask, but the best and most economical apparatus is Junker's, Fig. 182, Avhich is made by Messrs. Krohne and Sesemann, &n of Duke Sfcreet, Manchester Square. It consists of a bottle Inhaler.------------__________._____________________________________________________ * British Medical Journal, July, 1883. OF THE ADMINISTRATION OF ANESTHETICS. 417 capable of holding about 2 oz. (the loAver half being graduated up to 8 drachms), closed by an air-tight fitting top, through which two tubes are made to pass, a long one communicating with a Richardson's hand-belloAvs, and ex- tending to the bottom of the bottle, and a short one com- mencing at the top of the bottle and connected by a flexible tube Avith a vulcanite face-piece. In using the apparatus, about six drachms of the anesthetic should be poured into the bottle, which is then to be hooked on to the button-hole of the administrator's coat (if more than six or seven drachms are put in, some of the fluid is likely, on forcible pressure of the bellows, to overflow into the face-piece). The face-piece should be held quite lightly over the patient's face, and very gentle pressure of the belloAvs should be made at each inspiration. The quantity of the anesthetic vapour is regulated by- the frequency and amount of the pressure on the belloAvs. The advantages of Junker's anesthetic apparatus, which can be used for is equally suited for the administration of chloroform or methylene, are, that as it occasions no Avaste of the anesthetic, a. much less quantity is required than in other methods, and that the vapour can be supplied with great regularity. In operations about the mouth and nose, a plan (Avhich Anassthesia for has for some years been employed at St. Bartholomew's aEout the5 Hospital) will be found very useful, namely, of detaching the mouthi etc' face-piece as soon as the patient is sufficiently under the in- fluence of whatever anesthetic may be employed for the op- eration to be commenced, and substituting a flexible metallic tube or gum elastic catheter, the former of which may be inserted into the mouth, the latter into the nostril. In this way perfect anesthesia may be maintained, even throughout the longest operation, such as that for cleft palate, without causing obstruction to the operator.* Ethidene Dichloride, (C2H4Cb), first used by Shoav, was Ethidene strongly recommended by the Scientific Grants Committee Dlchlonde- of the British Medical Association! as being intermediate in action betAveen ether and chloroform, and Avas used in a great * See Lancet, December 14th, 1878 ; British Medical Journal, May 19th, 1883. But in operations, such as for the removal of the tongue, or of tumours occupying the back of the pharynx, the practice is becoming more general of performing a preliminary tracheotomy, and maintaining the anaesthesia through the aperture, the top of the pharynx being plugged the while with a piece of sponge, so that no blood trickles down the trachea, (w.p.) f Britinh Medical Journal, December 18th, 1880. 418 OF THE ADMINISTRATION OF ANESTHETICS. many cases by Mr. Clover. But, in addition to its expense, it appears to be rather unstable, and in some cases has caused great depression of the heart's action. Although it cannot therefore be recommended for general anesthesia, it is of very great value for prolonging the effects of nitrous oxide gas in dental operations, for in these cases the small amount Avhich is required (and this during the last three or four inspirations only) to very materially prolong the effects of the gas, is not sufficient to affect the circulation. Anaesthetic mixtures. Tixtui4'C'E'" ^n or(ler to (1° away w^h ^e depressing effect of chloro- form, and the disagreeable odour of ether,many combinations of these aiuesthetics have been employed, the favourite being that Avhich iscommonly knoAvn as the " A.C.E." or the "1 23" mixture, Avhich consists of—Alcohol, 1 part; Chloroform, 2 parts; Ether, 3 parts. But it must be borne in mind that this is merely a mechanical mixture. No new chemical compound has been formed, and it is a mixture of liquids of three different specific gravities, three different boiling points, and, although they are slightly soluble in one another, of different rates of volatility. It folloAvs that in the em- ployment of such a mixture care must be taken that it is quite fresh, and that no form of inhaler be used which will alloAv of the accumulation of the less volatile fluids after the evaporation of the lighter Arapours. Local [It remains for us to consider in this section the action of those substances which are used to produce local anesthesia. The drugs Avhich possess this power in any surgically useful degree are few in number, although many more, such as morphia, aconite, or menthol, when locally applied, have a distinct numbing effect. The substances which we shall consider here are Cocaine, Iodoform, Ether spray, and Carbolic Acid. Cocaiue. Cocaine may noAv be regarded as an established method of procuring local anesthesia, and is the most valuable of all the drugs found on the short list of local anesthetics. The preparation used for local anesthesia is the neutral hydrochlorate of the alkaloid Cocaine (or Cucaine), obtained from the leaves of Erythroxylon Coca. Its anesthetic pro- perties were discovered in connection Avith ophthalmic surgery by Roller, of Vienna, and its use was at first con- fined to operations about the eye, such as tenotomy for strabismus, ectropion, etc. Then its employment Avas ex- tended to the throat for the purposes of laryngoscopy, and operations about the larynx and pharynx, and then to the OF THE ADMINISTRATION OF ANESTHETICS. 419 uterus and urethra, and for minor operative purposes all over the body, its employment in some of which will be mentioned in the section on Minor Surgery. Cocaine is applied as a watery solution, of a strength varying from 4 to 20 per cent, (or even more, as it is very soluble), which may either be painted upon a mucous sur- face 'e.g., over an internal pile), or injected into the submucous or subcutaneous tissues with a Pravaz syringe. The tAvo methods are often employed together.* The solution may also be applied as a spray, which may, if necessary, be maintained throughout an operation. A convenient form has been devised by Mr. Percy Dunn. The anesthesia takes from five to ten minutes to develop after the drug has been applied, and does not generally last longer than ten minutes. In all cases the solution should be freshly prepared. The local anesthetic poAver of iodoform is distinct although iodoform. not very powerful. It is especially manifested when it is applied to the rectum, and iodoform dressings are very suitable after operations such as for fistula in ano in that region; but the sensibility of all wound surfaces is diminished by iodoform. The dry poAvder is the most effective form. Local anesthesia may be produced by means of the ether By the ether spray (see the Formulary), Avhich by its rapid evaporation, spray" freezes and numbs the tissues. By this spray the parts are rendered sufficiently insensitive for abscesses to be opened, small amputations to be per- formed, etc. ; but the freezing and the thaAving are them- selves painful, and the frozen tissues are hard and awkward to operate upon. For these reasons the production of local anesthesia by the ether spray is losing rather than gaining ground at the present time. But when this method is adopted, the procedure simply consists in subjecting the place of opera- tion to a spray of ether (a cheap kind of Avhich is manu- factured for the purpose), by means of a hand-belloAvs spray producer of the ordinary pattern, until the part is hard and white. A very marked loAvering of sensibility may also be pro- By carbolic duced by rubbing a crystal of carbolic acid, or painting the acid' * Thus Mr. F. S. Edwards states that internal piles may be absolutely painlessly operated upon after painting them on the out- side with a 4 per cent, solution of Cocaine, and injecting one drop of the same into the centre of each pile. British Medical Journal. 1885, Vol. I., p. 227, 420 OF THE ADMINISTRATION OF ANESTHETICS. pure acid, liquified by 1 part in 20 of water, thoroughly into the area of the skin Avhich is to be incised or punctured. In this Avay abscesses may be painlessly opened, unless they are deeply seated, thorns extracted, aspiration performed, etc., Avithout the inconvenience to the surgeon of an operation through frozen tissues, or the pain to the patient of the freezing and thawing. Lastly it may be remembered that morphia may be ad- ministered to prolong the anesthesia Avhich has been pro- duced by chloroform or ether, and that alcohol in doses in- sufficient to cause intoxication lowers the cutaneous sensi- bility to a mavked degree, whilst in alcoholic stupor the tissues may almost be termed anesthetic. W.P.] OF THE EXTRACTION OF TEETH. 421 SECTION VIII. OF THE EXTRACTION OF TEETH AND THE MANAGEMENT OF AURAL CASES. CHAPTER XXXI. Of the Extraction of Teeth. [For this chapter, as also for the description of the setting of diffi- cult fractures of the jaws (pp. 161-164), we are indebted to our col- league Mr. H. H. Hayward, Dental Surgeon to St. Mary's Hospital.] It falls within the scope of this manual to afford, in a General compendious form, such simple instruction concerning the consider extraction of teeth as may be useful to those who may often, by their isolation in country places and in the army and navy, have to rely solely on the knoAvledge and skill they have, or should have attained, under the surgeon dentist during their student career. Although extraction is the operation Avhich surgeons are called upon to perform most frequentlv, yet there are feAV Avhich are so badly executed and which give rise to such anxiety. And all this Avould be avoided by a little careful attention in the third or fourth year of the curriculum. It is much to be desired that every candidate for the M.R.C.S. should be required to ex- tract a feAV decaved teeth in the presence of an examiner attached to the Dental Board of the College of Surgeons. It is assumed that the anatomy of the teeth, their correla- tion, and that of the jaAvs to the alveolar processes, etc., are fully knoAvn to the reader. The extraction of sound teeth may become necessary in the deciduous, or temporary set, to make room for permanent teeth, or from malposition of, or serious injuries to the jaw bones or parts of the face, from diseases of the jaw, and to facilitate the removal of tumours. The extraction of de- cayed teeth of the second or permanent set may be neces- sitated from several of the above causes, and in addition. 422 OF THE EXTRACTION OF TEETH. from toothache, and the provocation of disease in the tongue, cheeks and gums, through merely mechanical roughness, or ichorous discharges from sloughing pulps. It is of the utmost importance that every student of this subject of the removal of teeth, should abolish from his mind the idea that either violent force, or indiscriminate wrenching are aids to a successful result. Such proceedings fortunately defeat themselves, but unfortunately the amount of torture inflicted on the victim at the time, and (in the young especially) the injury to the developing jaw and partially calcified teeth of the permanent set imbedded in the jaAv, Avill very probably lead to lasting deformity. No mere verbal description of extraction can make even the most attentive student moderately proficient, Avithout the frequent observation of the skilful operator, and the per- formance of the operation himself. Fig. 183 is a diagram- matic representation of an ideal jaw sawn through at the Fig. 183.—Diagrammatic Section through Upper Jaw. level which Avould correspond to that of those teeth Avhich have more than one root or fang. On the right side of the drawing, a complete half set of the upper jaw is repre- sented ; it is unnecessary to diagrammatize the loAver jaw, as the broad principle about to be explained applies equally to both. Now, let the reader consider the left side of the draw- ing, and liken each of the section, numbered 1 to 8 in- clusive, to the stones in an arch. If he Avere called upon to remove each separately, it is clear that they could not be pushed or draAvn away, as the stones on either side would prevent this movement \ it is equally evident that as each OF THE EXTRACTION OF TEETH. 423 stone is narrower on its inner side than on the periphery, none of them could be drawn inwards Avithout crushing one of those which are contiguous ; hence the stones can only be moved wholly towards the outside on a radius from the imaginary centre C m the direction of each of the eight arrows = A to A- Now let the reader look at the right half of the diagram, it will there be evident that the section of the fangs belonging to each tooth represents a wedge, the peripheral or outer side of which is Avider than the inner; hence the teeth indicated by these fangs cannot be draAvn inwards, but must be drawn outwards. In addition to this mechanical comparison, which is con- structed to explain the actual correlation of the teeth to each other and to the alveolar process, it must be added that, as shoAvn in Fig. 184, in life, the layer of alveolus on the Fig. 184.—Section through Upper Bicuspid and Alveolus. a a, Inner and Outer Alveolus; G, Gum ; d, Dentine ; e, Enamel; c p, Pulp Cavity. outer side of all the single fanged teeth and buccal fangs of upper bicuspids and molars, and of lower molars, except the third or so called Avisdom teeth, is thin, elastic, and often incomplete, but on the inner side the alveolar process is thick and tough, and not only is never deficient in health, but is often most persistent in many forms of disease and in the aged. We have now to consider:— 1. Hoav to apply the above mechanical conditions to the extraction of teeth. 424 OF THE EXTRACTION OF TEETH. 2. What instruments should be used. 3. Hoav they should be applied. Method of ex- Assuming the tooth to have been appropriately seized in the most suitable Avay possible, and by the best adapted instrument, it must first be pressed towards the outside of the jaAv, in the line radiating from the imaginary centre C in the direction of that arrow which is nearest to the tooth which is to be removed. The effect of this is to bend outwards and occasionally to split up the outer side of the socket, and at the same time to rupture the fibrous netAvork of the peridental membrane on the inner or tongue side of each fang. The next movement is to press inwards the tooth to its original position. This breaks partly or entirely, the tooth's periosteum—peridental membrane—on its outer side. Then by a repetition of these movements, ahvays pressing the tooth more forcibly outAvards, it is fully released from the peri- osteum, and the socket is sufficiently either bent or split so as to leave it free. It must be sufficiently obvious that the action of pulling an upper tooth doAvn or a lower one up, even when it is nearly released from its periosteal connections, is liable to many casualties, such as pulling the (toavh from the roots, or from some of them; there is also the risk of the tooth suddenly leaving its socket, and the instrument striking violently the teeth of the opposite jaAv, which accident, so called, leads to the vertical fracture of one or more of them, if not a partial or complete destruction of the crown. complications The exceptions to the broad rule laid doAvn of moving extraction. from £ne imaginary centre of the buccal cavity outwards and returning to it, are feAV and must be made in accordance with the results of abnormal anatomical arrangement of fangs, such as excessive spreading or radiation of the roots of a molar or bicuspid, or the coalescence of tAvo or more of them, so as to form a ring grasping a portion of tough alveolar process. Exostosis of the fang, again, or hypertrophy of the cementum, as it is more properly called, often converts the end of a fang into a bony lump, larger than any other part of it; in these conditions the operator Avill have a fortunate escape if he succeeds in wholly removing the tooth, by breaking aAvay that portion of the alveolus, Avhich is sur- rounding, or included in the fangs. A fourth exception to the usual rule, is in the removal of the loAver wisdom teeth, from jaws where all the other OF THE EXTRACTION OF TEETH. 425 molars persist; as this tooth is under such circumstances seldom entirely erupted, and is embedded in dense bone close to the base of the coronoid process. _ The instruments used in removing teeth, are of two kinds, viz., forceps and elevators. (1.) Forceps are of almost endless variety, but the more Extraction ot experienced an operator becomes, the fewer he will use and upper teeth' teach the use of. Thus the best pattern for the upper in- cisors, canines, and bicuspids, is a pair with jaws straight from the hinge (Avhich should be circular and not screwed up tightly), but sufficiently hollowed out and curved on the side nearest the tooth to be extracted, so that even if the fang be quite small, as an upper lateral often is, still the blades do not touch the crown of the tooth, while the bill clenches the fang at the edge of the alveolar process (Fig. 185). It li i I ''! Fig. 185.—Forceps for Upper Incisors, Canines, and Bicuspids. is a great advantage for the handles of such forceps to be curved, as this will enable the operator to take out the ten anterior upper teeth Avithout pinching the loAver lip between the handle and the loAver teeth. This form also has the great advantage of not requiring the mouth to be opened very Avidely—a boon to the patient Avho may have sore lips, or the muscles matted together by exudation or oedema— such forceps are known as " bayonet shaped," and further on 426 OF THE EXTRACTION OF TEETH. it will be explained in what manner this form may be used in the extraction of stumps even beyond the upper bicuspids. Upper molar forceps (Figs. 186, 187) are necessarily curved both in the handles and the bills or blades, but the Fig. 186. Fig. 187 Figs. 186, 187.—Molar Forceps (in 186 the right hand blade is the inner one, the left hand, the outer). smallest amount of bend is to be advised, as the more an instrument is a direct extension of the hand the better. A normal upper molar has two fangs on the outer or buccal side, and one on the inner or palatal side. The forceps require only one concavity to grasp the inner or palate fang (Fig. 186), and two, Avith an intervening ridge or spine, to grasp the tAvo buccal fangs and to aid in the insinuation of the forceps between the gum and neck and fang as far as the alveolar edge (Fig. 186). The extraction of the third upper molar, or wisdom tooth, if all the other molars persist, requires forceps more curved in the blade and in the handle. The fangs are often agglutinated into a conical form, and the tooth being fre- quently small and deformed, a strong pair of stump forceps curved in both handles and blades is the most useful. It is usually advisable to avoid the use of the elevator in remov- ing these teeth, as the tuberosity of the superior maxilla is often so very porous and riddled with tubes for nerves, arteries, and veins, as to break away very readily, and to bleed excessively, when fractured. The difficulties that present themselves in the extraction OF THE EXTRACTION OF TEETH. 42? of what is left of upper teeth, are chiefly that one or other or all sides of the tooth are decayed away, and are soft, so that there is no secure hold to be obtained of a large stump. In cases where one side is visible, is fairly hard, or can be reached by pushing that blade of the forceps into the socket, so as to use this strongest side of the fang as a director, and keeping the index finger of the right hand between the handles, so as to feel the Avay with the opposite blade into the socket of the more buried fang ; such action if steadily pursued will often extract even the three fangs of an upper molar; should this fail, by the crushing together of the fangs, then a strong pair of bayonet-shaped forceps, as described before for incisors, etc., should be used, by inserting the inner blade, at a point where the fangs radiate, and the outer one upon the strongest outer or buccal fang ; the removal of one fang will leave ample space for reaching the rest, pressing them towards the space vacated by the one removed. Extraction of teeth from the lower jaw is most easily Extraction of effected by using forceps with blades at right angles to their handles. Fig. 188 shows a lower bicuspid, grasped as Fig. 188.—Forceps for Lower Anterior Teeth. it should be by an instrument Avhich is equally adapted to the ten anterior lower teeth. This pair of forceps should not be very wide, as the loAver incisors are frequently very narrow. The same principles are applicable here, as to the upper teeth, and for similar reasons ; in a subsequent para- graph the position of the operator and the firm fixture of the jaAvs and head will be mentioned. The removal of the lower molars, especially of the anterior, is the most frequent of all, and occurs earliest in life; the modus operandi is similar to that for uppers, except that the fangs usually are double and occasionally united, partly or 428 OF THE EXTRACTION OF TEETH. entirely ; in the former case they are more closely approxi- mated at their apices, enclosing a tough portion of alveolus Avhich requires much steady pressure outAvards, and a firm hold of the tooth, to bend or break, failing either of Avhich, the same kind of forceps as for bicuspids must be used, and each fang taken by itself. Third lower molars require much care now and again in their removal. Their position at the root of the coronoid process and the density of the bone, and their distinct lean imvards, often renders it imperative to press the tooth to- wards the tongue as firmly as it will bear before the peridental membrane gives Avay, and ultimately to turn it entirely over on its own axis ; occasionally the point or points of the fangs are so tAvisted, that turning the tooth backAvards will alone release it. Elevators. Elevators (Fig. 189, Nos. 1, 2, 3, 4, 5,) are of various patterns; the Author prefers the straight kind, as the most FlG. 189, No. 1.—Straight Elevator, front view. direct extension of the hand; and if so guarded by the fingers that hold it, there is no danger of the point slipping, and the operator always knows where that point is. Fig. 189, No. 2.—Straight Elevator, side view. use of elevators. Whatever kind of elevator is adopted, it should be inserted into the socket of the fang to be removed, and pressed diagonally downwards and inwards, using that septum of alveolus between the fang and the nearest and firmest tooth, and the operator's own thumb as joint fulcra, ultimately turning the instrument on its own transverse axis. If possible the use of this or other extractors, such as fang dividers, should be avoided, especially on deciduous teeth, as injuries to capsule, socket, etc., may occur. Screws, keys, etc., need not be described in this manual, nor need they ever be used by the general surgeon. As a General maxim, the patient's OAvn statement as to the particular aching tooth should never be accepted without verification; an aching tooth is usually looser than any other, OF THE EXTRACTION OF TEETH. 429 or is more sensitive to a sharp tap into, or across, its socket; or by probing, either an exposed pulp, or a purulent discharge can be detected. The position of the patient should be facing a good light a pa>ts?*,n°tna°fd little higher than the head, which, Avith the neck, ought to surgeon. be securely placed, leaning a little backwards, in a firm FlG. 189, (Nos, 3, 4, 5). 3, Curved Elevator, front view ; 4, Pointed Elevatot, front view; 5, Pointed Elevator, side view. heavy chair Avithout wheels, or resting against a table ; the operator should stand on the right side, out of his OAvn light, in full view of his Avork, with a firm grip of the patient's jaAv, especially of the lower one, so as to keep the head pressed against the chair-back. In extracting the lower teeth on the right side Avith right-angled forceps, it will be necessary to stand behind the head on that side, encircling it Avith the left forearm and hand, which latter must securely hold that side of the jaAv back, and keep the lips and cheek from obstructing a full view, from the beginning to the end of the operation. CASUALTIES. The casualties that majr occur in extracting teeth, which casualties the general surgeon may have to deal with, are: (1) uon\noreafTer? hsemorrhage, (2) dislocation of lower jaw, (3) fracture of teeth, (4) extraction of a tooth next to that removed, (5) extraction of the non-aching tooth, (6) tearing of the gum. 430 OF THE EXTRACTION OF TEETH. Bleeding. Dislocation of jaw. Fracture of teeth. Extraction of wrong tooth. Tearing of gum (1) Bleeding to a serious extent may occur without any fault on the part of the operator, and may be entirely due to the hsemorrhagic diathesis. From Avhatever cause it may arise it is sometimes very difficult to arrest. The use of stimulants is to be avoided. Cold water or ice may be first tried. Clear the clot of blood from socket, wash it out Avith iced water, failing that, plug the socket tightly with lint soaked in tannin, or use perchloride of iron on the plug, which must in all cases be tightly jammed into the cavity, and allowed to project above the level of contiguous teeth, or so as to be forced into it by the teeth or gums of opposite jaw. Replacing the tooth, or even the forcible insertion of a soft deal Avood plug hammered into its place may have to be resorted to.* (2) Dislocation of the lower jaw takes place usually on one side only, and more often during anaesthesia, especially from chloroform. It is best to reduce it at once. Wrap the thumbs into pads either Avith lint or napkins, place them firmly on the molars or upon the corresponding place in the jaw, hold the horizontal ramus securely with the fingers, push the jaAv dowmvards and backwards till the condyle slips under the eminentia articularis, when it will jerk into the glenoid cavity. It will be well to bandage the lower jaAv, with either a "four tail"t or a Avide elastic bandage, for a feAV days. (3) Fracture of teeth. If the remnants can be easily reached by fine, sharp-pointed forceps, it is better to remove them at once ; but if much crushing of the alveolus is necessary, it is best to leave the broken fang till it rises to a convenient level, Avhen it is often more or less loose. (4) Extraction of the next tooth, or (5) extraction of a non- aching one. WTash them in water of temperature _ of the blood ; see that no coagulum remains ; replace them in their sockets, and fix the jaw with a four-tailed bandage (6) Tearing of the gum. If only slight it should be pressed into'its place, when the elastic fibre in it and the coagulum, will soon keep it in position, when it will soon re- unite If extensive, a few stitches will place it in a position for rapid reunion; occasionally a pad may be necessary, or a small vessel may have to be tied. _____________ ♦ See also p. 38. t See Figure No. 62. OF ATJRAL CASES. 431 CHAPTER XXXII. On Some Points in the Practical Management of Aural Cases. [We are indebted to our colleague, Mr. G. P. Field, Aural Sur- geon to St. Mary's Hospital, for almost the whole of this chapter.] Impaction of wax is a very common cause of deafness. To Deafness by remove this obstruction nothing more than water at a tem- lJ£|?cMon of perature of 100° Fah. and a syringe is necessary. Sometimes, where the wax is very hard, it may be necessary tAvice or thrice to pour into the ear a warm solution of bicarbonate of soda (10 grs to the Jj) at bedtime, before it is possible to remove the Avhole mass by the syringe. The patient should always stop up his ear with cotton wool after the removal of the wax. The syringe should be used gently and sloAvly, as the employment of much force will cause giddiness, and may rupture the membrana tympani, and for this reason a syphon tube, arranged somewhat upon the plan of the "nasal douche" shown in Fig. 22, is a very safe and convenient method. We should be careful not to give too favourable a prognosis in such cases, for masses of wax constantly increasing may lead to perforation of the membrane, to gradual dilatation of the osseous meatus, or to the formation of ulcers, or to worse eArils. Moreover, impacted wax may cause thickening of the surface of the membrane, or even an abnormally deep posi- tion of it, with narrowing of the tympanum and over-pressure upon the contents of the labyrinth. Earpicks should be es- pecially avoided, for severe injuries are often caused by these instruments, which, in the form of metal probes, hairpins, bodkins, knitting needles, etc., are used for the relief of itching in the ears, or for the removal of foreign bodies. It is not uncommon to meet with patients who suffer from deafness due to a collection of epithelial laminse, or what has been called " keratosis obturans," in contradistinction to " ceruminosis obturans " the impacted plug of ear-wax. The laminae are derived from the horny elements of the external auditory canal by gradual accretion, causing great deafness 432 OF ATjRAL CASES. and offering great resistance to removal.* In this affection we have always found the use of warm solutions of bicarbon- ate of soda. Avhich avc have before recommended for obstinate cases of hardened cerumen, the best treatment. of Childrenears ^ie wax *n ^G ears °^ cm^ren hecomes sometimes fluid and highly offensive, a condition Avhich, if not speedily attended to, is likely to lead to catarrhal inflammation, or more serious mischief. Absence of In adults, cerumen is sometimes entirely absent, but aluits.en m the deficiency appears in no way to affect the hearing power, f Use of otoscope. For the thorough examination of the meatus auditorius, or of the membrana tympani, some form of speculum or oto- scope will be necessary. If a simple speculum be used, such as those which are shoAvn in Fig. 190 (one attached to an Fig. 190.—Brunton's Otoscope, with Speculum attached. otoscope), some form of concave mirror will generally be necessary. This may be either a hand mirror, or may be worn upon the forehead, or supported upon a spectacle frame so that both hands are free. In all cases there must be a * See " A Treatise on the Ear," by C Burnett, M.D., pp. 293, 294 ; also Dr. Duncanson, Edinburgh Mudical Journal, Nov. 1879, + Although the absence of wax does not in itself .seem to have any ill effect on audition, a condition of unusual dryness in the external meatus is often associated with diseases of the internal ear. OF AURAL CASES. 433 small central aperture as in the ophthalmoscope or laryngo- scope, through Avhich the surgeon looks. A good light, either natural or artificial, is essential, and attention must be paid to the position of the patient. It is well also to remember that in the adult the meatus is larger in its vertical than in its horizontal meridian ; whereas in children the reverse is the case. Of Otoscopes, Brunton's (Fig. 190) is the one in most com- mon use. In order to inspect the tympanum with it, all that is necessary is so to place the patient that the large conical speculum receives the light, Avhile the surgeon can conveni- ently look through the end of the instrument. It requires little practice to use, and either sunlight, or an artificial light will do. The magnifying glass at the end can be used or not, at pleasure. At times the removal of cerumen, pus, hairs, etc., is requisite, as they hinder a proper view of the mem- brana tympani. A pair of rectangular forceps, and a " cot- ton holder" (Fig. 191), are the most useful instruments for Fig. 191.—Aural "cotton holder." this purpose. The holder here figured consists of a Avire in a handle, with the end fashioned into a screAv with a very shalloAv worm, so that the cotton avooI may be easily detached. Of the removal of foreign substances from the meatus. Removal of Generally speaking, the instruments introduced for this pur- stances from pose do great mischief. Instrumental interference is hardly the meatus- ever necessary, and is often dangerous. Careful and perse- vering use of the syringe and warm water will almost always be successful, especially if the auricle be pulled upwards and backwards. Where there is much SAvelling and inflammation of the soft parts (and this is often very severe from the irri- tation and pressure of the foreign body), it must, together with the acute pain, be relieved by freely applying leeches in Pain, bow front of the tragus, for the meatus and membrana tympani a aye are extremely sensitive when pressed upon by hard sub- stances. After the inflammation has been allayed by this means, and also by the use of fomentations, the syringe will easily remove the foreign body ; but Ave should by no means attempt the remoA-al so long as the slightest tumefaction is present. Above all, it is necessary in each case to make a careful in- 28 434 OF AURAL CASES. spection of the meatus Avith the speculum to see whether Danger of there be actuallv anvthin first time, the mistake is very generally made of proceeding as if the operator were in the dissecting room, instead of at the operating table. The temptation to use the knife, in order to get an anatomical display of the parts is very hard to resist, and it is not rendered easier by the fact that many written descriptions of the operation appear rather to favour this idea. But in fact, if the head be held still and straight, and the forefinger of the left hand be used to define and steady the cricoid cartilage, one incision, abso- lutely in the middle line should, in infants and children, be made from the cricoid cartilage nearly to the sternal notch,* dividing the tissues down to the fascia, and then the knife need not be used again, until the trachea is to be opened. Without removing the left forefinger, the fascia may be torn through Avith a director, and the parts displaced so as to get a perfectly free and sufficient exposure of the tracheal rings. If the isthmus of the thyroid gland prevent a full exposure of the trachea, it may be toru through with forceps, or ligatured in tAvo places and then divided. Opening of the The assistant should noAv hold the sides of the wound apart Avith the blunt hooks or retractors, Avhile the surgeon * In a patient that is of the age we are supposing, this will give an incision of about 1^ inches. Many surgeons maintain that this length is excessive, but to those who have no large experience, the gain of a free exposure of the parts is very great and outweighs the slight increase of the risk of the downward tracking of pus. In skilful hands however, one small, direct incision, not more than an inch, or even |-inch, may be made straight down to the trachea. But for this the operator must know exactly what he is about. OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. 497 proceeds to open the windpipe. It is generally advised use of the that the sharp hook before mentioned should be thrust into smrp the first tracheal space, and the cricoid cartilage partly steadied, partly pulled up with the trachea, by its means. This may be necessary, but unless the trachea lies deep in consequence of fatness or SAvelling of the neck, it should be possible to avoid this disturbance of parts; and if so, so much the better, for the introduction of the hook is frequently the signal for a violent spasm, in the course of which the asphyxia is increased, and the bed of the trachea may be injured. With the aid of the hook, or guided by the finger without it, two or three upper rings of the trachea can now be divided, the knife being entered edge upwards Avith a stab below the lowest ring concerned, and exactly in the middle line. The other rings are divided in the one incision ; and if this does not give room enough, the cricoid cartilage may also be split. For this, a pair of strong blunt-pointed scissors will be found most convenient. The incision of the trachea should be done deliberately, and the insertion of the tube which noAv immediately fol- lows, should especially not be performed by any push in the dark; for the surgeon must satisfy himself that it has fairly entered the trachea. With regard to the size of the tube, in the case Ave are size of tube. supposing (i.e., in a child of five years of age), the second largest tube of the set of four will probably be the right one ; but in every case the tube should be as large as can be admitted easily" into the wound in the trachea of the patient,* and this will be, in the operation Ave have de- scribed, somewhat larger than the natural opening of the glottis. If the bivalve or piloted tube be used, tracheal forceps will hardly ever be required, but for the common form (Fig. 213) it will often be necessary to dilate the edges of the tracheal wound with Mathieu's three bladed forceps, or some similar ones, or Avith Golding Bird's dilator. The chief difficulties which are met with in this operation chiefdifficui- are :___ operation. I. Hcemorrhage. This is almost ah\ ays due to the too free Haemorrhage. use of the knife, and is principally venous. It must be borne in mind that much, or all of it, will stop of itself directly the trachea is opened and the venous congestion * See " Holme's Surgical Diseases of Children," p. 324. 498 OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. removed. Moreover, time is very probably of great moment; it is therefore generally unnecessary to carefully secure the vessels, but a Spencer Wells's forceps may be clipped on, the Aveight of Avhich, also, hanging down at the sides of the wound, can often be made serviceable for retraction. It may, however, be necessary to tie divided vessels, and if a large vein be seen directly crossing the line of incision, it should be tied in two places and then cut. insufficient II. Insufficient opening of the trachea. A blunt knife, or trachea.0 e one unskilfully used, may slip along the cartilages, and only "nick" and not fully open the trachea. In this case the insufficient wound should be left alone, and another incision in the middle line made as described above. III. As has been pointed out by Mr. Howard Marsh,* there may exist a dense exudation or false membrane, or a thickened condition of the natural mucous membrane, which is pushed before the point of the knife Avhen it is made to enter the trachea, so that the air passage itself is not opened up; this may be avoided in some cases by taking care that the point of the scalpel is very sharp, and that it is made to " stab " the trachea properly, but if the membrane be very tough, it will be necessary either to pull it away Avith forceps, or to incise it separately, after the tracheal rings have been divided. cessation of IV. Cessation of respiration during operation. If this respiration. happens during the early stages of the operation, the surgeon must choose between an immediate opening by laryngotomy, or completing with all possible speed the operation he has begun, and his decision will depend upon whether he anticipates any difficulty in at once finding the trachea. In any case the Avindpipe ought to be opened within a very feAV seconds. It very often happens that the breathing stops at the moment of inserting the hook, or of opening the trachea, especially the first. This appears to be a kind of reflex inhibition, and is not in itself alarming. The surgeon should complete the tracheal incision as he intended, but of course quickly, and upon the insertion of the tube the respiration will almost certainly recommence. But in all cases, if the breathing has stopped, artificial respiration, and other restoratiVe steps, should be energetically adopted, as soon as the tube is in, but the operation must never be inter- * Brit. Med. Journal, 1885, Vol. I., p. 200. r OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. 499 mitted (as Ave have seen done) for the purpose of artificial respiration. V. Non-insertion of the tube. The trachea may be imper- Non-insertion fectiy opened, and then the tube may be pushed down ° between it and the surrounding tissues. This may happen more easily than might at first sight be supposed. If there be the smallest doubt as to Avhether the tube has fairly and completely entered the trachea (thus one valve of the bivalve might be in, and the other out) the parts must be thoroughly explored, and if the opening in the trachea be not easily found, a fresh one must be made as before advised. VI. The neck may be very fat and short, or very swollen, shape of neck. This is the special difficulty in the operation in infants. In them, the trachea may lie so deep that it may be very hard to find. Rigid attention to the middle line, and making the skin incisions sufficiently free, are the best precautions to take. What we have written here Avill stand for tracheotomies performed for almost all conditions. But if it be for the removal of a foreign body, the trachea should be incised particularly cleanly, and, as has been before mentioned, the edges of the tracheal wound should be held apart with forceps, or Golding Bird's dilator should be inserted (see also p. 377). After treatment of tracheotomy cases. After treat- As soon as the tube is adjusted, and all the membrane which has presented itself has been removed, the ratient should be put to bed in a cot with a tent-like arrangement over it, so that the steam from a bronchitis kettle may be led into it, keeping the air which is inspired always warm and moist. This is further effected by laying two or three folds of lint or flannel, wrung out of warm water, lightly over the aperture of the tube. For the first few days after the operation very constant attention is required, and every tracheotomy case should have a special nurse for the first week at least. The nurse (or dresser) must be on the watch against any sudden choking from plugging by a piece of dislodged membrane, and as soon as any presents itself it must be seized and removed. At regular intervals also, of an hour, an hour and a half or two hours, according to the amount of secretion, the inner tube must be removed and thoroughly cleansed, and at the same time a plumage feather, not a quill, well rubbed up the wrong way, should be passed 500 OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. doAvn the outer tube into the trachea, to catch any pieces of membrane or more adherent mucus.* At the end of three or four days it is often wise to substitute one of Baker's india-rubber tubes for the silver one, and about the sixth day the tube may begin to be left out, at first for an hour or tAvo at the best time of the day, and soon for longer. For at least a fortnight it will be avcII to replace the tube at night. The house surgeon should be at hand the first time or two that the tube is taken out, lest there should be any difficulty in replacing it.f When the tube is changed at the third or fourth day, it is a good plan to have a hole cut in the new one at the top of the arch of the tube, so that air can pass through the glottis into the lungs if it will, as Avell as through the Avound. If a Baker's rubber tube be used this can be done with a pair of scissors, but silver tubes are also made with this aperture. If this method be adopted, it is easy, by placing the finger over the neck opening, at first for a feAV seconds, and afterwards for longer, to bring the glottis and vocal cords gradually into Avork again. intubation. Intubation has recently been advocated as an alternative to tracheotomy, more especially in diphtheria. To Dr. O'DAvyer, of New York, is due the merit of bringing the operation to its present state of perfection. The necessary instruments. instruments are a gag, introducer, extractor, and tubes of various sizes ; there is also a gauge to show the size of the tube suitable for the age of the patient. The tubes, of which there are usually five, are somewhat flattened, and vary in length from 1| to 2 J inches, the smallest being suitable to a child under tAvo years, and the largest to one between eight and ten years of age. Each tube has an enlarged head to prevent it from slipping into the trachea, and in the middle of its length is a fusiform enlargement to prevent it from being expelled. A hole is also drilled at one side of the head through Avhich a long piece of silk * Much has been written concerning the propriety or justifi- ability of the surgeon's sucking at the tracheotomy tube with his mouth in order to clear it of mucus or of false membrane. We will only here express our belief that no clearance of the air passage can be effected in this way which could not be much better done with a ruffled feather, or with a fine brush, and that we do not consider the proceeding to be either necessary or right. t The reader is referred to a verv interesting paper on the manage- ment of tracheotomy cases by Dr. W. E. Steavenson, for further remarks as, to their nursing, and as to those cases in which the re- moval of the tube has to be delayed. See " Notes on Tracheotomy Cases," St. Bartholomew's Hospital Reports, 1882, p. 30'J. OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. 501 must be threaded before the tube is introduced. Each tube is fitted with a jointed obturator, into the upper end of which the introducer is screwed, and on the latter is a Fig. 219.—Intubation Instruments. Above is the Extractor; below, the Introducer with Tube attached. sliding fork, which on being pushed downwards releases the obturator from the tube. The only use of the obturator is to facilitate the introduction of the tube. The extractor consists of a pair of forceps the blades of which are grooved on the exterior, so that on being passed into the tube and expanded, sufficient hold is obtained to enable it to be withdraAvn. The steps of the operation are as follows. A suitably The operation. sized tube must be selected and threaded, and the intro- ducer screAved into the obturator. The patient, if a child, should be Avrapped in a shawl to prevent struggling and held on the nurse's lap, an assistant steadying the head. The gag having been introduced, the operator passes his left index finger over the epiglottis and feels for the arytenoid cartilages ; with his right hand he then introduces the tube, taking care to keep it in the middle line, and passing the end of it betAveen the tongue and finger. When the opening of the larynx is reached, the tube will be directed into it by raising the handle of the introducer. The tube being in the larynx, the obturator should be released, by pushing forAvard the button of the introducer, and withdrawn; the tube should then be pushed on Avith the finger until the head is in the rima. That the tube is in the larynx will be shown by the temporary dyspnoea which will occur. When this has passed off, the finger must again be inserted in order to hold the tube in position Avhilst the silk thread is cut and withdrawn. A tent and 502 OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. steam kettle must be used in the after treatment of the case as in tracheotomy. Extraction ot In extracting the tube the finger must be passed as before, and the blades of the extractor guided into the tube. If after one or two attempts the tube is not ex- tracted, it is better to give the patient an ansesthetic. In a case of diphtheria the tube will probably not be required for more than five or six days, but in a case of. stenosis it may be worn for a much longer period. Advantages of Intubation has this great advantage over tracheotomy, that parents will often give permission for its performance Avhile forbidding tracheotomy. The rapidity of its per- formance, the absence of risk from haemorrhage, and from the giving of an anaesthetic, are also in its favour. On the other hand there are difficulties and dangers Avhich must not be forgotten :— ■ Difficulties and 1. The difficulty of the operation. Considerable practice is required to insert and extract the tube, and it is most desirable to practise on the cadaver before resorting to it. 2. The tube in its insertion may push membrane before it and so block the trachea. Should this happen, and if the membrane cannot be extracted with forceps, tracheo- tomy must be done. 3. The tube itself may become blocked. In this case the tube will probably be expelled, and if this occurs before the tube can be dispensed with, the choice lies between its re-introduction and tracheotomy. 4. Difficulty of feeding. As the head of the tube inter- feres with the movements of the epiglottis, liquid food is apt to pass into the trachea and lungs and cause pneumonia. Recent improvements in the shape of the tube have to a certain extent lessened the chance of this occurring, but liquids must be given in small quantities, and attention paid to the position of the patient, who should be lying down with the head thrown well back when being fed. It will thus be seen that after intubation even greater care and watchfulness are required than after tracheotomy. Tonsillotomy. Of Tonsillotomy. The house surgeon is often required to remove portions of hypertrophied tonsils, and he will find that the cases vary greatly as to their difficulty; the age and disposition of the patient, the shape of the hypertrophy, the size of the aperture of the mouth, etc., all affecting the question. The whole tonsil is never taken away, and speaking generally, the object of the operation is to get as large a OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. 503 shaving, or cut surface as possible, so that the pillars of the fauces may be tucked up by a process of cicatrisation. The removal itself may be performed by seizing the projecting mass Avith a pair of vulsellum forceps, and cutting off what is required Avith a blunt-pointed bistoury, the greater part of the blade of which should be guarded (a special tonsil knife is also made). This was the old operation, and as such was strongly recommended by Syme, but noAv some form of guillotine is The guillotine. commonly used. The usual pattern is shown in Fig. 220. FlG. 220- Mathieu's Guillotine. It is a very ingenious and efficient instrument, but is some- what liable to get out of order, and should always be tested before use. The dresser must learn how to take this instru- ment to pieces and put it together again, for only by doing this can it be properly cleaned, as it must be, after each time it is used. The especial feature of this (Mathieu's) instrument is, that by an automatic movement the tonsil is transfixed and drawn further through the encircling ring, at the moment that it is sheared off by the guillotine or circular knife. The extent of this traction is regulated by a screw. This arrangement is often useful if the tonsils are flat, but FlG. 221.—Mackenzie's Tonsillotome. if they project into the throat after their ordinary fashion, a much simpler tonsillotome (Mackenzie's, Fig. 221) does at Maoken^s least equally well. It is made to be adjustable for either side. 504 OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. Tonsil scissors. Lastly, tonsil scissors, with hooks for seizing the gland, are sometimes used, but they are the least convenient of all. Question of an Whichever instrument is chosen, the question of an anaesthetic will be settled mainly by consideration of the probable behaviour of the patient. With one who can be trusted to sit still and keep the mouth open, it is much better dispensed with, for the operation is almost painless ; but if there is likely to be any struggling (or in very young children) the surgeon will best consult his own convenience by having gas, or gas and ether, administered. Position of The patient should sit in the same position, and with the Da ien ' same conditions of light as for the extraction of teeth (q.v.); if under an anaesthetic, a gag and tongue depressor will be required ; if not, a simple spatula will suffice. Direction of Supposing the guillotine to be the chosen plan, its ring must be adjusted round the tonsil, taking care that theaais of the instrument is directly from before backwards; with a sharp sudden closure of the fingers the projecting part of the gland is then cut off. If the direction of the instrument be kept in mind, it is impossible to injure any important vessel; indeed, it will often be advisable, and is perfectly safe, to press the tonsil into the ring of the guillotine with the fingers on the outside of the neck. The bleeding is generally slight, so that it may be easily checked by gargling with cold water. If it be more severe, an astringent gargle may be used. It very rarely happens that there is any profuse haemorrhage, but if such should occur, ice should be kept in the mouth, or pieces held to the part Avith a pair of vulsellum forceps, or digital pressure may be made. If a vessel were to be seen spouting, it could be secured without much difficulty, but this is ex tremely rare. Relaxed uvula. The uvula is often relaxed and elongated from chronic congestion, and hanging down, produces tickling and irrita- tion of the throat. It may, in this case, be shortened as much as may be necessary, and for this purpose a uvulatome, and also a pair of scissors of especial form have been made. Neither of these are in the least necessary; a pair of rather long forceps and sharp scissors are all the instruments which can be required to seize the uvula and snip it off. Tenotomy. Of Tenotomies. Of this operation we need say little, for its chief diffi- culties concern questions of surgical anatomy. Moreover the house surgeon will only be called upon to do the ope- OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. 505 ration in straightforward cases, and these generally under the supervision of his senior. An anaesthetic is very advisable even in adults, and an instruments assistant will be required to hold the limb. The instruments reqm required are, one sharp, and one blunt pointed tenotomy knife (Figs. 222, 223); both, but especially the latter, should be very sharp edged. Fig. 222.—Sharp Pointed Tenotomy Knife. e^ Fig. 223.—Blunt Pointed Tenotomy Knife. Taking as an example, a tenotomy for a simple equinus Metti^of club foot, as being the one a house surgeon commonly oper- op ates on; the assistantholds the foot so that the tendon is relax- ed, and the surgeon slips the sharp pointed knife beneath it, until the point is felt under the skin at the opposite side. He then withdraAvs it exactly as he put it in, and substitutes the blunt pointed one, in order to be able to cut close up to the skin on the side opposite his puncture without danger of dividing it. He then turns his knife edge outwards, against the tendon, and directs his assistant to gradually put this latter on the stretch. The knife now is made to divide its fibres by depressing the handle with a slightly sawing movement, giving the sensation as of cutting through some- what fibrous celery. As the tendon becomes more nearly divided, the assistant must be careful, while still keeping up extension, that at the final parting, no sudden jerk occurs, i hich might cause the knife to come through the skin, for if the division be complete there should always be a kind of "snap," caused by the retraction of the upper (the muscular) endof the tendon. The knife is then carefully and quickly withdraAvn, and a small pad of lint, which should be in readiness, is immediately put on and firmly secured Avith a larger pad over it, by a strip of adhesive plaster The foot and ankle should then be bandaged with a flannel roller, and either left to itself, or bandaged to a flexible metal splint for three or four days, before any attempt is made to reduce the deformity. It often happens that a small arterial branch of the pos- Hemorrhage tcrior tibial is divided, and for a few seconds may bleed so freely that it may suggest the division of the trunk vessel. 506 OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. This, however, is here hardly possible, and all that is neces- sary is to apply somewhat firmer pressure than usual for a few hours, watching the circulation in the toes, to see that the whole foot is not strangulated.* Minor ampu- Of Minor Amputations. These may be primary or secondary, and if the latter, are performed as planned operations, and as such are fully de- scribed in surgical works. But as primary operations, neces- sitated by injuries to the hand, or foot, and especially of the former, we most strongly hold that the attempt to make miniature flaps, etc., results only in the sacrifice of portions of the limb which might have been saved. The vitality of these parts is so good, and every bit of hand or finger is so valuable a possession, that the right practice certainly is to save every scrap of the soft parts, in which there is a chance of vitality, Avhich may serve to cover the bones, and to trim the parts up with scalpel, bone forceps, and scissors, Avithout following any regular or orthodox plan of amputation. The parts are almost always bruised badly, and must be lightly but Avarmly dressed. In those patients Avho are to be treated as casualty out-patients, even in the case of fingers, the whole fore-arm and hand should be splinted, for they will not otherAvise rest the part; and in such cases also, sutures should be sparingly used, lest these patients should neglect to attend regularly, and thus suffer from pus being shut up in the Avound. Removal of Qf (jie removed of Foreign Bodies from certain parts. The question of foreign bodies in the air and food passages, and in the ear, has been discussed already, but some othei examples remain. Needles, spiin- . I. Needles, splinters of wood, etc,, often run deeply into etc? ° ° ' such parts as the palm, or sole, and unless they project so that one end can be easily felt, may give great trouble. These "needle cases," as they are called, are often occa- sions of much bad surgery, which may be indeed disastrous. For example, a servant runs a needle into her hand; it can be felt Avith difficulty, and the person from whom she seeks • It is however not only possible, but easy, in the division of the tendon of the tibialis posticus, to divide the posterior tibial artery, but as we have said, the tendo Achillis is almost the only one com- monly operated on except by the senior surgeon, or under his imme- diate direction, and for full descriptions of thS anatomical and surgi- cal difficulties of the diA'ision of the other tendons about the foot, about the knee, or the hip, the reader must be referred to systematic surgical works, or to works on Orthopaedic Surgery. OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. 50? relief has neither the courage to leaA e it alone, nor to make a sufficiently free dissection to find it. He makes a small half- hearted cut, pulls and bruises the fibrous fat of the palm to no purpose, and covers it all up with a piece of strapping. Inflammation is the natural result of the double irritation of the needle and the bruised Avound, and this, once started, may be of any severity, up to being fatal. We believe that the rule to be folloAved is this. If a when *° be foreign body, such as a needle, can undoubtedly be felt, it must be taken away, and this can generally be done Avithout trouble, even in situations such as the palm, if the superficial incisions be properly free. But supposing that the body can only be indistinctly felt, and that there is not sufficient irri- tation present to make it certain that it is there, it will be wiser to wait for a few days (watching the part carefully), when its locality will probably become more evident. Under no circumstances should an attempt be made to ex- when extrac- tract a supposed foreign body Avhich cannot be felt at all, be attempted. and which is not producing decided irritation. If it be un- felt, it is probably non-existent, and however confident the patient may be that it really Avent in, and is still there, this must not be taken as a proof. II. Small objects, such as boot buttons, beads, etc., are Foreign bodies often pushed up the nostril, and may give great trouble. in They may sometimes be removed by syringing, and sometimes by forceps. But the best way is to make a fine wire snare, and get it behind the obstruction. Sometimes, if the object is known to be small enough to pass the posterior nares, and if it lies very far back, it may be advisable to push it through into the pharynx. The house surgeon may be called upon to pick out small shot, slugs, or grains of gunpoAArder, and, speaking generally, the sooner the extraction is performed, the better; but it may sometimes be right to leave them. Small fragments of cinder, or chips of iron or stone, often Foreign bodies become embedded in the cornea, and if they are not promptly in removed Avill become firmly fixed, and may Avork great mis- chief. To get them away the patient should be placed in a good light (as in a dentist's chair); then the eyelids should be parted and held open Avith the finger and thumb so as to steady the eyeball, and the speck picked out of the cornea with the point of a small scalpel, or a " spud " made for the purpose. After the removal a drop of castor oil should be put between the lids. A small convex lens is often useful to concentrate the light, or to magnify the image of the body. 508 of Tracheotomy, and other minor operations. Nasal polypi. Removal by forceps.) By wire snare. By cautery. Thickening of the mucous membrane of the nose. The operative measures Avhich must be taken when a body has penetrated more deeply into the structures of the globe are of a much more serious character, and are fully discussed in Avorks on ophthalmic surgery. Of simple Nasal Polypi. These can be removed with forceps, or by a snare of a pattern similar to that shown in Fig. 194, Avhile very rarely, the thermal, or electric cautery is useful. These simple gelatinous polyps are generally pedunculate, and grow from one of the turbinated bones. They bleed readily, and obstruct and deform the nostrils. The patient should sit facing the light, as for the extraction of teeth, with a towel round the neck after the fashion of a bib. If forceps are used, the surgeon should endeavour to catch the pedicle and tAvist it off. Care must be taken not to mistake the end of the lower turbinated bone for a polyp. The wire snare is generally used for the larger growths, and it may be difficult to adjust it. The polyps often hang down into the throat behind, and then the finger will have to be passed behind the soft palate in order to get the Avire round them. The cautery will be found to be the best plan for small fleshy polypi, which may bleed profusely if removed in the ordinary way, and the most convenient form is the small platinum point of Pacquelin's Thermo-Cautery ; it may also be possible to scrape away Avith the finger nail some of the growths. The polyps havingbeen removed as completely as possible, the freedom of the nostril should be ascertained by directing the patient to Woav through it, and the bleeding checked by syringing Avith cold water. The patient should then be directed to use an astringent snufl' (equal parts of tannic acid and nitrate of bismuth do \rery well), and sometimes the application of solid nitrate of silver will be found advisable. It often happens that, Avhen all the polypi which can be seen at the time of the operation have been removed, within a day or two others present themselves to view, Avhich have hitherto been kept up in the upper parts of the nose by the pressure of the loAver ones. These must be treated in the same way. A condition of thickening of the mucous membrane of the nose, Avith hypertrophy of the turbinated bones, is very common in strumous people, and resembles true polypoid growths someAvhat closely. It is generally treated by strong of tracheotomy, and other minor operations. 509 local astringent lotions, or snuffs, and recently chromic acid as a caustic has been recommended. The pure acid is applied by fusing small crystals of it over a lamp upon a silver probe to Avhich they will adhere. Small sebaceous cysts often call for removal or evacuation. Removal or This latter method is not practised as often as it should be. SSS?sebaceous In a large number of instances if a little trouble be taken, cysts- the aperture into the cyst can be found, and can be dilated, beginning with a lachrymal probe, and going on to an ordinary one. The contents can then be squeezed out, after which the patient should be instructed to keep the opening patent, and to squeeze the secretion out regularly ; after a little time it will cease to accumulate. But these cysts very often have to be cut out. It is generally recommended that they should be cut across, their contents turned out, and the cyst Avail seized with a pair of dressing forceps, and pulled away. This method is very apt to leave portions of secreting membrane behind which will * suppurate, and we think it is always wise to take the little additional trouble Avhich is involved in the careful dissecting away of the Avhole sac, if possible without opening it at all. The clean wound which is thus left readily heals up under any simple dressing. The allied condition which is found in the eyelids, the Tarsal tumours. retention cysts of the Meibomian glands, commonly called Tarsal Tumours, are treated differently. They should gene- rally be left alone until the skin over them looks bluish and thinning (LaAvson). The lid (usually the loAver one) is then everted, the conjunctiva and cyst wall incised, and the contents broken up and turned out with a scoop, such as is found at the end of a common probe. The incision should be prevented from healing for a short time by passing a probe along it every day. If the wall be very tough, or the contents solid, it is wise to rub the inside of the cavity with lunar caustic. Of Naili. Of nEevi. We will here consider cutaneous or capillary nceri (mother's marks), and the smaller subcutaneous ones. With regard to both, but especially the former, one fact is often forgotten, indeed, seems hardly to be generally known, namely, that if left alone they Avill very frequently disappear. To shoAv often disappear this, let the reader consider hoAv very rarely the affection is st)0IUaiieoU;>1J'- met with in adults as compared with the number of children who are brought to the O.P. rooms for treatment. It is, therefore, in infants, a good general rule to postpone 510 OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. Of superficial nsevi. By actual cautery. treatment, for a month or two at least, after they are first seen, unless the stain be rapidly growing, or be in a very disfiguring situation. The only Avay of treating superficial ncevi is to destroy them with some form of caustic or cautery. Nitric acid Avill generally be found best, but Dr. Richardson's ethylate By nitric acid, of sodium or strong chloride of zinc may also be used. It is only Avaste of time to employ the milder caustics, as the nitrate of silver, alum, etc. Sometimes the nsevus is vaccinated, and the consequent inflammation may be sufficient to effect a cure, but it gene- rally fails. Any form of actual cautery may be successfully used, Pacquelin's being the most convenient. The whole depth of the skin must be destroyed, and the parts dressed iu some simple fashion while the sloughs separate. In situations, such as the face, Avhere complete destruction of a large superficial naevus Avould leave a disfiguring scar, good may occasionally be done by slight superficial appli- • cations of the cautery, frequently repeated, a small portion of the nsevus being done at one time. If successful a thin white scar will ultimately be formed, but the treatment is long and tedious. There are two principles on Avhich subcutaneous ncevi may be treated; that is to say, measures may be taken which will produce sloughing out of the entire mass, or which will merely produce a consolidation and stasis of the blood current through it, which consolidation is later folloAved by a gradual absorption. For the ligature of a subcutaneous nsevus of ordinary size, the readiest Avay is to take a needle, double threaded Avith stout silk or Avhipcord, and with it to transfix the base of the growth. The needle having been cut off, there will be left two cords running beloAv the tumour, and these may if necessary be increased to four or six by repeating the process of transfixion. The cut ends of these ligatures have now to be knotted together very tightly, each to each, and before this is done it will almost always be advisable to cut the skin in the form of a ring at the base of the growth. The naevus will then be completely strangulated, and must be left to slough off. During its separation it may be dressed Avith fomentations, or Avith any simple cleanly dressing. Sometimes elastic ligatures, or ones which can be tight- ened up from time to time are used; but in any case the cords must be tied very tight. Of subcuta- neous nsevi. By ligature. OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. 511 The means Avhich may be adopted for securing consoli- dation of naevoid groAvths are numerous, but we shall only mention one or two of the principal ones. Electrolysis or the passage of a constant current, finds an By electrolysis. application here, its object being to produce stasis and coagulation in the blood vessels, but not sloughing of the tissues. The current should be just strong enough to decompose Avater; and the needles must be insulated Avith the exception of about a \ inch at the end, to prevent the current from acting on the skin and causing sloughing. One needle is connected with each pole of the battery and inserted into the tumour, care being taken that the non- insulated portion is buried in the naevus. The current is passed until the SAvelling becomes Avhite and hard ; it must then be reversed for a short time to prevent haemorrhage. If the naevus be deeply seated, the effect Avill have to be estimated by the hardening of the tumour. The operation frequently has to be repeated, and it is often advisable to use more than tAvo needles, especially if the naevus be large. One of the most common plans of treatment, and a very By setons successful one, is the passage of threads, soaked in the strong tincture of the perchloride of iron, through the sub- stance of the growth. It is best to use worsted, as it takes up more of the tincture, double threaded through a stout needle. Three or four of these double threads may be passed, and their ends may then be loosely knotted together, and cut short. After a feAV days they will begin to work loose in their channels, as seton threads do, and should then be removed. The action of iron perchloride in effecting consolidation of naevoid tissue is very marked. The actual cautery may also be used, multiple punctures By cautery. being made into the naevus. Cure takes place by a mixture of sloughing and consolidation. The liquid iron perchloride, and other fluids, are also By injection. sometimes injected into these groAvths Avith a hypodermic syringe, but although stasis and consolidation may thus be produced, the risks of thrombosis and embolism prevent this method of treatment from becoming common. Small subcutaneous nre/i, Avhich are distinctly encapsuled, may often be dissected out, and although the operator requires to be careful to avoid cutting into the small tumour Avhile it is being removed, it is a very satisfactory treatment, though net one Avnich is generally applicable. All bleeding ceases as soon as the naevus is taken away. 512 OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS, Of piles. External. Internal. Treatment. Preparation of patient. By ligature. Of Piles. External piles give little trouble to the surgeon. They may ahvays be snipped off with a pair of scissors, the cuts being made in a radiating direction, and there is never any haemorrhage which pressure Avill not arrest. The only point to be kept in mind is the risk of contracting the anal orifice by taking aAvay too much skin. But internal (mucous) and muco-cutaneous piles require more careful treatment, and we will here consider the chief plans Avhich are adopted. These are, the ligature, the ecras-ur, the clamp, and the clamp and cautery, and of these the ligature is still the most commonly employed. Whichever plan is to be folloAved, the rectum must ahvays be thoroughly cleared out with an enema, and it is frequently a good plan to direct the patient to sit and strain, as if at stool, over a bucket half full of very hot water, so as to bring the piles down as far as possible, just before the operation. An anaesthetic should always be given* and the patient is most conveniently placed in the lithotomy position ; the surgeon then fully dilates the sphincter ani, and brings doAvn the piles, or as many of them as he proposes to Fig. 224.— Vulsellum Forceps. remove, Avith his finger or Avith vulsellum forceps (Fig. 224), and keeps them protruding from the anus. If the pile be of moderate size, it must be drawn well fonvards, and, supposing the method by ligature to be chosen, its base should be transfixed Avith a strong needle fixed upon a handle (the best pattern is one bent at right angles, about an inch away from the point, and Avith the bent end curved on the flat), Avhich should then be double- threaded Avith stout Avhipcord, well waxed. The needle is then Avithdrawn, so that there are two threads running across the centre of the base of the pile. The next step is * Unless local anaesthesia has been produced, as by cocaine. note p. 419. See OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. 513 to divide the skin where the pile encroaches on it, and also the mucous membrane, all round the base of the pile, with a pair of curved scissors. This greatly shortens the time of separation, and diminishes the pain of the ligature, but of course care must be taken not to cut into the pile. All that now remains to be done is to tie the pile in two halves with the tAvo cords. This strangulation cannot possibly be done too tightly, and the ligatures must lie in the trenches which have been cut for them. One of each pair of ends of cord may then be cut short, the tAvo portions of the pile may be separated with scissors from each other, and then the Avhole mass is generally returned within the anus, there to come aAvay by sloughing ; but it is sometimes advisable, and if the ligature be properly tight, is safe, to cut off the two halves of the pile itself, and return the pedicles only. Quite small piles do not need transfixing and splitting, but may be tied in one piece, the mucous membrane being snipped all round the base as before. Very large piles, or masses of piles, on the contrary, will require to be ligatured in several places, but the principle remains the same. After any operation for piles, it saves much pain to place After manage- a morphia suppository in the rectum, and throughout the men" time of the separation of the ligatures, say from five to seven days, opium may be required to allay pain, and for the first three or four days after, also for the purpose of confining the action of the bowels. After this time, laxa- tives should be given, so that the stools may be soft. Though the ligature is still the most common way of treating internal piles, it is quickly becoming displaced by other less painful methods. Of these the best knoAvn is By damp and that of the clamp and cautery. cautery. In this method the piles are draAvn down as before, and Fig. 225.—Cautery Clamp. then seized Avith a screw clamp (Fig. 225), the blades of which are made parallel, and have ivory plates attached to them, as non-conductors of the heat of the cautery. 33 5H OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. The pile is firmly clamped, and then cut off Avith one of the knives of a Pacquelin's cautery, at an almost invisible red heat, and very sloAvly applied ; or Avith some other form of cautery; or with a scalpel and pair of scissors. The surface aftenvards must be thoroughly cauterised before the clamp is removed, this removal being done gradually, so that if there be any spouting, the jaAvs can be tightened up again, and the cautery re-applied. By crushing. By other methods, even the cautery is dispensed with. Thus by means of a poAverful clamp, such as is here figured (Fig. 226), the pile having been draAvn doAvn, may have its base so thoroughly crushed* that it may be at once cut off FlG. 226.—Clamp for crushing Piles. with a pair of scissors. The clamp should remain on the stump of the pile for about two minutes. Fig. 227.—Chain Ecraseur. By the gcraseur. A chain ecraseur (Fig. 227), worked slowly (say one link in about 10 seconds) is also a very efficient form of removal. * See Lancet, July 3rd, 1880, for explanation of the method; where, however, a different form of clamp (Benham's) is figured, OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. 515 In principle its employment does not differ from the other methods we have described, and the preparation and after treatments are alike in all. The ecraseur may be used to remove a small pile whole, or larger ones in two or more portions, one end of the chain being passed through the base of the pile, as was the whipcord in the case of the ligature. The mucous membrane should also-be similarly divided, in a ring, by the scissors. Again, internal piles may be brought down, clamped, and By nitric acid. thoroughly cauterised with strong nitric acid. This treat- ment is especially applicable to florid sessile piles. Where the haemorrhoids are very large'and involve the AVhitehead's entire circumference of the boAvel, the operation devised by operatlon- Whitehead is most likely to effect a permanent cure, ft consists in removing the mucous membrane, and with it the haemorrhoids from the lowest 1£ or 2 inches of the gut. The sphincters having been stretched, the mucous mem- brane is divided with scissors at its junction Avith the skin all round the anus. The ring of mucous membrane is then separated from the muscular coat as hieh as may be neces- sary ; this is best done with scissors, ah nsemorrnairc must be stopped by forcipressure, and, if necessary, fine silk ligatures. The detached mucous membrane.is next divided above, a small piece at a time, and the edge of the mucous membrane is brought down and sutured to the skin. If the entire segment were removed before commencing to suture, there would probably be very troublesome haemor- rhage. A morphia suppository shoufd be given, and a dry antiseptic dressing applied. The after treatment consists in frequent syringing of the part with an antiseptic lotion. the sutures being alloAved to come aAvay of themselves. The greatest care must be taken to obtain union by first intention, otherwise there will be great risk of the formation of a fibrous stricture. Of painful Fissure or Ulcer of the Anus. of pamfui fis- Small, but very painful cracks, or small ulcers, are often theeanus!lcer oi found at the margin of the anus, and although they are very insignificant in appearance, tbey may render life almost intolerable. Lunar caustic, nitric acid, or a touch wich the actual Treatment. cautery will sometimes cure them, the treatment being combined Avith the use of astringent enemata ; but in severe cases there will be hardly any improvement unless, in addition to such applications, the superficial fibres of the sphincters in the neighbourhood of the ulcer are set at rest, 516 OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. This may often be done by inserting the thumbs within the anus, and suddenly stretching the part; or a rectal dilator may be similarly employed. But the most certain way to attain this rest is to incise the base of the fissure in its Avhole length, so as to divide the fibres of the sphincters which have, by their spasm and irritability, prevented the sore from healing. To do this effectually, an anaesthetic will be required, and a speculum is very necessary to ensure a complete vieAv of the parts. It often happens that these fissures are in connection with small piles, and occasionally with polyps. These must be removed at the time the fissure is incised. of prolapsus Of Prolapsus Ani. This condition is found in children and adults, but is more in infants. frequent and much less serious in the former. Infants are very often brought to the casualty room with the complaint that "their body comes down," every time that the bowels are opened. The patients will generally be weakly and ill- nourished, and on inquiry it will often be found that they have been allowed to crouch for as much as a quarter, or General treat- it may be, half-an-hour, upon a chamber pot. The first direction which must be given is that a proper chair be provided, and that the child is not to remain upon it a moment longer than is necessary. The protruding anus, or rather the rectum, must be returned each time that it comes doAvn, and the opportunity may be taken to apply an astringent lotion (as 2 gr. of sulphate of iron to an ounce of water) to the part." The buttocks may be douched with cold water, anything like constipation avoided, and general tonics, as Parrish's food, given. 0/ 'ad83' plug' . Under such general treatment, most cases of prolapsus in infants will very quickly get Avell; but if the case be more severe it may be necessary to apply some kind of spring truss, made on the principle of those for uterine displace- ment, or some kind of plug or pad, one pattern of Avhich is shown in Fig. 228. When the prolapse is the result of worms or rectal polypi the removal of these will usually effect a cure. in adults. But prolapsus in adults is a more serious affair, and may require extensive operative treatment. Supposing that the case does not yield to a patient replacement of the gut, with the application of astringent lotions, the surgeon may use a stronger caustic application, as the lunar caustic in the solid form, or in strong solution, or nitric acid ; or may score the mucous membrane over Avith the Pacquelin's cautery, taking OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. 517 care in each case that the caustic or cauterising action be limited to the mucous tissues. The prolapse should then be returned, and the case treated in the same way as if it Avere one of internal piles. Fig. 228.—Plug for Prolapsus Ani. In more severe cases still, portions of the prolapsed mem- brane may have to be removed Avith the ligature, clamp and cautery, or ecraseur, as in the case of piles, but these measures are too serious to find a proper place here. Of Fistula in Ano. _ _ of fistula,, We shall here only consider the less serious form of this an0- affection, and will suppose that in all the cases Avith which we have to do, the fistula is one which involves only the loAver inch-and-a-half, or so, of the rectum, and is thus well within the limits of safety as regards haemorrhage. In most cases the fistulae commence as ischio-rectal abscesses, more or less acute at first, and afterwards becoming chronic. On examination a small, often a very small, aperture will be found, which on pressure will exude a little thin sero-pus; and on probing, this will be found to lead along a small channel, tending in the direction of the rectum. The only efficient treatment for this condition is to lay Treatment. this sinus open, so as to convert it into a trench opening along its whole length into the rectum, and by subsequent management to force it to heal up from the bottom. In all fistulae the actual operation is much easier than the Fig. 229.—Brodie's Fistula Probe. conscientious carrying out of the subsequent dressing. The readiest way to cut a fistula is to take a Brodie's fistula probe (Fig. 229), to pass it along the sinus, and if possible, 518 OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. to find the natural opening into the rectum; if this is non- existent, or lies too high up, the end of the probe must be pushed through the rectum, Avherever the sinus seems to come closest to the mucous surface. As soon as the finger placed in the rectum feels the end of the probe, the instrument should be pushed on further and turned, so that its end comes out at the anus; the sphincters (one, or both, if both are involved), and all the tissues betAveen the sinus and the rectum must then be divided by a curved, sharp pointed, bistoury. It sometimes happens, even in the simple fistulae we are considering, that a probe passed along the sinus cannot be turned out of the rectum in this way ; if so, a director of the ordinary pattern should be passed along the track, a curved probe pointed bistoury should then be passed along its groove till its point is felt by the forefinger of the left hand, placed in the rectum, and against the end of the director. This finger must then be kept in contact with the end of the knife Avhile both are withdrawn. In this Avay the tissues betAveen the fistula and the gut will be divided as before. The sinus itself having been slit up, it is necessary to perform certain trimming details, in order to ensure a sound healing. Thus the bottom of the trench into which the sinus is noAv converted, should be incised along its whole extent, and oftentimes it will be Avise to scrape out the granulation tissue which lines it, with the scoop which is here figured (Fig. 230); the unhealthy margins also should Fig. 230.—Scoop for Scraping Sinuses, etc. be freely clipped off, the best instrument for doing this being the fistula scissors (Fig. 231). Fig. 231.— Scissors for Trimming Edges of Fistula;, etc. When all this has been done, the wound must be carefully packed with narrow strips of lint, or with absorbent avooI, and the whole secured with a ~T bandage. There is hardly OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. 519 ever any bleeding which moderate pressure will not arrest. An anaesthetic will be almost ahvays required, unless the parts have been rendered insensitive by cocaine, of which 10 rn. of a 4 to 8 per cent, solution might be injected along the sinus, and a similar quantity into the fibres of the sphincter ani. However thoroughly a fistula may have been operated upon, the ultimate success or failure -lies absolutely in the hands of the dresser. If, through carelessness, he allows the channel to roof itself over, no good will have come of all the surgeon's efforts; he must, therefore, most patiently plug the Avound quite from the bottom, so that it granulates soundly. It matters little with Avhat he does this ; a Aveb of cotton avooI, nariOAv strips of lint soaked in carbolic or eucalyptus oil, or in Friar's balsam, or several other dressings Avill all do about equally Avell. Of Phimosis, Paraphimosis, etc. of phimosis, Of Circumcision for Phimosis in Children. In the first P£ratjhimoS)S' place it may be stated that all children with a long foreskin of circumcision will be placed in a better position, morally and physically, chiidren.0Sls ln by being circumcised, whether they have a true phimosis or no; but these considerations apart, it is certain that many young children Avho have a certain amount of contraction of the aperture of the foreskin, but in whom the skin itself is not specially redundant, are subjected to circumcision quite unnecessarily. In a great number of these cases, all that is necessary is that the orifice should be dilated with a pair of Dilatation. dressing forceps, and the foreskin peeled from off the glans penis to which it is generally adherent.* But if the amount of the foreskin be distinctly redundant, Avhether the orifice be contracted or not, a circumcision should be performed, and in children this is a simple operation. An anaesthetic The operation having been given, the foreskin should be drawn well for- °n chud^n?10" ward over the glans, and held between the jaws of a clamp, such as a haemorrhoidal clamp (Fig. 225), or of a pair of dressing forceps, but not so tightly as to bruise the parts (a pair of parallel rulers do admirably for this purpose). The redundant skin should then be cut away, and if the mucous surface be adherent to the glans it should be peeled off. There will now be an extensive ring of raw surface round the glans, betAveen the edge of the mucous membrane and the edge of the skin, which has retracted. The next * Mr. Richmond has described a convenient instrument for the gradual dilatation of the prepuce. Lancet, 1884, Vol, IL, p. 544. 520 OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. step is to cut through the mucous membrane down the dorsal middle line to the level of the skin margin, and then, turning the mucous surface over, to attach the skin and mucous edges round the organ by a feAV points of suture, silk or catgut being the best to use. There are not more than two arteries which ever seem to require tying, but in these soft tissues ligatures are best avoided. " This can always be managed by keeping a couple of Spencer Wells's, or torsion forceps, on the bleeding points for a minute or tAvo. The dressing of the Avound should be perfectly light and simple; a piece of carbolised oil lint does as well as anything. circumcision, Circumcision, and slitting up the prepuce in adults. etc, in adults. T^s 0peratjon mav De required, as it is in children, for congenital phimosis, and in such cases will not differ at all from that avc have just described; but it may also become necessary in consequence of an acquired contraction of the foreskin, and this again may be due to an inflammatory condition Avhich is present at the time of operation, or to one Avhich has passed off. If a long foreskin be in a state of acute inflammatory oedema, it may be necessary to expose the glans penis for urination, or for the purpose of getting at sores, etc. In such a case no planned circumcision is called for, nor would the results be satisfactory. All that can, or need be done is to pass a director under the foreskin in the middle line of the dorsum, and to cut the tissues along this with a scalpel or strong scissors doAvn to the sulcus. The bleeding up to a certain point, will be beneficial, but it can be easily stopped by pressure, or by the ligature of any spouting vessel. The phimosis which residts from such an inflammation, but Avhich has not required slitting up in its acute stage may be operated on later in the more artistic method we considered first. This may sometimes be the best plan, but more often it will be found advisable to divide the prepuce along the dorsum, and then to readjust the divided skin and mucous surfaces in the most symmetrical way possible. Paraphimosis. Pa raphimosis. In this condition the glans penis and some of the everted mucous membrane of the foreskin is strangulated by the narroAved aperture of the natural or acquired phimosis, through which it has protruded, but cannot be returned in consequence of the oedema, OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. 521 In children, a natural phimosis is generally the cause; in adults, as a rule, the case is one of balanitis with inflam- matory effusion and contraction of the foreskin. In any case the condition causes pain, and will get steadily worse until it is relieved. In children, and in the less severe forms in adults, the Reduction. foreskin can, as a rule, be drawn over the glans Avithout much difficulty. The part having been first well oiled, the size of the cedematous glans can be reduced by wrapping a piece of lint round it and firmly grasping it in the hand for a minute or so, after which, by pressing it directly back- wards with the thumb, at the same time drawing the foreskin foiAvards with the first and second fingers of both hands, the prepuce will come over. In more severe cases an ice bag may be found useful, or the swollen tissue may be stabbed with a scalpel in several places, thus reducing the oedema. If these measures fail, the patient should be given an incision. anaesthetic, and if reduction still cannot be effected, the constricting-ring must be divided along the dorsum of the penis. This ring will probably be found to be very deeply imbedded in the SAvollen parts, so that care must be taken to identify the real seat of strangulation. If a paraphimosis be not reduced, the parts fall quickly into a sloughing condition, which will eventually relieve the constriction at the expense of deformity, through the loss of portions, or it may be of the whole of the glans penis. It will often be advisable to slit up the foreskin at the same time that the paraphimosis is relieved by incision, but this should be done, after the reduction of the glans, as the natural condition of the part can then be more accurately seen. Of Corns, Warts, Coudy'omata, etc. of corns. The common corn Avhich generally forms about the foot deserves perhaps more notice than it generally gets, for it often occasions much suffering, and may even effect com- plete disablement. These growths like other forms of papillomata may be removed with the knife, but this operation, small as it seems, should not be very lightly undertaken, for even small corns dip deeply into the sub-adjacent tissues, and will certainly recur unless they are completely removed, while all cuts about the foot refuse to heal kindly, so that the patient may be laid up for a good while. Professional corn cutters as a rule confine their efforts to diminishing 522 OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. the amount of direct pressure upon the sensitive papillae, by judicious paring of the horny layers, but when they do attempt to remove the whole growth, they commonly effect it by setting up a little suppuration about or beneath its base. In other cases, a caustic, nitric acid being the best, is applied time after time; the burnt parts being pared away. But in the great majority of cases, palliative measures in the way of relief of pressure by properly cut corn plasters will effectually prevent pain Avithout laying up the patient for an hour, and in the end will generally cure the corn. "Corn plasters" as sold are too small, and are of the wrong shape They should be cut to a pattern out of ■ isinglass felt, or out of a similar adhesive stuff, and should be of a shape c| open towards the ankle, to allow of free circulation. The sides of the <3 should be at least thrice the thickness of the central space, which should just admit the corn. The plasters can be taken off at night and put on again in the morning. warts. Warts upon the hands are common in children, and in those who have to handle animal tissues (post-mortem room men, and the like). In children the}r commonly disappear, vanishing sooner or later Avithout being noticed. The best way to remove them is to touch them repeatedly with nitric acid and pare them aAvay. urethral car- Urethral caruncles occur about the aperture of the female urethra, and are exquisitely tender. It is generally neces- sary to give an anaesthetic before removing them, which is best done with the actual cautery, or with scissors, afterwards applying the cautery to their bases, to arrest the bleeding, or the application of a 4 per cent, solution of cocaine will alloAv them to be snipped off, and the cautery to be applied quite painlessly. Removal of Warty groAvths of venereal origin are common about war y grow s. ^^ ^e male and female genitals. They may generally be snipped off with scissors and their bases touched Avith lunar caustic, or nitric acid; but sometimes they are so large, that it is safer to ligature them, when the method detailed for piles may be followed. In other cases, when they are more sessile, the application of nitric acid Avill be best. condylomata. True condylomata, moist cutaneous tubercules, are sometimes treated locally with the stronger caustics, but more fre- quently powders which are somewhat escharotic, but Avhich also serve to keep the parts dry, are preferred. Thus equal parts of calomel and zinc oxide, or of verdigris and savin OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. 623 may be used. These also yield to constitutional treatment much more readily than warty growths. Of Fistulous Tracks in the Groin and elsewhere. Sinuses in of fistulous the groin are very common as the result of buboes, and j^oinYnd^ise- once formed, will burrow to an almost unlimited extent. wnere« But Avherever the sinus may be, the same line of treatment must be adopted, as has been before described for fistula in ano. It is hopeless to expect any healing until the tunnel has been converted into a trench, and made to heal from the bottom. The windings of the fistulae must be followed up with the director and scalpel, and the details of scraping, trimming and dressing, are precisely as before described. We should, however, add here, what we omitted to mention before, namely, the great use of an occasional application of lunar caustic to the edges and base of the trenches. Of Ingrown Toe-nail, and Avulsion of Nails. The great toe-nail often produces an extremely painful of ingrown toe ulceration, on one or both sides, by an ingroAvth of its mar- s\on'ofnaiis. gins. The irritation thus produced causes a hypertrophy of the neighbouring skin, and a condition of paronychia, so that the nail may come to be half buried in fungous granulations, with a foetid discharge, and the patient may be unable to put his foot to the ground. There are prob- ably very few, if any, cases of ingroAvn toe-nail which cannot be cured by measures short of pulling out the nail, but in all except the slighter forms, much time and patience will be required to achieve success. If the nail is to be kept, the common treatment is to cure without gradually lift it up from its bed, by gently packing some- thing, such as a pledget of cotton avooI, beneath its edge, three or four times a day; and at the same time to reduce its thickness to that of a piece of note paper by rubbing it down, for which purpose pumice stone will be most service- able. The exuberant edges may be touched with caustic; and iodoform, or the powder of the nitrate of lead, will be found good applications to the ulceration. The use of a small piece of sheet lead slipped beneath the Master's nail to raise its edge has long been knoAvn, but we believe m that the following plan, for the knowledge of which we are indebted to Mr. H. T. Masters, of Whitchurch, is as orig- inal as it is certainly successful. A piece of silver, about the thickness of note paper, and about \ an inch long, and \ of an inch broad, is bent to the shape of A. B. in Fig. 232 (this can very conveniently be made out of a threepenny piece filed down), one end, B, being bent up to a right angle. 524 OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. This end is inserted underneath the nail so that the ingrown edge just rests in the groove thus formed. The rest of the plate must then be used as a lever, and pressed down upon Fig. 232.—Silver Lever for Ingrown Toe-nails. the side of the toe until it lies against it as shown in the illustration. By this means the edge of the nail is raised, and the exuberant granulation tissue, which is almost always present, pressed down, and aAvay from it. The plate is then fixed in position by a circular turn of strap- ping, cut about an inch wide (not shown in the figure). The relief afforded by this simple adjustment is immediate and very striking, so that patients can Avalk with ease as soon as the plate is fixed, and a permanent cure is generally speedy. Working on these lines, as we have said, almost all in- grown nails can be cured, and the patient can himself assist the process greatly; but it takes time, and it may be readier and more satisfactory to remove the nail. Removal of If this plan be chosen, the whole nail should be removed, not the ingrown half, as is sometimes recommended. An anaesthetic having been given, the surgeon runs one blade of a strong pair of scissors beneath the centre of the nail, down to its root, and cuts it in two. Then with two pairs of forceps he twists the two halves inwards and outwards, and pulls them off. All bleeding is easily arrested by pres- sure, and the part is lightly dressed. Any trimming of the edges that is required should be done at the same time. Other nails, both of fingers and toes, may require removal for onychia, abscess of matrix, injury, etc., but in such cases it will generally be best, in preference to splitting the nail and wrenching it off, to gently separate the nail from its bed, until it can easily be pulled away; this is especially the case in removal of a finger nail, where great care is required lest the matrix itself should be scarred; the results will not sIioav at the time, but as the neAV nail grows, the OF TRACHEOTOMY, AND OTHER MINOR OPERATIONS. 525 cicatrix in the matrix will cause the nail to be permanently misshapen. Warty growths not infrequently form from beneath the warty growths nails, and especially from beneath the great toe-nails. They beneath nails- will, if neglected, cause pain and ulceration by pressure, and it is always best to remove them. This may generally be done by paring, and the use of some caustic; but it may be necessary to remove a portion, or the whole of the nail in order to get at the base of the growth. A small cancellous exostosis is also apt to form beneath suh-unguai the nail of the great toe, and this is often mistaken for a exostosis- warty growth, but its nature will be recognised by any properly careful examination. It should be removed early, for if it be allowed to grow, it will be sure to occasion inconvenience. The best method of getting it away is to pass a scalpel round its base, cutting all the tissues down to the bone, and then to snip it off' with small sharp bone forceps. As in the case of warts, it may be necessary to remove a part or the whole of the nail for the sake of exposure. Two infantile conditions remain for notice, namely, Tongue-tie, and adhesion of the vaginal margins. Mothers frequently bring their infants to the hospital in Tongue-tie. the belief that they are tongue-tied, when either there is nothing the matter with them, or else there is only a fragile band of membrane Avhich can easily be broken down Avith the finger. But if the fraenum linguae be really too short and thick, it must be divided with a pair of blunt pointed scissors, the points of Avhich must turn downwards, towards the floor of the mouth. The tongue must be held up by two fingers, or by that special form of spatula with a slit in it, combined with a director, Avhich may often be found in pocket instrument cases. The tongue should be freed more by tearing than by cutting. Very commonly indeed, neAvly born female children are vaginal brought with the report that " the womb is shut," or some a similar phrase is used; Avhen, upon examination, a small pin-hole aperture is seen, by which the urine escapes, and at first sight the rest of the vaginal opening seems to be absent.* But if a probe or director be passed into this * We have known medical men advise infants to be taken long journeys to a hospital for operation, this condition being supposed to be one of imperforate hymen, or of absence of the vagina. 526 OF TRACHEOTOMY, AND OTHER. MINOR OPERATIONS. opening, and pressed doAvnwards, it Avill be seen that the parts are perfectly normal, and that there has been only an adhesion of the margins of the vaginal orifice. No further treatment is required, and we mention the condition only because it is so often mistaken by mothers and dressers for something far more serious, whereby much anxietv is caused. OF VENISECTION 527 CHAPTEE XXXVII. Of Venisection, Cupping, etc., and of Blisters and other Methods of Counter Irritation. Of Venisection. Of venaesection. The practice of venaesection is so much out of fashion that probably the majority of house surgeons noAv in office have never seen the operation performed, still less performed it themselves. It is to be hoped that so effectual and certain a remedy will soon become again more general, and it is most unlikely that it will ever really die out of use. The veins which are opened for the purpose of letting The veins blood, are, one of those at the bend of the elbow, the suitable.'6 jugular, and much more rarely, the internal saphena at the ankle. The method is much the same in each case, and we will describe in detail only the commonest, namely, of one of the veins at the bend of the elbow, usually the median basilic. The patient, who should be sitting, is directed to hang Method. the arm down so as to produce turgescence of the veins. A piece of bandage is then tied tightly round the, arm, a pad being placed over the trunk vein on the inside, and the bandage knotted over that. The hand should then be raised to the horizontal position, and be made to grasp a strong pole resting on the ground (the origin of the barber's sign pole), a broom handle will do very well. The limb is thus steadied, and the forcible muscular flexion aids the venous fullness. Supposing the median basilic to be selected, the thumb should be placed just beloAv the spot chosen for incision, so that the vein, and the skin over it, is steadied, and the blood prevented from spurting out. The surgeon . then, with a lancet, or a very sharp knife (the former is best, from the extreme thinness of its blade) incises the vein obliquely, cutting it about half across. On removing the thumb, blood should immediately Aoav in a somewhat forcible stream, and this should continue until about five or six ounces have been removed; it will then generally slacken, and if more blood is to be draAvn, the surgeon must rub the limb from beloAv upAvards, and direct the 528 OF VENISECTION. patient to alternately open and close the hand, or to flex and extend the elboAV, so that the muscular contraction may aid the Aoav. When as much blood as is required has escaped, the ligature on the arm must be relaxed, the arm raised, and a pad placed upon the wound. The pad should be secured by a double figure of 8, the ends being tied in a bow, or reef knot over it. Complications Complications of Venisection. of venisection. Tf the instruments are perfectly clean, diffuse inflam- mation can hardly occur, but in older and ruder days this was not infrequent. A more serious accident still, seems to have happened somewhat unaccountably often, namely a puncture of the brachial artery, or an opening of it in mistake for the vein. This sometimes resulted in the formation of an arterio- venous aneurism, or in an aneurismal varix, and sometimes in consequences still more serious. It is very necessary that the wound in the skin and that in the vein should exactly correspond, and every care must be taken that the former does not slip over the latter during the incision. This is best prevented by using a very sharp lancet, and by fixing the vein firmly. In cases where the vein is difficult to find, a careful exposure of the vessel by dissection will prove of great service. (See Transfusion, p. 56.) Bieedin? from Bleeding from the Jugular Vein is sometimes adopted in vein. children from the small size of the arm veins, and in adults for other reasons. (See Apoplexy, p. 363.) The operation is conducted on the same principles as for bleeding from the arm, but the compress to produce distension of the vein must be applied very firmly above the clavicle, outside the sterno-mastoid, lest air should enter. The vessel is incised upon the sterno-mastoid, in its long axis, as the platysma fibres here cross it obliquely. The after management is the same as before, but the pad must be placed on the . Avound before the compress over the clavicle is relaxed. Arteriotomy. Arteriotomy is still more rarely performed than venae- section. The temporal artery, or one of its branches, is the only vessel opened for this purpose. It should be half cut through with a lancet, as in the case of the vein, but trans- versely ; and Avhen the desired amount of blood has escaped, the division of the vessel should be completed and a very firm compress applied, which should be left undisturbed for four or five days. OF VENISECTION. 529 Cupping. cupping. By means of "cups" the blood may either be merely drawn to the surface by taking off the atmospheric pressure, or it may, having been thither attracted, be removed by a scarificator. The former proceeding is "dry," the latter "wet," cupping. The nape of the neck and the posterior surfaces of the thorax and loins are by far the most common situations, but any part which will hold the glass will do. In order to cup successfully some dexterity is required. Dry cupping. The principle on Avhich it depends is the creation of a considerable A'acuum beneath bell-shaped glasses (Fig. 233), which are made in various sizes. These glasses are some- times made so that they can be attached to an exhausting syringe, like the bell jar of an air pump. But in skilful hands a better vacuum is obtained by quickly rarefying the air by heat. A good cupper will do this by simply putting a lighted paper spill within the cup for an instant and im- mediately applying the latter to the surface of the skin; but Fig. 233.—Cupping Glass. for most people it will be easier to put a feAV drops of spirits of Avine into the cup, and to distribute the spirit over its interior. A pledget of cotton wool placed on a stick should then be dipped in spirit, lighted, and mopped round the inside of the glass. This will produce a large but momen- tary flame, and as soon as it is alight, the cup should be "clapped" upon the required place. The flame will be immediately extinguished, and the vacuum will shoAv itself by an almost instantaneous rising of the skin. The essential points to attend to are, that only just so much spirit should be put into the cup as will moisten its sides, and that the rim of the cup be applied perfectly to the skin, so as to exclude all air. 530 OF VENISECTION. Wet cupping. The scari- ficator. In dry cupping, six or eight glasses are frequently used, and in the absence of those of the regular form, wine glasses will do nearly as well, although their sharp edges are apt to cause pain.* If wet cupping is to be practised, one, two, or more glasses are placed on the skin as before; as soon as the skin has risen within them they are removed, and numerous small incisions are made in the swollen area, by means of a scari- ficator. The cups are then replaced (the measures for their exhaustion being repeated), and will quickly be nearly filled with blood. They then become loose and must be taken aAvay with their contents. These cups can again be applied, if still more blood be required, and when the operation is over, the wound should be lightly and simply dressed. The Scarificator (Fig. 234) is an arrangement of knife Fig. 234.—Scarificator. edges, protruding through a plate with slits in it, and having a set screw and trigger mechanism, so arranged that the depth to which the tissues will be divided can be determined, and that the knives shall only momentarily be protruded when the trigger is released. The depth desired is that Avhich will incise the true skin, but not open up the cellular tissue below. If the cuts are too deep, pellets of fat A\rill choke the incisions, and prevent the flow of blood. This instrument should be pressed pretty firmly against the skin surface Avhen the trigger is released. We should not omit to mention the usefulness of scari- fication as a means of depletion in forms of local congestion, * An india-rubber cup of the same shape as the glass ones has been introduced, and appears to work well. The rubber is sufficiently stout to tend forcibly to recover its shape, after it has been squeezed out of it. Its bell-shaped cavity can thus be com- pressed, and its margin applied to the skin. When left alone it will be found to adhere with considerable suction. OF VENISECTION. 531 other than those for Avhich wet cupping is indicated. Thus in acute orchitis, relief may be afforded by numerous punc- tures with a sharp lancet or scalpel; and some of the good effects of the incisions which we have already described as being essential in certain forms of erysipelas, are due to the local abstraction of blood thus effected. Of Leeches. Of leeches. If leeches are to be applied anywhere within the cavity of the body, such as in the mouth, nose, vagina, etc., a leech glass from which they cannot escape should be used; but if they are required for outside surfaces, they may be placed within a pill-box, covered with a piece of lint, or held lightly in the hand. The part to be leeched should be washed Avith warm water, or milk, and must be perfectly clean. Those leeches should be chosen which are thinnest and most lively.* It is estimated that a leech should extract from 5j to 51'j of blood before it is gorged, but if a poultice be put over the bites, much more will flow. A leech should never be allowed to bite into a vein, or troublesome haemorrhage may follow; pressure would always stop this, in any situation where it could be applied, but it may be necessary to adopt such measures as passing a needle below the bite, and twisting silk round it, etc. Of certain Methods of Counter-irritation. of counter- ed/ Blisters. These are usually produced by painting ^mister's. blistering fluid (Liquor Epispasticus P.B.) over the required area, or by applying a cantharides plaster, cut to the desired shape. If there are any hairs on the part to be blistered, they should be shaved off, and the skin washed with a strong soap, to remove the natural oil. Any form of blister will rise less painfully, and more effectually under a light bread or linseed poultice. If the blistering fluid be used, the most convenient way to apply it is to cut a hole of the desired size in a piece of note paper, to hold it firmly over the part, and then to paint on the fluid with a camel's-hair brush. In this way the blister * In old days at St. Bartholomew's, before the days of house physicians, there was a resident apothecary, who had charge of the leeching, then a very laborious task. We just recollect the last of these officers and his management of his leeches. He handled them, indeed, as Isaac Walton recommends that their cousin annelids should be handled, as though he loved them; in cold weather, always gently chafing them beside the fire between warm flannels, before he set them to their work. 532 OF VENISECTION. is strictly limited. Another plan is to smear simple oint- ment round the part to be blistered. The dresser or nurse must be careful to keep the hands well away from the eyes during the application of any blistering fluid. When the bleb has fully formed, it may either be snipped at its most dependent part, and the serum soaked up with blotting paper; or if it be desired that the blister should remain open for some time, the whole cuticle should be cut off, and the sore dressed Avith some irritant ointment, of Avhich the Unguentum Savinae is the most frequently em- ployed. (Blisters are occasionally dressed with mercurial ointment, Avhen a poAverful counter-irritation is required.) of the actual Of the Actual Cautery. We have so frequently considered the employment of different forms of the actual cautery for various surgical purposes, that we need only here remind the reader that in addition to its employment for the arrest of haemorrhage, the removal of growths, etc., the cautery has a large field of usefulness as a most effectual counter-irritant. Thus for chronic diseased conditions of joints, " firing " is often very successful, as it is also for the relief of neuralgias, such as sciatica. Whether the cautery irons, or Pacquelin's instrument be used, the usual method is to "score" the skin surface over the seat of pain or disease, very much as a horse's leg is fired. But in the treatment of spinal disease by the various forms of thermo-cautery, other methods are adopted, such as the needle cautery, etc., descriptions of which will be found in books especially dealing with this subject. of setons. Of Setons. The use of setons is the last method of counter-irritation which we shall mention. These are foreign bodies, intro- duced, and retained, beneath the skin, in the neighbourhood of diseased organs or tissues. The regular "seton knife," formerly used, was a thin, double-edged, flat-bladed one, shaped like a small spatula. It was run through a pinched-up fold of the skin, and the slit thus made was occupied by a flat, ribbon-like piece of whalebone, gum elastic, or ivory. But at the present time, the general way is to pass two, four, or more strands of silk or Avhipcord, by means of a stout-handled needle, having its eye near the point. This is entered, and passed for a sufficient distance beneath the skin, and is then double, or quadruple threaded. The needle is then retracted, and the OF VEN.-ESECTION. 533 ends of the threads thus placed are loosely tied together. In the course of a day or two, they will begin to make a suppurating track. They are then worked to and fro, to keep up the irritation as long as may be desired. Of Vaccination. Of Vaccination. The chief plans of vaccination are: (1) From arm to arm; (2) by means of tubes containing lymph from ripe vesicles; (3) by means of ivory points which have been dipped in the lymph and allowed to dry; and (4) by means of tubes of calf lymph. The chief methods of vaccination are: (1) By means of small oblique punctures into the cutis vera, made Avith an arrow-headed lancet, charged Avith the lymph, this being procured direct from the vesicle, or from a tube; (2) by inserting the ivory points into such punctures, these having been moistened the instant before by being dipped in Avarm water; (3) by making within a small area, numerous scratches through the cuticle, like the cross hatching of an engraving, and then rubbing in the lymph from the vesicle, tube, or point, for a minute or two. There is little doubt that this last method is the most Arm-to-arm generally trustworthy, although it is somewhat more troublesome. If the arm-to-arm plan be adopted, the lymph, quite free from blood, must be taken from a matured vesicle on the eighth day after inoculation, by puncturing its upper pearly portion, from which slightly opalescent droplets will exude. The lancet may be charged with this, and inserted as has just been described, or a scratched area may have the lymph rubbed into it with some rounded instrument like the end of a common pen- holder. In all cases, for a primary vaccination, three inoculations should be made, and the place nearly ahvays chosen is the top of the arm, near the surface of the deltoid. If ivory points be used, the best plan, as has just been By ivory points. stated, is to insert them into small oblique incisions made with an arrow-headed lancet; or they may just be dipped in water and rubbed upon the scratched surfaces. These points are the least satisfactory of all methods of vaccin- ation, but they are convenient. The lymph which is enclosed in capillary tubes is pro- By capillary cured from ripe vesicles. The tubes being immediately tubes- sealed hermetically, humanised lymph will, under these circumstances, keep for a long time. When it is to be used, the ends of the tube are broken off and the contents 534 OF VENISECTION. blown out upon a clean slip of glass. The vaccination may then be performed with a lancet or by scratching with a needle as before. These tubes can always be procured from Whitehall. calf lymph. The methods of vaccination with calf lymph are precisely the same as Avith the humanised kind. It may be performed direct from calf to child, or by means of tubes, but in the latter case, it is now known that the lymph will only be certainly successful, if used within a few days of the time the tubes were charged. It is absolutely necessary that all instruments, etc., used for the purposes of vaccination should be scrupulously clean. OF PREPARATION OF PATIENTS FOR OPERATION, ETC. 535 SECTION X. CHAPTER XXXVIIL On the Preparation of Patients for Operation, and their after-treatment. Of the preparation of patients for operation, etc. In the case of the prepara- of an operation upon a child, the house surgeon should for^peration"*" always be sure that its parents, or responsible relatives, et0, understand and consent to its performance. In many cases it will be found much harder to gain this consent than if the operation had to be performed upon the persons of the parents themselves. AVith most hospital patients argument is of little avail, and a plain statement of the facts and issues of the case, will be found to outweigh any eloquence. The ward sister will alsod>e found an invaluable auxiliary in cases where persuasiveness is required. No operation should ever be performed on an adult with- out his consent, and here also tact "will be required; patients much more commonly object to come into a hospital for an operation, than refuse to undergo it. when it is put to them after they have been in the wards a short time, when they have learned to know and trust the surgical and nursing staff, and to recognise that the large majority of patients operated upon recover. It is therefore sometimes wise to defer the question of the necessity of an operation until the patient has been admitted for a little time, and has become used to the ward. But although a patient may be so far managed for his OAvn benefit, mere good faith demands that in all cases the necessity, or desirability of the operation, its possible results, and its risks, should be fully explained to every person, before they submit themselves to it, and neither honesty nor policy demands that its importance should be minimised. We do not mean by this that any vieAv but the most cheer- ful one should be taken. It is not wise or necessary, for example, that a woman with a scirrhous growth in the 536 OF PREPARATION OF PATIENTS FOR OPERATION, ETC. breast, should have the statistics of recurrence forced upon her attention, but the facts should rather be emphasised that life is undoubtedly prolonged, and health and comfort retained by an operation which is not in itself dangerous, and that complete removal has resulted in permanent cure. In women, the date of an operation should be arranged to fall as far as possible from a menstrual period, unless they have ceased to menstruate, but in cases of urgency the floAv of the menses should not be made a bar to the operation. The evening before the day of operation, a mild purgative should be given, and it is also wise to give a simple enema upon the morning of the day itself, so that the patient may not be troubled by the presence of hardened faeces in the rectum, if, as commonly happens, the bowels are not opened for a few days aftenvards. In cases of haemorrhoids it should be ascertained that the enema has been returned. Directions as to the appropriate dieting of patients pre- vious to taking an anaesthetic, have already been given. (See page 397.) cleansing of If the part to be operated upon be hairy, as the head, skin' pubes, or axilla, it should be shaved beforehand, and had better be washed Avith soap, and with AArater containing a little soda, so as to remove the natural oil from the skin. clothing. The clothing Avhich the patient is to wear during the operation must be light, and warm, and loose, and so arranged that the part to be operated upon can be easily exposed with little disturbance of the rest of the body. In hospital, it will save the patient needless distress of mind for the anaesthetic to be administered in some place other than the operating theatre, crowded with students. AVarmth. If the patient be feeble, or the operation a protracted one, a precaution Avhich is too often neglected is to keep a hot water tin at the feet during its performance. The operating room must in all cases be properly warmed, and during the operation the bed to which the patient is to return, must also be Avarmed, and should have hot water tins placed Avithin it beneath the under sheet. The crowding round the operating table of any by- standers beyond the surgeon and the necessary assistants, should be absolutely prohibited, and students fresh from the dissecting, or post mortem rooms, should not be allowed to come near. a^d^ngel A11 instruments which are likely to be required should be OF PREPARATION OF PATIENTS FOR OPERATION, ETC. 537 got ready and examined beforehand by the house surgeon, and are generally placed in trays containing carbolic acid solution, 1 part in 20; if sponges are used they should be kept in their carbolised solutions until they are wanted. (See page 234). Especially should those instruments which may be re- quired for the arrest of haemorrhage be carefully kept ready to hand, and the condition of the edges of scalpels, and the points of needles looked to. At the conclusion of the operation, when the patient has watching of been put back into bed, the head should be kept Ioav, to operation, er avoid any faintness, and a special nurse, or a dresser, detailed to Avatch the course of events for the next few hours. Patients must never be left alone to come to themselves after operation, for not only may reactionary haemorrhage occur, but it sometimes happens that recovery from anaesthetic unconsciousness is marked by a delirium of more or less violence, during Avhich the patient may tear off the bandages, or do other mischief. It is very desirable that the patient should have a good importance of night after undergoing an operation, and a late visit should be paid by the house surgeon to ascertain this point. If there be much restlessness, an injection of morphia should be given in preference to opium by the mouth, but this drug, or chloral, or any other hypnotic, should not be ordered as a matter of routine, for it frequently happens that the trials of the day will produce a sound natural sleep. Vomiting after an operation is generally due to the vomiting. action of the anaesthetic, and is sometimes a very serious complication; it may be set up by allowing food to be taken too soon. In all cases the patient should be directed to lie quite still, and must never be encouraged to be sick, Avith the idea that the emesis will give relief. Lumps of ice, or ice cold water, with a little brandy in it if required, Avill generally check this. Morphia in small doses (say I- to i gr.) may be injected hypodermically. Bromide of potash and small doses of ipecacuanha may be useful in this condition, and iced champagne is often ordered for its relief, but in most cases the nausea will be most readily checked by keeping the patient still, and giving only iced Avater, or iced milk and water, by the mouth. Inquiry AoHond chould ahvays be made as to the action of the bladder after an operation. If six or eight hours pass without the urine being passed, hot flannels, or a poultice should be placed 538 OF PREPARATION OF PATIENTS FOR OPERATION, ETC. Best time for operating. Condition of bowels. Poisoning from antiseptics. Perchloride of mercury. Carbolic acid. over the supra-pubic region, and as soon as there are physical signs of distension, if the warmth thus applied does not give relief, a catheter must be passed. Other things being equal, the morning hours (say from 9 to 10 o'clock) are the best for operating, and it may be said broadly that harm only can come from the presence of the patient's friends either shortly before, or from twenty- four to forty-eight hours after any serious operation. If the bowels are not opened naturally by the third day after the operation (except in herniotomies or other ab- dominal cases), a dose of castor oil, followed by a simple enema is generally all that will be required. Poisoning from Antiseptics. Under the present system of dressing wounds poisoning occasionally occurs from absorption of drugs used in the lotions or dressings, and the house surgeon should remember the possibility of this occurring, and be able to recognise the early symptoms. . Perchloride of mercury, carbolic acid and iodoform, are the three antiseptics most liable to be followed by toxic effects, and a brief account of the most common symptoms will be here given. The signs are often vague, and a certain diagnosis may be impossible, but in any case of doubt the method of dressing should at once be altered. Perchloride of mercury. Poisoning most frequently occurs after large irregular cavities have been washed out with a strong lotion, some of which is retained and absorbed. The chief symptom is diarrhoea Avith abdominal pain and distension, and blood also may be passed per rectum. Salivation is rare. There may be at first some rise of temperature. Death occurs either from collapse or the exhausting effect of the diarrhoea. Post mortem, imflam- mation and ulceration of the intestines will be found, usually most marked in the large gut. Carbolic acid. Under the old Listerian method of dress- ing it was not unusual for the urine, yelloAv when first passed, to become of an olive green colour on standing; or it might be tinged when first passed, the colour deepening afterwards, until it became almost black. This condition by itself is not of any great importance, but when poisoning occurs there are other symptoms added, of which severe vomiting is the most important. The temperature usually becomes subnormal, and a condition of collapse supervenes, with a rapid feeble pulse, fixed pupils and muscular twitch- ings, ending in death. The sulphates also disappear from the urine and albumen may be present. 6F PREPARATION OF PATIENTS FOR OPERATION, ETC. 53§ Iodoform poisoning is rarely seen in England where the iodoform. drug is used in much smaller quantities than abroad. The symptoms are very variable, and the diagnosis is often difficult. In some cases there is simply collapse, in others, a high temperature. The pulse is frequent and feeble, and there may be wild delirium, or drowsiness, especially in children. The patient rapidly emaciates, there is loss of appetite, and a complaint that everything smells and tastes of the drug. In all cases of poisoning the first and most obvious treat- Treatment ment is to discontinue the use of the toxic drug, and the wound should be thoroughly cleansed with a non-poisonous lotion, such as boracic acid. In carbolic acid poisoning the frequent administration of small doses of sulphate of soda has been recommended, and should be tried. 540 on The making oF poultices, fomentations, etc. CHAPTER XXXIX. On the making of Poultices, Fomentations, etc. Poultices, etc. Materials for making poul- tices. Linseed meal poultice. How to make. Poultices are to be applied in surgical cases Avhen a super- ficial inflammation is to be allayed, the process of suppura- tion hastened, or when any wound or sore has assumed a sloughing or otherwise unhealthy character. In medical cases their useful action is less direct, inasmuch as they are mainly intended to reduce an inflammation of parts at a distance from the skin surface to which the heat and moisture are applied. But in all cases the immediate object to be served by putting on a poultice is to warm and moisten the tissues with which it is in contact. The manner of its action is partly mechanical, for by relaxing the tissues, pain and tension are reduced; and partly physiological, as it affects, primarily, the circulation of the part poulticed, and secondarily the tissues or organs at a distance. A great variety of materials have been used at one time or another for making poultices, carrots, turnips, potatoes, etc., but we shall here consider the following only:— 1. Poultices of crushed linseed meal. oatmeal. bread. starch. j) bran. yeast. with charcoal. with mustard with iodine (Marshall's). flour. The common linseed meal poultice is the one in the most general use, and is the easiest to make. The crushed seed, not the ground linseed flour, should always be chosen, for the former still retains a good deal of oil which gives a surface to the poultice mass, and prevents it from sticking to the skin. All that is necessary to make a good linseed poultice is to see that the Avater is boiling to begin with, and to waste no time in the mixing. The general plan is to scald out a ON THE MAKING OF POULTICES, FOMENTATIONS, ETC. 541 pudding basin, to put into it the linseed, and to add boiling water gradually, stirring the mass with a warm spoon; or if it is preferred, the Avater may be put first into the basin and the meal gradually added; or again (and in this way all cooling of the poultice mass during mixing is avoided), a sufficient quantity of water may be kept boiling in a sauce- pan upon the fire, and the linseed gradually stirred into it. In any case, when the proper consistence has been reached, the contents of basin or saucepan should be emptied out upon a piece of old linen or cotton stuff, of the shape of, but a little larger every Avay than the poultice required, and quickly spread with a spatula, or large knife (an ivory paper knife does well), Avhich must be kept well wetted Avith boiling Avater, until it is everyAvhere about \ inch thick. This spreading should have distributed the mass evenly over the stuff', up to about an inch of its edges; this inch must now be neatly turned over upon the margins of the poultice to Avhich it will adhere. Another good plan is to card out Ioav and fashion it into a bed for the poultice mass. The manipulation of the tow requires some practice, and can hardly be described in words, but it forms a very light non-conducting backing. If the mean has been hit betAveen sloppiness and dryness, the poultice should now be able to be folded up or handled freely Avithout coming to pieces, and its surface should be smooth and non-adherent to the skin, to Avhich it should be, Avhen first made, still too hot to be applied. If it be desired to keep a poultice hot for a little time before it is applied, or if one has to be carried for any distance, it is best to fold it up and place it between tAvo hot plates. Poultices should be applied as hot as they can be borne, and to get the full benefit of them they should be changed at least every two hours, for whatever they are made of they soon get stiff and cold ; as a rule, every three or four hours is considered to be the time for changing poultices, and in hospital it is perhaps hardly possible that it should be otherwise. But under no circumstances should eight or ten hours be allowed to pass, for by that time the poultice will have become sour. Of whatever kind the poultice may be the surface of the mass must be placed upon the skin itself, Avithout the inter- vention of any woven stuff', even of the thinnest muslin. If oiled silk or oiled paper be placed over the back of the poultice it will retain its heat and moisture better. 542 ON THE MAKING OF POULTICES, FOMENTATIONS, ETC. All old poultices should be burned directly, never allowed to remain in a ward, or be throAvn into a dust-bin. An aseptic character is thought by some to be given to poultices, by making them Avith condy, carbolic lotion, sanitas, or liq. carbonis detergens, instead of with simple water. Of these fluids, the tAvo last are the best, and are certainly of some use in the case of foul or sloughing wounds Avhich are being poulticed. chaicoai. Charcoal poultices. A more distinct antiseptic action is supposed to be exercised by poultices made of three parts of linseed to one of charcoal in powder, but the poAvder used in this way has much of its disinfectant poAver destroyed, and it is much better to sprinkle it in the dry form over the wound, and then to apply an ordinary poultice over all. Mustard. Tor counter-irritation mustard flour may be added to the crushed linseed in varying proportions (generally equal parts of each), and the poultice made as before. These " mustard plasters " are largely used in domestic medicine, but they are often a useful stimulant in surgical cases, as in cold, or callous ulcers of the legs. Such applications as iodoform, or opium in powder, are sometimes dusted upon the surfaces of poultices; or laud- anum, or the tincture of belladonna, may be sprinkled over them for anodyne purposes, but this is not generally con- sidered a good Avay of administering such local remedies. oatmeai. Oatmeal poultices are commonly used in Scotland, but more rarelv in the south of England. They are somewhat heavier than linseed ones, but in the respect of caking when cold, etc., they are practically identical; they are also made in just the same manner. Bread. Bread poultices are also in very common use, although they are rather difficult to make "of the right consistence, neither sloppy nor crumbly, and so as to be non-adherent to the skin. Their lightness is their chief merit. The readiest way, but one which will do only for small poultices, is to take a slice of stale bread Avithout crust, to place it in a scalded basin, and pour boiling water upon it. The basin should then be kept hot upon the hob, or in an oven for a feAV minutes. Then the water should be poured off it as completely as possible, and the remaining bread pulp spread out upon linen or tow as in the case of linseed. But no large bread poultice of any consistence can be made in this way; if this be required, the crumb of a very stale loaf should be passed through a grater until it is like coarse flour. The poultice can then be made in the ON THE MAKING OF POULTICES, FOMENTATIONS, ETC. 543 same way as a linseed one, and if spread out to a similar thickness will be a much lighter poultice. The lack of any natural oil in the bread must be made up by pouring a little olive oil over the surface of the poultice Avhen made, or it will stick to the skin. A starch poultice is non-irritant and keeps its heat Avell. starch. A stiff starch paste should be made with cold water in a basin, and then enough boiling water added to bring this to a proper consistence, the mass being then spread upon linen. Starch and iodine chemically combine to form a mass starch and which may be termed a cold poultice, and which is a very iodine• useful application for syphilitic ulcerations. It is made by adding 35s liq. iodi to a hot starch jelly, which itself has been made by adding ^vj of boiling water to ^ij of starch. Bran poultices are made simolv with bran and water; Bran. they are light, but do nor. retain neat weu. Yeast poultices are the last Ave shall mention. One form Yeast. consists simply of a mass of Avarm dough Avhich is at the time fermenting through the action of yeast added to it (either of breAver's yeast or any other kind), the quantities • required being roughly 14 oz. flour, 6 oz. brewer's yeast, 6 oz. hot water (i.e., 100° F.). Another form of yeast poultice is made by spreading warm yeast over an ordinary linseed or bread poultice. Both kinds have been supposed to exercise a special cleans- ing action upon sloughy wounds, gangrenous parts, and the like. A fomentation is made by soaking a piece of flannel in Fomentations. boiling water, and wringing it as drv as possible in a Avarmed towel. Some few people, laundresses especially, are able to perform this wringing with their unaided wrists, but for most it will be necessary to use a set of wringing sticks. These consist of two pieces of stick-like rulers, about 2ft. Gin. in length, passed through the ends of a round toAvel, about 2ft. 6in. by lOin. When the soaked flannel is picked out of the boiling water it should be alloAved to drip for a few seconds, and then it must be placed in the centre of the towelling, and the Avhole twisted up by the leverage of the sticks, until no more water comes away. This should take but a few moments. Another good AAray is to seAv the ends of the flannel together and to pass the sticks through, before the boiling water is poured on to it. It can then be lifted and Avrung without loss of time, and put into a dry warm towel. 544 ON THE MAKING OF POULTICES, FOMENTATIONS, ETC. For a simple fomentation the flannel should just be applied to the skin as an application of Avarmth and mois- ture, and covered with a piece of oiled silk slightly larger than the fomentation; over this again a layer of cotton wool should be laid, and the whole fixed with a triangular bandage or a feAV turns of a roller. Instead of ordinary flannel, boracic lint is frequently used, and has the advan- tage of being antiseptic. But these fomentations are often used with some counter-irritant or anodyne ; thus laud- anum, or the tincture of belladonna may be sprinkled over the flannel, or turpentine is used more frequently still. Turpentine This last forms the common turpentine stupe, so often used stupe. £Qr ium|jag0 Xn all cases if the fomentation is to produce its proper action, the flannel must be wrung dry out of boiling Avater, and if the Avringing be not effectually per- formed, it is quite likely that some scalding of the skin will take place. UPON SURGICAL CASE TAKING. 545 CHAPTER XL. Upon Surgical Case Taking. The art of taking notes of surgical cases well, is one not Surgical case easily acquired, and for the notes to be of much value,taking> something more than vague general notions upon surgical subjects must be presupposed. Yet in many hospitals, dressers who are beginning their work in the surgical wards, or clinical clerks in the medical ones, are expected to be able to Avrite intelligible histories of cases Avhich are themselves very possibly obscure to the last degree; and further, to write these so that their account shall stand for all time as being full, true, and particular, and so that those, Avho may on some future occasion require to look up the case books of the hospital, will find therein a trustworthy account of Avhat- ever case, or group of cases, may be under investigation. Notes which will perfectly fulfil these conditions can hardly be expected, and will only exceptionally be obtained from dressers, at any rate during the first few months of their Avard Avork; but nevertheless there is hardly any other part of these same dressers' work which will be so useful to him educationally, as his case taking. Litem scripta manet, and he will find that every case which he intelligently records (and therefore studies, because he has to record), will remain with him a lifelong experience. What he must aim at in his case taking must be first and foremost, absolute truth, and it will be found that sometimes there is a strong temptation to make the facts square Avith a preconceived theory ; and secondly, to present a clear story of the case, Avithout introducing any personal opinions, letting the facts tell their own tale. The notes of a case then, should comprise :— (1) A description of the patient, and of the symptoms, Main points to objective and subjective, presented by him (or her, but for be noted- shortness we will use the male appellation) when he first comes under the notice of whomsoever has to record the case. (2) An account of those facts in his previous life history, and in his family history, Avhich may throAv light upon his present condition, and the sources of this information. (3) The previous story of the illness, derived from the patient himself, his parents, or from other people, the source being in all cases stated. 3q 546 UPON SURGICAL CASE TAKING. (4) A diary recording the measures, operative and other, which are adopted for the relief of his complaint, after he has come under observation, and the subsequent course of events. (5) The residt of such treatment, namely, cured, relieved, unrelieved, or died, and in the last event, (6) Whether or no a post mortem examination Avas made, and if so, an account of the results of this examination. Scheme or plan tor recording cases. The following scheme will be found a generally convenient and workable plan for recording cases upon the lines we have here laid down. Ward m > a Name. X CD No. of Register. Occupation. Date of admission. Res deuce. Date of discharge. Result— Cuiel. Relieved. Unrelieved. Died. By whom taken. Name of Surgeon. Date of taking case. The patient's family history, i.e., (a) If the parents are alive or dead, if the latter, at what ages, and how. (b) Brothers and sisters? No. of, whether alive or dead, etc. (c) Place of patient in his family. (d) Results of enquiries about hereditary tendencies, as to gout, insanity, cancer, etc. The patient's previous history, including (a) previous illness. \b) habits of life (state source of information). (c) other facts bearing on this part of the case. History of the present illness from its commencement up to the date of taking the case, as derived from the patient, or from his friends or relatives (state the source) given in as nearly as pos- sible the words actually used by them. The patient's condition at the time of taking the case. (a) General description. Position of patient in bed. State of nutrition, local and general. Indica- tions of a diathesis (i.e., strumous, syphilitic, etc.) The condition of the organs of circulation, respiration, and digestion. The condition of the skin and of the glands. The temperature (noting time when taken). The appearance, sp. gr., and quantity of urine passed, and whether albumen is present or no. The con- dition of the organs of motion and locomotion. Sleep, its amount and character of. (b) Description of actual seat of disease, its locality, its objective physical appearances, and the sub- jective abnormal sensations connected with it. (c) Other noteworthy local abnormalities. UPON SURGICAL CASE TAKING. 547 The " case " being thus taken, it will be the duty of the continuation of dresser, or of whomsoever is appointed to continue the te record, to preserve a consecutive account of the course of events from the moment the patient comes under treatment. If an operation be performed, it must be fully described, especial attention being paid to the following points :— The actual incisions and manipulations. The approximate Description of amount of blood lost, and the condition of the patient at the opeia lons' close of operation. The number and method of insertion of sutures (if any used). The position of the drainage tubes. The plan of dressing the wound, the position of the patient subsequently in bed, and the nature of the anaesthetic. If the operation be of the nature of a removal, either of a growth, or of a limb, the notes must always describe fully the part taken aAvay. For example, if the thigh be amputated in its lower third, for disease of the knee, the details of the condition of the joint, and the ligaments, muscles, etc., in its neighbourhood, the cartilages and the bones, must all be fully pictured. Were the case one of an epithelioma of the lip, in addition to the naked eye appear- ances of the growth, its microscopic structure should also be given. As the case goes on it will probably be found unnecessary to make daily entries on the case paper, but however chronic the disease in question may be, and. however slow the con- valescence, it Avill be found convenient to make some note of the patient's condition at the very least once, and as a rule, twice, in the week, upon the occasion of the surgeon going his rounds. The patient's temperature is now commonly taken night and morning by a ward nurse, and entered upon a chart, appended to the case book. This plan is a good one in many ways, inasmuch as the observations are made at every 12 hours, and at the most suitable times, but it involves a certain risk that this condition of the patient may be over- looked by the dresser. It should therefore be a rule that the temperature readings should be entered in the notes, as well as placed upon the chart, in all serious cases. When the notes record a patient's discharge the extent of recovery should ahvays be noted, and in the care of death, the actual cause should be carefully stated, if it be apparent; in those cases where a post mortem examination is made, the results must be fully recorded, and the dresser should be especially careful not to lose this opportunity of clearing up obscurities, and verifying and correcting opinions formed during the patient's lifetime. 518 APPENDIX. APPENDIX. FORMULARY. We here give the composition of the non-officinal pre- parations which have been mentioned in this book, Avith other local applications, dressings, etc., Avhich will be found useful. Local applications and hypodermic injections alone are here considered. LOTIONS. 1.—Of Acetate of Lead. The Liq. Plumbi Subacet. P.B. 2.—Of Acetate of Lead with Opium. The above with 1 gr. of extract of opium to 1 oz. 3.—Of Alum. 4 grs. of alum to 1 oz. of water (or more). 3a.—Of Alum and Oak Bark. 4 grs. of alum to 1 oz. of decoction of oak bark. 4.—Of Boracic Acid. The saturated solution of boracic acid in Avater. 5.—Of Extract of Belladonna. 2 grs. of the extract to 1 oz. of water. 6.—Of Calamine. 6 drms. of levigated calamine, 6 drms. oxide of zinc, 6 drms. glycerine, 2 ozs. lime water to 12 ozs. of Avater. 7.—Of Carbolic Acid. The glycerine of carbolic acid diluted with Avater fron} I in 20 to 1 in 60? or less, APPENDIX. 549 8.—Of Carbonis Deter gens. 2 to 4 drms. of the Liq. Carbonis Detergens (made by digesting coal tar in a tincture of soap bark, Quillaia) to 12 r oz. of water. 9.—Of Chlorate of Potash. 10 grs. of chlorate of potash to 1 oz. of water. 10.—Of Chloride of Zinc. 1 to 4 grs. chloride of zinc to 1 oz. of water for a stimu- lant lotion; and 40 grs. to 1 oz. of water for Avashing over operation wounds for purposes of asepsis (is somewhat caustic). 11.—Of Chlorinated Soda. 30 n\ of the Liq. Sodas Chlorinatae (P.B.) to 1 oz. of water. 12.-0/ Chlorine. The Liq. Chlori (P. B.) diluted. 13.—Evaporating Lotion. 1 drm. spirits of wine and 2 drms. of the solution of ace- tate of ammonia to 1 oz. of water. 14.—Of Iodine. 20 to 30 m. of the. tincture of inrKnp. to 1 oz. of water. 15.-0/ Nitrate of Silver. 3 to 10 grs. of nitrate of silver to 1 oz. of water. 16.—Perchloride of Mercury (Corrosive Sublimate). 1 part in 800 of water to 1 in 2000. 17.—Of Nitric Acid. 2 to 4 TTj. of the strong nitric acid to 1 oz. of water. 18.—Of Permanganate of Potash (Condy s Fluid). 12 to 36 m of the liq. pot. permang. (P.B.) to 1 oz. of water. 19.—Befrigerating Lotion. 30 grs of ammonium chloride, 1 drm. diluted acetic acid, \ drm. spirits of wine to 1 oz. of Avater, 550 APPENDIX. 20.—Of Sanitas. The patent preparation, as supplied, or diluted. 21.—Of Sulphate of Copper. 2 to 4 grs. of the sulphate of copper to 1 oz. of water. 22.—Of Sulphate of Iron. 2 to 6 grs. of the sulphate of iron to 1 oz. of water. 23.—Of Sulphate of Zinc. 2 to 6 grs. of the sulphate of zinc to 1 oz. of water. 24.-0/ Tartrate of Iron. \ to 1 drm. tartrate of iron to 1 oz. of water. 25.—Of Terebene. The patent preparation of terebene diluted. OINTMENTS. 1.—Of Belladonna. 80 grs. extract of belladonna, 1 drm. glycerine, 1 oz. pre- pared lard. 2.—Of Boracic Acid. 1 drm. boracic acid, 1 oz. lard. 3.—Of Iodoform. 1 drm. iodoform, 1 oz. lard, or vaseline. 4.—Of Iodoform and Oleate of Zinc. 2 oz. iodoform, 1 oz. oxide zinc, 6 oz. oleic acid, 14 oz. lard, or vaseline. (The odour of iodoform is stated to be thus much diminished.) 5.—Of Mercury and Belladonna. Mercurial ointment and belladonna ointment, equal parts. 6.—Of Mercury and Camphor (Scotts's dressing). 1 oz. mercurial ointment, 20 grs. camphor. 7.—Of Nitrate of Mercury, diluted. The P.B. ointment and lard, or vaseline, equal parts, APPENDIX. 551 8.—Of Oleate of Mercury (20 per cent)*. 2 drms. peroxide of mercury, 10 drms. oleic acid. (Re- quires frequent trituration for 24 hours for thorough preparation.) .______ 9.—Of Petroleum. 120 grs. paraffin, 1 oz. vaseline. LINIMENTS, Etc. 1.—Of Belladonna and Chloroform. (1.) Equal parts of the two P.B. liniments. (2.) 6 drms. liniment of belladonna, 2 drms. chloroform, 1 oz. compound camphor liniment, P.B. 2.—Of Catron Oil (Linimentam Calcis). Equal parts of lime Avater and linseed, or olive oil. 3.—Of Iodide of Potash. 1 drm. iodide of potash, 2 drms. Liq. ammon. fortior, 2 oz. soap liniment. 4.—Of Iodoform. (1.) A saturated ethereal solution (1 in 7), is used for painting on sores, etc., the drug being left as a pellicle, by evaporation. (2.) Is also easily mixable Avith glycerine, and may thus be conveniently used in proportion of 10 grs. iodoform to 1 oz. of glycerine. (3.) 1| drms. iodoform, 1 oz. oil of Eucalyptus, 5 oz. olive oil. . ------ 5.—Of Lead and Olive Oil. $ oz. Liq. Plumbi Acetatis, 3^ oz. olive oil. 6.-0/ the Sub-Acetate of Lead. A patent preparation (see page 277). CAUSTICS, f 1.—Arsenious Acid. 20 grs. arsenious acid, 1 oz. lard, or vaseline. * The 10 p.c. oleate is a liquid—a liru/jient; the 15 p.c. is seruj, solid. | For other caustics, see chap. V, 552 APPENDIX. 2.—Caustic Potash and Lime. Equal parts of potash and quicklime, with water (q.s.) \ is then moulded into sticks. 3.—Nitric Acid. The strong acid is used. Should be applied with a splinter of wood, or with a brush made of glass hairs. 4.—Sulphuric Acid (Bicord's Paste). Strongest sulphuric acid and Avillow charcoal, sufficient of each to make a paste. 5.—Zinc Chloride. The chloride in fine powder may be rubbed up Avith wheaten flour in the proportions of 1 to 1, or § to 1, or A to 1, forming a paste by deliquescence. All solutions stronger than 10 p.c. are caustic in various degrees. 6.—Ethylate of Sodium. Is prepared according to Dr. Richardson's formula; is applied with a glass rod or splinter of wood. DUSTING POWDERS. 1.—Of Calomel and Zinc Oxide. | oz. of calomel, | oz. zinc oxide; or the same with the addition of 1 oz. of starch. 2.—Of Fuller's Earth, otherwise Pulvis Terra Cimolice. 3.—Of Iodoform. 4.—Of Iodoform and Calamine. Equal parts of each in powder. 5.—Of Savin and Verdigris. Equal parts of each in powder. SUPPOSITORIES. 1.—Of Galls and Opium. 3 grs. powdered galls, 1 gr. opium, to 20 grs. oil of theo- broma. APPENDIX. 553 2.—Of Iodoform. 1J grs. iodoform, 15 grs. oil of theobroma. 3.—Of Opium. 10 to 12 grs. of the compound soap pill (P.B.). HYPODERMIC INJECTIONS. 1.—Of Acetate of Morphia. The P.B. solution for injection contains 1 gr. in 10 T\ (altered to this strength in the last edition), but provided that the solution be kept perfectly neutral, a solution of 1 gr. in 6 n\ will often be found more convenient, especially if large doses are required. It may be thus prepared : To 352 grs. of hydrochlorate of morphia dissolved in 8 oz. distilled water, with heat, add 4^ drms. liq. ammonias, or sufficient quantity to produce slight alkalinity. AVhen cool, wash the precipitated morphia by decantation, and on a filter, till free from chlorides. Drain well and dissolve in 1| drms. distilled water, warmed, and 150 m acetic acid, or sufficient to produce slight acidity. Make up to 4 oz. with distilled water, and filter.* 2.—Of Morphia and Atropia. To the above add ■£■* to tV gr. of atropia. 3.—Of Apomorphia. 2 p.c. hydrochlorate of apomorphia dissolved in water. Dose : 5 m = ro gr. ------- 4.—Of Carbolic Acid. The pure acid with 5 p.c. of water (see p. 280). 5.—Of Ergotine. 15 grs. ergotine, 15 mT. glycerine, 1 oz. water, and 1 p.c. pure carbolic acid. Dose: 1 to 4 m. = \ to 1 grain ergotine. 6.-0/ Ether. 10 to 20 n\ pure ether, or of ether with equal parts of pure alcohol or brandy. (Page 358). * Morphia injections keep better if 1 p.c. of pure carbolic acid be added, and if the solution be made up with 25 p.c. of glycerine in place of so much water, clogging of the needle by evaporation will be greatly prevented. 554 APPENDIX. 7.—Of Pilocarpine. A 1 in 20 solution of the nitrate may be used in doses of *V to \ gr., i.e., 1 to 5 m. 8.-—Of Perchloride of Mercury. The perchloride of mercury in aqueous solution, with the addition of a little glycerine, may be injected subcutancous- ly, or intra-muscularly, in doses of j\ to I gr. ENEMATA. 1.—Of Brandy (restorative). 1 oz. brandy, 3 oz. strong beef tea. Note.—For the purpose of nutrition various forms of peptonised fluids are now largely used as enemata. 2.-0/ Olive Oil. 4 oz. olive oil, 15 oz. decoction of barley (or the oil may be used by itself). (See page 355.) 3.-0/ Soap. . 1 oz. soft soap to 20 oz. of hot Avater. 4.—Of Starch and Opium. 20 m. laudanum or Battley (Liq. Opii Sedativus). 20 oz. mucilage of starch. 5.—Of Turpentine. | oz. oil of turpentine, 1 oz. castor oil, yolk of 1 egg. Infusion of linseed to 20 oz. FOMENTATIONS. 1.—Of Belladonna. 1 drm. extract of belladonna, 20 oz. (or less) of water. 2.-0/ Poppy Heads. 1 to 3 ozs. of the dried poppy heads, sliced, without seeds, 20 to 40 oz. of water. Boil 20 minutes, and strain. 3.—Of Turpentine (The Turpentine Stupe). Flannel soaked in boiling water, and wrung dry as quickly as possible Avith Avringing sticks, then sprinkled with from 30 m. to 2 drms. of oil of turpentine. (See page 544.) appendix. 555 SPRAYS, Etc. 1.—Lotiom of Boracic Acid, Chlorinated Soda, etc. Can be used in the form of sprays, especially for ulcera- tions about the mouth and throat, or for dressing foul Avounds, etc. 2.—Of Carbolic Acid. The 1 in 20 solution of carbolic acid is generally used, but for directions for this and other antiseptic dressings, see page 239. 3.—The Ether Spray for Local Anaesthesia. Ether purus P.B. may be used, or anhydrous ether, or a yet cheaper form, the "Anaesthetic Ether." 4.—Of Sulphurous Acid. 5 Tfl. sulphurous acid to 1 oz. water. 5.—Of Tannic Acid. 5 to 20 grs. tannic acid to I oz. water. 6.—Mercurial Vapour Bath. The following is Mr. Henry Lee's description of his mercurial vapour bath :—" It consists of a kind of tin case, containing a spirit lamp (Fig. 235). In the centre, imme Fig. 235.—Mercurial Lamp. diately over the Avick of the lamp, is a small circular tin plate, upon which the mercurial powder is placed. Around this is a circular depression, which is half filled with boiling water. The patient places this on the ground, and sits over it, or near it, on a small cane stool. He is then enveloped, lamp and all, in a circular cloak. When a cloak cannot be procured, a double blanket ansAvers the purpose very well. 556 APPENDIX. At the expiration of a quarter of an hour or twenty minutes, the calomel Avhich is placed upon the lamp, the water, and the spirit will have disappeared, and the patient may then get into bed. During the time the patient is taking the bath he may inhale the vapour for half a minute or a minute, on two or three different occasions, Avith advantage; and after the bath is over he must contrive not to wipe off the calomel deposited on his skin. Patients are generally recommended to sit over the bath for two or three minutes after the lamp has gone out." * "Article "Syphilid/" by Henry Lee, Hoime's "System of Sur- gery," Vol. I. p. 442. INDEX. PAGE A Abdominal belts .. .. 105 Abscesses...... 442-456 acute........443 — alveolar — of antrum — chronic — deep cervical — Hilton's method of opening — ischio-rectal — in kidney — in liver — of joints — mammary — methods of opening.. Manson's method of opening 449 455 445 448 414 455 452 452 458 450 442 452 — psoas .. .. •• •• 452 — retro-pharyngeal — thecal.. — tonsillar Acid, boracic .. .. — gallic, a haemostatic — sulphuric, a haemostatic — tannic, a haemostatic Actual cautery......65 Acupressure .. • • • • 28 Acute abscesses......443 449 451 449 248 73 73 73 Adam's forceps — nasal truss .. — splint Air, entrance of, into veins Alcoholic poisoning ----- acute Alkalies, caustic, as poisons Alum .. • • — a hsemostatio — snuff Alveolar abscesses — tourniquet Amputations, minor .. Anaesthetics _.. mixtures __preparation of patients for Anasarca 159 .. 159 .. 333 .. 380 .. 381 .. 382 .. 393 .. 62 .. 73 .. 35 .. 449 .. 39 .. 506 394-420 .. 418 397 465 PAGE Aneurism .. .. • • 46 — arterio-venous from clumsy venaesection .. .. 528 — haemorrhage from .. .. 46 Ankle, compound dislocation of 151 — strapping for .. .. 120 Anterior tibial artery, compres- sion of .. .. •. 16 Antimony poisoning .. .. 391 Antiseptic dressings .. 239-249 -----poisoning from .. .. 538 Antrum, abscess of .. .. 455 Anus, fissure of .. .. .. 515 Aorta abdominal, compression of...... 14, 21 Apomorphine in poison cases .. 384 Apoplexy .. .. .. • • 363 Arsenical poisoning .. .. 391 Arteriotomy .. .. .. 528 Arteritis........27 Artery compression of abdom- inal aorta.. .. 14, 21 -----of axillary .. .. 12 ----- brachial .. .. .. 12 -----common carotid .. 10 -----coronary of lip .. .. 10 -----dorsal of foot .. .. 16 -----facial -----femoral common .. 15 -----femoral superficial .. 15 -----iliac, common .. .. 14 -----iliac, internal .. .. 14 -----occipital .. — digital, haemorrhage from .. 29 — forceps .. • • • • 22 — of frasnum of penis, bleeding from — popliteal — radial .. — subclavian — temporal — tibial, anterior — tibial, posterior — ulnar 29 16 13 10 8 16 16 13 582 Index. PAGE Arthritis, acute......457 — suppurative .. .. 458, 459 Artificial respiration .. .. 370 — tendon .. .. .. 336 Aspirating apparatus, Bigelow's 44 Aspiration of bladder, by the rectum .. .. .. 482 — of bladder over pubes 342, 481 Aspirators .. .. .. 445 Asphyxia .. .. .. .. 369 — from drowning .. .. 369 — from foreign bodies in larynx 377 — from foreign bodies in oesoph- agus .. .. .. 375 — from gas poisoning .. .. 374 Atheroma.. .. .. .. 27 Atropine, antidote to morphia 384 — antidote to muscarin .. 393 Aural polypi .. .. .. 440 Auto-transfusion .. .. 56 Aveling's method of transfusion 57 Avulsion of nails .. .. 524 Axillary artery, compression of 12 B Back, triangular bandage for .. 77 Bandages 74-101 .. 98 — chest .. .. 97 — common roller .. 84 .. 83 —■ domette .. 83 — double-headed .. 94 — double-headed spiral .. 86 — double spiral . 95 -- T...... ------- for ear.. . 101 --------for lips . 101 ------- for nose . 101 -------for perinseum . 99 — effects of, on skin and cir- — elastic . 104 -----Martin's .. . 104 . 104 — flannel . 83 — four-tailed jaAv . 96 — gluteal . 81 — for groin .... . 82 — for shoulder .. — gum and chalk . 139 Page Bandages, heel .. 88 _ knee...... 119, — knotted, for head 96 — Martin's for ulcerated legs. 266 — paraffin 140 — perineal .. .. 6 1, 100 — plaster of Paris 137 -----for "jacket" . 311 — roller .. 84 -----inelastic .. 84 -----reversing .. 84, 85 -----recurrent .. 93 — St. Andrew's cross .. . 100 — semi-elastic .. . 83 — silicate . 139 — silk net . 83 — simple spiral . 84 — single T . 99 — spica .. . 89 — starch .. ... . 140 — stearine . 140 — for stump, roller . 93 — for stump, triangular . 80 — suspensory . 105 — triangular . 75 -----for back .. . 77 -------chest .. . 77 ------- cravat 75 -------elbow .. 80 -------foot . 80 ------- gluteal 81 -------hand .. . 80 -------head .. . 77 -------knee .. 79 -------sling .. 75 -------shoulder 78 -------scrotum 82 — tAvisted for head 96 Bandy legs 327 Barnes' bag 43 Basilic vein, blood letting from 527 Bavarian splints 138 Bed sores 282 -----from fracture of spine . 185 -----in hip disease 305 Belladonna poisoning .. 386 Belloc's sound 36 Belts, abdominal 105 Bichloride of methylene 415 Bigelow's aspirating apparatus 44 Black eye.. 263 Blackwash 272 Bladder, aspiration of over th< pubes 481 — blood-clots in 44 — exploration of, for stone ,. 479 INDEX. 583 PAGE Bladder, hsemorrhage into .. 43 — rupture of .. .. .. 348 — washing out the .. .. 483 -----Ultzman's method .. 484 — washing out by syphon .. 484 Bleeders .. .. .. .. 50 — constitutional treatment for 52 — ulcers in .. .. .. 52 Bleeding from jugular vein .. 528 -----median basilic vein .. 527 Blisters .. .. .. .. 531 Boils ........280 Boracic acid .. .. .. 248 — ointment .. .. .. 248 Borogiyceride .. .. .. 248 Bougies........470 — Lister's ......472 — oesophageal .. .. .. 489 — rectal, passage of .. .. 485 Bowed legs ......327 Brachial artery, compression of 12 Breast bandage .. .. .. 98 Brodie's catheters .. .. 471 — fistula probe .. .. .. 517 Bruised wounds .. .. .. 250 Bruises...... •• 261 Bryant's splint for hip-joint disease .. .. .. 29G Bryant's splints .. 125, 191, 296 Bubo, virulent .. .. . • 275 Buboes........454 Bulb of corpus spongiosum. haemorrhage from .. 44 Bull-dog forceps for compression 25 Bullets, extraction of .. .. 259 Bums and scalds .. .. 284 Bursse, incision of .. .. 460 — patellae, suppuration of .. 453 -----enlarged......459 C Cabs for conveyance .. .. 153 Calculus, impacted .. • • 344 Canalised, vessels a cause of haemorrhage .. . • 31 Cancrum oris .. • ■ • • 279 Capeline bandage .. •. 94 Carbolic acid .. • ■ • • 62 -----poisoning .. .. • • 390 Carbonates of the alkalies as poisons .. • • • • 392 Carbuncles ......280 Caries, cervical .. .. • • 319 Carron oil ......286 PAGE Carr's splint for Colles' fracture 183 Carte's tourniquet .. • • 20 Cartilage, loose, of knee .. 220 Case taking, surgical .. .. 545 -----main points to be noted 545 -----points to be noted in cer- tain kinds of operations 547 -----scheme or plan for re- cording .. • • 546 Catgut ligatures......24 — sutures .. .. •• 228 Catheters........470 — breaking in urethra.. .. 481 — Brodie's ......471 — double-channelled for syring- ing the bladder .. . • 483 — cleaning .. • • • • 476 — Eustachian......438 — flexible ......472 — flexible, passage of .. .. 480 — india-rubber......474 — Jacque's .. . • • • 474 — olivary .. • • • • 473 — passage of .. . • • • 474 — preparation of .. • • 476 — prostatic .. .. 343, 471 -----passing......479 — silver .. .. . • • • 471 — tying in .. • • • • 477 Caustic alkalies, as poisons .. 392 Caustics...... 63, 551 — list of........60 Cautery, actual .. .. 65, 532 -----for bleeders .. .. 52 — clamp for internal piles .. 513 — galvanic .. .. • • 67 — irons .. .. .. •• 65 — Pacquelin's......68 Cellulitis........278 Cervical abscesses .. .. 448 — caries .. .. .. . • 319 Charpie, styptic, for bleeders .. 51 Chest, aspiration of .. .. 461 — strapping for .. .. .. 171 — triangular bandage for .. 77 Chloral poisoning .. .. 387 Chloride of zinc .. .. .. 64 Chloroform, administration of 400 — versus ether .. .. • • 398 Chromic acid .. .. . • 63 Chronic abscesses .. .. 445 Cinchona bark .. .. • • 46 Circumcision .. .. .. 519 Clamp for piles .. .. .. 514 Clavicle, fracture of .. 146, 164 _____Sayre's treatment .. 168 584 INDEX. PAGE Cline's splints .. • • 128, 206 Clips ........25 Clots in bladder......44 Clove-hitch knot .. .. 102 Clover's gas and ether apparatus 412 — inhaler . • • • • • 410 Club-foot .. _......3'29 — classification of • • • • 329 Cobwebs........60 Cocaine .. . • _ • • •• 418 Cooking's poroplastic felt . • 135 Cold, as styptic .. .. 3, 34, 64 Coles' truss .. • • • • 109 Collapse .. .. • • • • 356 — extreme, venaesection for .. 358 Colles' fracture (see Fracture) 148, 180 Collodion........60 — closing wounds by .. • • 229 — flexible ......61 — for erysipelas . • • • 277 Common carotid artery, com- pression of .. • • 10 — femoral artery, compression of........15 Compound ganglia .. • • 460 Compress, the graduated .. 5 Compression by acupressure .. 28 — bulldog forceps .. . • 25 — digital .......6-16 — Esmarch's band and tube .. 16 — forci-pressure .. . ■ 25 — levers .. .. • • • • 15 — serrefines .. .. • • 25 — strangulation .. . • 16 — tourniquets .. .. • • 18-21 Concussion .. .. • • 362 Condylomata .. . ■ • ■ 522 Convulsions in infants .. .. 367 Cornea, removal of foreign bodies from .. . • 507 Corns ........521 Coronary artery of lips, com- pression of .. • • 10 Corpus spongiosum, haemorrhage from ......44 Corrosive sublimate poisoning 391 Cotton-net bandage .. • • 83 Cotton-wool for plugging wound 4 Counter-extension .. • • 191 Cradle and swing . • • • 210 Creasote .. .. • • • • 61 — a haemostatic • • • • 73 Croft's method of splinting .. 207 Cupping .. .. • • • • 529 Cyanide dressings .. • • 247 Cysts, sebaceous......509 PAGK Daw's lever ......*5 Deafness from impacted wax .. 431 Deep sutures .. • • • • 28 Delayed union......1J6 Dieffenbach's, or bulldog forceps 25 Digital artery, bleeding from .. 29 Digitalis, a haemostatic .. 73 Dislocation, compound of ankle, immediate treatment of 151 __ of jaw, in extraction of teeth 430 Domette bandage .. • • 83 Dorsal artery of foot, compres- sion of .• • • • • 16 Douche, nasal......35 Drainage of wounds .. ■ • 230 -----tubes . • • • • • 230 Dressings, antiseptic .. . • 239 — anti-syphilitic .. • • 272 — dry .. • • •• • • 233 — oily .. . = • • • • 237 — surgical .. • • • • 222 -wet........234 Drowning.. .. - • • 369 Dupuytren's splints for Pott's fracture .. .. ■• 214 Durham's flexible forceps .. 378 Dusting powders .. . • 552 Eab, diseases of .. .. . • 431 — double T bandage or .. 101 — foreign bodies in .. .. 433 — how to syringe .. . • 434 — insects in .. • • • • 435 — wounds of .. • • • • 253 Ecchymosis treated by compres- sion .. .. • • 261 — sub-conjunctival .. • • 263 Ecraseur, galvanic .. . • 67 — for piles .. •. • • 514 Elastic bandages .. • • 104 — tourniquet .. • • • ■ 21 Elbow splint .. .. • • 125 — fracture at .. .. 148, 177 — triangular bandage for 79, 80 Electricity for chronic ulcers .. 270 Elevators.. .. .. ■• 428 Emergencies, et seq. .. .. 339 Emphysema, surgical .. .. 173 ----Southey's trocars for .. 173 Empyema, incision for .. 462 Enemata...... 485, 554 Enlarged prostate .. .. 342 Epilepsy........366 INDEX. 585 PAGE PAGE Epileptic malingering .. .. 367 Fit, apoplectic .. .. 363 Epistaxis .. .. 33 — epileptic .. 366 — digitalis, for .. .. 73 — fainting .. 359 — ergot, for .. 72 Flannel bandage .. 83 — in exhaustion .. 38 Flat foot...... .. 329 — in fevers .. 38 Flexion of joint for checking Ergot ...... .. 72 haemorrhage .. 12 Ergotine for bleeders .. .. 52 Fomentations 543, 554 Erysipelas .. 277 Foods, poisonous .. 392 — constitutional treatment f< >r 278 Foot, fracture of bones of 151, 214 — phlegmonous .. 278 — triangular bandage for .. 80 — punctures for .. 277 Forceps, Adam's flat blades .. 159 Esmarch's tube, as figure of fi 18 — bulldog .. 25 — bandage .. 16 — bullet extracting .. 253 — tube .. 16 — Dieffenbach's, or bulldog 25 Ether ...... .. 409 — Durham's flexible .. .. 378 — injection for collapse .. 358 — fenestrated .. .. 23 — poisoning .. 383 — for ligaturing ■ • 22 — spray, for haemorrhage 64 — for teeth .. 425 — — local anaesthesia .. 419 — hare-lip 10 Ethidene dichloride .. 417 — laryngeal .. 376 Eucalyptus oil .. .. 248 — Luer's .. 260 Eustachian tube, digital exai n- — Mackenzie's cannula .. 379 ination of .. 439 — pharyngeal .. .. 376 — catheter .. 438 — serrefine .. 25 — tube, syringing of .. 439 — Spencer Wells's .. 25 Ewen's elastic bandage .. 104 — torsion .. 27 — plaster .. 122 — vulsellum, for piles .. .. 512 Excision of hip joint .. 306 Forci-pressure .. 25 Extension in fractures .. .. 191 Forearm, fracture of 148, 179 Extravasation of urine .. 345 Foreign bodies in air and food — incisions for .. .. 346 passages, et seq. .. 375 — from old stricture .. .. 347 -----in external auditory meatus 433 -----in cornea .. .. 507 F — — removal of, from various parts .. 506 Facial artery, compression o: 8 .. 507 Faecal impaction .. 354 Fractures, diagnosis of .. 153 Fainting fit .. 359 — Colles' 148, 180 Feeding by nostrils .. 488 — compound .. 214 Femoral artery (superficial] > — beds . .. 154 compression of .. .. 15 — immediate setting of 144-151 Femoral truss .. 110 — of bones of foot 151, 214 Femur, fracture of, at neck L49, 188 — of bones of leg 150, 205 — shaft of .. .. '. L49, 188 — of clavicle 146, 164 — shortening of .. 199 — of femur 149, 188 Ferguson's long splints.. .. 189 — of forearm 148, 179 Fevers, epistaxis in .. 38 — of humerus .. 147, 175 Figure of 8 bandage .. 87 — of humerus about elbow 148, 177 Fifo-pressure 22 — of lower jaw .. 146, 160 Finger bandage 91 — of metacarpal bones .. 184 Fingers, strapping for .. .. 119 — near knee .. 150 Fissure of anus .. 515 — of neck of femur 149, 188 Fistula in ano .. 517 — of nasal bones .. 159 Fistulae, scissors for .. 518 — of olecranon .. .. 179 Fistulous tracks in groin .. 523 — of patella 150, 199 36 586 INDEX. PAGE PAOE Fracture of patella, with effusion Hematuria, renal 54 of blood into knee-joint 200 — turpentine for 72 — permanent setting of t56-216 Haemoptysis 54 — Pott's...... 151, 212 — acetate of lead for .. 71 — of pelvis .. .. 149, 187 — digitalis for .. 73 — removal of clothes after 145, 155 — ergot for 72 — of radius, about insertion of Haemorrhage 1-73 pronator radii teres . 180 — acupressure for 28 — of ribs .. .. 148, 170-173 — arterial 6 — of ribs, with injury to tl e — capillary 3 lungs, etc. . 172 — caustics for .. 63 — of scapula . 174 — compression for 6 — of skull . 158 — deep sutures for 28 — near shoulder . 147 —■ drugs used to arrest.. 60 — of spine .. .. 149, 184 -- ether spray, for 64 — of sternum . 170 — extreme, syncope from 359 — of teeth . 430 — favoured by clots 64 — of upper jaw .. .. 159, 104 — flexion of joints for .. 12 — of zygoma, etc. . 159 — forci-pressure for 25 Frost bite . 208 — horn amputation stump 50 Fungus haematodes . 52 -----aneurism .. 46 Furneaux Jordan's, Mr., jury -----artery ligatured in con masts . 322 tinuity .. 49 — — bulb of urethra .. 44 G -----canalised vessels.. 31 — — corpus spongiosum 44 Gallic acid, a haemostatic . 73 — — extraction of teeth l 8, 430 Galvano-cautery 66 — — gangrene .. 45 Ganglia . 400 -----genito-urinary tract 43 Gangrene, haemorrhage from . 45 — — granulations 44 — hospital 45, 278 — — imperfectly divided vcsse 1 29 Garrot, the 18 -----malignant growths 46 Genito-urinary tract, haemor- -----nose 33 rhage from . 43 — — palmar arch 30 Genu Valgum . 326 — — phagedsena 45 Gluteal bandage 81 —- — rectum 39 Golding Bird's tracheal dilator 379 — — sloughs 50 Gordon's splint for Colles' frac- -----special arteries (see alsc ) ture . 183 Artery) .. 8-16 Graduated compress 5 ----- urethra 44 Grafting skin . 287 -----venereal sores 274 Granny-knot . 102 — in division of tendo Achillis 505 Granulations, bleeding from 44 — intermediary 50 Groin, bandage for . 82 — internal, syncope from 55 Guillery's flexible splint . 127 — internal 54 Guillotine, Mathieu's .. . 503 — into abscess cavity .. 447 Gum, tearing of .. . 430 — into bladder .. 43 Gumboil . 419 — in tracheotomy 497 Gunshot wounds . 219 — ligature of arteries for 22 Gutta-percha for splints . 135 — natural arrest of 1 — permanent arrest of 2 H — plugging for..... ■J, 5 — position of limbs in .. 3 — pressure for .. 3 Hasmatoma . 262 — primary arrest of 2 — of sculp , t ,, , . 263 — reactionary .. 48 INDEX. 5'87 PAGE PAGE Haemorrhage, recurrent .. 48 Humerus, fracture of .. 147 , 175 — secondary 49 ---------about elbow, splints 359 for .. 178 — special means for arresting 6-29 ---------non-union in .. 176 — styptics for .. 59 Hydrocele 466 — tenaculum for 24 Hydrochloric acid poisoning 389 — torsion of arteries for ,. 26 Hydrops articuli 457 — transfusion after .. 56 Hypodermic injection .. ,, 489 — typhoidal .. 72 — injections 553 — venous 3 — syringe 490 Haemorrhagic diathesis 50 Hysteria .. .. ,, 360 — ulcer 44 . 269 Haemostatics 59. 71 Hagedorn's needle holder #, 226 ■ 337 64 Hamamelis, a haemostatic (see Iliac artery (common) compres- Hazeline) sion of 14 Hare-lip forceps .. 10 ------(internal) compression of 14 — pins 52 , 227 Inclined plane for applying the Hazeline 61 jacket .. 309 Head bandage .. 94 ------for fractured femur 196 96 India-rubber bandage, Martin's -----knotted 96 104 ,266 -----triangular 75 — band, Esmarch's 16 Hernia 350 — tube, Esmarch's 16 — non-strangulated 353 Infants, convulsions in 367 — obturator 116 Inflammation, erysipelatous 277 116 Ingrown toe-nail ,. 523 — of testis 116 Inguinal truss 110 — strangulated .. .. 351 Inhalers .. 401 — trusses for 107-116 — Clover's 410 412 — umbilical ,. 115 — Junker's 416 — vaginal 115 Insects in ear 435 — ventral 116 Instruments, preparation of," Herniotomy, mortality from for operation 536 delay of .. 350 Insufflation of tympanum 439 Hilton's method of opening ab- Intestinal obstruction .. 350 scesses 444 ------from accumulation of" Hip-joint disease 293 faeces 354 ----- acute 294 Intubation 500 -----anaesthetics for .. 298 Iodine plaster 122 -----Bryant's splint for ,. 296 Iodoform .. 234 272 -----chronic 298 — as anaesthetic 419 -----counter irritation for .. 295 — for chancre .. 272 -----divisions of 293 — paste 273 -----excision of joint in 305 Ipecacuanha, a haemostatic 73 -----forcible straightening for 304 Iron compounds, haemostatics 71 -----osteotomy in 306 Irrigation of wounds 235 -----Sieveking's splint for 298 Ischio-rectal abscesses .. ,. 455 -----suppurative 305 ■-----tenotomy for .. 304 J -----Thomas's splint for 300 Hospital gangrene 45 278 Jackets .. ,. 307 Housemaid's knee 459 — applied by suspension 311 Howard's method of treating — inclined plane, for applying 309 drowning .. ., .. 372 — on Dr. Walker's method . ■ 313 588 INDEX. PAGE Jackets, poroplastic .. .. 315 -----application of .. .. 316 Jacque's catheters .. .. 474 Jaw, fracture of lower .. 146, 160 — fracture of upper .. 159, 164 Joints, effusion into .. .. 457 — wounds of .. .. •. 255 Jugular vein, bleeding from .. 528 Junker's inhaler .. .. 416 Jury masts .. .. .. 319 -----Mr. Furneaux Jordan's.. 322 K Kangaboo's tendon, for ligatures 24 Kerosine a poison .. .. 383 Kettle-holder splinting .. .. 128 Key for compressing subclavian artery .. .. .. 11 Knee, fracture near .. .. 150 — housemaid's .. .. .. 459 Knee-joint, aspiration of .. 459 -------in fracture of patella 200 — effusion of blood into .. 458 — incision of .. .. .. 459 — sprains of .. .. .. 219 — strapping for .. .. .. 119 — triangular bandage for .. 79 Knife, tenotomy .. .. 505 Knots .. ......101 Labtngeal forceps .. .. 376 Laryngotomy .. .. .. 492 Larynx, foreign bodies in .. 377 — scalds of .. .. .. 291 Laudanum as poison .. .. 383 Lead, acetate of, a haemostatic 71 Leather splints .. .. .. 130 -----for knee .. .. .. 131 Leeches .. .. .. .. 531 Leg, fracture of .. .. 150, 205 Lever, Davy's .. .. .. 15 Ligature of arteries .. .. 21-28 — catgut .. .. .. .. 24 — materials for .. .. .. 23 — of arteries by filo-pressure .. 22 --------with forceps .. .. 22 --------with tenaculum .. 24 — of naevi .. .. .. 510 — preparation of .. .. 24 — silk...... 23, 24 Liniments ., ,, ,. 551 Lint for plugging bleeding wound Lips, double T bandage for .. Listerian dressings -----for compound fractures Lister's tourniquet — bougies Liston's eplint Lonsdale's splints Loose cartilage in knee-jokit .. Lordosis Lotions Luer's forceps Lung, injured by broken rib .. Lungs, congested in spinal in- jury ...... 4 101 240 215 21 472 189 161 220 299 548 260 172 185 M Macewen's splints .. .. 197 Mclntyre's splint .. .. 127 Mackenzie's cannula forceps .. 379 -— tonsillotome .. .. .. 503 Macleod's splint for Colles' frac- ture ......182 Malgaigne's hooks .. .. 204 Malignant growths, haemorrhage from .. .. .. 46 Malingering, epileptic .. .. 367 Mammary abscesses .. .. 450 Manson's method of opening abscesses .. .. .. 452 Marshal Hall's method of treat- ing the apparently drowned 372 Martin's elastic bandage 56, 104, 266 Mathieu's forceps .. .. 379 — guillotine .. .. .. 503 Matico........60 Measurements for elastic sup- ports .. .. .. 105 — for trusses .. .. .. 115 Median basilic vein, blood-let- ting from .. .. .. 527 Menorrhagia, digitalis for .. 73 Mercurial vapour bath .. .. 555 Metacarpal bones, fracture of .. 184 Methylene ......415 Mineral acid poisoning .. .. 389 — oil, poisoning by .. .. 383 Minor amputations .. .. 506 Morphia as haemostatic .. 72 — poisoning .. .. .. 383 Moulded splints .. .. 130-142 Mucous tubercules .. .. 522 Muscarin poisoning .. .. 393 Mushroom poisoning ., ,. 393, INDEX. 589 N Nevi, cutaneous — electrolysis for — ligature of — perchloride of iron for — subcutaneous Nails, avulsion of . 509 . 511 . 510 . 511 . 510 . 524 — ingrown .. .. .. 523 Nasal douche .. .. .. 35 •— bones, fracture of .. .. 159 — cartilages, displacement of 159 — truss, Adams's .. .. 159 Needles, extraction of, from hand, etc... .. .. 506 — Dr. Hagedorn's holder .. 226 — tubular ......225 Nelaton's splint .. .. .. 181 — treatment of syncope 360, 405 Neville's splint .. .. 126, 209 Nitrate of silver .. .. .. 63 Nitric acid .. .. .. 64 -----poisoning .. .. .. 389 Nitro-benzoi as poison .. .. 387 Nitrous-oxide gas .. .. 407 Noma ........279 Nose, bleeding from .. .. 33 -------recurrent, digitalis for 73 — broken.. .. .. .. 159 — double T bandage for .. 101 — foreign bodies in .. .. 507 Oak bark decoction .. .. 40 Occipital artery, compression of 8 -----haemorrhage from .. 8 Oesophageal bougies .. .. 489 Oesophagus, foreign body in .. 375 Oil of turpentine .. .. 61 Ointment, boracic .. .. 248 Ointments .. .. .. 550 Olecranon, fracture of .. .. 179 Olivary catheters .. .. 473 Onychia, removal of nail for .. 524 Operation, preparation of patient for........535 — action of bladder after .. 537 — best time for .. .. .. 538 — cleansing of skin before .. 536 — clothing of patient during .. 536 — condition of bowels after .. 538 — importance of good night after ......537 — preparation of instruments, sponges, etc., before .. 536 *s- vomiting after .. .. 537 PAGE Operation, warmth during 536 — watching patient after 537 Opium after haemorrhage 72 — a haemostatic.. 72 — as styptic for bladder 44 — for bleeders .. 53 — for neuralgic ulcers .. 269 — poisoning 383 Otoscope 432 Oxalic acid poisoning .. 390 P Pacquelin's cautery .. 68 Palmar arch, bleeding from . 30 Patella, fracture of 150, 199 Paracentesis abdominis 463 — thoracis 461 Paraphimosis . 520 Patients, preparation of, for anaesthetics 397 Patterns for splints 132 Pelvis, fracture of .. 149, Perchloride of iron 62, 71 -------for bleeders .. . 52 — — — for nasvi 5U Perineal bandage 81, 100 Perineum, double T tan dage for 99 Periostitis, acute 452 Petersen's bag .. .. 43 Petit's tourniquet .. 18 Phagedaena, sloughing .. 45, Pharynx, foreign bodies in 375 — scalds of 291 Phlegmonous erysipelas 278 Phosphorous poisoning 391 Phimosis .. ,, 519 — cause of retention .. 344 Piles connected with fissure oi : anus 516 — bleeding from 40 — crushing of .. 514 — external 512 — internal ,, 512 — Whitehead's operation for .. 515 Pilocarpine, antagonistic to atropia 386 Pins, hare-lip 52, Piper angustifolium 60 Plaster, adhesive (see Strapping 117 — Ewen's 122 — iodine .. 122 — medicated 121 — of Paris .. .. 137 --------splints T, ! 137 590 INDHX. PAGE Pleurisy, paracentesis for Plug, " petticoatcd " Plugging...... — materials for .. .. 461 43 4,5 4 — nostril 36 Pneumonia caused by haemo r- rhage 173 Poisoning, alcoholic — antimony — apomorphia for — arsenical 381 391 384 391 — belladonna 386 — carbolic acid .. 62 — chloral 387 — corrosive sublimate .. 391 — ether .. 383 — from antiseptics — gas • • . • • 538 374 — hydrochloric acid — mineral acid .. 389 389 — muscarin 393 — mushroom 393 — nitric acid 64 — opium .. — oxalic acid 383 390 — phosphorous — prussic acid .. — shell-fish 391 386 392 — strychnia — sulphuric acid Poisonous foods 385 389 392 Poisons 881-3! — irritant and corrosive 387 Politzer's bag 436 Polypi, aural — nasal, removal of 440 508 — simulated by thickening nasal mucous membrai of le 508 Popliteal artery, compression Posterior tibial artery, compr< sion of of 3S- 16 16 Poroplastic felt .. — jacket Potash, caustic 135 315 63 Potassa fusa 60 Pott's fracture 151 , 212 -----Dupuytren's, splint for Poultices .. 236 214 , 540 — of bran .. 543 — of bread .. 542 — of charcoal .. 542 — of linseed meal 540 — materials for .. 540 — of mustard and flour 542 — of oatmeal 542 ■<— qI starch ., ,. ? ■ 543 Poultices, of starch and iodine — of yeast Powders, dusting Psoas abscess Preparation of patient for oper- ation I'ri pnoe. slitting up in adults I'ruUuu;...... Pnflir. Nelaton's.. — Sayre's vertebrated .. Prolapsus ani -----plug, for .. Prostate, enlarged Prostatic catheters .. 343 Prussic acid poisoning .. Pulley and weight Pus, detection of — in joints — in neck PAGE 543 543 552 452 585 520 375 260 260 516 517 342 471 386 192 444 458 253 )uinsy .. .. .. .. 449 13 180 485 39 485 485 42 41 41 102 Radial artery, compression of Radius fracture of, at insertion of pronator teres Rectal bougies, passage of Rectum, haemorrhage from — passage of long tube into, for administration of ene- mata — stricture of .. — surgical regions of .. — ulceration of .. — — in dysentery Reef-knot Respiration, artificial, in syn- cope .. .. .. 56 Retention of urine .. .. 340 -------after operations 345, 537 -------from enlargad prostate 342 -------from fractured pelvis 187 -------from fractured spine 185 -------hysterical .. .. 345 -------from impacted calculus 344 -------from phimosis .. 344 -------from spasm .. .. 311 —-----from stricture .. 341 Retro-pharyngeal abscesses .. 449 Rheophore .. .. .. 67 Ribs, fracture of.. .. 148, 170 Rickety legs ......327 Roller bandage (see " Bandage") 84 Rose's tampon ., ,, ,, 43. INDEX. 591 PAGE PAGE Rupture of bladder . 318 Sounding for stone ,, 479 -----fraenum . 29 Sounds 471 -----urethra, traumatic . 345 Southey's trocar 464 Ruspini's styptic . 62 Spanish windlass Spencer Wells' forceps .. 18 25 S Sphincters of anus, division Spica, double of" 42 90 Sal alembroth . 247 91 Salicylic wool . 247 89 Salmon's truss . 108 — of shoulder .. 90 Sayre's treatment of fracture 1 — of thumb 91 clavicle . 168 Spinal cases, the jacket for 307 ■— vertebrated probe .. . 260 Spine, fracture of 149 ,184 Scalds . 284 Splint, Adam's .. 333 — of larynx . 291 — flexible 127 — of pharynx . 291 — leather 130 Scalp wounds .. .. S 9, 2-.2 ----for knee .. 131 Scapula, fracture of 174 — Liston's 189 Scarificator . 530 — long, application of .. 192 Scarpa's shoe . 333 — Lonsdale's 161 Scoop for scraping sinuses . 518 — Macewen's 197 Scott's dressing .. 122 — Macleod's for Colles' fract ure 182 Scrotal bandage .. .. 6 2, 105 — Mclntyre's 127 — truss 111 — moulded 130-1' Scurvy . 53 -----for lower jaw 160 Sebaceous cysts 509 — natural 123 Sedan chair for transport . 151 181 Septum of nose, injury to 159 — Neville's back 126 209 Serous cavities, evacuation of. 461 — padding for .. 128 — effusion into cellular tissue 465 — patterns for .. 132 Serrefme, compression by 25 — Plaster of Paris 137 Shell-fish poisoning 392 — poroplastic felt for .. 135 Shock ....... 356 — rigid 124 — from burns .. .. 284 — Sieveking's 199 — from haemorrhage .. 359 — St. Andrew's Cross .. 297 — from injury without haemor — Thomas's 300 rhage 356 — — double 302 Shoulder, fracture near 147 — trap-doors in .. .. 141 — triangular bandage for 78 — wooden 124 Sieveking's splint for hip-join Splinting, kettle-holder.. 128 disease 298 Splints 123-li Signorini's tourniquet 20 — angular 124 Silicate of soda bandage 139 — attachment of 129 Silk ligatures 24 - - Bavarian 138 — net bandage 83 — Bryant s .. 125, 199, 297 Silver catheters 471 — cap (metal) for lower jaw 162 Sinuses, scoop for scraping 518 — Carr's, for Colles' fracture 183 Skey's tourniquet 20 — Cline's.. 128 20G Skin grafting 287 — coverings for .. 128 Skull, fracture of 158 — Croft's plaster 207 — necrosis of 253 — Dupuytren's, for Pott's frac- Sling, triangular bandage for .. 76 ture 214 Sloughing from ice bags 264 — Ferguson's long 189 — phagedeena .. .. 4 5, 278 — for elbow 125 Sloughs, cause of haemorrhage 5 0, 275 — for fracture of humerus near Soda as a caustic .. . 63 elbow ., ,, ,, 178 592 INDEX. PAGE PAGH Splints for talipes 332 Subclavian artery, compression — Gordon's, for Colles' fracture 183 of........ 10 — Guillery's flexible 127 Suffocation (see Asphyxia) 369 — gutta-percha, for 135 Sulphate of copper 61 — improvised .. .. 123 144 -----iron 61 162 Sulphuric acid, for arrest of — interrupted .. 125 haemorrhage 73 — iron 126 -----poisoning 389 Sponge for plugging anus 43 Superficial femoral artery, com- — for plugging bleeding wound 4 pression of 15 — grafting 289 — temporal artery, compression Sprains 217 of........ 8 — galvanism for 219 "Suppositories 552 Spray producer 241 Suppository of morphia 42 Sprays, etc. 555 Surgical case taking 545 St. Andrew's Cross 297 — dressings 222 -----bandage .. 100 Sutures, deep .. .. 28 , 224 -----splint 297 — superficial 228 Staffordshire knot 103 Sylvester's method of treating Starch bandage .. .. 140 the apparently drowned 370 Stearine bandage 140 Syncope .. 359 Sternum, fracture of 170 — from extreme haemorrhage, Stirrup and weight .. 191 , 192 etc. .. .. 55 359 -----for hip disease 294 — from administration of Stomach, foreign bodies in 377 chloroform 404 — pump, use of .. 486 — from internal haemorrhage.. 55 — washing out 487 Synovitis 457 Stone, sounding for 479 271 Strangulated hernia 351 Syringe, hypodermic 490 Strapping 117 Syringing the ear 434 — accurate adjustment of 118 — closure of wounds by 118 T — for ankle 120 120 Talipes, calcaneo-valgus 336 — for chest 171 — calcaneus 336 — dangers of 117 — classification of 329 — for fingers 119 — equino-varus .. 331 — for knee 119 — equinus 335 120 329 — for wrist 119 — varus 330 — isinglass 117 Tampons 38 — on leather 117 Tannic acid, a haemostatic 73 ■— on linen 117 Tannin 62 117 73 — precaution in using .. 158 35 — ulcers 266 — styptic for bladder 44 Stricture of rectum 485 Tartarated iron 274 ----urethra .. .. 341 ,475 T-bandage, double 99 Stump, haemorrhage from 50 —. — for ear 101 — bandage for .. 93 -----for perineum 99 — triangular bandage for 80 -----single 99 Strychnia poisoning 385 Teeth, extraction of .. 421-430 59 -------haemorrhage after .. 38 — charpie 51 — fracture of 430 — for bleeders 51 — replacing in socket 430 — opium and cinchona bark as 46 Temporal artery, compression of 8 INDEX. 593 Tenaculum .. Tenotomy — for club foot .. — in hip disease — knife .. „ Thecal abscesses Thermo-cautery .. -----Pacquelin's Thiersch's method of skin graft ing....... Thomas's splint .. ----- double Thomson's piston trocar Throat, wounds of Thymol....... Tibia, curvature of — fracture of Tibial artery (anterior), com pression of -----(posterior), compression Toe-nail ingrown Toes, twisted Tongue-tie Tonsillar abscess Tonsillotome, Mackenzie's Tonsillotomy Torsion forceps .. — of arteries Tourniquet, alveolar — Carte's — improvised — Lister's — Petit's....... — Signorini's •— Skey's Tourniquets Tow, carbolic Tracheotomy — for removal of foreign bodies — haemorrhage in — non-insertion of tube in — stopping of breathing in — the operation.. — treatment after .. — tubes Transfusion — Aveling's apparatus for Transport, methods of .. Triangular bandage -----for back .. ------- buttock ----■ — chest .. -------cravat.. --------elbow .. ----- — foot -------head of PAGE 24 504 332 304 505 451 65 288 300 302 461 253 247 327 205 16 16 523 337 525 449 503 502 27 27 39 20 18 21 18 20 20 18-21 247 493 378 497 . 499 . 498 . 496 . 499 . 493 . 56 . 57 . 151 . 75 . 77 . 81 . 77 . 75 79, 80 . 80 . 77 PAGE Triangular bandage for knee .. 79 -------shoulder .. 78 -------sling .. 75 Trocar for hydrocele .. 467 — Southey's .. 464 — Thomson's piston .. 461 Truss, Coles' .. 109 — femoral .. 110 — for half-descended testicle . 116 — for infants .. 112 — for varieties of hernia .. 110 — inguinal . 110 — measurement for . 115 :— nasal, Adam's . 159 — Salmon's . 108 — scrotal . Ill — selection of .. . 107 — worsted . 112 Trusses 107-116 — measurements for .. . 115 Tubercles, mu co-cutaneous . 522 Tubes, drainage . 230 Turpentine, for haematuria . 72 — a haemostatic.. . 72 — a styptic for bladder . 44 — stupe . 544 Twisted toes . 337 Tympanum, insufflation of . 439 Typhoidal haemorrhage . 72 u Ulcebs...... 265-276 — cautery for .. .. .. 271 — chronic .. .. .. 267 — cold........267 — compression for .. .. 270 -- electricity for .. .. 270 — excision of .. .. .. 271 — flabby........268 — haemorrhagic.. .. 44,269 — in bleeders .. .. .. 52 — in external auditory meatus 435 — incision of .. .. .. 270 — inflamed .. .. .. 268 — of anus .. .. .. 515 — of legs........265 — Martin's bandage for .. 266 — neuralgic .. .. .. 269 — "sealing of" .. .. .. 271 — sloughing ......269 — strapping ......266 — syphilitic .. .. .. 271 Ulnar artery, compression of .. 13 Ultzman's method of washing out the bladder .. .. 484 594 INDEX. Urethra, haemorrhage from — rupture of — size of normal — stricture of .. Urethral caruncle — fever Urine, extravasation of — retention of .. -------from fractured pel... -------from fractured spine Uvula, relaxed Vaccination Vaginal adhesions Valgus pad Varicose veins, rupture of Veins, entrance of air into — median basilic, blood-lett from Venaesection for collapse — complications of — method of — to relieve congestion Venereal sores .. ----dressings for -----suppurating — warts Volckman's spoon Vulsellum forceps for piles PAGE 44 44, 345 475 475 522 476 345 340 187 185 504 533 525 330 32 380 ing 527 358 528 527 55 271 272 273 522 45 512 W Walkeb's, Dr. method of jackets 313 PAGE Warts ........552 Wax in ear .. .. .. 431 Weak ankle ......329 Wells's, Sir Spencer, forceps .. 25 Whitehead's operation for piles 515 Whitlow........451 Worsted truss .. .. .. 112 Wounds, etc..... 222-264 — bruised ......250 — contused .. .. .. 250 — digestion of .. .. .. 250 — drainage of .. .. .. 230 — ear........253 — foetid........251 — gunshot .. .. .. 259 — incised .. .. 222-238 — irrigation of .. .. .. 235 — of buttocks .. .. .. 255 — of joints .. .. .. 255 — of nerves .. .. .. 258 — of tendons .. .. .. 257 — of throat ......253 — punctured .. . . .. 251 — scalp .. .. .. .. 252 Wrist, strapping for .. .. 119 Yellow wash......273 7 Zygoma, fracture of 159 I. WO 178 P995s 1892 NLM Q5E3717T fi NATIONAL LIBRARY OF MEDICINE ivC^'t ^* \*v^ v. V1 fi :S^31 NLM052371798