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MINOR SURGERY 
 
 BANDAGING 
 
 INCLUDING 
 
 THE TREATMENT OF FRACTURES AND DISLOCATIONS, THE 
 LIGATION OF ARTERIES, AMPUTATIONS, EXCISIONS 
 AND RESECTIONS, OPERATIONS UPON NERVES 
 AND TENDONS, TRACHEOTOMY, INTUBA- 
 TION OF THE LARYNX, ETC. 
 
 BY 
 
 HENRY R. WHARTON, M.D., 
 
 DEMONSTRATOR OF SURGEBY IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE 
 
 PRESBYTERIAN HOSPITAL, THE METHODIST EPISCOPAL HOSPITAL, AND 
 
 THE CHILDREN'S HOSPITAL | CONSULTING SUBGEON TO 
 
 THE PBESBYTEEIAN OBPHANAGE. 
 
 THIRD EDITION, THOROUGHLY REVISED AND ENLARGED, 
 "WITH 475 ILLUSTRATIONS. 
 
 IIIN 
 
 v\*' 
 
 LEA BROTHERS & CO., 
 
 PHILADELPHIA AND NEW YORK. 
 1896. 
 
Entered according to the Act of Congress, in the year 1896, by 
 
 LEA BKOTHEHS & CO., 
 In the Office of the Librarian of Congress. All rights reserved. 
 
 DORNAN, PRINTER. 
 
PREFACE TO THIRD EDITION. 
 
 In the preparation of the third edition of this work 
 the subject-matter has been carefully revised and certain 
 additions have been made. From the fact that much 
 attention is now paid in our medical schools to operative 
 work upon the cadaver, it has seemed advisable to the 
 author to add a considerable amount of new material 
 upon the subjects of excision of the joints, operations 
 upon nerves, tendons, etc. The descriptions of these 
 operative procedures are brief and are not intended to 
 take the place of the more varied and elaborate descrip- 
 tions given in works upon operative surgery, but have 
 been introduced to add to the value of the work as a 
 handbook for students in their operative work upon the 
 cadaver. The author's thanks are due to Dr. Joseph P. 
 Tunis for kind assistance in revising the proof-sheets. ' 
 
 1725 Spruce St., Philadelphia, January, 1896. 
 
PREFACE TO SECOND EDITION. 
 
 The author has been much gratified at the favorable 
 reception which has been accorded to this work, and has 
 endeavored in the preparation of a second edition to make 
 it more worthy of a continuance of that favor. The 
 aseptic and antiseptic methods of wound treatment have 
 been thoroughly revised, and a considerable amount of 
 new matter, with a number of new illustrations, have 
 been added. The author's thanks are due to Dr. Joseph 
 P. Tunis for his kind assistance in revising the proof- 
 sheets. 
 
 112 South Eighteenth St., Philadelphia, July, 1893. 
 
PREFACE TO FIRST EDITION. 
 
 The author has, in this work, endeavored to present, 
 in as concise a manner as possible, a description of the 
 various bandages, surgical dressings, and minor surgical 
 procedures which are employed in the practice of surgery 
 at the present time. The preparation and application of 
 the antiseptic dressings now most commonly used have 
 also received full consideration. The article upon Ban- 
 daging is fully illustrated with cuts, mostly new and 
 taken from photographs, which, it is hoped, will prove of 
 value as furnishing an accurate representation of the most 
 important bandages used in surgical practice ; the same 
 is in a measure true of the article upon the dressing of 
 Fractures and Dislocations, in which many new cuts of 
 the same kind appear. 
 
 The work also contains short articles upon Tracheot- 
 omy, Intubation of the Larynx, the Ligation of Arteries, 
 and Amputations, and, although these procedures are 
 scarcely to be included with those of Minor Surgery, it 
 is hoped that their description will increase the value 
 of the work to medical students, for whose use it has 
 
viii PREFACE. 
 
 been prepared. The author's thanks are due to Dr. 
 Walter D. Green for his kind assistance in revising the 
 proof-sheets, and to Mr. James Wood for the skilful 
 photographic work used in illustrating several of the 
 articles. 
 
 112 South Eighteenth St., Philadelphia, August, 1891. 
 
CONTENTS. 
 
 PART I. 
 BANDAGING. 
 
 Varieties of Bandages 
 Bandages for the Head and Neck 
 Bandages of the Upper Extremity 
 Bandages of the Trunk . 
 Bandages of the Lower Extremity- 
 Special Bandages 
 Fixed Dressings or Hardening Bandages 
 
 PAGES 
 
 13-41 
 
 41-57 
 
 57-75 
 
 75-80 
 
 80-93 
 
 93-100 
 
 100-118 
 
 PART II. 
 
 MINOR SURGERY. 
 
 Theory of Asepsis and Antisepsis in Wound Treatment 119-124 
 
 Agents Employed to Secure Asepsis .... 124-132 
 Preparation of Materials Used in Aseptic Surgery and 
 
 Dressings 132-140 
 
 Preparation of Gauze Dressings 140-145 
 
 Methods and Dressings Employed in the Treatment of 
 
 Wounds to Secure Asepsis 145-146 
 
 Preparation for Aseptic Operation and Dressing of 
 
 Wounds 146-158 
 
 Materials Used in Surgical Dressings .... 158-166 
 
 Procedures Employed in Minor Surgery . . . 166-229 
 
 Anaesthetics 229-241 
 
 Trusses 241-245 
 
x CONTENTS. 
 
 PAGES 
 
 Use of Catheters and Bougies 245-254 
 
 Sutures 254-274 
 
 Ligatures Used in the Treatment of Vascular Growths 274-280 
 
 Treatment of Hemorrhage .... . . 280-304 
 
 Opening and Dressing of Abscesses .... 304-307 
 
 Dressing of Wounds, Burns and Scalds, Bedsores, 
 
 Sprains 307-317 
 
 PART III. 
 
 FRACTURES. 
 
 General Consideration of Fractures .... 318-331 
 Treatment of Special Fractures . . . . . 331-392 
 
 PART IV. 
 
 DISLOCATIONS. 
 
 General Consideration of Dislocations .... 393-395 
 Special Dislocations 395-423 
 
 PART V. 
 
 OPERATIONS. 
 
 Ligation of Arteries 424-426 
 
 Ligation of Special Arteries . . . ... 427-458 
 
 PART VI. 
 
 AMPUTATIONS. 
 
 General Consideration of Amputations .... 459-472 
 Special Amputations 473-515 
 
CONTENTS. xi 
 
 PART VII. 
 EXCISIONS AND RESECTIONS. 
 
 PAGES 
 
 General Consideration of Excisions and Resections . 516-519 
 Special Excisions and Resections 519-537 
 
 Trephining 538-540 
 
 Operations upon Nerves 540-546 
 
 Operations upon Tendons ...... 547-552 
 
 Tracheotomy . 553-562 
 
 Laryngotomy 562-563 
 
 Laryngo-tracheotorny 563-564 
 
 Intubation of the Larynx 564-569 
 
 Operations upon the Kidney ...... 570-571 
 
 Operations upon the Colon . . . . . . 571-572 
 
 Lithotomy 572-574 
 
 Special Operations 574-577 
 
 Osteotomy . . 577-579 
 
 Index 580 
 
PART I. 
 
 BANDAGING 
 
 Bandages constitute one of the most widely used and 
 important surgical dressings ; they are employed to hold 
 dressings in contact with the surface of the body, to make 
 pressure, to hold splints in place in the treatment of frac- 
 tures and dislocations, and to restore to their natural posi- 
 tion parts which may have become displaced. 
 
 Bandages may be prepared of various materials, such as 
 linen, crinoline, flannel, cheese- or tobacco-cloth, rubber- 
 sheeting, or muslin, bleached or unbleached; the latter ma- 
 terial is the most commonly employed, by reason of the ease 
 with which it is obtained and its cheapness ; flannel, from 
 its elasticity, is sometimes used, but its employment for 
 bandages is now generally limited to its use in dressings 
 for operative w r ork in connection with the eye, and for a 
 primary roller in the application of the plaster-of-Paris 
 dressings. 
 
 Bandages are either simple, when composed of one piece 
 of material, such as the ordinary roller-bandage, or com- 
 pound, when prepared of one or more pieces, adapted by 
 size and shape to peculiar objects. 
 
 Bandages are also described as uniting, dividing, com- 
 pressing, expelling, or retaining bandages, according to the 
 purposes they serve by their application. 
 
 The importance of being perfectly familiar with the gen- 
 eral rules of bandaging and proficient in the application of 
 the roller-bandage cannot be overestimated, and both the 
 student and general practitioner will never have cause to 
 
 2 
 
14 BANDAGING. 
 
 regret the time occupied in learning to apply neatly this 
 form of surgical dressing. 
 
 A well-applied bandage adds to the comfort of the pa- 
 tient, and the method of its application often secures for 
 the physician the confidence both of the patient and of his 
 friends, while, on the other hand, a badly applied bandage 
 is apt to be uncomfortable and insecure, and to meet with 
 their adverse criticism. 
 
 The Roller-bandage. 
 
 The roller-bandage consists of a strip of woven material, 
 prepared from some of the materials previously mentioned, 
 of variable length and width according to the portion of 
 the body to which it is to be applied ; this, for ease of 
 application, is rolled into a cylindrical form. 
 
 Fig. 1. 
 
 Bandage-winder. 
 
 The material commonly employed for the roller-bandage 
 is unbleached muslin, although, for special purposes, linen, 
 flannel, rubber-sheeting, crinoline or cheese-cloth may be 
 used. It is important that the roller-bandage should con- 
 sist of one piece, free from seams and selvage, for if made 
 of a number of pieces sewed together, or if it contains 
 
THE B OLLER-BANDA GE. \ 5 
 
 creases or selvage, it cannot be so neatly applied, and it is 
 not so comfortable to the patient, as it is apt to leave 
 creases upon the skin. 
 
 In preparing the ordinary muslin-bandage the material 
 is torn in strips varying in length and width according to 
 the part of the body to which it is to be applied, and it is 
 then rolled into a cylinder, either by the hand or by a 
 machine constructed for the purpose. (Fig. 1.) 
 
 It is important that every student and practitioner 
 should be able to roll a bandage by hand, for in practice 
 the medical attendant may at any moment be called upon 
 
 Fig. 2. 
 
 Rolling a bandage "by hand. 
 
 to roll a bandage, in order to apply a dressing, and as the 
 art of preparing a bandage is acquired by a little practice, 
 it should be familiar to every student and physician. To 
 roll a bandage by hand the strip should be folded at one 
 extremity several times until a small cylinder is formed ; 
 this is then grasped by its extremities by the thumb and 
 index-finger of the left hand ; the free extremity of the 
 strip is then grasped between the thumb and index-finger 
 of the right hand, and by alternate pronation and supina- 
 tion of the right hand the cylinder is revolved and the 
 roller is formed ; the firmness of the roller will depend 
 
16 
 
 BANDAGING. 
 
 upon the amount of tension which is kept upon the free 
 extremity of the strip during the revolution of the cylin- 
 der. (Fig. 2.) 
 
 Fig. 3. 
 
 Single roller. 
 
 A bandage rolled in the form of a cylinder is called a 
 single or sinc/le-headed roller (Fig. 3) ; if rolled from each 
 extremity toward the centre so that two cylinders are 
 
 Fig. 4. 
 
 Double roller. 
 
 formed joined by the central portion of the strip, the 
 double or double-headed roller is formed. (Fig. 4.) Double 
 rollers are not much used, and in practice the single roller 
 
GENERAL RULES FOR BANDAGING. 17 
 
 will be found to be amply sufficient for the application of 
 almost all the bandages employed in surgical dressings. 
 
 The free end of the roller-bandage is called the initial 
 extremity ; the end which is enclosed in the centre of the 
 cylinder is its terminal extremity ; and the portion between 
 the extremities the body ; a roller has also two surfaces, 
 external and internal. 
 
 Dimensions of Bandages. 
 
 Bandages vary in length and width according to the pur- 
 poses for which they are employed, and in practice it will 
 be found that a small variety of bandages will be amply 
 sufficient for the application of the ordinary surgical 
 dressings. 
 
 The following list comprises those most frequently used 
 and will show their dimensions : 
 
 Bandage one inch wide, three yards in length, for ban- 
 dages for the hand, fingers, and toes. 
 
 Bandage two inches wide, six yards in length, for head- 
 bandages and far the extremities in children. 
 
 Bandage two and a half inches wide, seven yards in 
 length, for bandages of the extremities in adults ; a roller 
 of this size is the one most generally used. 
 
 Bandage three inches wide, nine yards in length, for 
 bandages of the thigh, groin, and trunk. 
 
 Bandage four inches wide, ten yards in length, for ban- 
 dages of the trunk. 
 
 General Rules for Bandaging. 
 
 In applying a roller-bandage the operator should place 
 the external surface of the free extremity of the roller upon 
 the part, holding it in position with the fingers of the left 
 hand until fixed by a few turns of the roller, the cylinder 
 being held in the right hand by the thumb and fingers ; 
 for thus as the bandage is unwound it rolls into the oper- 
 ator's hand, thereby giving him more control of it ; care 
 
]{ 
 
 BANDAGING. 
 
 should also be taken that the turns are applied smoothly 
 to the surface, and that the pressure exerted by each turn 
 is uniform. 
 
 When a bandage is applied to a limb the surgeon 
 should see that the part is in the position it is to occupy 
 as regards flexion and extension when the dressing is com- 
 pleted, for a bandage applied when the limb is flexed will 
 exert too much pressure when the limb is extended, and 
 then may, by the pressure it exerts, become a matter of 
 discomfort or even of danger to the patient, or if applied 
 to an extended limb it will become uncomfortable upon 
 flexion. 
 
 Fig. 5. 
 
 Method of removing a bandage. 
 
 My experience has been that, as a rule, those who have 
 had little experience with the application of the roller- 
 bandage are apt to apply their bandages too tightly, and 
 this may lead to disastrous consequences, especially in the 
 dressing of fractures. Professor Ashhurst, in his clinical 
 teaching, advises students to make use of a larger number 
 
VARIETIES OF BANDAGES. 19 
 
 of turns of a bandage in securing fracture-dressings rather 
 than to depend upon a few turns too firmly applied ; advice 
 which certainly conduces to the safety and comfort of the 
 patient. When the bandage has been completed the ter- 
 minal extremity should be secured by a pin or safety-pin 
 applied transversely to the bandage, and if a pin be used 
 its point should be buried in the folds of the bandage ; if 
 
 Fig. 6. 
 
 Bandage-scissors. 
 
 the bandage be a narrow one, the end may be split and 
 the two tails resulting may be secured around the part by 
 tying. In removing a bandage the folds should be care- 
 fully gathered up in a loose mass as the bandage is 
 unwound, the mass being transferred rapidly from one 
 hand to the other, thus facilitating its removal and pre- 
 venting the part from becoming entangled in its loops. 
 (Fig. 5.) If it is desirable to cut the bandage to remove 
 it, the use of scissors made for this purpose will be found 
 most satisfactory. (Fig. 6.) 
 
 Varieties of Bandages. 
 
 The Circular Bandage. 
 
 This bandage consists of a few circular turns around a 
 part, each turn covering accurately the preceding turn. 
 This variety of bandage may be used to retain a dressing 
 to a limited portion of the head, neck, or limbs, to make 
 
20 
 
 BANDAGING. 
 
 compression upon the veins of the arm before performing 
 venesection. (Fig. 11, b.) 
 
 The Oblique Bandage. 
 
 In this form of bandage the turns are carried obliquely 
 over the part, leaving uncovered spaces between the suc- 
 
 Fig. 7. 
 
 Oblique bandage. 
 
 cessive turns. (Fig. 7.) Its principal use is for the 
 application of temporary dressings. 
 
 The Spiral Bandage. 
 
 In this bandage the turns are carried around the part 
 in a spiral direction, each turn overlapping a portion of the 
 
 Fig. 8. 
 
 Ascending spiral bandage. 
 
 preceding one, usually one-third or one-half; it may be 
 applied as an ascending spiral (Fig. 8) or as a descending 
 
VARIETIES OF BANDAGES. 21 
 
 spiral (Fig. 9). This bandage may be used to cover a 
 part which does not increase too rapidly in diameter ; for 
 instance, the abdomen, chest, or arm. 
 
 Fig. 9. 
 
 Descending spiral bandage. 
 
 The Spiral Reversed Bandage. 
 
 This bandage is a spiral bandage, but differs from the 
 ordinary spiral bandage in having its turns folded back or 
 reversed as it ascends a part, the diameter of which gradu- 
 ally increases. By its use it is possible to cover by spiral 
 turns a part conical in shape, so as to make equable 
 pressure upon all parts of the surface. The reverses are 
 made as follows : After fixing the initial extremity of the 
 roller, as the part increases in diameter the bandage is 
 carried off a little obliquely to the axis of the limb for 
 from four to six inches ; the index-finger or thumb of the 
 disengaged hand is placed upon the body of the bandage 
 to keep it securely in place upon the limb, the hand hold- 
 ing the roller is carried a little toward the limb to slacken 
 the unwound portion of the bandage, and by changing the 
 position of the hand holding the bandage from extreme 
 supination to pronation the reverse is made. (Fig. 10.) 
 Care should be taken not to attempt to make the reverse 
 while the bandage is tense, for by so doing the bandage is 
 twisted into a cord which is unsightly and uncomfortable 
 to the patient, instead of forming a closely fitting reverse. 
 
 2* 
 
22 BANDAGING. 
 
 The reverse should be completed before the bandage is 
 carried around the limb, and when it has been completed 
 the bandage may be slightly tightened so as to conform to 
 the part accurately. 
 
 Fig. 10. 
 
 Method of making reverses. 
 
 The reverses should be in line to have the bandage 
 present a good appearance, and care should be taken that 
 the reverses should not be made over salient parts of the 
 skeleton, for if they occupy such positions they cause 
 creases in the skin and become uncomfortable to the 
 patient. 
 
 To make reverses neatly and to have them in line 
 require skill and practice ; a well-applied spiral reversed 
 bandage is a test of a competent bandager. 
 
 Spiea-bandage. 
 
 When the turns of the roller cross each other in the 
 form of the Greek letter lambda, leaving the previous turn 
 about one-third uncovered, the bandage is known as a 
 spica -bandage. (Fig. 11, a.) These spica-bandages are 
 especially serviceable as a means of retaining surgical 
 
VARIETIES OF BANDAGES. 
 
 23 
 
 dressings upon particular portions of the surface of the 
 body, such as the shoulder, groin, or foot. 
 
 Fig. ll. 
 
 Spica-bandage. 
 
 Circular bandage. 
 
 Figure-of-eight Bandage. 
 
 This bandage receives its name from the turns being 
 applied so as to form a figure-of-eight. This method of 
 
 Fig. 12. 
 
 Recurrent bandage. 
 
 application is made use of in the Barton's bandage, the 
 bandages of the knee and elbow, and many other bandages. 
 
24 
 
 BANDAGING. 
 
 Recurrent Bandage. 
 
 This bandage derives its name from the fact that the 
 roller after covering a certain part of the surface is re- 
 flected and brought back to the point of starting ; it is 
 then reversed and carried toward the opposite point, and 
 this manipulation is continued until the part is covered 
 by these recurrent turns, which are then secured by a few 
 circular turns. (Fig. 12.) This is the bandage usually 
 employed in the dressing of stumps. 
 
 Compound Bandages. 
 
 These bandages are usually formed of several pieces of 
 muslin or other material, sewed or pinned together, and 
 are employed to fulfil some special indication in the appli- 
 cation of dressings to particular parts of the body. The 
 most useful of the compound bandages are the T-bandages 
 and the many-tailed bandages. 
 
 T-bandage. 
 
 The single T-bandage consists of a horizontal band to 
 which is attached, about its middle, another having a ver- 
 
 Fig. 13. 
 
 Single T-bandage. 
 
 tical direction ; the horizontal piece should be about twice 
 the length of the vertical piece. (Fig. 13.) The single 
 
COMPOUND BANDAGES. 
 
 25 
 
 T-bandage may be used to retain dressings to the head, 
 the horizontal piece being passed around the head from the 
 occiput to the forehead, the vertical piece being passed over 
 the head and secured to the horizontal piece, the shape 
 and width of the two pieces being varied according to the 
 indications. In applying dressings to the anal region or 
 perineum, or in securing a catheter in a perineal wound, 
 the single T-bandage will be found most useful. In 
 applying a T-bandage for this purpose the body of the 
 bandage is placed over the spine, just above the pelvis, and 
 the horizontal portion is tied around the abdomen. The 
 free extremity is split into two tails for about two-thirds 
 
 Fig. 14. 
 
 Single T-bandage for chest. 
 
 of its length, and is carried over the anal region and 
 brought up between the thighs, the terminal strips passing 
 one on each side of the scrotum and being secured to the 
 horizontal strip in front. The single T-bandage may be 
 variously modified according to the indications which are 
 to be met; for instance, in applying a dressing to the 
 breasts the horizontal strip passing around the chest may 
 be made ten or twelve inches in width, the vertical strip, 
 two inches in width, passes from the back over the shoulder 
 and is secured to the horizontal strip in front. (Fig. 14.) 
 The single T-bandage may be variously modified, according 
 to the ideas of the surgeon, so as to meet the indications 
 
26 
 
 BANDAGING. 
 
 presented in special cases. For the groin a piece of 
 muslin six inches wide at its base and thirty inches long 
 is sewed to a horizontal strip of muslin one and a half 
 
 Fig. 15. 
 
 T-baudage oi groin. 
 
 yards long and two inches in width. It may be applied 
 as in Fig. 15 to hold a dressing to this part. 
 
 Double T-bandage. 
 
 The double T-bandage differs from the single bandage 
 in having two vertical strips attached to the horizontal 
 strip and it may be used for much the same purposes as 
 the single T-bandage. (Fig. 16.) It may be conveniently 
 used for retaining dressings to the chest, breasts, or abdo- 
 men ; when used for this purpose the horizontal portion 
 should be from eight to twelve inches wide and long 
 enough to pass one and a quarter times about the chest ; 
 two vertical strips, two inches wide and twenty inches 
 long, should be attached to the horizontal strip a short 
 
COMPOUND BANDAGES. 
 
 27 
 
 distance apart near its middle. In applying this bandage 
 to the chest, the horizontal strip is placed around the chest 
 so that the vertical strips occupy a position on either side 
 
 Fig. 16. 
 
 Double T-bandage. 
 
 of the spine ; the overlapping end of the horizontal portion 
 is secured by pins or safety-pins, and the vertical strips 
 
 Fig. 17 
 
 Fig. 18. 
 
 Double T-bandage of chest. 
 
 Double T-bandage of nose. 
 
 are next carried one over either shoulder and secured to 
 the other portion of the bandage in front of the chest. 
 (Fig. 17.) 
 
28 
 
 BANDAGING. 
 
 The double T-bandage may also be used to secure dress- 
 ings to the nose, in which event the strips should be quite 
 narrow, about one inch in width, and should be applied 
 as shown in Fig. 18. 
 
 Many-tailed Bandages or Slings. 
 
 These bandages are prepared from pieces of muslin of 
 various lengths and breadths, which are split at each ex- 
 tremity into two, three, or more tails up to within a few 
 inches of their centres, their width and length being regu- 
 lated by the part of the body to which they are to be 
 applied. 
 
 Fig. 19. 
 
 Fig. 20. 
 
 Four-tailed bandage of chin. 
 
 Four-tailed bandage of head. 
 
 The four-tailed bandage may be found useful as a tem- 
 porary dressing in cases of fracture of the jaw, or to hold 
 dressings to the chin. It may be prepared by taking a 
 portion of a roller-bandage three inches wide and one yard 
 in length, and splitting each extremity up to within two 
 inches of the centre ; it is then applied as seen in Fig. 1 9. 
 
 The four-tailed bandage may also be used to retain 
 dressings to the scalp, and can be prepared by taking a 
 
HANDKERCHIEF-BANDAGES. 29 
 
 piece of muslin one yard and a quarter long and six or 
 eight inches in width, splitting it at each extremity into 
 two tails within six inches of the centre ; it may then be 
 applied as seen in Fig. 20. 
 
 The four-tailed bandage may also be used in the tem- 
 porary dressing of fractures of the clavicle — the body of 
 the bandage being placed upon the elbow of the injured 
 side, two tails passing around the body, fixing the arm to 
 the side, and two tails passing over the sound shoulder. 
 
 The many-tailed bandage may also be used for holding 
 dressings in contact with the abdomen or trunk, and is the 
 bandage which many surgeons employ to hold the dressings 
 to a laparotomy-wound, and to give support to the abdom- 
 inal walls after this operation. In preparing this bandage, 
 a strip of muslin or flannel, one and a half yards in length 
 and eighteen to twenty inches in w r idth, is required : the 
 extremities may be split so as to form an eight-tailed ban- 
 dage. In applying this bandage to the abdomen, the body 
 is placed upon the patient's back and the tails are brought 
 around the abdomen and overlap each other, and when 
 sufficiently firmly drawn to make the desired amount of 
 pressure they are secured by means of safety-pins. 
 
 Haxdkeechief-baxdages. 
 
 The use of handkerchiefs or square pieces of muslin for 
 the temporary or permanent dressing of wounds, fractures, 
 or dislocations was advocated many years ago by M. Mayor, 
 a Swiss surgeon, who wrote an extensive work upon this 
 subject, in which he reduced their application to a system. 
 He employed a handkerchief or a square piece of muslin, 
 and by various modifications in the application of these 
 developed a number of very ingenious bandages. 
 
 The various forms which the handkerchief or square 
 (Fig. 21) is made to assume are as follows : The oblong, 
 made by folding the square once or twice on itself (Fig. 
 22). The triangle, made by bringing together the diagonal 
 angles of the square (Fig. 23). The line of folding is 
 
30 
 
 BANDAGING. 
 
 known as the base, the angle opposite the base the apex, 
 and the other angles the extremities 
 
 The cravat is prepared from the triangle by bringing 
 the apex to its base, and folding it a number of times 
 upon itself until the desired width is obtained. (Fig. 24.) 
 
 Fig. 21. 
 
 Fig. 22. 
 
 -=k 
 
 1 J 
 
 f-~=r:r-"j 
 f>..- \ 
 
 || ™==J 
 
 ill i 
 
 J J 1 
 
 t 
 
 ii - -'-'-'■- 
 
 ill! a 
 
 
 
 i 
 
 ill: --- i 
 
 1! 
 
 i 
 
 "if----- 
 
 :.;:—:==.:..- ■ ■ 
 
 J:3f!=^ 
 
 
 Thesq 
 
 uare. 
 
 
 The oblong. 
 
 Fig. 23. 
 
 The triangle. 
 
 The cord is formed from the cravat twisted upon itself. 
 (Fig. 25.) The names of the various handkerchief-ban- 
 dages are derived from the shape of the handkerchiefs 
 used and the parts to which they are applied ; the names 
 serve as guides in their application. It is to be remem- 
 bered that the base of the triangle or the body of the 
 cravat is to be placed upon the portion, the designation of 
 
HANDKEECHIEF-BANDA GES. 
 
 31 
 
 which forms the first portion of the Dame of the bandage; 
 thus, in the occipitofrontal triangle, the shape of the hand- 
 
 FlG. 24. 
 
 The cravat. 
 Fig. 25. 
 
 The cord. 
 
 kerchief is given, and we know that the base of the 
 triangle is to be applied to the occiput and then pass to 
 
 Fig. 26. 
 
 Occipi to -frontal triangle. 
 
 the forehead. In using the cravats the same rule applies ; 
 thus, in the bis-axillary cravat the body of the cravat is 
 to be placed in the axilla of the aifected side, the extremi- 
 
32 BANDAGING. 
 
 ties crossed over the corresponding shoulder and carried 
 over the chest, one before, the other behind, to the axilla 
 of the opposite side, where they are secured. 
 
 The Occipitofrontal Triangle. 
 
 To apply this handkerchief place the base of the tri- 
 angle upon or a little below the occiput, and bring the 
 apex forward over the head, allowing it to drop over the 
 forehead ; next bring the extremities of the handkerchief 
 forward and tie them in a knot over the forehead ; finally 
 turn up the apex over the knotted ends and pin to the 
 body of the handkerchief. (Fig. 26.) 
 
 The Mento-vertico-occipital Cravat. 
 
 Fig. 27. 
 
 Meuto-vertico-occipital cravat. 
 
 To apply this handkerchief the middle of the base of 
 the cravat is placed under the chin, the extremities are 
 
HANDKERCHIEF-BANDA GES. 
 
 33 
 
 then carried in front of the ear on each side to the vertex 
 of the skull, and are crossed at that point ; the ends are 
 then carried downward over the parietal region to the 
 occiput and are secured by a knot at this point. (Fig. 
 27.) Another method of applying this handkerchief con- 
 
 Fig. 28. 
 
 Mento-vertico cravat (modified). 
 
 sists in placing the base of the cravat under the chin and 
 carrying the extremities over the vertex of the skull, 
 crossing them at that point, then carrying them down- 
 ward to the occiput, and crossing them again here and 
 
34 
 
 BANDAGING. 
 
 passing them forward around the chin, and finally securing 
 the ends by a knot. (Fig. 28.) The turns of the latter 
 handkerchief correspond exactly to the turns of the 
 Barton bandage of the head. 
 
 These handkerchief- bandages may be used to secure 
 dressings to the chin or scalp, or may be employed as 
 temporary dressings to secure fixation of the parts in 
 cases of fracture or dislocation of the jaw. 
 
 The Bis-axillary Cravat. 
 
 Fig. 29. 
 
 Bis-axillary cravat, 
 
 To apply this handkerchief the body of the cravat is 
 placed in the axilla, and the ends are brought up, one in 
 front, the other behind the axilla, and are made to cross 
 
HANDKERCHIEF-BANDA GES. 
 
 35 
 
 over the top of the shoulder; the extremities are then 
 carried across the back and chest respectively to the 
 opposite axilla, when they are secured by tying. (Fig. 
 29.) This handkerchief may be employed to secure dress- 
 ings in the axilla, or to hold dressings in contact with 
 the shoulder. 
 
 The Dor so-axillary Cravat. 
 
 This handkerchief is applied by placing the body of 
 the cravat over the spine between the scapulae, and then 
 carrying one extremity over the shoulder and through the 
 
 Fig. 
 
 Dorso-axillary cravat. 
 
 axilla backward to meet the other extremity, which has 
 been carried through the axilla and over the other shoulder 
 to the back, when the ends are secured by a knot. (Fig. 
 30.) This handkerchief may be used to hold dressings 
 to the axilla or upper portion of the back of the chest. 
 
36 BANDAGING. 
 
 The Compound Dorso-bis-axillary Cravat. 
 
 To apply this handkerchief two cravats are required. 
 The base of one cravat is placed over the front of one 
 shoulder, and the ends are passed, one over the top of the 
 shoulder, the other through the axilla, and they are then 
 secured by a single knot over the scapula ; the ends are 
 next secured by tying them in a loop. The second cravat 
 is next placed in front of the shoulder on the opposite 
 
 Fig. 31. 
 
 Compound dorso-bis-axillary cravat. 
 
 side, and the ends are respectively carried over the shoul- 
 der and through the axilla to the back, where they are 
 secured by a single knot; the ends of the handkerchief 
 are then passed through the loop of the other handker- 
 chief and secured by a knot. (Fig. 31.) This handker- 
 chief may be used to draw the shoulders backward in 
 cases of dislocation or fracture of the clavicle. 
 
HANDKERCHIEF-BANDAGES. 37 
 
 Triangular Cap or Suspensory of the Breast 
 
 To apply this handkerchief the base of the triangle is 
 placed under the affected breast, and one extremity is car- 
 ried beneath the axilla of the same side, and the other 
 extremity is carried around the opposite side of the neck. 
 
 Fig. 32. 
 
 tiff 
 
 Triangular cap or suspensory of the breast. 
 
 and they are secured together upon the back by a knot ; 
 the apex should then be brought up over the breast and 
 shoulder of the affected side and pinned to the bandage 
 over the scapula. (Fig. 32.) This handkerchief may be 
 employed to sling the breast in nursing- women, or to hold 
 a dressing to the breast. 
 
38 
 
 BANDAGING. 
 
 The Gluteo-femoral Triangle. 
 
 In applying this handkerchief a cravat is first fastened 
 around the waist, and a second handkerchief folded into a 
 triangle has its base placed in the gluteo-femoral fold, 
 and its extremities are carried around the thigh and 
 secured in front by a knot ; the apex of the handkerchief 
 
 Fig 33. 
 
 Gluteo-femoral triangle. 
 
 is then carried upward and passed beneath the cravat 
 around the waist, and is turned down and pinned to the 
 body of the triangle. (Fig. 33.) This handkerchief may 
 be used to retain dressings to the region of the buttock or 
 hip ; by unpinning the apex and turning it downward 
 ready access can be had to the parts beneath. 
 
 Gluteo-inguinal Cravat. 
 
 In applying this handkerchief the base of the cravat 
 is placed just over the gluteo-femoral fold, and the ex- 
 
HANDKEECHIEF-BANDA GES. 
 
 39 
 
 tremities are carried forward, one around the inner, the 
 other around the outer portion of the thigh, and they 
 are made to cross in the groin ; the ends are next passed 
 around the pelvis and secured together upon the back by 
 a knot. (Fig. 34.) This handkerchief may be employed 
 to hold dressings to the region of the groin. 
 
 By employing two cravats a double gluteo-inguinal 
 cravat may be applied, w r hich may be used to hold dress- 
 ings to both groins. The turns of these cravats corre- 
 spond to the turns of the single and double spica-bandages 
 of the groin. 
 
 Fig. 34. 
 
 Gluteo-iD^uinal cravat. 
 
 I have described a few of the many very ingenious ban- 
 dages devised by Mayor to substitute the use of the roller- 
 bandage, which will give the student some idea of their 
 design and application. It is well to bear in mind this 
 system of dressing, for the occasion might occur in which 
 the ordinary means of bandaging could not be obtained, 
 and the use of handkerchiefs might answer a useful purpose 
 as temporary dressings. I think their principal use is for 
 temporary dressings, and I do not think they will ever 
 take the place of the roller-bandage, which can be applied 
 with much greater nicety and exactness, and certainly 
 presents a much neater appearance. 
 
40 
 
 BANDAGING. 
 
 Barton' *s Handkerchief. 
 
 This dressing may be employed to make extension in 
 cases of fracture of the leg or thigh. It is applied by 
 taking a handkerchief folded into a narrow cravat and 
 placing the body of it on the extremity of the os calcis 
 below the insertion of the tendo Aehillis, so that two-thirds 
 of the cravat comes around under the outer malleolus, and 
 the other third remains on the inside. The inside portion 
 
 Fig. 35. 
 
 Barton's handkerchief. 
 
 remaining parallel with the sole of the foot, the outside 
 piece is carried over the instep and passed around it so as 
 to form a knot, and also passed under the sole of the foot 
 to be turned around the first turn and to form another 
 knot at the metatarsal articulation, when both ends are 
 carried off perpendicularly from the foot. 
 
BARTON'S BANDAGE. 
 
 41 
 
 REGIONAL BANDAGING. 
 
 Bandages for the Head and Neck. 
 
 Barton's Bandage. 
 
 Roller Two Inches in Width, Six Yards in Length. 
 
 Application.— The initial extremity of the roller 
 should be placed on the head just behind the mastoid pro- 
 cess, and the bandage should then be carried under the 
 
 Fig. 36. 
 
 Barton's bandage. 
 
 occipital protuberance obliquely upward under and in 
 front of the parietal eminence across the vertex of the 
 skull, then downward over the zygomatic arch, under the 
 
42 BANDAGING. 
 
 chin, thence upward over the opposite zygomatic arch and 
 over the top of the head, crossing the first turn, which 
 was made as nearly as possible in the median line of the 
 skull, carrying the turns of the roller under the parietal 
 eminence to the point of commencement. The bandage 
 is then passed obliquely around under the occipital pro- 
 tuberance and forward under the ear to the front of the 
 chin, thence back to the point from which the roller started. 
 
 Fig. 37 
 
 Barton's bandage, showing crossing of turns at vertex. 
 
 These figure-of-eight turns over the head and the circular 
 turns from the occiput to the chin should be repeated, each 
 turn exactly overlapping the preceding one until the ban- 
 dage is exhausted. (Fig. 36.) The extremity should then 
 be secured by a pin ; and pins should be introduced at the 
 points where the turns cross each other to give additional 
 fixation to the bandage. In applying the bandage care 
 should be taken to see that the turns overlap each other 
 exactly, and that the turns passing over the vertex cross 
 as near as possible in the median line of the skull. (Fig. 37.) 
 
MODIFIED BARTON'S BANDAGE. 43 
 
 Modified Barton's Bandage. 
 
 To obtain additional security in the application of the 
 Barton's bandage a turn of the bandage passing from the 
 occiput to the forehead may be made, this turn being in- 
 terposed between the turns of the bandage as ordinarily 
 applied. (Fig. 38.) In applying this bandage after the 
 first set of turns has been completed, that is, after the 
 bandage has been brought back to the occiput, the bandage 
 
 Fig. 38. 
 
 J* 
 
 ^90 
 
 Modified Barton's bandage. 
 
 is carried forward upon the head just over the ear, around 
 the forehead and backward above the ear on the opposite 
 side to the occiput ; this being done, the ordinary figure- 
 of-eight and circular turns are made, and when these have 
 been completed another occipitofrontal turn may be made 
 as described above, and this may be repeated as often as is 
 desired until the bandage is exhausted, when the extremity 
 
44 BANDAGING. 
 
 is fastened with a pin, and pins are also introduced at all 
 points at which the turns cross. 
 
 Use. — This bandage is one of the most useful of the 
 bandages of the head, being employed to secure fixation 
 of the jaw in cases of fracture or dislocation, and for the 
 application of dressings to the chin. I have also employed 
 it in place of the head-gear in slinging patients for the 
 application of the plaster-of-Paris bandage in cases of 
 disease of the spine, a stout cord or a piece of bandage 
 about three inches wide and one yard long being passed 
 under the turns crossing over the vertex ; this cord is then 
 secured to the cross-bar of the extension apparatus ; this 
 will be found quite as comfortable to the patient as the 
 ordinary head-gear employed and much less likely to slip 
 out of place and interfere with the breathing of the patient. 
 
 A firmly applied Barton's bandage holds the jaws so 
 closely together that care should be taken in applying it 
 to patients who are under the influence of an anaesthetic, 
 for if vomiting occurs the material may not be able to 
 escape from the mouth and suffocation might occur unless 
 the bandage were promptly removed. This accident I once 
 saw occur, and the patient's condition was alarming until 
 the bandage was cut, allowing the jaw to be opened and 
 the contents of the mouth to escape. 
 
 Gibson's Bandage. 
 
 Boiler Two Inches in Width, Six Yards in Length. 
 
 Application. — The initial extremity of the roller 
 should be placed upon the vertex of the skull in a line 
 with the anterior portion of the ear ; the bandage is then 
 carried downward in front of the ear to the chin, and 
 passed under the chin, and is carried upward on the same 
 line until it reaches the point of starting. The same turns 
 are repeated until three complete turns have been made ; 
 the bandage is then continued until it reaches a point just 
 above the ear, when it is reversed and is carried backward 
 
GIBSON'S BANDAGE. 45 
 
 around the occiput, and is continued around the head and 
 forehead until it reaches its point of origin ; these circular 
 turns are continued until three have been made. When 
 the bandage reaches the occiput, having completed the 
 third turn, it is allowed to drop down to the base of the 
 skull, and it is then carried forward below the ear and 
 around the chin, being brought back upon the opposite side 
 of the head and neck to the point of origin ; these turns 
 are repeated until three complete turns have been made, 
 
 Fig. 39. 
 
 Gibson's bandage. 
 
 and upon the completion of the third turn the bandage is 
 reversed and carried forward over the occiput and vertex 
 to the forehead, and its extremity is here secured with a 
 pin. Pins should also be applied at the points where the 
 turns of the bandage cross each other. (Fig. 39 ) 
 
 Use. — This bandage may be used to fix the lower jaw 
 in cases of fracture or dislocation of the jaw, but is very 
 apt to change its position, and is, therefore, not so satis- 
 factory as the Barton's bandage for this purpose. 
 
46 BANDAGING. 
 
 Oblique Bandage of Angle of the Jaw. 
 
 Roller Two Inches in Width, Six Yards in Length. 
 
 Application. — The initial extremity of the roller is 
 placed just in front of and above the left ear, and if the 
 left angle of the lower jaw is to be covered in, the bandage 
 is to be carried from left to right, making two complete 
 turns around the cranium from the occiput to the fore- 
 head. If however the right angle of the lower jaw is to 
 be covered in, the turns should be made in the opposite 
 direction. 
 
 Fig. 40. 
 
 Oblique bandage of angle of the jaw. 
 
 Having made two turns from the occiput to the fore- 
 head, the bandage is allowed to drop down upon the neck, 
 and is carried forward under the ear and under the chin 
 to the angle of the jaw ; it is now carried upward close to 
 the edge of the orbit, and obliquely over the vertex of the 
 skull, then down behind the right ear, continuing this 
 oblique turn under the chin to the angle of the left jaw, 
 where it ascends in the same direction as the previous turn. 
 Three or four of these oblique turns are made, each turn 
 overlapping the preceding one and passing from the edge 
 
RECURRENT BANDAGE OF THE HEAD. 47 
 
 of the orbit toward the ear until the space is covered in ; 
 the bandage is then carried to a point just above the ear 
 on the opposite side, is reversed, and finished with one or 
 two circular turns from the occiput to the forehead, the 
 extremity being secured by a pin. (Fig. 40.) 
 
 Use. — This will be found to be one of the most useful 
 of the head-bandages ; it may be used with a compress in 
 treating fractures of the angle of the lower jaw, for holding 
 dressings to the lower part of the chin and to the vault of 
 the cranium, and is especially useful in retaining dressings 
 to the sides of the face and the parotid region. As before 
 stated, it may be applied to cover either the right or left 
 side of the face, and, by reason of the oblique turns, holds 
 its position most securely, having little tendency to become 
 displaced. 
 
 Recurrent Bandage of the Head. 
 Roller Two Inches in Width, Six Yards in Length. 
 
 Application. — The initial extremity of the roller is 
 placed upon the lower part of the forehead and the ban- 
 dage is carried twice around the head from the forehead to 
 the occiput to secure it. When the bandage is brought 
 back to the median line of the forehead it is reversed and 
 the reversed turn is held by the finger of the left hand 
 while the roller is carried over the top of the head along 
 the sagittal suture to a point just below the occipital pro- 
 tuberance ; here it is reversed again and the reverse is 
 held by an assistant while the roller is carried back to the 
 forehead in an elliptical course, each turn covering in two- 
 thirds of the preceding turn. These turns are repeated 
 with successive reverses at the forehead and occiput until 
 one side of the head is completely covered in, and when 
 this is accomplished a circular turn is made from the fore- 
 head to the occiput to hold the reverses in place. 
 
 The opposite side of the head is next covered in by 
 elliptical reversed turns made in the same manner, and 
 when this has been accomplished two or three circular 
 
48 BANDAGING. 
 
 turns are carried around the head from the forehead to the 
 occiput to fix the previous turns. Pins should be applied 
 at the forehead and occiput at the points where the re- 
 versed turns concentrate. (Fig. 41.) 
 
 Fig 
 
 Recurrent bandage of the head. 
 
 Use. — This bandage when well applied is one of the 
 neatest of the head-bandages, and it will be found useful 
 to retain dressings to the vault of the cranium in the treat- 
 ment of wounds of the scalp in this region. It will also 
 be found of service in holding dressings to fractures of the 
 cranium and to wounds after the operation of trephining. 
 In restless patients it will sometimes become displaced, 
 and it may be rendered more secure by pinning a strip of 
 bandage to the circular turn in front of the ear and carry- 
 ing it down under the chin and up to a corresponding 
 point on the opposite side, where it is pinned to the cir- 
 cular turn ; or one or two oblique turns passing from the 
 circular turn over the vertex of the skull downward behind 
 the ear, under the chin and up to the circular turn in front 
 of the ear, may be applied. The course of these turns is 
 the same as those employed in the oblique bandage of the 
 angle of the jaw, the extremity being secured by a pin. 
 
TRANSVERSE RECURRENT BANDAGE OF HEAD. 49 
 
 Tpansvekse Recukrent Bandage of Head. 
 
 Roller Two Inches in Width, Six Yards in Length. 
 
 Application. — The initial extremity of the roller is 
 placed upon the lower part of the forehead and the ban- 
 dage is carried twice around the head from the forehead to 
 the occiput to secure it. The head is then covered in by 
 transverse turns of the bandage ; the first turn, starting 
 from a point behind the ear on one side, is carried below 
 the occiput to a corresponding point behind the opposite 
 
 Fig. 42. 
 
 Transverse recurrent bandage of the head. 
 
 ear, and ascending transverse turns are then made and 
 carried over the head, each turn covering in about two- 
 thirds of the preceding turn, until the forehead is reached, 
 and when this has been reached two or three circular turns 
 are carried around the head from the forehead to the 
 occiput to fix the recurrent turns. Pins should be applied 
 at the point of starting of the reversed turns behind the 
 ears, and at the occiput and forehead. (Fig. 42.) 
 
 Use. — This bandage may be employed to secure dress- 
 ings to the scalp in case of wounds, or in injuries to the 
 
50 BANDAGING. 
 
 skull, and is used for the same purposes as the recurrent 
 bandage of the head. 
 
 Y-BANDAGE OF THE He AD. 
 
 Boiler Two Inches in Width, Four Yards in Length. 
 
 Application. — The initial extremity of the roller is 
 secured by two turns of the bandage around the cranium 
 from the forehead to the occiput, and when the roller 
 reaches the occipital protuberance it is allowed to drop 
 slightly a little below this and is carried forward below 
 the ear around the front of the chin and lower lip, then 
 
 Fig. 43. 
 
 V-bandage of the head. 
 
 backward to the point of starting. These turns passing 
 from the occiput to the forehead and from the occiput to 
 the chin are alternately made nntil a sufficient number 
 have been applied, and the extremity is secured by a pin 
 over the occiput. (Fig. 43.) 
 
 This bandage may be modified by carrying the turns 
 from the occiput forward under the ear and around the 
 upper lip and back to the occiput and alternating these 
 turns with the occipito-frontal turns ; if employed in this 
 
HEAD-AND-NECK BANDAGE. 51 
 
 way, a bandage of one and one-half inches in width should 
 be used. 
 
 Use. — This bandage may be employed to hold dressings 
 to the front of the chin, to the upper and lower lips in 
 cases of wounds, or to give support to these parts after 
 plastic operations. 
 
 Head-and-neck Bandage. 
 Roller Two Inches in Width, Four Yards in Length. 
 
 Application. — The initial extremity of the roller is 
 placed upon the forehead and carried backward just above 
 the ear to the occiput and is then brought forward around 
 the opposite side of the head to the point of starting. Two 
 
 Fig. 44. 
 
 Head-and-neck bandage. 
 
 of these circular turns are made to fix the bandage, and 
 when it is carried back to the occiput it is allowed to drop 
 down slightly upon the neck and is then carried around the 
 neck, the turns around the head alternating with the neck- 
 turns until a sufficient number of these have been applied, 
 
52 BANDAGING. 
 
 when the extremity of the bandage is secured by a pin at 
 the point of crossing of the turns at the back of the 
 head. (Fig. 44.) 
 
 Use. — This bandage may be found useful in securing 
 dressings to the anterior or posterior portion of the neck 
 or to the region of the occiput. 
 
 Care should be taken to apply it in such a manner that 
 too much pressure is not made by the turns around the 
 neck, which would be uncomfortable to the patient, and 
 might seriously interfere with respiration. 
 
 Ckossed Bandage of One Eye. 
 
 Roller Two Inches in Width, Four Yards in Length. 
 
 Application. — The initial extremity of the bandage is 
 placed upon the forehead and fixed by two circular turns 
 passing around the head from the occiput to the forehead ; 
 
 Fig. 45. 
 
 Crossed bandage of one eye. 
 
 the roller is then carried back to the occiput and passed 
 around this and brought forward below the ear, and pass- 
 ing over the outer portion of the cheek is carried upward 
 to the junction of the nose with the forehead, and is then 
 conducted over the parietal eminence downward to the 
 
CROSSED BANDAGE OF BOTH EYES. 53 
 
 occiput ; a circular fronto-occipital turn is next made, and 
 when the bandage is brought back to the occiput it is 
 brought forward again to the cheek. It should then 
 ascend to the forehead, covering in two-thirds of the 
 previous turn, and be again conducted back to the occi- 
 put ; these turns are repeated, the oblique turns covering 
 the eye alternating with circular turns around the head 
 until the eye is completely enclosed (Fig. 45), and the 
 bandage is finished by making a circular turn about the 
 head and introducing a pin to secure its extremity. It 
 will be found more comfortable to the patient to include 
 the ear on the same side on which the eye is covered in 
 the turns of the bandage. 
 
 Use. — This bandage will be found useful in retaining 
 dressings to one eye. It will be more comfortable to the 
 patient if a flannel roller be used to apply this bandage, 
 as well as the bandage which includes both eyes. 
 
 Crossed Bandage of Both Eyes. 
 
 Boiler Two Inches in Width, Six Yards in Length. 
 
 Application.— The initial extremity of the roller is 
 placed upon the forehead and secured by two circular turns 
 of the bandage, passing around the head from the forehead 
 to the occiput ; the roller is then carried downward behind 
 the occiput and brought forward below the ear to the upper 
 portion of the cheek ; it is then carried upward to the 
 junction of the nose with the forehead and conducted over 
 the parietal eminence to the occiput; a circular turn is 
 now made around the head from the occiput to the fore- 
 head, and the roller is carried from the occiput over the 
 parietal eminence of the opposite side forward to the 
 junction of the nose with the forehead, then downward 
 over the eye and outer portion of the cheek below the ear 
 and back to the occiput ; a circular turn around the head 
 is next made, and this is followed by a repetition of the 
 previous turns, ascending over one eye, descending over 
 the other eye, each turn alternating with a circular turn 
 
54 BANDAGING, 
 
 around the head. These turns are repeated until both 
 eyes are covered in, and the bandage is finished by making 
 a circular turn around the head, the extremity being 
 secured by a pin. (Fig. 46.) In this bandage both ears 
 may be covered in, or left uncovered. 
 
 Crossed bandage of both eyes. 
 
 Use. — This bandage may be used to apply dressings to 
 both eyes, and both of these bandages covering the eyes 
 are used where it is desired to make pressure; but, for the 
 simple application of a light dressing or of a bandage for 
 the exclusion of light, the Liebrich's bandage (Fig. 76) 
 Avill be found more comfortable to the patient. 
 
 OCCIPITOFACIAL BANDAGE. 
 
 Roller Two Inches in Width, Four Yards in Length. 
 
 The initial extremity of the roller is placed upon the 
 vertex of the head and the bandage is carried downward 
 in front of the ear, under the jaw, and upward upon 
 the opposite side in the same line to the vertex ; two or 
 three of these turns are made, one turn accurately cover- 
 
OBLIQUE BANDAGE OF THE HEAD. 55 
 
 ing in the other. A reverse should be made just above 
 and in front of the ear, and two or three turns are then 
 made around the head from the occiput to the forehead, 
 which completes the bandage. (Fig. 47.) Pins should be 
 inserted at the points where the turns of the bandage 
 cross each other. 
 
 Fig 
 
 Occipito-facial bandage. 
 
 Use. — This bandage is employed to secure dressings to 
 the vertex, temporal, occipital, or frontal region. 
 
 Oblique Bandage of the Head. 
 
 Roller Two Inches in Width, Six Yards in Length. 
 
 The initial extremity of the bandage is placed upon the 
 forehead, and is secured by two circular turns passing 
 around the head from the forehead to the occiput. From 
 the occiput the bandage is carried obliquely over the 
 highest part of the lateral aspect of the head, which is to 
 be covered in, and is passed over the forehead and back to 
 the occiput. It is then carried to the forehead by a circu- 
 lar turn, which is conducted obliquely over the other side 01 
 
56 BANDAGING. 
 
 the head and back to the occiput. A circular turn from 
 the occiput to the forehead should be made between the 
 oblique turns. These turns are repeated, so that each 
 succeeding turn covers in three-fourths of the preceding 
 turn until the sides of the head are covered in by de- 
 scending turns, and the bandage is completed by a cir- 
 cular turn passing around the head from the forehead to 
 the occiput. (Fig. 48.) This bandage may be applied 
 with descending or ascending turns. 
 
 Fig. 48. 
 
 Oblique bandage of the head. 
 
 Use. — This bandage is employed to make pressure upon 
 or to hold dressings to the lateral aspects of the head. 
 
 Occipitofrontal Bandage. 
 
 Roller Two Inches in Width, Four Yards in Length. 
 
 Application. — The initial extremity of the roller is 
 placed upon the forehead, and a circular turn is made 
 around the forehead and occiput to fix it. A circular turn 
 is then made passing around the head from a point below 
 the occiput to a point just above the forehead ; the next 
 circular turn is made around the head ascending pos- 
 teriorly and descending anteriorly, and after a sufficient 
 
SPIRAL BANDAGE OF THE FINGER. 57 
 
 number of these turns have been made to cover in the 
 front and back of the head, the end of the bandage is 
 secured with a pin. (Fig. 49.) 
 
 Fig 
 
 Occipitofrontal bandage. 
 
 Use. — This bandage will be found useful in securing 
 dressings to the forehead and anterior and posterior por- 
 tions of the scalp. 
 
 Bandages of the Upper Extremity. 
 
 Spiral Bandage of the Fixgeb. 
 
 Roller One Inch in Width, One and a Half Yards in 
 Length. 
 
 Application. — The initial extremity of the roller is 
 secured by two or three turns around the wrist ; the ban- 
 dage is then carried obliquely across the back of the hand 
 to the base of the finger to be covered in, then to its tip 
 by oblique turns ; a circular turn is then made and the 
 finger is covered by ascending spiral or spiral reversed 
 
58 BANDAGING. 
 
 turns until its base is reached; the bandage is then carried 
 obliquely across the back of the hand and finished by one 
 or two circular turns around the wrist ; the extremity may 
 be pinned or may be split into two tails, which are tied 
 around the wrist. (Fig. 50.) 
 
 Fig, 50. 
 
 Spiral*bandage of the finger. 
 
 Use. — This bandage is employed to retain dressings 
 upon the finger and to secure splints in the treatment of 
 fractures or dislocations of the phalanges. 
 
 Gauntlet-bandage. 
 
 Roller One Inch in Width, Three Yards in Length. 
 
 Application. — The initial extremity of the roller is 
 fixed at the wrist by one or two circular turns of the ban- 
 dage ; it is then carried down to the tip of the thumb by 
 an oblique turn of the roller, and this is covered in by 
 
GA UNTLET-BANDA GE. 59 
 
 spiral or spiral reversed turns to the metacarpophalangeal 
 articulations ; the roller is then carried back to the wrist 
 and a circular turn is made around it. The bandage is 
 then carried down to the tip of the next finger by an 
 oblique turn, which is covered-in in the same manner. 
 When all the fingers have been covered in, the bandage 
 is finished bv circular turns around the hand and wrist. 
 (Fig. 51.) 
 
 Fig. 51. 
 
 Gauntlet-bandage. 
 
 Use. — This bandage may be employed to apply dress- 
 ings to the fingers and hand in case of wounds or frac- 
 tures. It was formerly much employed in the treatment 
 of burns of the fingers to prevent the opposed ulcerated 
 surfaces from adhering, but its use for this purpose has 
 been supplanted by wrapping each finger in a separate 
 dressing and applying a dressing over the whole with a 
 few recurrent and spiral turns of a wide roller, the applica- 
 tion of this dressing being much less painful to the patient, 
 and being at the same time equally satisfactory in its 
 results. 
 
60 BANDAGING. 
 
 Demi-gauntlet Bandage. 
 Roller One Inch in Width, Four Yards in Length. 
 
 Application. — The initial extremity of the bandage 
 should be placed upon the wrist and fixed by two circular 
 turns passing from the ulnar to the radial side; then carry 
 the roller obliquely across the back of the hand to the base 
 of the little finger, pass the bandage around this and carry 
 the roller back to the wrist, making a circular turn ; it 
 
 Fig. 52. 
 
 Demi-gauntlet bandage. 
 
 should then be carried obliquely across the hand to the base 
 of the next finger, and so successively until the base of 
 each of the fingers and of the thumb has been included ; 
 the bandage is then completed by a circular turn around 
 the wrist. (Fig. 52.) 
 
 The demi-gauntlet bandage may also be applied in such 
 a manner as to cover only the palm and leave the dorsum 
 of the hand uncovered. 
 
SPICA-BANDAGE OF THE THUMB. 
 
 61 
 
 Use. — This bandage may be employed to retain light 
 dressings to the dorsal or palmar surface of the hand. 
 
 Spica-baxdage of the Thumb. 
 
 Fig. 53. 
 
 Roller One Inch in Width, Three Yards in Length. 
 
 Application. — The initial extremity of the roller is 
 placed upon the wrist and fixed by two circular turns; then 
 carry the roller obliquely over 
 the dorsal surface of the thumb 
 to its distal extremity ; next 
 make a circular or spiral turn 
 around the thumb, and carry the 
 bandage upward over the back of 
 the thumb to the wrist, around 
 which a circular turn should be 
 made. The roller is next car- 
 ried around the thumb and wrist, 
 making figure-of-eight turns, 
 each turn overlapping the pre- 
 vious one two-thirds as it as- 
 cends the thumb, and each figure- 
 of-eight turn alternating with a 
 circular turn about the wrist. 
 These turns are repeated until 
 the thumb is completely covered in with spica-turns, and 
 the bandage is finished by a circular turn around the 
 wrist. (Fig. 53.) 
 
 Use. — This bandage is employed to apply dressings to 
 the dorsal surface of the thumb, and for the retention of 
 splints in the dressings of fractures or dislocations of the 
 bones of the thumb. 
 
 S pica-ban dage of the thumb. 
 
62 BANDAGING. 
 
 Spiral Reversed Bandage of the Upper 
 Extremity. 
 
 Roller Two and a Half Inches in Width, Seven Yards 
 in Length. 
 
 Application. — The initial extremity of the roller is 
 placed upon the wrist, and secured by two turns around 
 the wrist; the bandage is then carried obliquely across the 
 back of the hand to the second joint of the fingers, where, 
 a circular turn should be made; the hand is covered in by 
 two or three ascending spiral or spiral reversed turns. 
 When the thumb has been reached, its base and the wrist 
 are covered in by two figure-of-eight turns ; the bandage 
 is then carried up the forearm by spiral and spiral reversed 
 
 Fig. 54. 
 
 Spiral reversed bandage of the upper extremity. 
 
 turns until the elbow is reached ; this may be covered in 
 with spiral reversed turns, and the bandage is next carried 
 up the arm with spiral reversed turns to the axilla. (Fig. 54.) 
 If, on reaching the elbow, the arm is bent, or is to be flexed 
 in the subsequent dressing, the elbow should be covered in 
 with figure-of-eight turns, and when this has been done the 
 arm may be covered in with spiral reversed turns. When 
 properly applied, the reverses should be in a line, and 
 should not be made over the prominent ridge of the ulna. 
 
FIGURE-OF-EIGHT BANDAGE OF THE ELBOW. 63 
 
 Use. — This is one of the most generally employed of all 
 the roller-bandages ; it constitutes the primary roller which 
 is applied in the dressing of fractures of the humerus, and 
 it is also the bandage employed in holding dressings to the 
 arm and forearm, and in securing splints to these parts in 
 the treatment of fractures and dislocations. 
 
 Figure-of-eight Bandage of the Elbow. 
 
 Roller Two Inches in Width, Four Yards in Length. 
 
 Application. — The initial extremity of the bandage is 
 placed upon the forearm a short distance below the elbow- 
 
 Fig. 55. 
 
 Figure-of-eight bandage of the elbow. 
 
 joint, and fixed by one or two circular turns, the arm being 
 flexed. The bandage is then carried by an oblique turn 
 
64 BANDAGING. 
 
 across the flexure of the elbow-joint, and passed around 
 the arm a few inches above the elbow ; a circular turn is 
 then made, and the roller is next carried across the flexure 
 of the elbow and passed around the forearm. These turns 
 are repeated, the turns from the forearm ascending and 
 those from the arm descending, each set of turns crossing 
 in the flexure of the elbow until it is covered in, and a 
 final turn is passed circularly around the elbow-joint. 
 (Fig. 55.) This bandage is sometimes applied by first 
 making one or two circular turns around the elbow and 
 then applying the figure-of-eight turns as previously 
 described. 
 
 Use. — This bandage is often employed as a part of the 
 spiral reversed bandage of the upper extremity when the 
 arm is to be flexed, and is also used to hold dressings to the 
 region of the elbow-joint. It was formerly much used to 
 hold the compress upon the wound resulting from venesec- 
 tion at the elbow. 
 
 Spica-bandage of the Shoulder (Ascending). 
 
 Roller Two and a Half Inches in Width, Seven Yards 
 in Length. 
 
 Application. — The initial extremity of the roller is 
 placed obliquely upon the outer surface of the arm opposite 
 the axillary fold, and fixed by one or two circular turns. It 
 the right shoulder is to be covered, the bandage is next 
 carried across the front of the chest to the axilla of the 
 opposite side, then around the back of the chest to the 
 point of starting upon the arm ; then the roller should be 
 conducted around the arm of this side up over the shoulder, 
 across the front of the chest, through the opposite axilla 
 and back over the posterior surface of the chest to the point 
 of starting ; continue to make these ascending turns, each 
 turn overlapping the preceding one about two-thirds until 
 the shoulder is covered in (Fig. 56), when the extremity of 
 the bandage may be secured by a pin at the point of end- 
 ing, or the last turn may be carried from the shoulder 
 
SPICA-BANDAGE OF THE SHOULDER. 65 
 
 around the back of the neck and brought forward over 
 the opposite shoulder and piuned to the turns which pass 
 around the axilla. It should be remembered that the 
 turns of the roller overlap each other exactly in the oppo- 
 site axilla, and it will be found more comfortable to the 
 patient to apply a little cotton-wadding in the axilla to 
 prevent the bandage from excoriating the skin of this part. 
 Care should be taken to see that the turns are made in such 
 
 Fig. 56. 
 
 S pica-bandage of shoulder ^ascending). 
 
 a manner that the spica-turns occupy, as nearly as possible, 
 the median line of the shoulder. When this bandage is 
 applied to the left shoulder, after fixing the initial ex- 
 tremity by circular turns around the arm, the roller should 
 be carried over the back of the chest to the axilla of the 
 opposite side and then brought back to the point of start- 
 ing ; the succeeding turns are then applied in the same 
 manner. 
 
66 
 
 BANDAGING. 
 
 Spica-bandage of the Shoulder (Descending). 
 
 Roller Two and a Half Inches in Width, Seven Yards 
 in Length. 
 
 Application. — The initial extremity of the roller 
 should be fixed upon the arm as near as possible to the 
 axillary fold by one or two circular turns; and if it is 
 applied to the right shoulder, the bandage should be passed 
 under the axilla and carried obliquely over the shoulder 
 to the base of the neck, then downward across the front of 
 the chest to the axilla of the opposite side ; from the axilla 
 
 FIG. 57. 
 
 Spica-bandage of shoulder (descending). 
 
 the roller is carried over the back of the chest to the base 
 of the neck so as to cross the first turn at this point ; it is 
 then carried through the axillary space, then back to 
 the neck, the turns descending toward the shoulder. 
 These turns, taking the same course, are repeated, each 
 turn overlapping two-thirds of the previous one until the 
 shoulder is covered in and the circular turn around the 
 
FIGURE-OF-EIGHT BANDAGE. 
 
 67 
 
 arm is reached, at which point the extremity is secured 
 by a pin. (Fig. 57.) 
 
 Use. — The spica-bandages of the shoulder are employed 
 to hold dressings to the shoulder, to hold compresses over 
 the acromial end of the clavicle in case of dislocation of 
 that portion of the bone, to retain the shoulder-cap used 
 in the treatment of fractures of the upper portion of the 
 humerus, and to retain dressings to the axilla. 
 
 Figure-of-eight Bandage of the Neck and 
 Axilla. 
 
 Fig. 58. 
 
 Roller Two Inches in Width, Five Yards in Length. 
 
 Application. — The initial extremity of the roller is 
 fixed upon the side of the neck and secured by one or two 
 loosely applied circular turns ; if applied to the right 
 axilla, carry the bandage from left to right over the right 
 shoulder to the posterior part 
 of the axilla under which it 
 passes, to ascend in front 
 over the same shoulder to 
 the back of the neck ; these 
 figure-of-eight turns around 
 the neck and axilla, each 
 turn overlapping two-thirds 
 of the previous turn, are 
 repeated until the desired 
 space is covered and the ban- 
 dage is completed by a cir- 
 cular turn around the neck. 
 
 (Fi K . 58.) 
 
 Use. — This will be found 
 a useful bandage to secure dressings to the base of the 
 neck, the upper part of the shoulder, and to the axilla, 
 as it does not restrict the motions of the arm unless 
 drawn too tight. 
 
 Figure-of-eight bandage of the 
 neck and axilla. 
 
68 BANDAGING. 
 
 Velpeau's Bandage. 
 
 Two Rollers Two and a Half Inches in Width, Seven Yards 
 in Length. 
 
 Application. — The patient should place the fingers of 
 the hand of the affected side on the opposite shoulder ; the 
 initial end of the roller should be placed on the body of 
 the scapula of the sound side and secured by a turn made 
 by carrying the bandage over the shoulder of the affected 
 side, near its outer portion, then conducting it downward 
 over the outer and posterior surface of the arm of the same 
 
 Fig. 59. 
 
 Velpeau's bandage. 
 
 side, behind the point of the elbow, and obliquely across 
 the front of the chest to the axilla of the opposite side, 
 thence to the point of starting. This turn should be 
 repeated, to fix the initial extremity of the bandage. 
 Having completed the second turn, carry the roller trans- 
 versely around the thorax, passing over the flexed elbow 
 of the affected side, from this point to the axilla, and 
 through this to the back. From this point the roller is 
 
DESATJLTS BANDAGE. 69 
 
 carried over the shoulder and down the outer and posterior 
 surface of the arm behind the elbow and obliquely across 
 the front of the chest through the axilla to the back, and 
 continuing, passes transversely across the back of the chest 
 to the elbow, which it encircles, then passes to the axilla. 
 These alternating turns are repeated until the arm and 
 forearm are bound firmly to the side and chest. The 
 vertical turns over the shoulder, each turn covering in 
 two-thirds of the previous turn and ascending from the 
 point of the shoulder toward the neck and from the 
 posterior surface of the arm toward the elbow, are applied 
 until the point of the elbow is reached. The transverse 
 turns passing around the chest and arm are so applied that 
 they ascend from the point of the elbow toward the 
 shoulder, each turn covering in one-third of the previous 
 one, and the last turn should pass transversely around the 
 shoulder and chest, covering the wrist. (Fig. 59.) 
 
 The extremity of the bandage should be secured by a 
 pin where it ends, and additional fixation will be secured 
 by introducing a number of pins at the points where the 
 turns of the bandage cross each other. 
 
 Use. — This bandage is employed to fix the arm in the 
 treatment of certain fractures of the clavicle and scapula, 
 also to secure fixation of the humerus after the reduction 
 of dislocations of the shoulder-joint. 
 
 Desault's Bandage. 
 
 Three Rollers Two and a Half Inches in Width, Seven 
 Yards in Length. 
 
 A wedge-shaped pad to fit in the axilla is also required. 
 These rollers are known as the first, second, and third 
 rollers. 
 
 First Roller of Desault's Bandage. 
 
 Application. — Before applying the first roller the arm 
 of the patient on the injured side should be elevated and 
 
 4* 
 
70 BANDAGING. 
 
 carried off at right angles to the body ; the wedge-shaped 
 pad with its base in the axilla should next be applied to 
 the side of the chest, and the initial extremity of the roller 
 should be placed upon the middle of the pad, which may 
 be fixed by two or three circular turns around the chest; 
 the bandage is then carried down the chest by oblique 
 circular turns until the lower extremity of the pad is 
 
 Fig. 60. 
 
 First roller of Desault's bandage. 
 
 reached, and it is then carried up the chest until the upper 
 extremity of the pad is reached, when it is conducted 
 obliquely across the front of the chest to the sound 
 shoulder and passed under the axilla, brought over the 
 shoulder and conducted around the chest, where it is 
 secured. (Fig. 60.) 
 
 Second Roller of DesauWs Bandage. 
 
 Application. — The arm should be brought down 
 against the side so as to press upon the pad previously 
 applied, and the forearm should be flexed upon the arm 
 and brought across the lower portion of the chest. The 
 initial extremity of the roller is placed in the axilla of 
 the sound side, and the bandage is carried around the chest 
 
DESAULTS BANDAGE. 
 
 71 
 
 and over the arm of the injured side, making a circular 
 turn around the chest to fix it; then spiral turns are made 
 around the chest from above downward until the elbow is 
 reached, the turns being more firmly applied as they de- 
 scend, and when this point is reached the end of the ban- 
 dage is secured. Or the initial extremity of the bandage 
 
 Fig. 61. 
 
 Second roller of Desault's bandage. 
 
 may be placed upon the chest of the sound side and a 
 circular turn may be made to fix it, and then spiral turns, 
 including the chest and arm, may be made from below 
 upward until the axilla is reached. (Fig. 61.) 
 
 Third Roller of DesauWs Ba?idage. 
 
 Application. — The initial extremity of the roller is 
 placed in the axilla of the sound side, and the bandage is 
 carried obliquely over the front of the chest to the shoulder 
 of the injured side, passed over this, and conducted down 
 the back of the arm to the elbow, thence obliquely upward 
 over the upper fifth of the forearm to the axilla of the 
 sound side. From this point it is carried backward ob- 
 liquely over the back of the chest to the shoulder ; crossing 
 
72 
 
 BANDAGING. 
 
 the previous shoulder-turn , it is conducted down the front 
 of the arm to the elbow, then around this and backward 
 obliquely over the back of the chest to the axilla of the 
 sound side. These turns are repeated until three sets 
 of turns have been applied, which should overlie each 
 other exactly. (Fig. 62.) The course of the turns of the 
 third roller is considered the most difficult to remember, 
 and the student may be assisted in its correct application 
 by remembering that all the turns start at the axilla, 
 pass to the shoulder, and then to the elbow, and from the 
 elbow always return to the starting-point — the axilla. 
 
 Fig. 62. 
 
 Third roller of Desault's bandage. 
 
 The turns of the third roller make two triangles, one on 
 the anterior surface of the chest, the other upon the back. 
 (Fig. 63.) 
 
 After the application of the three rollers the hand and 
 uncovered portion of the forearm should be supported in 
 a sling suspended from the neck. 
 
 Use. — This bandage, applied completely, or some one 
 of its various rollers, is employed in the treatment of 
 fractures of the clavicle. 
 
ARM-AND-CHEST BANDAGE. 
 Fig. 63. 
 
 73 
 
 Posterior view of turns of third roller of Desault's bandage. 
 
 Arm-axd-chest Bandage. 
 
 Roller Two and a Halj Inches in Width, Seven Yards in 
 
 Length. 
 
 Before applying this bandage the arm should be placed 
 against the side of the chest and a folded towel or a pad 
 of cotton should be placed in the axilla and allowed to 
 
74 BANDAGING. 
 
 extend from the axilla to the elbow ; the latter is used to 
 prevent the opposing surfaces of skin from becoming ex- 
 coriated by contact. 
 
 Application. — The initial extremity of the bandage 
 is placed upon the spine at a point opposite the elbow- 
 joint, and it is fixed by a turn or two passing around the 
 
 Fig. 64. 
 
 Arin-and-chest bandage. 
 
 arm and chest ; the bandage is then continued by making 
 ascending spiral turns, covering in the arm and chest until 
 the axilla is reached ; at this point the baudage is carried 
 through the axilla and over the back of the chest to the 
 top of the opposite shoulder, and it is then conducted 
 down the front of the arm to the elbow, is passed between 
 
SPIRAL BANDAGE OF THE CHES1. 
 
 75 
 
 the arm and chest and carried up the back ot the arm to 
 the shoulder. It is then passed obliquely across the front 
 of the chest and is secured upon the back of the chest. 
 Pins should be introduced at the points of crossing of the 
 bandage. (Fig. 64.) 
 
 Use. — This bandage will be found useful in fixing the 
 arm to the body and in fixing the shoulder-joint where it 
 is desirable to allow the forearm to be free. It is em- 
 ployed in the treatment of fractures of the shaft and neck 
 of the humerus to fix the arm and hold splints in position. 
 
 Bandages of the Trunk. 
 Spiral Bandage of the Chest. 
 
 Roller Three Inches in Width, Nine Yards in Length, 
 
 Application. — The initial extremity of the roller is 
 applied to the anterior portion of the waist, and fixed by 
 one or two circular turns ; the bandage is then carried 
 
 Fig. 65. 
 
 Spiral "bandage of the chest. 
 
 upward, encircling the chest by ascending spiral turns, 
 each turn covering in one-half of the previous turn until 
 
76 
 
 BANDAGING. 
 
 the axillary fold is reached; the roller is next carried 
 around the axilla to the back, and obliquely over this to 
 the base of the neck of the opposite side, and then it may 
 be passed down over the chest and pinned to the spiral 
 turns at several points ; a pin should also be inserted at 
 the point where the last turn of the roller leaves the spiral 
 turn upon the back of the chest. (Fig. 65.) 
 
 Use. — This bandage is employed to hold dressings to 
 the chest, and may be used as a temporary dressing in 
 fractures of the ribs or sternum. Care should be taken 
 that the bandage be not so tightly applied as to interfere 
 with respiration. 
 
 Anterior Figure-of-eight Bandage of the 
 Chest. 
 
 Roller Two and a Half Inches in Width, Seven Yards in 
 
 Length. 
 
 Application. — The initial extremity of the roller 
 should be placed in the axilla of one side, and the ban- 
 
 FlG. 66. 
 
 Anterior figure-of-eight bandage of the chest. 
 
 dage is then carried obliquely across the anterior portion 
 of the chest to the shoulder of the opposite side ; it is then 
 carried backward around the shoulder and through the 
 
FIGURE-OF-EIGHT BANDAGE OF CHEST. 77 
 
 axilla, and is next conducted obliquely over the anterior 
 portion of the chest to the opposite shoulder, through the 
 axilla and again back to the anterior portion of the chest, 
 the turns crossing in the median line over the sternum. 
 These turns should be repeated, ascending from the 
 shoulder toward the neck, each turn overlapping three- 
 fourths of the preceding one, until five or six turns have 
 been applied, the end of the bandage being secured by a 
 pin (Fig. 66), or it may be completed by a circular turn 
 around the chest. 
 
 Use. — This bandage may be employed to bring the 
 shoulders forward, and to hold dressings to the anterior 
 portion of the chest. 
 
 Posterior Figure-of-eight Bandage of the 
 Chest. 
 
 Roller Tico and a Half Inches in Width, Seven Yards 
 in Length. 
 
 Fig. 67. 
 
 Posterior figure-of-eight bandage of the chest. 
 
 Application. — The initial extremity of the roller 
 should be placed in the axilla of the left side, and the 
 
78 BANDAGING. 
 
 bandage should then be carried obliquely across the back 
 of the chest to the tip of the opposite shoulder; it is next 
 carried through the axilla and conducted across the poste- 
 rior portion of the chest to the tip of the opposite shoulder, 
 and passed through the axilla to the point of starting. 
 These turns are repeated, ascending from the shoulder to- 
 ward the neck, until five or six have been applied, the end 
 of the bandage being secured by a pin. (Fig. 67.) In 
 applying both of these bandages the crosses of the ban- 
 dage, either anterior or posterior, should be made in the 
 median line of the chest. 
 
 Use. — This bandage may be employed to hold dressings 
 to the posterior portion of the chest and to draw the 
 shoulders backward. 
 
 Suspensory and Compressor Bandage of the 
 Breast. 
 
 Roller Two and a Half Inches in Width, Seven Yards 
 in Length. 
 
 Application. — The initial extremity of the roller 
 should be placed upon the scapula of the affected side, and 
 secured by two oblique turns carried over the opposite 
 shoulder and conducted downward under the breast to 
 be covered in, and then carried to the axilla of the same 
 side. Next carry the roller transversely around the chest, 
 covering in the lowest portion of the affected breast. 
 These turns should be repeated, the oblique turns from the 
 axilla over the shoulder alternating with the transverse 
 turns around the chest, until the breast is covered in, each 
 series of turns ascending, and covering two-thirds of the 
 preceding turn. (Fig. 68.) 
 
 Use. — This bandage is employed to support the breast 
 and to make compression at the same time ; it may also 
 be employed to hold dressings to the breast. 
 
SUSPENSORY AND COMPRESSOR BANDAGES. 79 
 
 Fig. 68. 
 
 Suspensory and compressor bandage of the breast. 
 
 Suspensory and Compressor Bandages of Both 
 Breasts. 
 
 Ttvo Boilers Two and a Half Inches in Widths Seven 
 Yards in Length. 
 
 Application. — The initial extremity of the bandage 
 should be secured by oblique turns of the axilla and 
 shoulder as in the preceding bandage ; the roller should 
 next be carried transversely around the back to the breast, 
 then under the breast and upward over the opposite 
 shoulder, then obliquely downward around the chest to 
 the other side, being carried transversely over the lower 
 portion of both breasts to the point of starting upon the 
 back. Repeat these oblique turns from the shoulder to 
 the breast and from the breast to the shoulder, and alter- 
 nate them with a transverse turn around the chest and 
 over both breasts. Both series of turns should ascend, 
 and each turn should overlap two-thirds of the preceding 
 one. (Fig. 69.) 
 
 Use. — This bandage is employed to support and com- 
 press both breasts and to retain dressings to them. 
 
80 
 
 BANDAGING. 
 
 Fig. 69. 
 
 Suspensory and compressor bandage of both breasts. 
 
 Bandages of the Lower Extremity. 
 
 Single Spica-bandage of the Groin (Ascending). 
 
 Roller Two and a Half Inches in Width, Seven Yards 
 in Length. 
 
 Application. — Place the initial extremity of the ban- 
 dage upon the anterior portion of the right thigh just 
 below the groin and secure it by one or two circular turns 
 
SINGLE SPICA-BANDAGE OF THE GROIN 81 
 
 around the thigh, or place the initial extremity of the roller 
 obliquely upon the upper part of the thigh and carry it 
 behind the limb and upward around the outer side of the 
 thigh to the abdomen, omitting the circular turns ; then 
 carry the bandage obliquely across the lower part of the 
 abdomen to a point just below the crest of the left ilium 
 and conduct it transversely around the back of the pelvis 
 
 Fig. 70. 
 
 Ascending spica-bandage of the groin . 
 
 to a corresponding point on the opposite side ; then bring 
 it obliquely downward to the groin over to the inner por- 
 tion of the thigh, carrying it around the limb, crossing 
 the starting-turn in the middle line of the thigh. These 
 turns are repeated, each turn ascending and covering in 
 two-thirds of the previous turn, until six or eight com- 
 plete turns have been made, and the bandage is secured at 
 any point where it ends. (Fig. 70.) 
 
 Single Spica-bandage of the Groin (Descending). 
 
 Roller Two and a Half Inches in Width, Seven Yards 
 in Length. 
 
 Application. — Place the initial extremity of the roller 
 obliquely upon the anterior surface of the right thigh and 
 
82 
 
 BANDAGING. 
 
 secure it by one or two circular turns around the limb, or 
 start the bandage with an oblique turn, as previously 
 described; then carry the bandage obliquely across the 
 abdomen to a point just below the crest of the ilium, and 
 conduct it transversely around the back of the pelvis to a 
 corresponding point on the opposite side ; then bring it 
 obliquely down over the lower portion of the abdomen, 
 crossing the first turn, to the junction of the thigh with 
 the scrotum, pass it under the thigh and bring it up over 
 the lower part of the abdomen, and let it follow the course 
 
 Fig. 71. 
 
 Descending spica-bandage of the groin. 
 
 of the first turn. These turns are repeated, each turn 
 descending and overlapping two-thirds of the previous 
 turn until the groin is covered. (Fig. 71.) When either of 
 these bandages is applied to the left groin, after the initial 
 extremity of the roller is fixed, it is carried first to the crest 
 of the ilium of the same side, then around the back of the 
 pelvis to a corresponding point on the opposite side, then 
 obliquely across the lower part of the abdomen to the 
 outer aspect of the thigh, being conveyed under this aud 
 brought up between the thigh and the scrotum, passing 
 obliquely over the groin to follow the course of the 
 original turn. 
 
DOUBLE SPICA-BANDAGE OF THE GROINS. 83 
 
 Double Spica-baxdage of the Groins. 
 Holler Three Inches in Width, Nine Yards in Length. 
 
 Application. — The initial extremity of the roller is 
 placed upon the abdomen just above the iliac crests and 
 secured by one or two circular turns ; the bandage is then 
 carried from a point just below the crest of the right ilium 
 obliquely across the lower portion of the abdomen to the 
 outer portion of the left thigh, and is carried around this 
 and brought up between the scrotum and the thigh, and is 
 
 Fig. 72. 
 
 I 
 
 Double spica-bandage of the groins. 
 
 passed obliquely over the groin, crossing the previous turn 
 in the median line, and is conducted to a point just below 
 the crest of the ilium on the same side. The bandage is 
 then continued around the pelvis to the same point on the 
 opposite side, and from this point is made to pass obliquely 
 over the groin to the inner side of the thigh, passing 
 around this and coming up on its outer side, crossing the 
 previous turn at the middle line of the groin, to be carried 
 obliquely across the groin and lower part of the abdomen 
 
84 BANDAGING. 
 
 to the crest of the ilium on the opposite side. These turns 
 are repeated, each turn covering in two-thirds of the pre- 
 vious turn, until both groins have been covered. (Fig. 72.) 
 The turns may be so applied as to ascend or descend, 
 forming the ascending or descending double spica-bandage 
 of the groin. When properly applied, this bandage pre- 
 sents three sets of crossing-turns, one in each groin and 
 one in the median line of the abdomen. 
 
 Use. — The spica-bandages of the groin, either single or 
 double, are employed to hold dressings to wounds in the 
 inguinal region —for instance, those resulting from herni- 
 otomy, or from operation upon the glands of the groin. 
 They are also employed to make pressure upon this region, 
 and will often prove of use in the securing of compresses 
 applied for the temporary retention of hernise. 
 
 Spica-bandage of Buttock. 
 
 Roller Two and a Half Inches in Width, Seven Yards 
 in Length. 
 
 Fig. 73. 
 
 Spica-bandage of buttock. 
 
FIGURE-OF-EIGHT BANDAGE OF KNEE. 85 
 
 Application. — The initial extremity of the bandage 
 is placed upon the back of the thigh just below the gluteal 
 fold, and is carried around the thigh and brought back to 
 the posterior aspect of the limb so as to fix and cross the 
 starting turn near the middle of the thigh. It is next 
 conducted obliquely across the thigh and buttocks and 
 carried to the brim of the pelvis of the opposite side, when 
 it is brought obliquely over the abdomen and back to the 
 posterior surface of the thigh. There ascending turns are 
 applied, each turn covering in about three-fourths of the 
 preceding one, until the buttock is covered, and the ban- 
 dage is then finished by one or two circular turns around 
 the pelvis and abdomen. (Fig. 73.) 
 
 Use. — This bandage is employed to hold dressings to 
 the upper posterior portion of the thigh, or the buttock. 
 
 FiGUBE-OF-EIGHT BANDAGE OF THE KNEE. 
 
 Roller Two and a Half Inches in Width, Five Yards 
 in Length. 
 
 Fig. 74. 
 
 Figure-of-eight bandage of the knee. 
 
 Application. — The initial extremity of the roller is 
 placed upon the thigh three inches above the patella and 
 
 5 
 
86 BANDAGING. 
 
 secured by two or three circular tarns ; then conduct the 
 bandage over the outer condyle of the femur across the 
 popliteal space to the inner border of the tibia and around 
 the anterior surface below the tubercle and head of the 
 fibula, and make one circular turn ; the roller should then 
 be carried obliquely across the popliteal space to the inner 
 condyle of the femur, crossing the previous turn ; then 
 carry it around the front of the thigh to the outer condyle ; 
 repeat these turns, ascending toward the knee from the 
 leg and descending from the thigh toward the knee, and 
 finish the bandage by a circular turn over the patella. 
 (Fig. 74.) 
 
 Use. — This bandage is employed to hold dressings to 
 the knee-joint either anteriorly or posteriorly. These 
 figure-of-eight turns are often employed in covering the 
 knee in applying the spiral reversed bandage of the lower 
 extremity when it is desired that the patient be allowed to 
 bend the knee. 
 
 Figure-of-eight Bandage of Both Knees. 
 
 Roller Two and a Half Inches in Width, Seven Yards 
 in Length. 
 
 Application. — Place the knees of the patient together 
 with a compress between them ; then place the initial ex- 
 tremity of the roller upon one thigh, about three inches 
 above the patella, and secure it by one or two circular 
 turns around both thighs ; then conduct the roller from 
 the outer condyle of the femur obliquely across the pop- 
 liteal spaces of both legs to the head of the fibula on the 
 opposite side, making a circular turn around both legs ; 
 pass the roller from the head of the fibula on the opposite 
 side across the popliteal space to the external condyle 
 opposite the point of starting. 
 
 Repeat these turns, descending from the thighs and 
 ascending from the legs, until the knees are covered, and 
 finish the bandage by carrying a turn of the bandage at 
 
SPICA-BANDAGE OF THE ¥001. 87 
 
 right angles to the previous turns between the thighs and 
 the legs. (Fig. 75.) 
 
 Use. — This bandage is employed to secure fixation of 
 the limbs after operations upon the perineum, and may also 
 
 Fig. 75. 
 
 Figure-of-eight bandage of both knees. 
 
 be employed to obtain temporary fixation of the limbs in 
 transporting cases of fracture of the neck of the femur, 
 and after the reduction of dislocations of the head of that 
 bone. 
 
 Spica-bandage of the Foot. 
 
 Roller Two and a Half Inches in Width, Five Yards 
 in Length. 
 
 Application. — Fix the initial extremity of the roller 
 upon the ankle and secure it by two circular turns ; then 
 carry the bandage obliquely over the dorsum of the foot to 
 the metatarso-phalangeal articulation and make a circular 
 turn around the foot at this point ; then continue it upward 
 over the metatarsus by making two or three spiral reversed 
 turns ; next carry the bandage parallel with the inner or 
 outer margin of the sole of the foot, according to whether 
 
88 BANDAGING. 
 
 it is applied to the right or left foot, directly across the 
 posterior surface of the heel ; thence along the opposite 
 border of the foot and over the dorsum, crossing the 
 original turn in the median line of the foot. This com- 
 pletes the first spica turn. These spica turns are repeated, 
 gradually ascending by allowing each turn to cover in 
 three-fourths of the preceding turn, until the foot is 
 covered in with the exception of the posterior portion of the 
 sole of the heel. (Fig. 76.) Care should be taken to see 
 
 Fig. 76. 
 
 Spica-bandage of the foot. 
 
 that the turns cross each other in the median line and that 
 they are kept parallel to each other throughout their course. 
 Use. — This bandage will be found very useful when it is 
 desired to make firm compression upon the foot or to retain 
 dressings to it ; it is especially useful in the treatment of 
 sprains of the ankle or the anterior tarsus. 
 
 Bandage of Foot Covering the Heel (American). 
 
 Roller Two and a Half Inches in Width, Seven Yards 
 in Length. 
 
 Application. — The initial extremity of the roller is 
 placed upon the leg just above the malleoli and fixed by 
 
BANDAGE OF FOOT N01 COVERING THE HEEL. 89 
 
 two circular turns around the leg ; the bandage is then 
 carried obliquely across the dorsum of the foot to the 
 metatarsophalangeal articulation, at which point a circular 
 turn is made ; two or three spiral or spiral reversed turns 
 are then made, ascending the foot ; the roller is next car- 
 ried directly over the point of the heel and continued back 
 to the dorsum of the foot; thence beneath the instep around 
 one side of the heel and up over the instep ; from this 
 
 Fig. 77. 
 
 Bandage of foot covering the heel. 
 
 point it is carried beneath the instep around the other side 
 of the heel and up in front of the ankle, from which point 
 it may be continued up the leg. (Fig. 77.) 
 
 Use. — This bandage is employed to cover in the foot 
 and retain dressings to the foot and heel. 
 
 Bandage of Foot not Covering the Heel (French). 
 
 Roller Two and a Half Inches in Width, Seven Yards 
 in Length. 
 
 Application. — Fix the initial extremity of the roller 
 upon the leg just above the malleoli and secure it by two 
 circular turns around the leg ; the bandage is then carried 
 
90 
 
 BANDAGING. 
 
 obliquely across the dorsum of the foot to the meta- 
 tarsophalangeal articulation, and at this point a circular 
 turn should be made The roller is now carried up the 
 foot, covering it in with two or three spiral reversed turns, 
 and at this point a figure-of-eight turn is made around the 
 ankle and instep ; this should be repeated once, which will 
 cover in the foot with the exception of the heel ; the ban- 
 dage may then be continued up the leg with spiral reversed 
 turns. (Fig. 78.) 
 
 Fig. 78. 
 
 Bandage of foot not covering the heel. 
 
 Use. — This bandage may be employed to secure dress- 
 ings to the foot, and is the one generally used to cover this 
 part in applying the spiral reversed bandage of the lower 
 extremity. 
 
 Spiral Reversed Bandage of the Lower 
 Extremity. 
 
 Roller Two and a Half Inches in Width, Seven Yards 
 in Length. 
 
 Application. — The initial extremity of the roller is 
 placed upon the leg just above the malleoli and secured by 
 
FIGURE-OF-EIGHT BANDAGE OF LEG. 91 
 
 two circular turns. It is then carried obliquely over the 
 foot to the inetatarso-phalangeal articulation, where a cir- 
 cular turn is made around the foot. Two or three spiral 
 reversed turns and two figure-of-eight turns of the ankle 
 and instep should be made, while just above the ankle 
 one or two circular or spiral turns are made around 
 the leg, and as the bandage is carried up the leg, as it 
 increases in diameter, spiral reversed turns are made until 
 it approaches the knee ; at this point, if the limb is to be 
 kept straight, the spiral reversed turns may be continued 
 
 Fig. 79 
 
 Spiral reversed bandage of the lower extremity. 
 
 over this region and up upon the thigh. If the knee is 
 to be bent, figure-of-eight turns may be applied until the 
 knee is covered, and then the thigh may be covered with 
 spiral reversed turns. (Fig. 79.) To cover in the thigh 
 as well as the leg, two bandages of the dimensions before 
 given will be required. Care should be taken to keep the 
 reverses in a line and not to make them over the spine of 
 the tibia, as they may thus become painful to the patient. 
 Use. — This is one of the most frequently employed of 
 the roller bandages ; it is used to apply pressure to the 
 lower extremity, to retain dressings, and to secure splints 
 in the treatment of fractures and dislocations. 
 
 Figure-of-eight Bandage of the Leg. 
 
 Roller Two and a Half Inches in Width, Seven Yards 
 in Length. 
 
 Application. — This bandage differs from the spiral 
 reversed bandage of the lower extremity only in the fact 
 
92 
 
 BANDAGING. 
 
 that when the swell of the calf is reached figure-of-eight 
 turns are made around the leg instead of spiral reversed 
 turns. In applying the roller, when the calf of the leg is 
 reached, the bandage is carried obliquely around the leg 
 to the crest of the tibia and made to cross the starting- 
 turn in the median line ; these turns are repeated until 
 the calf of the leg has been covered in, and the bandage 
 is finished with one or two circular turns just below the 
 knee. (Fig. 80.) 
 
 Fig. 80. 
 
 Figure-of-eight bandage of the leg. 
 
 Use. — This bandage holds its place more firmly than 
 the ordinary spiral reversed bandage of the leg, and may 
 be employed in the treatment of ulcers of the leg in con- 
 junction with strapping, where it is desirable to change 
 the dressings at infrequent intervals and to allow the 
 patient to walk about during the course of treatment. 
 
SPIRAL REVERSED BANDAGE OF THE PENIS. 93 
 
 SPECIAL BANDAGES. 
 
 Spiral Reversed Bandage of the Penis. 
 
 Roller Three-quarters of an Inch in Width, Thirty Inches 
 in Length. 
 
 Application. — Fix the initial extremity of the roller 
 by two circular turns around the penis close to the pubis ; 
 then carry the bandage obliquely down to the corona 
 glandis ; from this point ascend the body of the penis by 
 
 Fig. 81. 
 
 Spiral reversed bandage of the penis. 
 
 spiral reversed turns to the pubis and finish the bandage 
 by two figure-of-eight tarns around the neck of the scrotum 
 and root of the penis ; split the end of the bandage so as 
 to form two tails and secure it by tying these around the 
 root of the penis. (Fig. 81.) 
 
 5* 
 
94 SPECIAL BANDAGES. 
 
 Kecukrent Bandage of Stump. 
 
 Roller Two and a Half Inches in Width, Five to Seven 
 Yards in Length. 
 
 Application. — Place the initial extremity of the roller 
 upon the anterior or posterior surface of the limb a few 
 inches above the extremity of the stump, and carry the 
 bandage to the end of the stump, and then conduct it 
 upward or downward on the limb, as the case may be, to 
 a point directly opposite the point of starting ; then bring 
 the bandage back over the face of the stump to the point 
 of starting and continue these recurrent turns, each turn 
 
 Fig. 82. 
 
 Recurrent bandage of stump. 
 
 overlapping two-thirds of the previous one, until the face 
 of the stump is covered ; then reverse the bandage and 
 secure the recurrent turns at their points of origin by two 
 or three circular turns. The roller should next be car- 
 ried obliquely down to the end of the stump, and a cir- 
 cular turn should be made around this. The bandage 
 should next be carried up the limb by spiral or spiral 
 reversed turns beyond the point at which the recurrent 
 
BANDAGE FOE LITHOTOMY POSITION. 95 
 
 turns terminated, and secured by one or two circular turns. 
 (Fig. 82.) ... 
 
 In applying this bandage in very short stumps resulting 
 from amputations at or near the shoulder or hip-joints, 
 after making the recurrent and spiral turns, it will be 
 found necessary to carry the bandage, in the case of the 
 shoulder, across the chest to the opposite axilla and back, 
 and apply several of these turns ; so in case of the hip 
 amputations it will be found best to finish the bandage 
 with a few turns about the pelvis. 
 
 Bandage for Securing the Hands and Feet in 
 the Lithotomy Position. 
 
 Roller Two and a Half Inches in Width, Three Yards in 
 
 Length. 
 
 Bandage for securing the hands and feet for lithotomy. 
 
 Application. — The hand of the patient should be 
 brought down and made to grasp the outer side of the 
 foot ; the initial extremity of the roller is fixed by two 
 
96 SPECIAL BANDAGES. 
 
 circular turns around the wrist and ankle, and the bandage 
 is then passed around the foot and hand, and these turns 
 are alternated with turns around the wrist and ankle, until 
 the hand and foot are firmly secured. The same procedure 
 is adopted with the hand and foot of the opposite side. 
 (Fig. 75.) 
 
 Use. — This bandage is useful in securing the hands and 
 feet while the patient is put in the lithotomy position for 
 that operation, or for perineal section. 
 
 Liebreich's Eye-bandage. 
 
 This bandage consists of a strip of flannel two and a 
 half inches in width and from six to ten inches in length, 
 
 Fig. 84. 
 
 Liebreich's eye-bandage. 
 
 to the extremities of which tapes are sewed. It may be 
 applied transversely so as to cover both eyes, or obliquely 
 so as to cover one eye only, and it is secured by the tapes 
 carried around the head and tied over the forehead. 
 (Fig. 84.) 
 
 Use. — This bandage is used to hold compresses or dress- 
 
BANDAGE OF SCULTETUS. 
 
 97 
 
 ings to the eye or eyes, and the elasticity of the flannel 
 permits of its being applied so as to make a variable 
 amount of pressure. 
 
 Bandage of Scultetus. 
 
 This is a compound bandage, consisting of a number of 
 pieces of muslin, and may be prepared from a two and a 
 half or three-inch roller by cutting off strips long enough 
 
 Fig. 85. 
 
 Bandage of Scultetus. 
 
 to encircle the part about one and one-third times. These 
 strips are placed under the part in such a manner that the 
 first piece shall be overlapped by the second, the second 
 by the third, and so on from below upward ; the pieces are 
 
98 SPECIAL BANDAGES. 
 
 then brought around the limb, and the extremities of the 
 last piece are secured by pins. (Fig. 85.) This bandage 
 was formerly much employed in the treatment of com- 
 pound fractures to secure dressings to the wound, and 
 possessed the advantage that when a single strip became 
 soiled it could be removed without disturbing the whole 
 dressing, the new strip to be introduced being pinned to 
 the extremity of the soiled piece to be removed, and then 
 being drawn through by its removal. This bandage will 
 often be found convenient in applying dressings to cases 
 of excision of the joints, where as little disturbance of 
 the parts as possible is important in dressing the wounds. 
 When the strips are attached to each other by a thread 
 passed through each strip in the centre, the bandage is 
 known as Potfs bandage. This bandage is applied and 
 secured in the same manner, but it possesses no advantages 
 over the bandage of Scultetus. 
 
 Flannel Bandage. 
 
 These bandages are prepared from flannel which is cut 
 into strips from two to four inches in width and from five 
 to seven yards in length. These strips are formed into 
 rollers either by hand or by means of the bandage-winder. 
 Flannel bandages, by reason of the elasticity which they 
 possess, can be applied without reverses and are used to 
 make a moderate amount of elastic pressure. They are 
 often employed in applying dressings to the head, espe- 
 cially after operations upon the eyes, and are generally 
 applied as a primary roller before the application of the 
 plaster-of-Paris dressings, and may also be used in sub- 
 acute joint-affections, both to protect the parts and make 
 a moderate amount of elastic pressure. 
 
 The Rubber Bandage. 
 
 This bandage is made from a strip of rubber-sheeting, 
 from one inch to four inches in width and from three to 
 
THE RUBBER BANDAGE. 
 
 99 
 
 five yards in length, which, for convenience of application, 
 is rolled into a cylinder. 
 
 Its use was introduced to the profession by Dr. Martin, 
 of Boston, and it will be found a useful form of dressing 
 where it is considered desirable to apply elastic pressure 
 to a part, (Fig. 86.) 
 
 It may be employed in the treatment of varicose veins 
 of the legs, in chronic ulcers of those parts where pressure 
 
 Martin's rubber bandage. 
 
 is an important element in the treatment, and may be used 
 as a substitute for strapping to secure this object. Its 
 application has also been recommended in the treatment 
 of swelled testicle in that stage of the affection in which 
 pressure is indicated. 
 
 Application. — For application to the leg a rubber 
 bandage two and a half inches in width and three yards 
 in length is required. 
 
 The initial extremity of the roller is fixed upon the foot 
 near the toes and secured by a circular turn ; the foot is 
 then covered in by spiral turns overlapping each other 
 about two-thirds, and a figure-of-eight turn is made from 
 the ankle to the instep. The bandage is then carried up 
 the limb to the knee with spiral turns, where it is secured 
 by two tapes sewed to the terminal extremity of the ban- 
 dage, which are passed around the leg and tied. The 
 bandage need not be reversed, as its elasticity allows it to 
 conform to the shape of the limb. Care should be taken 
 not to apply the turns with too much firmness ; the 
 
100 SPECIAL BANDAGES. 
 
 bandage should be stretched very slightly ; if this pre- 
 caution is not taken, it soon becomes uncomfortable to the 
 patient. A patient using one of these bandages will soon 
 learn to apply it himself, making just the requisite amount 
 of tension to secure its holding its place and to insure a 
 comfortable amount of pressure upon the part. A well- 
 fitting stocking may be placed upon the limb before the 
 bandage is applied, or it may be applied directly to the 
 skin. 
 
 The bandage should be removed at night when the 
 patient goes to bed and hung up to dry, as its inner sur- 
 face becomes moist from the secretions from the skin ; it 
 should be reapplied as soon as the patient rises in the 
 morning. 
 
 In, using it in the treatment of ulcers of the leg no oint- 
 ments should be applied to the ulcer, as oily dressings soon 
 destroy the rubber; dressings may be made to the ulcer by 
 means of dry powders, such as oxide of zinc, iodoform, or 
 aristol, before the bandage is applied. 
 
 In the treatment of swelled testicle the bandage is ap- 
 plied to the testicle by means of recurrent turns not too 
 firmly made, and secured in place by spiral turns, until 
 the whole surface of the organ is covered in ; the end of 
 the bandage is secured with tapes tied around the root of 
 the scrotum. The same precaution to apply the bandage 
 so as to make only moderate pressure should also be 
 observed here. 
 
 Fixed Dressings or Hardening Bandages. 
 
 For the application of these dressings a variety of sub- 
 stances are used which are incorporated in the meshes of 
 some fabric, such as crinoline or cheese-cloth, or painted 
 over its surface to give fixity or solidity to the bandage. 
 
 The materials most commonly used in the preparation 
 of fixed dressings are plaster-of-Paris, starch, silicate of 
 sodium or potassium, paraffin, or a mixture of chalk and 
 gum or of oxide of zinc and glue. 
 
THE PLASTEB-OF-PABIS BANDAGE. 101 
 
 The Plaster-of-Paris Bandage. 
 
 The plaster-of-Paris used for the application of surgical 
 dressings should be of the same quality as that which the 
 dental surgeons employ in taking casts for teeth — that is, 
 the extra calcined variety. If moist or of inferior quality, 
 it will not set rapidly or firmly, and will fail to give suffi- 
 cient fixation to the dressing. 
 
 The plaster-of-Paris dressing may be applied in several 
 ways, either by covering the part to be enclosed with some 
 loose fabric, and rubbing the moist plaster into it, alter- 
 nating the layers of the fabric with layers of moist plaster, 
 or it may be applied by means of a roller which has been 
 prepared by incorporating plaster-of-Paris in its meshes. 
 
 To apply a plaster-of-Paris dressing according to the 
 first method, the part to be enclosed — the leg, for instance 
 — should first be covered by a neatly applied flannel ban- 
 dage or a muslin bandage, which has been shrunken by 
 being washed ; new muslin is not satisfactory as a primary 
 application to a limb in applying a plaster-of-Paris dress- 
 ing, as the moisture from the plaster wets it and causes it 
 to shrink, so that it may exert injurious pressure after the 
 bandage becomes dry. 
 
 The limb having been covered by the bandage, and any 
 bony prominences such as the malleoli having been padded 
 with small wads of cotton to prevent undue pressure upon 
 them, the part is next covered by a layer of turns of a 
 crinoline bandage or by strips of cheese-cloth or any other 
 loose material. A small quantity of plaster-of-Paris is 
 next mixed with water until it has the consistence of thick 
 cream, when it is smeared evenly over the whole surface 
 of the previously applied bandage. Another layer of the 
 bandage or of strips is next applied, and the plaster is 
 smeared over this in the same manner, and so alternate 
 layers of plaster-of-Paris and bandage are applied until a 
 casing of the desired thickness is obtained. If the plaster- 
 of-Paris of the quality previously described be used, it 
 will set or become hard in a few minutes. 
 
 The most convenient method of applying the plaster-of- 
 
102 SPECIAL BANDAGES. 
 
 Paris dressing is that employed by Prof. Sayre, which con- 
 sists in the use of bandages which have been previously 
 prepared with plaster-of- Paris ; these are moistened and 
 applied while moist to the part to be encased. 
 
 Preparation of the Plaster-of-Paris Bandage. 
 
 These bandages are prepared by taking cheese-cloth, 
 mosquito-netting, or crinoline, which latter is by far the 
 best fabric, and cutting or tearing it into strips two and a 
 half to three inches in width and five yards in length. 
 These are laid on a table, and plaster-of-Paris of the 
 quality before mentioned is dusted over them and rubbed 
 into the meshes of the fabric; the material when impreg- 
 nated with plaster is loosely rolled into a cylinder, and 
 these bandages when prepared should be placed in air- 
 tight jars or tin cans until required. 
 
 Bandages thus prepared, which have been exposed to 
 the air or have been kept for a long time, are not apt to 
 set well when applied ; but if such bandages are placed in 
 a hot oven and baked for half an hour before being used, 
 they will be found to set as satisfactorily as those freshly 
 prepared. 
 
 These bandages may be prepared by a machine made 
 for this purpose, but I do not think that they are apt to 
 have the plaster as evenly distributed through them, and 
 therefore are not as satisfactory, as those prepared by 
 hand. 
 
 Application of the Plaster-of-Paris Bandage. 
 
 Before applying this dressing, the part to be encased — 
 the leg, for instance — should be covered by a flannel roller, 
 the bony prominences being protected by pads of cotton, 
 or a closely fitting stocking may be applied to the part. 
 
 The bandage should be dipped in warm water and kept 
 covered for a few minutes ; it may be squeezed with the 
 hand, and as soon as bubbles of air cease to escape it is a 
 
APPLICATION OF PLASTEB-OF-PABIS BANDAGE. 103 
 
 sign that it is thoroughly soaked and is ready for appli- 
 cation. 
 
 On removing it from the water the excess of water 
 should be squeezed out by the hand, and the bandage 
 should then be evenly applied to the limb with just enough 
 firmness to make it fit the part nicely, and as few reverses 
 as possible should be made. A sufficient number of ban- 
 dages are applied to make a dressing as firm as may be 
 required; three rollers of the above dimensions are usually 
 quite ample for a dressing for the leg, and when the last 
 roller has been applied some dry plaster should be moist- 
 
 Fig. 87. 
 
 Leg encased in plaster-of-Paris dressing. 
 
 ened with water until it has the consistence of thick cream, 
 and it should be rubbed evenly over the surface of the 
 bandage to give it a finish. (Fig. 87.) If a good quality 
 of plaster has been used, the bandage should be quite firm 
 in from ten to fifteen minutes, but the patient should not 
 for a few hours be allowed to put any weight upon the 
 bandage. 
 
 An equally firm bandage may be applied with the use 
 of a less number of bandages, if the surgeon rubs over the 
 surface of each layer of bandage applied a little moist 
 plaster, then applying another layer and repeating the 
 
104 SPECIAL BANDAGES. 
 
 same procedure ; finishing the dressing by an external 
 coating of moist plaster, as above described. 
 
 In applying these dressings a fewer number of bandages 
 will be required if narrow strips of tin, zinc, or binder's 
 board are incorporated in the layers of the bandage, which 
 also increase the strength of the dressing. 
 
 Interrupted Plaster-of-Paris Dressing. 
 
 This form of plaster-of-Paris dressing is applied by first 
 placing a short iron rod under the extremity some distance 
 above and below the point at which the dressing is to be 
 interrupted; this is fixed by a few turns of the plaster 
 bandage above and below the portion of the limb which is 
 to be left exposed ; stout wire is next bent into loops, the 
 
 Fig. 88. 
 
 Interrupted plaster-of-Paris dressing. (Stimson. ) 
 
 extremities of which are incorporated in the subsequent 
 turns of the plaster bandage ; three loops thus placed in 
 addition to the posterior iron bar will usually make the 
 dressing sufficiently firm. (Fig. 88.) A number of turns 
 of the bandage are applied to firmly fix the loops and 
 the limb is held in the desired position until the plaster 
 has set. 
 
APPLICATION OF PLASTER-OF-PARIS JACKET. 105 
 
 Application of the Plaster-of-Pams Jacket. 
 
 The patient's body should be covered with a soft, closely 
 fitting woven shirt without arms, but with shoulder-straps 
 to hold it in position, or an ordinary woven undershirt 
 may be employed ; one or two folded towels, or a pad of 
 
 Fig. 89. 
 
 Suspensory apparatus. 
 
 cotton wrapped in a towel, are next placed over the ab- 
 domen between the shirt and the skin — this is called, by 
 Prof. Sayre, the dinner pad, and is intended to leave space 
 for the distention of the abdomen after eating. Small 
 pads of raw cotton may also be placed over the anterior 
 iliac spines, and, in the case of females, a pad of cotton 
 
106 
 
 SPECIAL BANDAGES. 
 
 wrapped in a handkerchief may be placed over each 
 mammary gland. 
 
 The patient should next be suspended by the apparatus 
 consisting of a collar and arm-pieces attached to a cross- 
 bar (Fig. 89), which is attached by a cord and pulley to a 
 
 Fig. 90. 
 
 Patient suspended for application of plaster jacket. 
 
 tripod. If this apparatus is not at hand, a very satis- 
 factory substitute may be made by folding two towels into 
 cravats and tying together the ends, so as to make two 
 loops, one of which is placed in each axilla ; a bar of 
 wood two and a half feet in length is next taken and the 
 loops are secured to the ends of this by stout cords or 
 
APPLICATION OF PLASTER- OF-PABIS JACKET. 107 
 
 handkerchiefs ; a Barton's bandage is next applied to the 
 head, and a strip of bandage is passed under the turns 
 which cross the vertex and is secured to the middle of 
 the cross-bar. The bar is next suspended by a cord 
 passed through a pulley or ring which may be attached 
 to the sill of a door if the ordinary tripod cannot be 
 obtained. 
 
 The patient should be slowly raised by the apparatus 
 until the toes only are in contact with the floor, and the 
 extension should not be carried to the point which makes 
 it uncomfortable to the patient. (Fig. 90.) The shirt 
 should be drawn downward over the hips by an assistant 
 and held in place until a few turns of the bandage have 
 been applied. 
 
 The plaster bandage having been soaked and squeezed, 
 a turn should be made around the body above the pelvis, 
 and it should then be carried downward below the iliac 
 spines, and from this point it should be made to ascend 
 gradually by spiral turns until it reaches the axillary line. 
 The turns should be applied smoothly and not too tightly. 
 After two or three layers of turns have been applied, the 
 surgeon may rub some moist plaster upon their surface if 
 he desires to use fewer bandages. These turns are repeated 
 until a bandage of the desired thickness is applied, and 
 the surface of the dressing may be finished by rubbing 
 it over with moistened plaster. This jacket for a child 
 will generally require the use of three or four bandages 
 of the dimensions given ; for an adult, six to eight band- 
 ages. 
 
 The patient should be kept suspended until the bandage 
 has set, usually from ten to fifteen minutes, and then should 
 be carefully lifted so as not to bend the spine, and placed 
 on his back upon a mattress, until the dressing becomes 
 perfectly hardened. The dinner pad and mammary pads, 
 if they have been used, should next be removed. In 
 applying this dressing, strips of zinc or tin may be placed 
 between the layers of bandage if it is desired to give more 
 strength to the jacket. 
 
108 
 
 SPECIAL BANDAGES. 
 
 Fig. 91. 
 
 Application of the Jury-mast by Means of 
 Plaster-of-Paris. 
 
 In disease of the spine involving the cervical or upper 
 dorsal region the ordinary plaster-of- Paris jacket is not 
 satisfactory, and in such cases the "jury-mast" is em- 
 ployed in connection with the 
 plaster jacket. In applying the 
 "jury-mast" the same steps are 
 taken in the preparation of the 
 patient as in applying the plaster- 
 of-Paris jacket, with the exception 
 of extension, which need not be 
 used. 
 
 After three or four layers ot 
 the plaster bandage have been 
 applied to the body, an apparatus 
 made of two bars of metal having 
 two perforated strips of zinc at- 
 tached to them a few inches apart, 
 which partly encircle the body, is 
 applied and held in position by 
 turns of the plaster bandage. The 
 perpendicular bars have at their 
 upper part a slot, into which the 
 lower end (Fig. 91) of the "jury- 
 mast" fits, and is secured by a 
 screw ; to the upper part of this 
 is attached a movable cross-bar, 
 to which are fastened the straps of the collar from which 
 the head is suspended. 
 
 Head-support and jury-mast. 
 
 The Bavarian Dressing. 
 
 To apply this dressing, which is sometimes employed 
 in the treatment of fractures, take two pieces of Canton 
 flannel the length of the part to be enclosed, and more 
 than wide enough to envelope its circumference. In 
 
THE BAVARIAN DRESSING. 
 
 109 
 
 applying it to the leg these pieces should be cut so as to 
 correspond to the outline of the leg and posterior portion 
 of the foot. 
 
 These pieces should be placed one over the other and 
 sewed together in the middle line, the seam corresponding 
 to the back of the leg. The leg and foot are then placed 
 upon this, and the inner layer of flannel is brought up in 
 front of the leg and over the dorsum of the foot and made 
 fast with pins. (Fig. 92.) Plaster-of-Paris is next mixed 
 with water to form a paste, which is rubbed thickly 
 
 Fig. 92. 
 
 Bavarian dressing. 
 
 and evenly over the flannel next to the limb until a 
 sufficient thickness is obtained ; the outer layer of flannel 
 is then brought up about the leg and moulded to its 
 surface by the hands. A loosely applied roller may now 
 be used to hold the dressing in place until the plaster 
 has set. 
 
 AVhen it is necessary to inspect the parts, the turns of 
 the bandage are cut, and upon separating the layers of 
 flannel the two halves can be turned aside, the seam at 
 the back acting as a hinge. Upon reapplying the splints 
 to the leg they may be retained in position by a roller or 
 by one or two strips of bandage. 
 
110 SPECIAL BANDAGES. 
 
 Moulded Plaster-splints. 
 
 It is sometimes found difficult to apply the ordinary 
 plaster dressings to parts irregular in their shape, and at 
 the same time to have a splint which can be removed with 
 ease. To accomplish this purpose moulded splints of 
 plaster may be made by cutting a paper pattern of the 
 part to be covered in, and then cutting pieces of crinoline 
 to conform to this pattern • eight or ten pieces will usually 
 form a splint of sufficient thickness. One of these pieces 
 of crinoline is laid upon a table and dry plaster is rubbed 
 into its meshes; another is laid upon this and plaster is 
 applied to it in the same way, and so on until all the pieces 
 have been placed in position, one over the other, with 
 plaster rubbed well into the meshes. The dressing is then 
 folded up and dipped into water, squeezed out, and moulded 
 to the part and held in position, until it sets, by the turns 
 of a bandage. The edges should overlap slightly, and in 
 applying it a strip of waxed paper may be placed under 
 the overlapping edge to prevent its adhesion to the dress- 
 ing below, and thus facilitate its removal. Splints pre- 
 pared in this way can be removed with ease, and are often 
 of service in cases where it is desirable to inspect the parts 
 frequently ; I have employed with advantage such splints 
 in making fixation of the hip-joint in cases of coxalgia, 
 and also for the same purpose in affections of other joints. 
 The splints upon being reapplied are secured by a few 
 strips of bandage, or by a roller-bandage. 
 
 Trapping Plaster-of-Paris Bandages. 
 
 In applying the plaster-of-Paris dressing to a part where 
 there is a wound which is covered by the plaster-bandage, 
 it is well to make some provision whereby the plaster- 
 dressing over the site of the wound may be cut away, 
 making a trap or window through which the wound may 
 be inspected or dressed, if necessary. (Fig. 93.) To 
 accomplish this, before applying the plaster-bandage, a 
 
REMOVAL OF PLASTER- OF- PARIS FROM HANDS. HI 
 
 compress of lint or gauze should be placed over the wound, 
 which, when the dressing is completed, forms a projection 
 on its surface, indicating the position of the wound, and 
 also allows the surgeon to cut away the dressing without 
 injuring the skin below. These traps may be cut out after 
 the bandage has partially set, or after it has become hard. 
 
 Fig. 93. 
 
 Plaster-of-Paris bandage trapped. (Esmaech.) 
 
 In applying the plaster-of- Paris dressing in cases of com- 
 pound fracture and after osteotomy, I always make pro- 
 vision for trapping of the bandage if it should become 
 necessary, although in the vast majority of cases it does 
 not have to be done. 
 
 Removing Plaster-of-Paris from the Hands. 
 
 One objection to the use of plaster-of- Paris dressings is 
 the difficulty of removing it from the hands of the surgeon, 
 and the harsh condition in which the skin is left after its 
 removal. If, however, the hands are washed in a solu- 
 tion of carbonate of sodium — a tablespoonful to a basin of 
 water — the plaster will be readily removed and the skin 
 will be left in a soft and comfortable condition. 
 
112 
 
 SPECIAL BANDAGES. 
 
 Removal of the Plaster-of-Paris Bandage. 
 
 The removal of the plaster-bandage is sometimes a 
 matter of difficulty, particularly if it has to be removed 
 before the parts below it are consolidated, as it may dis- 
 arrange them and cause the patient pain if it is not 
 accomplished without much force. 
 
 Fig. 94. 
 
 Cutting plaster-bandage upon lead strip. 
 
 When the bandage is applied to get a cast of a part, or 
 in the treatment of fractures where it may be necessary to 
 remove the bandage in a few days to inspect the parts, 
 a strip of sheet-lead one-half an inch in width is first 
 placed over the flannel bandage, and is allowed to project 
 at each end beyond the dressing ; the plaster can then be 
 readily cut through upon this strip with a knife without 
 injury to the parts below. (Fig. 94.) As soon as the 
 bandage has become firm, the lead strip is removed by 
 traction upon one end of it, and if the bandage has been 
 entirely divided it can be removed at any time without 
 difficulty. 
 
 It may also be removed by means of a saw devised for 
 
USES OF PLASTER-OF-PARIS DRESSINGS. 113 
 
 this purpose (Fig. 95), or by strong cutting-shears of 
 various kinds (Fig. 96) ; or a line may be painted over 
 the dressing with hydrochloric acid or vinegar, which 
 softens the plaster so that it can readily be cut through 
 
 Fig. 95. 
 
 Hunter's saw for removing plaster-bandages. 
 
 with a knife. Dr. William B. Hopkins has devised a 
 vertebrated metal chain which is applied to the part before 
 the plaster is applied and removed when the bandage has 
 set, leaving a hollow longitudinal ridge which can be cut 
 
 Shears for cutting plaster-bandages. 
 
 through or divided with a rasp. The use of the saw or 
 shears is, I think, most satisfactory in removing these 
 dressings. They should be used carefully, as the final 
 layers of the bandage are divided, to avoid wounding the 
 skin. 
 
 Uses of Plaster-of-Paris Dressings. 
 
 These dressings are employed to secure fixation, as pri- 
 mary or secondary dressings in the treatment of fractures, 
 and for a like purpose in injuries and diseases of the joints. 
 They are also largely used in the treatment of diseases 
 and deformities of the spinal column, and will also be 
 found most satisfactory applications after osteotomy and 
 tenotomy, to secure immobility and hold the parts in their 
 
114 SPECIAL BANDAGES. 
 
 corrected positions; when employed in the dressing of 
 cases after tenotomy, they are generally used for a few 
 weeks until the proper mechanical apparatus is applied. 
 
 The Starched Bandage. 
 
 To apply this bandage starch is first mixed with cold 
 water until a thick, creamy mixture results ; to this is 
 added boiling water until a clear mucilaginous liquid is 
 produced ; if too thin, it can be made thicker by heating it 
 upon a stove. The part to be dressed is first covered with 
 a flannel roller, and over this a few layers of a cheese-cloth 
 or crinoline bandage, which has been shrunken, are ap- 
 plied; the starch is then smeared or rubbed with the hand 
 evenly into the meshes of the material, and the part is 
 again covered with a layer of turns of the bandage, and 
 the starch is again applied : this manipulation is continued 
 until a dressing of the desired thickness is produced. 
 Strips of pasteboard may be applied between the layers 
 of the bandage to give additional strength to the dressing, 
 if desired. 
 
 It requires from twenty-four to thirty-six hours for the 
 starched bandage to become dry and thoroughly set. It 
 may be removed in the same way in which the plaster- 
 of-Paris dressing is removed. 
 
 Use. — Before the introduction of the plaster-of-Paris 
 dressing it was formerly much employed in the treatment 
 of fractures and in injuries of the joints. It may be used 
 in such cases, but possesses no advantage over the former 
 dressing and has the disadvantage of setting much less 
 promptly. 
 
 GUM-AND-CHALK BANDAGE. 
 
 In applying this dressing equal parts of powdered gum- 
 arabic and precipitated chalk are mixed with boiling water 
 until a mass of the consistence of cream results. This is 
 applied to the cheese-cloth or crinoline bandage in the 
 same manner as is the starch in the application of the 
 
THE PARAFFIN-BAND A GE. 115 
 
 starched bandage ; it has the advantage over the latter 
 dressing of setting more promptly, five or six hours only 
 being required for it to become hard. It may be employed 
 for the same purposes as the starched or plaster-of- Paris 
 bandage. 
 
 Silicate of Potassium or Sodium Bandage. 
 
 In applying this bandage, after a flannel-roller and 
 several layers of a cheese-cloth or crinoline bandage have 
 been applied to the part, the surface of the latter is coated 
 with silicate of sodium or potassium applied by means of 
 a brush, then a second layer of bandage is applied and 
 treated in the same manner, and this manipulation is con- 
 tinued until a bandage of the desired thickness is pro- 
 duced. It requires twenty-four hours for this dressing 
 to become firm. As it is irksome for a patient to keep a 
 part quiet while the silicate bandage is becoming hard, I 
 often cover it as soon as applied with a layer of tissue 
 paper and apply over it a light plaster- of-Paris bandage, 
 which becomes hard in a few minutes ; this is removed at 
 the end of twenty-four hours, when the silicate bandage 
 is hard. In removing the silicate bandage it may be first 
 softened by soaking it in warm water, and then it can be 
 readily cut with scissors. 
 
 In applying either the starched bandage or the silicate 
 of potassium bandage care should be taken to use cheese- 
 cloth or crinoline which has been shrunken by being 
 moistened and allowed to dry before being employed ; 
 otherwise dangerous compression of the part may occur if 
 the bandage has been firmly applied and shrinks after its 
 application. 
 
 The Paraffin-bandage. 
 
 Paraffin, which melts at from 105° to 120° F., is used 
 in the application of this bandage. The limb being 
 covered by a flannel-roller, a vessel containing paraffin is 
 placed in a basin of boiling water. As the roller, w r hich 
 
116 SPECIAL BANDAGES. 
 
 may be either of flannel, cheese-cloth, or crinoline, is 
 unwound it is passed through the melted paraffin and 
 applied to the part, and the turns are repeated until a 
 dressing of sufficient thickness results, and the surface 
 may be brushed over with melted paraffin. This dressing 
 sets very rapidly, being quite firm in from five to ten 
 minutes. 
 
 It possesses the advantage of the other fixed dressings 
 in that it does not absorb discharges and become offensive, 
 and for this reason it was formerly recommended in the 
 treatment of compound fractures. 
 
 Glue or Glue and Oxide of Zinc Bandage. 
 
 Glue or glue combined with oxide of zinc has been em- 
 ployed in the preparation of fixed dressings, but possesses 
 no advantages over those previously mentioned. 
 
 RAw r -HiDE on Leather Splints or Dressings. 
 
 In moulding raw-hide or leather splints it is necessary, 
 first, to apply a plaster-of-Paris bandage to the part to 
 which the raw-hide splint is to be fitted ; and as soon as 
 the plaster has set it is removed, and a solid plaster cast 
 is next made by pouring liquid plaster-of-Paris into this 
 mould. When this has become dry a piece of raw-hide, 
 which has been soaked for a time in warm water, is 
 moulded to the cast and held firmly in contact with it 
 by tacks or a bandage until it has become perfectly dry. 
 It is then removed, and its surface is covered with 
 several coats of shellac, to prevent its absorbing moisture 
 from the skin when applied, and changing its shape. 
 Eyelets or hooks are fastened to the edges of the splint, 
 through which strings are passed to secure the splint in 
 place. 
 
 Made in this manner raw-hide splints fit the part very 
 accurately, and constitute a very satisfactory dressing for 
 cases of joint-disease, and in the form of leather-jackets 
 
BINDER'S BOARD OR PASTEBOARD SPLINTS. 117 
 
 Fig. 97. 
 
 are often employed in the treatment of disease of the spine 
 in place of the plaster-of-Paris jacket. (Fig. 97.) 
 
 In the treatment of high dorsal or cervical caries a 
 leather-splint in two sections, which 
 rests upon the shoulders and sup- 
 ports the head, is often used with 
 good results. (Fig.98.) 
 
 Binder's Board or Pasteboard 
 Splints. 
 
 This material, which can be ob- 
 tained in sheets of different thick- 
 ness, is frequently employed for 
 the manufacture of splints. In 
 
 Fig. 98. 
 
 Leather-jacket with jury- 
 mast. 
 
 Leather-splint for cervical caries. 
 (Owen.) 
 
 moulding these splints a portion of the board of the 
 requisite size and thickness is dipped in boiling water 
 for a short time, and when it has become softened it is 
 removed and allowed to cool ; a thick layer of cotton- 
 batting is next applied over it, and it is then moulded 
 to the part and held firmly in place by the turns of a 
 roller-bandage ; in a few hours it becomes dry and hard. 
 
 This material, from its cheapness and the ease with 
 which it is obtained, is frequently employed to mould 
 
 6* 
 
118 SPECIAL BANDAGES. 
 
 splints for the treatment of fractures, especially in chil- 
 dren, and for the fixation of joints in the treatment of 
 acute and chronic joint affections. A moulded pasteboard- 
 splint is also often employed to fix the ends of the bones 
 after the excision of a joint. 
 
 Porous Felt-splints. 
 
 This material is also employed for the manufacture of 
 splints, and is applied by dipping the material in hot 
 water and then moulding it to the part ; as it dries it 
 becomes hard. 
 
 Hatter's Felt Splints. 
 
 Hatter's felt is also frequently employed for the manu- 
 facture of splints or dressings. It is softened by dipping 
 it in boiling water or heating it in the flame of an alcohol 
 lamp, and when soft and pliable it is moulded to the part, 
 and as it cools it again becomes hard. 
 
 These splints are employed for the same purposes as 
 those made of plaster-of-Paris, leather, or pasteboard. 
 
PAET II. 
 
 MINOR SURGERY. 
 
 Theory of Asepsis and Antisepsis in Wound 
 Treatment. 
 
 The term Asepsis, applied to a wound, implies that it 
 is free from those vegetable parasites or micro-organisms 
 whose presence sets up fermentative changes, accompanied 
 by suppuration and constitutional disturbance. 
 
 Antisepsis, on the other hand, has reference to the means 
 employed to bring about the destruction of micro-organisms 
 which may be present in the wound or upon the instru- 
 ments, dressings, or hands of the surgeon, and which, if 
 not destroyed or rendered inert, will set up fermentative 
 changes in the wound. 
 
 It has long been a well-recognized fact that albuminoid 
 substances, such as dead animal tissue, blood, or blood- 
 serum, will, when exposed to moisture, warmth, and the 
 presence of certain living organisms or fungi, bacteria and 
 micrococci, develop putrefactive changes ; and if these 
 changes take place in the living body, there result certain 
 constitutional disturbances known as symptomatic, inflam- 
 matory, or septic fever. 
 
 It was also recognized that these putrefactive changes 
 in albuminoid substances could be avoided by their ex- 
 posure to heat, cold, or by drying — any of these conditions 
 being sufficient to destroy or arrest the development of 
 the micrococci. 
 
 Sepsis in the living organism is due to the entrance and 
 
120 MINOR SURGERY. 
 
 multiplication of microbes, or the absorption of their 
 products, and is characterized by local inflammation of 
 the wound, grave constitutional disturbances, fever, dis- 
 orders of the nervous system, and infection of the viscera. 
 Microbic infection should be considered a disease-process 
 which causes disastrous wound-complications, and differs 
 materially from that process which attends the repair of 
 injuries and the union of wounds which run an aseptic 
 course. At the present time no surgeon should undertake 
 the performance of an operation or the treatment of an 
 open wound without having clearly impressed upon his 
 mind the important part the pyogenic microbes may play 
 in the subsequent course of the wound. It has been 
 clearly proved that certain species of microbes caused su- 
 puration and gangrene, that others cause inflammation, 
 and that others produce ferments, and some form different 
 substances known as ptomaines, toxins, toxalbumins, all 
 of which exercise a virulent influence upon the living 
 organism. It is an unquestionable fact that pyogenic 
 microbes under different conditions can produce a series 
 of different diseases, for it is now generally accepted that 
 Fehleisen\s streptococcus erysipelatis is identical with 
 the streptococcus pyogenes, which is recognized as the 
 cause of many different inflammatory .affections. The 
 theory has been advanced by Reger to account for this, 
 that all the so-called pus-diseases are simply a local ex- 
 pression of a general infection caused by many different 
 micro-organisms. It is scarcely possible that any wound 
 is entirely free from germs, when we take into considera- 
 tion their almost universal presence, so it may be assumed 
 that infection does not necessarily depend upon the pres- 
 ence of a few microbes, but rather upon the quantity and 
 quality of the germs which are present in the wound It 
 has been shown by Cheyne that the number of bacteria 
 entering the tissues is an important factor in producing 
 suppuration or septic infection, for we know that healthy 
 tissues will destroy or remove an innumerable number of 
 germs ; suppuration or infection occurring only when the 
 tissues are overwhelmed by the number of organisms, or 
 
THEORY OF ASEPSIS AND ANTISEPSIS. 121 
 
 their power of resistance is diminished by injury or disease. 
 The micro-organisms which set up fermentative and putre- 
 factive changes in animal tissues exist in great variety, but 
 those which are of most interest to the surgeon belong to 
 the cocci and bacilli. 
 
 Staphylococcus Pyogenes Aureus. — This organism, which 
 is spherical and apt to form clusters, has been shown to be 
 the most common cause of acute suppuration in living 
 human tissues. These microbes are found in great num- 
 bers upon the surface of the body and in the superficial 
 layers of the skin, especially in the region of the axilla, 
 umbilicus, perineum, and finger-nails ; they are also found 
 upon the mucous membrane of the mouth, pharynx, and 
 alimentary canal. 
 
 Staphylococcus Pyogenes Albus and Citreus. — These are 
 micro-organisms which frequently exist in connection 
 with the previously mentioned organisms. All these varie- 
 ties of staphylococci are found in circumscribed suppura- 
 tion, such as acute abscesses, adenitis and osteo-myelitis. 
 
 Streptococcus Pyogenes. — This is one of the most impor- 
 tant of the pyogenic cocci which extends rapidly along the 
 lymph spaces and lymphatics, and by rapid infiltration 
 causes gangrene. This micro-organism is found in the 
 vagina, urethra, and nasal cavities. It produces pro- 
 gressive suppurations, such as phlegmonous cellulitis and 
 erysipelas, and is morphologically similar to the strepto- 
 coccus erysipelatis. 
 
 Bacillus Pyogenes. — This is an organism which is found 
 in blue or green pus. 
 
 Bacillus Pyogenes Fcetidus. — This is a short, rod-like 
 organism, which is said to exist only in the human body, 
 and is found in abscesses containing foul-smelling pus, in 
 the region of the anus, brain, and other parts of the body. 
 
 Many other organisms exist which are of interest to the 
 surgeon, such as micrococcus gonorrhoea, bacillus tubercu* 
 losis, bacillus of tetanus, bacillus of malignant oedema, 
 bacillus mallei, and bacillus anthracis. 
 
 In w r ounds the result of accident or made by the 
 surgeon all the conditions are most favorable for the 
 
122 MINOR SURGERY. 
 
 entrance and development of these organisms. The 
 serum and blood and the dead or partially devitalized 
 cells of the various tissues are most favorable media for 
 their growth. We have present also warmth and moist- 
 ure, and in the air coming in contact with the wound we 
 have vast quantities of dust laden with spores, which 
 under these favoring conditions develop into the organ- 
 isms before mentioned, which rapidly set up fermetative 
 processes known as decomposition. 
 
 The products of this decomposition, carried into the 
 circulation by the lymphatics and veins, set up local 
 changes in the shape of inflammation and at the same time 
 give rise to systemic disturbances which we recognize as 
 septic fever. 
 
 Modern wound-treatment aims at the prevention of 
 decomposition and suppuration, and accomplishes this 
 purpose by having the wound kept aseptic, by perfect 
 cleanliness of the region of the wound, the hands and 
 instruments of the surgeon, and by not exposing the wound 
 to an atmosphere which contains dust ; as the latter con- 
 dition is difficult to obtain we secure the destruction of the 
 micro-organisms which may be present by heat, as seen in 
 the use of the actual cautery or by chemical sterilization, 
 which is accomplished by the use of germicides. 
 
 Surgical Cleanliness. 
 
 Surgical cleanliness may be obtained by following either 
 the aseptic or the antiseptic method. 
 
 Although at the present time these two methods are to 
 a certain extent combined, that is, it is impossible to be 
 strictly aseptic without employing means of disinfection, 
 that is, employing antiseptic methods to a certain extent, 
 the antiseptic method of wound- treatment was first intro- 
 duced, and produced a revolution in surgical practice, but at 
 the present time, recognizing that certain evils have arisen 
 from the use of antiseptics, and that equally good or better 
 results may be obtained without bringing antiseptic sub- 
 stances directly in contact with wounds, the aseptic method 
 
SURGICAL CLEANLINESS. 123 
 
 has been widely and successfully adopted, and to day the 
 weight of surgical opinion is decidedly in favor of the 
 latter method. 
 
 Antiseptic Method. 
 
 In the antiseptic method the sterilization of the field of 
 operation, the hands of the surgeon and assistants, the in- 
 struments, ligatures, sponges, and sutures, is accomplished 
 by the use of germicidal solutions, and in addition the 
 wound is irrigated constantly during the operation by ger- 
 micidal solutions, and is afterward covered with dressings 
 impregnated with germicidal substances. 
 
 Aseptic Method. 
 
 In the aseptic method the field of operation, the hands 
 of the surgeon and his assistants, the instruments, ligatures, 
 sponges, and sutures are sterilized by the use of germicidal 
 solutions and heat, and after this has been accomplished, 
 relying upon the completeness of the sterilization, no anti- 
 septic substances are brought in contact with the wound, 
 sterilized water being used if it is necessary to flush the 
 wound, and the dressings employed are only those which 
 have been sterilized by moist or dry heat. 
 
 The disadvantages of the antiseptic method in wound- 
 treatment which have caused it to be largely succeeded by 
 the aseptic method are, first, that recent investigations have 
 shown that many of the germicidal substances have not 
 the disinfecting power which has long been attributed to 
 them ; second, that antiseptic substances to be active as 
 germicides may cause irritation of the surface of the wound, 
 interfering with its repair, and are apt to cause very free 
 oozing of serum, which necessitates the use of drainage, 
 and makes the frequent dressing of the wound necessary ; 
 many antiseptic substances also produce marked toxic 
 effects upon the patient, and often cause very severe irrita- 
 tion of the skin in contact with the dressings. 
 
 The advantages of the aseptic method may be briefly 
 stated, that the method is applicable in all parts of the 
 
124 MINOR SURGERY. 
 
 body ; wounds treated by this method heal more promptly 
 and do not so often require dressing ; there is no risk of 
 toxic effects, and no irritation of the skin by the dressings ; 
 the dressings are also less expensive. Dry sterilized dress- 
 ings are efficient as dressings to produce absorption, and 
 at the same time the dryness may be a factor in the 
 destruction of germs, for exposing bacteria to dryness 
 deprives them of moisture, which is one of the conditions 
 necessary for their existence. It may, therefore, be laid 
 down as a general rule that the aseptic method is to be 
 preferred to the antiseptic method when and wherever it 
 is possible. 
 
 Agents Employed to Secure Asepsis. 
 
 A great variety of agents possessing more or less germi- 
 cidal properties have been at different times employed in 
 the practice of aseptic or antiseptic surgery ; those most 
 employed at the present time are heat, bichloride of mer- 
 cury, carbolic acid, iodoform, beta-naphtol, chloride of 
 zinc, peroxide of hydrogen, creolin, permanganate of potas- 
 sium, pyoktanin and boric acid, the double cyanide of 
 mercury and zinc, and aristol. 
 
 Heat. 
 
 The most reliable and universally available agent for 
 the destruction of pyogenic organisms is heat, either dry 
 or moist ; many forms of bacteria are rendered inert at a 
 temperature of 140° F., and none can withstand the appli- 
 cation of moist heat at a temperature of 212° F. continued 
 for a short time. Spores which will resist the action of 
 powerful germicides for a considerable time are destroyed 
 by boiling for a few minutes. As moist heat is the most 
 efficient sterilizer, it should be preferred, and can always 
 be made use of for this purpose by boiling the instruments 
 and dressings for a few minutes, and if for any reason it is 
 thought advisable to employ dry heat as a sterilizer, this 
 may be made use of by baking the instruments or dress- 
 
BICHLORIDE OF MERCURY. 125 
 
 ings in a hot oven. The same results, of course, may be 
 obtained by the use of one of the various dry or moist 
 sterilizers. 
 
 Bichloride of Mercury. 
 
 This is employed as an antiseptic in watery solution, 
 varying in strength from 1 : 500 to 1 : 10,000. 
 
 The solution 1 : 500 to 1 : 1000 is used only for the 
 irrigation and disinfection of the hands and skin ; for the 
 irrigation of wounds, a solution of 1 : 2000 is generally 
 employed. In using the bichloride solution in operations 
 upon children, I am in the habit of using a solution of 
 1 in 4000, and I find that it produces less irritation of the 
 skin and is equally efficient as a germicide. Where con- 
 tinuous irrigation is kept up or where it is employed in 
 large cavities, a still weaker solution, 1 : 5000 to 1 : 10,000 
 should be employed. 
 
 In using these solutions the surgeon should watch the 
 patient carefully for symptoms of poisoning due to the 
 absorption of the bichloride of mercury ; the symptoms 
 denoting this are vomiting, fetid breath, salivation, in- 
 flammation of the gums, diarrhoea, blood-stained stools, 
 and bleeding from the mouth and nose. 
 
 In preparing the solutions of bichloride of mercury for 
 use, it will be found convenient to have a concentrated 
 solution of the salt in alcohol, one part of the bichloride 
 of mercury to ten parts of alcohol ; this can be kept in a 
 well-stoppered bottle, and to this should be added one tea- 
 spoonful of common salt, which prevents the disintegration 
 of the mercuric compound. One teaspoonful of this 
 solution added to one quart of water makes a 1 : 1500 
 solution. 
 
 A ten per cent, bichloride solution may be made as 
 follows : 
 
 Bichloride of mercury 2 parts. 
 
 Sodium chloride 1 part. 
 
 Dilute acetic acid 1 " 
 
 Water 16 parts. 
 
 By adding water in an appropriate quantity, a 1 : 1000 or 1 : 2000 solution can 
 be made. 
 
126 MINOR SURGERY. 
 
 Or the solution may be prepared with tartaric acid in 
 the proportion of five parts of the acid to one part of the 
 bichloride of mercury, the following formula being em- 
 ployed : 
 
 Hydrarg. chlor. corrosiv grs. xv. 
 
 Ac. tartaric grs. lxxv. 
 
 Aquae dest Oij. 
 
 Pellets containing a definite amount of bichloride of 
 mercury compounded with a few grains of common salt 
 or muriate of ammonia, which, when dissolved in a definite 
 quantity of water, make a solution of 1 : 1000 or 1 : 2000, 
 will also be found very convenient for the preparation of 
 solutions. 
 
 These bichloride or sublimate solutions are also em- 
 ployed to sterilize the gauze and cotton which are largely 
 employed in antiseptic dressings. 
 
 Carbolic Acid. 
 
 This drug is employed in solutions of 1 : 20 or 1 : 40. 
 The stronger solution, 1 : 20, is usually employed to 
 sterilize the instruments, the latter being allowed to 
 remain in this solution for thirty minutes before being 
 used. As a carbolic solution of this strength benumbs 
 and cracks the skin of the hands of the operator, it should 
 be diluted just before the instruments are required, by 
 adding an equal quantity of water, making it a 1 : 40 
 solution. 
 
 The 1 : 40 solution is used for the irrigation of wounds 
 and the washing of sponges. Carbolic acid is also em- 
 ployed in the preparation of gauze. A ready method of 
 making a 5 per cent, carbolic solution is to add one table- 
 spoonful of carbolic acid to one pint of hot water. 
 
 In using carbolic acid solutions continuously the surgeon 
 should be on the watch for the symptoms of poisoning, 
 which will show itself by dark-colored urine, headache, 
 dizziness, vomiting, and in severe cases bloody diarrhoea, 
 hemoglobinuria, and death from collapse. Carbolic acid 
 solutions should be used with great caution in young 
 
IODOFORM. 127 
 
 children, as they seem to be more susceptible than adults 
 to the constitutional effects of this drug. I have seen 
 the use of quite dilute solutions produce the characteristic 
 symptoms of poisoning in such patients. 
 
 Iodoform. 
 
 Iodoform is one of the most valuable antiseptic drugs 
 we possess, although it has been shown by experimental 
 research to possess little germicidal action ; but in spite of 
 this fact clinical experience has proved that it possesses 
 powerful antiseptic properties, due not to the destruction 
 of germs, but to its undergoing a decomposition in their 
 presence, and thus rendering the ptomaines which have 
 resulted from the germ-growth inert. Iodoform may be 
 rendered absolutely sterile by washing it in a 1 : 1000 
 bichloride solution, which destroys all micro-organisms ; 
 it should then be dried, and kept for use in closely stop- 
 pered bottles : or it may be exposed to dry heat in a ster- 
 ilizer or oven, which will accomplish the same purpose. 
 
 Iodoform is very extensively employed as an application 
 to wounds ; it is especially useful as a dressing to infected 
 wounds and to tubercular or syphilitic ulcers. It is also 
 employed in the preparation of iodoform-gauze, and may 
 be combined with collodion to form iodoform- collodion, 
 which is a useful dressing in superficial wounds : 
 
 Iodoform -. grs. xlviij. 
 
 Collodion 5j. 
 
 An ethereal solution of iodoform (iodoform grs. xv, 
 ether §j) is also used as an application to chronic ulcers. 
 
 An emulsion of iodoform in glycerin (iodoform 5j> 
 glycerin 5x), or an emulsion of iodoform made by boiling 
 iodoform 5j, olive oil 5x, is much employed at the present 
 time as an injection in the treatment of chronic abscesses 
 and tubercular disease of the joints. 
 
 Elderly persons are more prone to the toxic action of 
 iodoform than young persons These symptoms are mani- 
 fested by sleeplessness, debility, headache, delirium, and 
 death may result from meningitis or cardiac depression. 
 
128 MINOR SURGERY. 
 
 Beta-naphtol. 
 
 Beta-naphtol, in a 1 : 2500 solution, is employed for 
 much the same purposes as the bichloride of mercury solu- 
 tion ; it is not, however, so powerful a germicide. It is 
 employed in irrigating large cavities because it is not a 
 poisonous agent, but is especially useful as a bath for 
 instruments, as it does not corrode them, as does the sub- 
 limate solution. It also possesses the advantage over a 
 carbolic acid solution of not irritating the skin of the 
 surgeon's hands. 
 
 Chloride of Zinc. 
 
 Chloride of zinc, in a solution of 30 to 40 grains to 
 water fgj, is a very powerful antiseptic. When employed 
 upon raw surfaces it produces marked blanching of the 
 tissues ; it is especially useful in wounds which are in- 
 fected or which have been exposed to infection. I have 
 found it by all means the best application to the poisoned 
 wounds which are received in dissecting dead bodies and 
 in operating. In such cases the whole cavity or surface 
 of the wound should be washed with a 30-grain solution 
 of the chloride of zinc, and then the wound should be 
 dressed with a bichloride dressing. 
 
 SuLPHO-CARBOLATE OF ZlNC. 
 
 This drug has been found to possess more decided anti- 
 septic properties than the chloride of zinc, and is much 
 less irritating. It may be used in the same strength and 
 for the same purposes as the former drug. 
 
 Aluminum Aceticum. 
 
 This substance is prepared by adding sugar of lead, 25 
 parts, to a solution of 5 parts of alum to 500 parts of 
 distilled water. It has decided germicidal qualities and 
 
KREOLIN OR CREOLIN. 129 
 
 is employed for irrigation, or on moist dressings when 
 carbolic or bichloride solutions cannot be used. 
 
 Peroxide of Hydrogen. 
 
 This drug is employed in what is known as a 1 5- volum 
 solution, which may be diluted from 10 per cent, upward 
 or used in full strength. It is employed in the steriliza- 
 tion of sinuses or suppurating cavities, such, for instance, 
 as often result from diseases of or operations upon bone. 
 It seems to have a direct action upon pus-generation by 
 destroying the micro-organisms of pus. It is injected 
 into sinuses and cavities by means of a syringe, or may 
 be applied to open wounds in the form of a spray ; its 
 activity is shown by the escape of bubbles of air, and it 
 should be used as long as these continue to escape. 
 
 Pyrozone possesses the same qualities as the peroxide of 
 hydrogen, apparently to a somewhat higher degree, and 
 is used for the same purposes. 
 
 Kreolin or Creolin. 
 
 This substance is obtained from English coal by dry 
 distillation, and has been found to possess powerful germi- 
 cidal properties ; it is non-irritating and practically non- 
 toxic. It is insoluble in water, but forms an emulsion 
 with it which possesses marked antiseptic properties. It 
 may be employed for the same purposes as carbolic acid, 
 and has the advantage over the latter drug that it is not 
 irritating to the skin, and is almost devoid of toxic 
 properties. 
 
 It is used in an emulsion, in strength from two to five 
 per cent., and is employed in the irrigation of large wounds 
 or cavities of the body, and has been most favorably 
 recommended in gynecological practice. As a bath for 
 instruments, to render them sterile during operations, it is 
 useful, but the opacity of the emulsion makes it difficult 
 to find the instruments and interferes with its efficiency. 
 
130 MINOR SURGERY. 
 
 Boric Acid. 
 
 This drug has not very marked antiseptic qualities, but 
 is unirritating even in saturated solutions. It is frequently 
 employed in a 5 to 30 per cent, solution to cleanse and 
 disinfect mucous surfaces and large cavities. It is often 
 employed to wash out the bladder before the operation for 
 the removal of calculi or growths from that organ. 
 
 In the dressing of superficial wounds, or in wounds in 
 which the bichloride or carbolic acid dressings produce 
 irritation, an ointment of boric acid, made by taking boric 
 acid 1 part, and vaseline 5 parts, will be found very 
 satisfactory. 
 
 BORO-SALICYLIC LOTION. 
 
 This lotion is prepared by adding 2 parts of salicylic 
 acid and 12 parts of boric acid to 1000 parts of hot water. 
 This forms a very bland solution, which can be used where 
 there is danger in using bichloride or carbolic solutions — 
 as, for instance, in the bladder or peritoneal cavity. 
 
 Permanganate of Potassium. 
 
 This drug, owing to its rapid absorption of oxygeu, 
 acts as an antiseptic, and is often employed for the disin- 
 fection of foul wounds and ulcers. It is also employed 
 in solution for washing the operator's hands and for the 
 washing of sponges. It is practically non-irritating, and 
 may be used in quite concentrated solutions, but is usually 
 employed in the following solution : Permanganate of 
 potash 5j ? water f§j. One fluid drachm of this solution 
 to a pint of water makes a 1 : 1000 solution. 
 
 Pyoktanin. 
 
 Methyl-violet, known in commerce under the name of 
 pyoktanin, has been recommended as a drug possessing 
 marked antiseptic powers. It is said to prevent suppura- 
 
DOUBLE CYANIDE OF MERCURY AND ZINC. 131 
 
 tion by destroying the organisms which are active in its 
 production, and which have an affinity for and are 
 killed by aniline colors. It has been claimed that it 
 sterilizes the pus of suppurating wounds and ulcers, and 
 it has been recommended as an injection in the treatment 
 of large suppurating cavities for this purpose, as it is 
 practically non-poisonous. 
 
 It is employed in a solution of a strength of 1 : 1000 or 
 1 : 2000, and for the sterilization of surgical instruments 
 a 1 : 10,000 solution may be employed. When employed 
 as a means of irrigating wounds, it should be used until 
 the tissues are of a deep-blue color. Eecent investigations 
 have shown that it is, as a germicide, much less reliable 
 than bichloride of mercury. 
 
 Aeistol. 
 
 Aristol, which is a compound of iodine and thymol, pos- 
 sesses germicidal properties, and has been introduced as a 
 substitute for iodoform. It has the advantage over iodo- 
 form of not being poisonous and is also without disagree- 
 able odor. It may be employed for the same purposes as 
 iodoform, and it seems to be particularly useful as a dress- 
 ing to chronic and specific ulcers. 
 
 Iodol. 
 
 This drug possesses antiseptic properties and is employed 
 for much the same purposes as iodoform and aristol, and 
 has much less odor than the former; it is soluble in 
 alcohol, ether, and oil, and may be employed in solution 
 or used as a dry powder. 
 
 It is used for the same purposes as iodoform, and is 
 much employed as a local application in inflammatory and 
 ulcerated conditions of the mucous membrane of the nose 
 and throat. 
 
 Double Cyanide of Mercury and Zinc. 
 
 Cyanide of potassium, cyanide of mercury, and sulphate 
 of zinc are mixed together in solution, in quantities pro- 
 
132 MINOR SURGERY. 
 
 portioned to the atomic weights of 2KCy, HgCy 2 and 
 ZnS0 4 + 7H 2 ; the cyanide of potassium and cyanide of 
 mercury being dissolved together in one and a half ounces 
 of water for every 100 grains of potassium cyanide, are 
 added to the sulphate of zinc dissolved in three times that 
 amount of water. The precipitate is collected and washed 
 in two successive portions of water equal in quantity to 
 that used for the solutions, that is, six ounces of water for 
 every 100 grains of the potassium cyanide, to free the 
 precipitate from the irritating salts associated with it in 
 its formation. The precipitate being well washed, is next 
 mixed with distilled water containing one part of hema- 
 toxylin for every 100 parts of the cyanide salt ; this, when 
 it precipitates the cyanide salt, changes its color to a pale 
 bluish tint. 
 
 Ammonia is next added in such a proportion to the 
 mixture that one fluidrachm of the ammoniacal liquid 
 shall correspond with one grain of hematoxylin, and the 
 ammoniacal mixture is allowed to stand for three or four 
 hours, when it is filtered and the dyed salt is drained and 
 dried at a moderate heat, is next levigated, and may then 
 be kept for any length of time until used. When employed 
 for charging gauze it is mixed with a 1 : 4000 bichloride 
 solution in the proportion of four pints of the solution to 
 100 grains of the salt. 
 
 Preparation of Materials Used in Aseptic Surgery 
 and Dressings. 
 
 Sponges. 
 
 Sponges cannot be sterilized by boiling, which destroys 
 them, so they have to be prepared by washing and by 
 treatment with germicidal solutions ; they are prepared as 
 follows : 
 
 Sponges, while dry, should be beaten to free them from 
 calcareous matter, then placed in a 1 5 per cent solution of 
 hydrochloric acid for thirty minutes to dissolve any lime 
 
GAUZE PLEDGETS OR PADS. 133 
 
 which may remain in them; they should then be removed 
 from this solution and thoroughly washed. They should 
 next be well washed with green or castile soap and warm 
 water for a few minutes, and then thoroughly rinsed and 
 placed in a 1 : 1000 bichloride solution or in a 5 per cent, 
 carbolic solution in closely covered jars until required for 
 use. 
 
 Or, after beating the sponges to remove any sandy mat- 
 ter, they may be placed for twenty-four hours in a solution 
 of hydrochloric acid — hydrochloric acid §iv, water four 
 pints — then removed and washed until free from acid, 
 then steeped for half an hour in a solution of permanganate 
 of potassium, 180 grains to six pints of water. Next wash 
 them and place them in the following solution : hypo- 
 sulphite of sodium, §x ; hydrochloric acid, f§v ; water, 
 fSlxviij ; and allow them to remain in this solution for 
 four hours ; remove them from this and place them in 
 running water for six hours ; they should then be placed 
 in jars and covered either by a 5 per cent, carbolic acid 
 solution or a 1 : 1000 bichloride solution. The carbolic 
 acid solution is better for keeping the sponges than the 
 sublimate solution, as it does not decompose. 
 
 They may be prepared also by beating and washing 
 them, and then soaking them for twelve hours in a solu- 
 tion of chlorinated soda — chlorinated soda 1 part, water 5 
 parts. They are then removed, well rinsed, and placed 
 in a 5 per cent, carbolic solution, or they may be placed 
 in a moderately warm oven until thoroughly dry, and then 
 placed in air-tight jars, if it is desired to keep them dry. 
 
 It is better to use a cheaper grade of sponges, and to use 
 them only once ; but if the same sponges are to be used 
 again, they should be well washed in a solution of carbonate 
 of soda, 1 ounce to the quart, and then placed in a 1 : 1000 
 bichloride solution. 
 
 Gauze Pledgets or Pads. 
 
 Pads or pledgets of sterilized or sublimated gauze may 
 be used in the place of sponges during operations, and in 
 
 7 
 
134 MINOR SURGERY. 
 
 preparing the gauze-pads, a piece of gauze composed of 
 from sixteen to twenty layers is cut into pads of the desired 
 size, and the layers in each pad are quilted together by a 
 few stitches, and the edges should be loosely whipped with 
 a thread to prevent the edges from fraying. The gauze- 
 pledgets are prepared by cutting a piece of gauze composed 
 of from twelve to sixteen layers in pieces six inches square, 
 the four angles of these pieces are then brought together 
 and tied by a thread or are secured together by a few 
 stitches. 
 
 The pads or pledgets are usually employed in a moist 
 condition, and before being used should be sterilized by 
 being placed in a 1 : 2000 bichloride solution or by boiling, 
 and any excess of moisture should be squeezed from them 
 before being brought in contact with the wound. 
 
 Silk. 
 
 Silk for sutures or ligatures, either the plaited silk or 
 the Chinese twisted silk, should be sterilized by boiling 
 for thirty minutes in a 5 per cent, solution of carbolic 
 acid or water, then placed in stoppered bottles and covered 
 with a 5 per cent, solution of carbolic acid or with abso- 
 lute alcohol. 
 
 SlLKWORM-GUT. 
 
 Silkworm-gut is an excellent material for sutures, and 
 is much easier to thread than the silk or catgut. A black 
 iron-dyed silkworm-gut has recently been introduced, the 
 use of which facilitates the finding of the sutures for re- 
 moval. It may be kept dry in glass jars, or preserved in 
 alcohol, and should be placed in a 5 per cent, carbolic 
 solution for a few minutes before being used, as this 
 renders it more supple. 
 
 Catgut Ligatures or Sutures. 
 
 In preparing catgut for ligatures or sutures, the ordinary 
 catgut of the shops should be washed with castile soap and 
 
CATGUl LIGATURES OR SUTURES. 135 
 
 water, and then should be placed in ether and allowed to 
 remain for four or five hours, and upon being removed 
 should be placed in 95 per cent, alcohol in a tightly stop- 
 pered bottle. 
 
 Before being used it should be soaked for a few minutes 
 in a 1 : 20 carbolic solution. 
 
 Von Bergmanns Method of Sterilizing Catgut. 
 
 First sterilize the vessel by boiling water or dry heat. 
 The catgut should then be loosely wound upon glass rods 
 or spools and placed in the sterilized vessel, covered with 
 ether, and allowed to remain for twenty-four hours. At 
 the end of this time the ether should be poured off and 
 the gut should be placed in the following solution : 
 
 Bichloride of mercury ....... 10 parts. 
 
 Alcohol (95 per cent.)* 800 «' 
 
 Distilled water . 200 " 
 
 Remove in twenty-four hours and place in a similar so- 
 lution for twenty-four hours longer, then remove and place 
 in alcohol if stiff catgut is required. If soft catgut is 
 desired, add 20 per cent, of glycerin to the alcohol in 
 which it is kept. 
 
 Catgut Boiled in Alcohol. 
 
 This is accomplished by placing the catgut in a strong 
 glass bottle containing alcohol, which is corked, placed 
 in hot water and boiled for fifteen minutes. The steriliza- 
 tion of the catgut is usually complete after this process. 
 
 Juniper Catgut. 
 
 Catgut, varying in size from No. 0, which is very fine, 
 to No. 4, which is quite thick, is placed in oil of juniper- 
 berries for one week, and is then transferred to absolute 
 alcohol, in which it should be kept until required for use. 
 
 No. 1 catgut is the size usually employed for ligatures 
 and sutures. 
 
136 MINOR SURGERY. 
 
 Alcohol is the best material in which to preserve the 
 catgut, as it keeps it firm and does not interfere with its 
 flexibility, while both carbolic acid and bichloride solu- 
 tions render it brittle and weak. 
 
 Chromic Acid Catgut. 
 
 The catgut is first washed in alcohol and placed in dne 
 quart of a 5 per cent, solution of carbolic acid, containing 
 30 grains of bichromate of potassium, and is allowed to 
 remain for forty-eight hours. This immersion should be 
 longer when large-sized varieties of catgut are used ; but 
 for the sizes of catgut which are ordinarily used, this length 
 of immersion will prepare the gut to resist the action of 
 the living tissues for a week or more. Catgut thus pre- 
 pared may be dried and placed in closely stoppered jars, 
 or may be kept in alcohol. 
 
 Catgut may also be prepared by soaking it in alcohol 
 for a short time, and then placing it in the following 
 solution for forty-eight hours : Chromic acid, 1 grain ; 
 carbolic acid, 200 grains ; alcohol, 2 drachms ; water, 2J 
 ounces. It is then removed and placed in glass jars for 
 use. 
 
 Before being used it should be soaked for thirty minutes 
 in a 5 per cent, carbolic acid solution, or in a 1 : 1000 
 bichloride solution. 
 
 The chromic acid catgut is by far the best variety ot 
 gut to use for sutures and for the ligation of the larger 
 vessels in their continuity. 
 
 Drainage-tubes. 
 
 The drainage-tubes usually employed are prepared from 
 rubber-tubing of different sizes perforated at short in- 
 tervals ; the black rubber tubes are softer and more pliable 
 than the red or white rubber tubes, and should be pre- 
 ferred. (Fig. 99.) Drainage-tubes are also made of glass, 
 straight or curved (Fig. 100), which are almost exclusively 
 used in abdominal surgery, and also of decalcified bone. 
 
HORSEHAIR AND CATGUT FOR DRAINAGE. 137 
 
 Drainage-tubes should be kept 111 a 5 per cent, solution of 
 carbolic acid, or, if kept dry, they should be well washed, 
 
 Fig. 99. 
 
 Rubber drainage-tube. 
 
 and may be sterilized by dipping them in boiling water 
 for a few minutes, or should be placed in a carbolic or 
 bichloride solution for thirty minutes before being used. 
 
 Fig. 100. 
 
 Glass drainage-tube. 
 
 Horsehair and Catgut for Drainage. 
 
 Cutgut as ordinarily prepared for ligatures may be used 
 to secure drainage in small and superficial wounds ; a 
 
138 MINOR SURGERY. 
 
 number of strands of catgut are placed in the bottom of 
 the wound, and the end or ends are allowed to project 
 from one or both extremities of the wound. 
 
 Horsehair may be employed for the same purpose, a 
 number of strands of the hair being placed in the wound 
 in the same manner. Before being used it should be well 
 washed with soap and water and then soaked in a 5 per 
 cent, carbolic solution or 1 : 1000 bichloride solution for 
 thirty minutes. 
 
 Protective. 
 
 Protective is employed to prevent the wound from being 
 irritated by the antiseptic substances with which the gauze 
 is impregnated or by its irregular surface. 
 
 Various materials are employed as protectives, the 
 principal requirement being that it is some tissue which 
 can be readily rendered aseptic, and does not absorb any 
 irritating materials from the dressings. 
 
 The protective first employed by Mr. Lister, which is 
 still generally used, is prepared by coating oiled silk with 
 copal varnish, and when this is dry a mixture of 1 part 
 of dextrine, 2 parts of powdered starch, and 16 parts of 
 a 1 : 20 carbolic acid solution is brushed over its surface. 
 Rubber-tissue may be employed very satisfactorily as a 
 substitute for this protective. 
 
 Before applying the protective to the wound, it is dipped 
 into a solution of bichloride of mercury or carbolic acid. 
 
 Mackintosh. 
 
 This consists of cotton-cloth, with a thin layer of India- 
 rubber spread on one side. It is employed in antiseptic 
 dressings as the layer placed outside of the gauze, and 
 should be applied with the rubber surface toward the 
 wound, to prevent the entrance of air and to allow the 
 serum from the wound to permeate the gauze and not 
 soak directly through the dressings. 
 
 The mackintosh cloth is not at the present time as much 
 employed as formerly, unless the moist method of dressing 
 is adopted. 
 
GA UZE-DRESSINGS. 139 
 
 Rubber-dam. 
 
 This is a thin, pure rubber-tissue, and as it has no cloth 
 surface like mackintosh, it is cleaned and sterilized with 
 greater facility. It is used in applying the moist method 
 of dressing to cover the gauze- dressings, and is attached 
 to the drainage-tube in abdominal wounds to shut off the 
 opening of the tube from the abdominal wound. Before 
 being used it should be washed with soap and water, 
 rinsed, and then placed in a bichloride or carbolic solu- 
 tion for a time sufficient to sterilize it. 
 
 Rubber-tissue. 
 
 This consists of a very thin sheet of India-rubber with 
 glazed surfaces, which can be obtained from the rubber- 
 manufacturers ; it is employed for the same purposes as 
 the mackintosh, is much less expensive, and, as previously 
 stated, may be used instead of protective for covering the 
 wound. 
 
 Parchment-paper. 
 
 This consists of a very tough paper which can be 
 soaked in a watery solution of corrosive sublimate or 
 carbolic acid without becoming so much softened as to 
 tear upon handling. It is prepared by the manufacturers 
 of surgical dressings, and is employed for the same pur- 
 poses as mackintosh. 
 
 Gauze-dressings. 
 
 The most convenient and cheapest material for wound- 
 dressing is a sheer material known in the trade as cheese- 
 or tobacco-cloth. By reason of having a very open mesh 
 it absorbs well either the materials with which it is pre- 
 pared or the discharges from the wound to which it is 
 applied as a dressing. It can be readily obtained any- 
 where, is inexpensive, and is soft and pliable, so that it is 
 a comfortable form of dressing to the patient. The gauze 
 
140 MINOR SURGERY. 
 
 is impregnated with different materials to render it anti- 
 septic, and its preparation is a matter of little difficulty. 
 
 Preparation of Gauze-dressing. 
 
 Bichloride of Mercury or Corrosive Sublimate 
 
 Gauze. 
 
 In preparing bichloride or corrosive sublimate gauze, 
 thirty yards of cheese-cloth are placed in a wash-kettle, 
 and covered with water, to which are added two pounds of 
 washing soda or a pint of lye, which should be boiled for 
 an hour; the soda or lye is added to remove any oily 
 matters which the cheese-cloth contains, and thus make 
 it more absorbent. The gauze is next removed from the 
 kettle, washed in clear water, and passed through a clothes- 
 wringer. It should then be immersed in a 1 : 1000 bi- 
 chloride of mercury solution for twenty-four hours. It 
 is then dried and cut into pieces several yards in length, 
 and packed in closely covered glass jars or tin boxes to 
 be kept until used. Or it may be preserved as moist 
 gauze by packing it in air-tight jars. If gauze has been 
 prepared for some time, it is well to soak it for a short 
 time in a 1 : 1000 bichloride of mercury solution before 
 using it. 
 
 In using the sublimate gauze on delicate skins there will 
 sometimes result a dermatitis which is known as mercurial 
 eczema ; this is particularly apt to occur if the gauze is 
 moistened or covered with rubber-tissue or mackintosh. 
 If this condition develops, the parts covered by the gauze 
 should be rubbed over with boric acid ointment or vase- 
 line before it is reapplied, or another variety of dressing 
 may have to be substituted, such as the iodoform or car- 
 bolized gauze. 
 
 IODOFORM-GAUZE. 
 
 lodoform-gauze may be prepared by sprinkling cheese- 
 cloth, which has been boiled in soda solution, with pow- 
 
CARBOLIZED GAUZE. 141 
 
 dered iodoform and rubbing it well into its meshes ; it 
 should then be dried and packed in glass jars for use. 
 
 It may also be prepared by rubbing an emulsion of 
 iodoform, made by adding 3 drachms of iodoform to 6 
 ounces of castile soap-suds, into 18 ounces of moist gauze; 
 this should be dried and packed in glass jars for use. 
 
 Double Cyanide of Mercury ajstd Zinc Gauze. 
 
 The preparation of this gauze is much more difficult 
 than that of the other varieties of gauze, requiring the 
 following : 
 
 Potass, cyanide 130 grains. 
 
 Mercuric cyanide 251.7 " 
 
 Zinc sulphate 268.9 M 
 
 Hematoxylin 1.3 " 
 
 Sal ammonia (gas, NH 3 , 1 per cent.) .... 6 minims. 
 Gauze (previously boiled and dried) .... 10 ounces. 
 
 Bichloride of mercury solution 7.6 pints. 
 
 Distilled water q. s. 
 
 In charging gauze with this substance, 100 grains of the 
 salt are dissolved in 4 pints of a 1 : 4000 bichloride solu- 
 tion, which will give from 2 to 3 per cent, of the cyanide 
 to the dry gauze. The gauze should be freshly prepared 
 and used moist, or, if allowed to become dry, it should be 
 moistened again with a weak bichloride solution before 
 being used. The advantages claimed for this gauze are 
 that it is not irritating to the skin, and as the antiseptic is 
 not soluble it is not washed out by the discharges from 
 the wound. Prof. J. William White, who has used it 
 extensively in his practice, considers that it possesses de- 
 cided advantages over the bichloride gauze. 
 
 Carbolized Gauze. 
 
 The carbolized gauze which is used in the University 
 Hospital is prepared in the following manner : Cheese- 
 cloth, which has been previously boiled and dried, is 
 soaked for a few hours in the following solution : 
 
 Resin 1 pound. 
 
 Alcohol 5 pints. 
 
 Castor oil .24 ounces. 
 
 Carbolic acid 12 " 
 
 7* 
 
142 MINOR SURGERY. 
 
 The gauze is next removed from this solution and passed 
 through a clothes-wringer, and is then cut in pieces four 
 to six yards in length, which are folded and packed in 
 air-tight tin boxes for use. 
 
 Pyoktanin, Salicylated, Borated Gauze. 
 
 Many other varieties of gauze, such as pyoktanin-gauze, 
 salicylated gauze, and borated gauze, etc., are prepared, but 
 as they are expensive and are not so satisfactory as the one 
 which has just been mentioned, they are not much em- 
 ployed. 
 
 Sawdust-dressing. 
 
 Sawdust is impregnated with a 1 : 1000 bichloride of 
 mercury solution for twenty-four hours, and then spread 
 out to dry ; after it has become sufficiently dry it is en- 
 closed in bags made of cheese-cloth of various sizes. This 
 will be found to be a satisfactory substitute for the ordi- 
 nary gauze. In using this dressing the wound should be 
 covered with a piece of protective or a few layers of gauze, 
 and the bags are then packed over this and held in place 
 by a bandage. 
 
 Moss-dressing. 
 
 Different species of sphagnum or moss, on account of 
 their cheapness, elasticity, and great absorbing power, 
 have been found a very satisfactory material with which 
 to make dressing-bags. 
 
 Clean moss is soaked for twenty-four hours in a 1 : 1000 
 bichloride of mercury solution and then dried ; cheese-cloth 
 bags are filled with this material and may be used dry or 
 may be moistened with 1 : 3000 bichloride solution before 
 being applied in the dressing of wounds. They are much 
 employed in the hospitals of Germany, and have largely 
 superseded the gauze-dressings. 
 
ANTISEPTIC BAN DA GES. 1 43 
 
 Improvised Aseptic or Antiseptic Dressings. 
 
 In cases of emergency, when the ordinary gauze-dress- 
 ings cannot be obtained, it is well to remember that old 
 muslin or linen, or mosquito-netting, which can usually 
 be obtained, will serve for a temporary dressing if prop- 
 erly sterilized, until a more elaborate dressing can be 
 applied. Old sheets, either of muslin or linen, should be 
 torn into pieces half a yard square and thrown into boiling 
 water; after remaining for fifteen minutes in this they 
 should be removed, and can be used as moist sterilized 
 dressings, or soaked for a few minutes in a 1 : 1000 or 
 1 : 2000 bichloride solution, or a 5 percent, carbolic solu- 
 tion, and applied to the wound, a number of layers of 
 this material being applied and held in position by a ban- 
 dage. This dressing will keep the wound aseptic until a 
 more elaborate dressing is obtained. 
 
 Antiseptic Bandages. 
 
 These bandages are prepared by tearing or cutting 
 bichloride or carbolized gauze into strips two or three 
 inches in width and five yards in length, and forming the 
 strips into rollers and packing them in air-tight vessels. 
 
 The bandages may also be prepared from boiled dry 
 gauze in the same manner, and are kept in air-tight boxes 
 or jars until required for use, when they are soaked for a 
 few minutes in a 1 : 1000 bichloride or 5 per cent, car- 
 bolic solution. 
 
 They may also be prepared from crinoline, the same 
 material which is used for the plaster-of-Paris bandage ; as 
 this material is quite stiff, the bandage should be soaked 
 in a bichloride or carbolic solution before being applied, 
 and as the material contains a certain amount of starchy 
 matter, it becomes firm as it dries, and makes a very secure 
 dressing. For this reason it is often applied over the 
 antiseptic bandage. 
 
144 
 
 MINOR SURGERY, 
 
 BlCHLOKIDE-COTTON. 
 
 This material, which is an important part of most anti- 
 septic dressings, is prepared by soaking absorbent cotton 
 in a 1 : 1000 bichloride of mercury solution for twenty- 
 four hours, and then allowing it to dry. When dry, it is 
 packed in jars or air-tight boxes. Its great absorbing 
 power and its elasticity make it, when properly prepared, 
 a most valuable dressing ; it is generally employed to cover 
 the gauze-dressing, a number of layers being applied. 
 
 Fig. 101 . 
 
 Sterilizing-oven. 
 
 Borated, carbolized, and salicylated cotton, prepared in 
 the same manner, are also frequently employed for a 
 similar purpose. 
 
METHOD B Y SIMPLE BR YING. 1 45 
 
 Moist Sterilized Dressings. 
 
 These may be prepared by steaming the gauze-dressings 
 in a steam sterilizer, or by boiling them in covered vessels. 
 
 Dry Sterilized Dressings. 
 
 These dressings are prepared by sterilizing ordinary 
 gauze with steam. Gauze cut into proper lengths is placed 
 in wire cases and exposed to superheated steam in an oven 
 for a few hours, and is then dried in another oven, removed, 
 and placed in air-tight jars or boxes. The apparatus re- 
 quired for the perfect sterilization of dressings is expensive, 
 and is not likely to be employed by practitioners, but is 
 used in hospitals where a large number of dressings are 
 constantly required. A convenient form of sterilizing 
 oven is shown in Fig. 101. Unless the sterilization is 
 perfect, these dressings should not be employed ; the same 
 method is employed in the sterilization of instruments. 
 
 Methods and Dressings Employed in the Treatment of 
 Wounds to Secure Asepsis. 
 
 To prevent infection of wounds the various chemical 
 sterilizers and dressings are employed in different ways, 
 and the principal types of dressings are as follows : 
 
 Method by Simple Drying. 
 
 This method is employed in small and not very deep 
 wounds. The edges having beeu brought together by 
 sutures the surface of the wound is dusted with powdered 
 iodoform, the serum and blood forming with this, as it 
 dries, a scab, which protects the wound from infection from 
 without, and repair takes place promptly under this scab. 
 Iodoform -collodion may be employed instead of powdered 
 iodoform in this method of dressing. 
 
146 MINOR SURGERY. 
 
 Method by Drying and Chemical Sterilization. 
 
 The object of this method of dressing is to provide a 
 means of sterilizing the blood or serum which escapes from 
 the wound, and at the same time to insure the sterilization 
 of the air coming in contact with the discharges of the 
 wound. 
 
 It is employed in large or deep wounds, where there is 
 always more or less escape of blood or serum, and is ac- 
 complished by applying a number of layers of sublimate 
 or iodoform-gauze and sublimated cotton over the wound. 
 Evaporation not being interfered with, the whole dressing 
 becomes hardened, and the wound is surrounded by a large 
 antiseptic crust made up of the dressing and serum or 
 blood. 
 
 This method of dressing is the one most generally em- 
 ployed at the present time. 
 
 Moist Dressings. 
 
 In this method of dressing, the wound is covered by 
 layers of moist gauze, which are kept moist and evapora- 
 tion prevented by applying over them some impervious 
 material, such as mackintosh or rubber- tissue. 
 
 Modified Moist Dressing. 
 
 In using this method, the wound itself is covered by a 
 piece of protective or rubber-tissue ; over this is placed 
 the sublimated or iodoform-gauze dressing and some layers 
 of bichloride cotton. In this way the wound itself is 
 kept in a moist condition favoring particularly the organ- 
 ization of blood- clots; the external dressings become 
 dry as the discharges which have escaped into them 
 evaporate, forming an antiseptic crust or covering over 
 the wound. 
 
DISINFECTION OF THE HANDS. 147 
 
 Preparation for Aseptic Operation. 
 
 Disinfection of the Hands. 
 
 The hands and forearms of the surgeon and of his assist- 
 ants should be well washed in hot water with soap for a 
 few minutes, and a nail-brush should be used to cleanse 
 the region of the finger-nails ; rings with irregular surfaces 
 which might retain filth should be removed. After the 
 hands and forearms have been thoroughly cleansed, they 
 should be immersed in a 1 : 1000 bichloride solution for a 
 short time. 
 
 Or the hands and forearms, having been washed with 
 soap and water, are dipped in absolute alcohol for one 
 minute, and immersed in a warm 1 : 1000 bichloride solu- 
 tion and scrubbed with a nail-brush for two or three 
 minutes. 
 
 A very satisfactory method of disinfecting the hands 
 and forearms consists in first scrubbing them with soap 
 and water, then washing them in a solution of perman- 
 ganate of potassium prepared by adding an excess of the 
 salt to distilled water until they are of a dark-brown color. 
 They should next be washed in a saturated solution of 
 oxalic acid until completely decolorized, and the oxalic 
 acid should finally be removed by washing them in warm 
 sterilized water. 
 
 The same precautions should be taken with the hands 
 and forearms of the nurses w T ho handle the instruments and 
 dressings. If in any manner the hands of the surgeon or 
 of his assistants come in contact, during the operation, 
 with any objects which have not been disinfected, such as 
 the clothing of the patient, the operating-table, etc., it is a 
 matter of the first importance that they should be thor- 
 oughly rewashed and disinfected before being again brought 
 in contact with the wound. 
 
148 MINOR SURGERY. 
 
 Preparation of Surgeon and Assistants. 
 
 It is desirable that the surgeon and his assistants should 
 wear some form of apron or operating-gown, both for the 
 protection of the patient and the preservation of their own 
 clothing. The operating-gown should be made of muslin 
 or linen ; a variety of linen known as butcher's linen is 
 very serviceable for this purpose ; it should fit closely 
 about the neck and should extend to the ankles, and 
 should have sleeves extending at least to the elbows ; it is 
 well, for additional protection, to wear under this a rubber 
 apron extending from the neck to the feet. The head 
 may also be covered with a closely fitting linen skull-cap. 
 An improvised apron may be prepared from a clean sheet 
 folded so as to be one and a half yards in width and about 
 six feet in length, by turning in about ten inches of one 
 end of the sheet over the upper part of the chest, and 
 placing a strip of bandage in this fold and securing it 
 around the neck, and by tying a strip of bandage over the 
 sheet at the waist. 
 
 The nurses assisting at the operation should also wear 
 aprons and gowns made of wash-goods. 
 
 Sterilizing of Instruments. 
 
 The instruments should be carefully scrubbed with warm 
 w r ater and soap, care being taken to see that all joints and 
 roughened surfaces are freed from any dry matter which 
 may adhere to them ; after being thoroughly cleansed in 
 this manner, they should be placed in a metal or porcelain 
 tray and covered by a 5 per cent, carbolic solution for 
 fifteen minutes before being used. 
 
 The instruments which are now constructed with metal 
 handles may be sterilized by placing them in boiling water, 
 or by boiling them for ten minutes in a 1 per cent, solu- 
 tion of carbonate of soda ; where instruments are employed 
 which have wooden handles this method of sterilization 
 
PREPARATION OF PATIENT FOR OPERATION. J 49 
 
 cannot be employed, and here it will be found necessary to 
 resort to the first method of sterilization. 
 
 Instruments which fall upon the floor or come in contact 
 with the clothing of the surgeon or the patient during the 
 operation, should be washed and placed in the carbolic 
 solution, or should be boiled before being again brought in 
 contact with the wound. 
 
 Preparation of the Patient for Operation. 
 
 The patient having been prepared for the operation by 
 whatever constitutional treatment the surgeon considers 
 necessary, the region of the proposed wound is first rubbed 
 over with cotton saturated with spirits of turpentine, and 
 next is thoroughly washed with soap and water ; if hairs 
 are present in the region, they should be shaved off; after 
 a careful washing with soap and water, the skin is carefully 
 washed with a 1 : 1000 bichloride or 5 per cent, carbolic 
 solution, and is then covered with a towel wrung out in a 
 1 : 2000 bichloride solution until the surgeon is ready to 
 begin the operation. 
 
 This cleansing of the region of the proposed wound in 
 hospital practice is generally made a few hours before the 
 operation, but in private practice it has often to be done 
 just before the operation is undertaken ; if carefully done, 
 however, the results will be in no wise less satisfactory. In 
 operations upon the face, neck, or chest it is well to apply a 
 handkerchief bandage of gauze to cover the hairy scalp. 
 In private practice the operation may have to be per- 
 formed while the patient is in his bed, or, if an ordinary 
 kitchen-table is at hand, it will be found more convenient 
 to place him upon this. The table should be prepared by 
 placing upon it a folded quilt or blanket, and over this a 
 sheet of rubber-cloth, upon which should be laid a clean, 
 folded linen or muslin sheet. The surgeon should carry 
 with him a sheet of rubber-cloth, three by four feet, which 
 he will find most useful in preparing the table for the 
 operation, or in protecting the bed of the patient if he is 
 
150 
 
 MINOR SURGERY. 
 
 not placed upon the table ; a rubber cloth of this size takes 
 up little space if carefully folded, and can be easily packed 
 in the instrument -bag. 
 
 Details of an Operation in which the Anti- 
 septic Method is Employed. 
 
 The patient being anaesthetized and placed upon the 
 table, the clothing is so arranged as to expose freely the 
 part to be operated upon ; the clothing or the skin sur- 
 rounding this region is next covered with towels wet with 
 a 1 : 1000 bichloride solution. If any considerable surface 
 of the patient's body is covered by these towels, to avoid 
 chilling the surface and adding to the shock which natur- 
 
 Fig.102. 
 
 Irrigating-apparatus. (Esmarch.) 
 
 ally follows the operation, they should be wrung out in a 
 hot bichloride or carbolic solution, and should be replaced 
 as they become cold by hot towels prepared in the same 
 manner. The patient being ready for operation, the sur- 
 geon should assign the assistants and nurses their duties, 
 
EMPLOYMENT OF ANTISEPTIC METHOD, 151 
 
 and having again immersed their hands and forearms in 
 the bichloride solution the operation is begun. 
 
 During the operation the wound is irrigated frequently 
 with a 1 : 2000 or 1 : 3000 bichloride solution, w T hich may 
 be allowed to run over the wound, or be applied by means 
 of a syringe or irrigating-apparatus (Fig. 93), and the 
 hands of the surgeon and assistants should also be washed 
 in this solution at not too long intervals. In prolonged 
 operations, or in those in which a large wound is made, I 
 think it is especially important that the irrigating solutions 
 should be used as warm as can be comfortably borne by 
 the hands of the surgeon; warm solutions, it has been 
 shown by recent investigations, possess a greater germicidal 
 power than those of the same strength when used cold, and 
 they also possess the advantage of preventing the chilling of 
 the patient, and thus diminish the shock of the operation. 
 
 Hemorrhage during the operation is controlled by 
 the use of haemostatic forceps, which are applied to the 
 bleeding vessels, or the vessels may be ligatured as they are 
 divided. After the operation has been completed, and all 
 hemorrhage has been controlled, the wound is thoroughly 
 irrigated with a 1 : 2000 or 1 : 3000 bichloride solution. 
 
 The next step is to provide for drainage ; this may be 
 disregarded in small or superficial wounds, but in a wound 
 of any considerable size or depth it is safer to provide free 
 drainage. This is accomplished by the use of perforated 
 rubber drainage-tubes, or a number of strands of catgut or 
 horsehair, or by decalcified bone or glass drainage-tubes. 
 
 The rubber tube in deep wounds will be found most 
 comfortable to the patient and satisfactory as regards 
 drainage ; it may be laid in the wound, the ends being 
 allowed to extend from the extremities of the wound, or it 
 may be so introduced that one end of the tube rests in the 
 deepest part of the wound and the other extremity is 
 brought out of the wound at its most dependent portion ; 
 in large or irregularly shaped wounds a number of tubes 
 may be required to secure free drainage. The ends of the 
 drainage-tubes are transfixed with safety-pins which have 
 been sterilized and allowed to remain in a 5 per cent. 
 
152 MINOR SURGERY. 
 
 carbolic solution until required, and the ends of the tube 
 should next be cut off close to the pins so as to be as nearly 
 as possible flush with the skin. 
 
 The wound is next closed by the introduction of sutures, 
 which may be of silkworm-gut, chromicized catgut, silk, 
 or silver wire ; the needles and sutures should be soaked 
 in a 5 per cent, carbolic solution for 30 minutes before 
 being used. The wound being closed, a final irrigation of 
 its deepest parts should be made, by injecting a stream of 
 bichloride solution, 1 : 2000 or 1 : 3000, into the end of 
 the drainage-tube ; if through-and-through drainage has 
 been employed, one end of the tube should be closed and 
 the solution should be injected into the wound through 
 the other end of the tube by means of a syringe or irri- 
 gating-tube, until the wound is slightly distended with the 
 solution, which allows the latter to find its way to all parts 
 of the cavity of the wound. The external surface of the 
 wound and the skin for some distance surrounding it 
 should next be washed with a 1 : 2000 bichloride solution, 
 and a piece of protective, a little longer and wider than 
 the wound, is next dipped in a bichloride or carbolic solu- 
 tion and placed over it. The use of this strip of protective 
 over the wound is only important if it is desired to keep the 
 wound moist, in order to obtain organization of the blood- 
 clot, otherwise it need not be employed. Over this is laid 
 the deep dressing, which consists of a pad of bichloride 
 gauze from eight to sixteen layers in thickness, and large 
 enough to overlap the wound two or three inches in all 
 directions. This should be dipped in a 1 : 2000 bichloride 
 solution, and wrung out as dry as possible before being 
 applied. The superficial gauze-dressing is next applied, 
 and consists of sixteen layers of gauze, which should be 
 large enough to extend from three to six inches beyond 
 the wound in all directions ; this gauze is applied dry. 
 Over the superficial gauze-dressing there is next applied 
 a number of layers of bichloride cotton, so arranged 
 as to extend a little beyond the margin of the superficial 
 gauze-dressing. These dressings are now secured in 
 position by the application of a gauze-bandage, which is 
 
EMPLOYMENT OF ASEPTIC METHOD. 153 
 
 prevented from slipping by the introduction of a few 
 safety-pins. 
 
 Iodoform, carbolized, or any other variety of medicated 
 gauze, may be used in the place of the bichloride gauze in 
 this method of dressing. The dressings should be volu- 
 minous ; it is a mistake to apply scanty dressings. 
 
 The dressing being completed, the patient is moved 
 from the operating-table to his bed, and care should be 
 exercised to see that the dressings do not become soiled 
 if the patient vomits upon coming up from the anes- 
 thetic. 
 
 In this method of dressing no mackintosh or rubber- 
 tissue is employed, outside of the superficial gauze-dress- 
 ing ; the discharges from the wound are disseminated 
 through the dressing and become dry by evaporation, and 
 the dressing forms an antiseptic scab which covers and 
 surrounds the wound. 
 
 Details of Operation in which the Aseptic 
 Method is Employed. 
 
 The patient having been prepared for operation and 
 placed upon the table, the clothing is arranged so as to expose 
 freely the part to be operated upon, which is washed with 
 sterilized water, and the surrounding parts are protected 
 by sterilized towels. The surgeon and assistants wash 
 their hands in sterilized water and the operation is begun ; 
 hemorrhage is controlled during the operation by haemo- 
 static forceps, and the wound is kept free from blood by 
 mopping it with sterilized sponges or pledgets of sterilized 
 gauze. When the operation is completed, the vessels are 
 tied and the haemostatic forceps are removed. The wound 
 is next dried with gauze-pledgets, or, if for any reason 
 the surgeon wishes to irrigate the wound, this may be 
 done with warm sterilized water or warm sterilized salt- 
 solution. The wound may next be closed by the intro- 
 duction of deep and superficial sutures without the intro- 
 duction of any material for drainage. If, however, the 
 
154 MINOR SURGERY. 
 
 wound be a deep one and the surgeon considers drainage 
 advisable, a sterilized rubber drainage-tube may be intro- 
 duced before the sutures are applied. The wound is next 
 covered by a number of layers of dry sterilized gauze 
 and by some layers of sterilized cotton, and the dressings 
 are held in place by a sterilized gauze-bandage. 
 
 Moist Method of Dressing. 
 
 If, for any reason, it is desired to adopt the moist 
 method of dressing, a piece of mackintosh or rubber- tissue 
 larger than the superficial gauze-dressing is placed over it, 
 and over this are placed a few layers of bichloride-cotton, 
 care being taken to see that the layers of cotton overlap 
 the mackintosh or rubber-tissue by a few inches; the 
 application of an antiseptic gauze-bandage then completes 
 the dressing. On the removal of this dressing the gauze 
 will be generally found to be soaked with the discharges 
 from the wound, and in a moist condition. The disad- 
 vantage of this variety of dressing is that there is apt to 
 be more irritation of the skin set up by the bichloride- 
 gauze when kept moist than when applied in the manner 
 of a dry dressing. 
 
 KE APPLICATION OF DRESSINGS. 
 
 The re-dressing of a wound which remains aseptic need 
 not be made for some days ; if the temperature remains 
 normal or a little above this point, and the patient exhibits 
 no unfavorable constitutional symptoms, and the dressing 
 is comfortable to the patient, it need not be disturbed for 
 a week or ten days; at the expiration of this time it is well 
 to examine the wound and to remove the drainage-tube if 
 a drainage-tube has been used, and to remove a portion or 
 all of the sutures if the superficial parts of the wound are 
 firmly healed. 
 
 In re-dressing an aseptic wound at the end of a week 
 or ten days, to prevent any possible infection, as much 
 
REAPPLICATION OF DRESSINGS. 155 
 
 care should be exercised as in the original dressing of the 
 wound. The patient's clothes should be removed so as 
 freely to expose the dressing, and a rubber cloth should be 
 placed under the patient so as to protect the bed, and the 
 clothing and skin in the region of the wound should be 
 protected by towels wrung out in a 1 : 1000 bichloride 
 solution. The surgeon should wash his hands and im- 
 merse them in a 1 : 1000 bichloride solution before re- 
 moving the dressings. The bandage retaining the dressing 
 should be divided with bandage-scissors and the gauze 
 should be removed layer by layer, and when the deep 
 dressing is removed care should be taken to see that the 
 drainage-tubes are not pulled upon if they are adherent to 
 the dressing ; the protective should next be removed, and 
 the surface of the wound should be irrigated with a 1 : 2000 
 bichloride solution; the drainage-tubes should next be in- 
 spected to see that they are free, and a stream of bichloride 
 solution may be passed through them by means of a 
 syringe. If the wound is found aseptic, the drainage-tube 
 may be removed, and the wound should next be irrigated 
 through its track by a stream of bichloride solution, or the 
 irrigation of the drainage-tubes or of the sinuses left by 
 their removal may be omitted. If the wound is healed, 
 the sutures may be removed at this dressing ; but if the 
 wound has been an extensive or deep one, it may be well 
 to remove only a portion of the sutures ; if animal sutures 
 have been employed, they need not be removed. The 
 surface of the wound is next washed with a 1 : 2000 
 bichloride solution and a piece of protective is placed over 
 the line of incision. The deep and superficial dressings 
 are applied as previously described and covered with layers 
 of bichloride-cotton, and the whole dressing is secured by 
 the application of an antiseptic bandage. If the wound 
 remains aseptic, the dressings need not be changed for a 
 week or ten days, and at this time the wound will usu- 
 ally be found healed, so that further dressings are not 
 required. 
 
 In the re-dressing of a wound in which the aseptic 
 method was employed, the use of germicidal solutions is 
 
156 MINOR SURGERY. 
 
 , omitted, and the wound is re-dressed with sterilized gauze 
 and cotton. 
 
 If, however, the wound is not running the typical 
 course of an aseptic wound, constitutional symptoms will 
 be developed, as evidenced by a rise in the temperature 
 and pulse-rate and other constitutional disturbances. In 
 this event the wound should be re-dressed as soon as pos- 
 sible, and if the cause of the disturbance can be found, it 
 should be removed ; for instance, hemorrhage may have 
 taken place into the wound, and the blood not being able 
 to escape through the drainage-tubes may have caused so 
 much distention of the wound that the vitality of the skin 
 covering the wound is threatened, or the sutures may be 
 found to be causing irritation, or suppuration may be 
 found to be present. 
 
 If, on exposure of the wound, it is found that it is dis- 
 tended with blood-clots, and blood is escaping from the 
 wound, the sutures should be removed, the clots should be 
 turned out, and the bleeding vessel or vessels should be 
 sought for and ligatured, and the wound, after a thorough 
 irrigation with 1 : 2000 bichloride solution, should be 
 drained and closed with sutures, and dressed as previously 
 described. 
 
 If, however, on exposure of the site of the operation, 
 and upon the removal of a portion or all of the sutures, 
 the wound is found distended with a blood-clot, and no 
 evidence of hemorrhage at the time exists, or of suppura- 
 tion in the wound, the clot may be allowed to remain in 
 place, and the wound should be re-dressed as in the original 
 dressing, trusting to the organization of the blood-clot if 
 it has remained aseptic. If the patient's condition im- 
 proves after the dressing, and the temperature and pulse- 
 rate become normal, it is an indication that the wound is 
 still aseptic, and it need not be re-dressed for some days. 
 
 If, on the other hand, examination of the wound shows 
 that the drainage is insufficient, or that the drainage-tubes 
 are occluded by blood-clots, these should be removed by 
 washing out the tubes with a 1 : 2000 bichloride solution 
 by means of a syringe, and introducing additional drain- 
 
DRESSING OF SEPTIC WOUNDS. 157 
 
 age-tubes, if it is deemed necessary ; the wound should 
 then be re-dressed. 
 
 When it is found on examination of the wound that 
 suppuration is present, the surgeon may adopt one of two 
 methods of treatment : he may thoroughly wash out the 
 wound through the drainage-tubes with a 1 : 2000 bichlo- 
 ride solution, and after thorough irrigation of the wound 
 re-dress it, and, if the patient's constitutional symptoms 
 improve, he may be assured that the wound has been ren- 
 dered aseptic, and is running an aseptic course. 
 
 If he does uot feel that this method of treatment is 
 sufficient, he may open the wound and wash it thoroughly 
 with a 1 : 2000 bichloride solution, and next apply to its 
 surface a 15- volume solution of the peroxide of hydrogen, 
 which may be diluted with water one-third or one-half, or 
 a 30-grain solution of chloride of zinc may be used ; and 
 after this application a final irrigation with the 1 : 2000 
 bichloride solution shall be made, and it should then be 
 drained, closed, and dressed, as previously described. 
 
 If the treatment instituted to render the wound aseptic 
 has been successful, the patient's constitutional condition 
 will improve, and it will heal as an aseptic wound. 
 
 Dressing of Septic Wounds. 
 
 It often happens that patients suffering from wounds 
 which have been improperly treated, or have had no treat- 
 ment, come under the care of the surgeon ; such wounds 
 are already infected, and to render them aseptic, if possi- 
 ble, should be the first duty of the surgeon. The most 
 important point in the treatment of infected wounds is to 
 provide free drainage, and some surgeons depend upon 
 this alone and do not attempt to destroy micro-organisms 
 which are in the wound by the use of mechanical or germi- 
 cidal agents. I think it wiser, however, to treat infected 
 wounds in the following manner : The skin surrounding 
 the wound should be carefully washed with spirits of tur- 
 pentine, and then with soap and water, and finally with a 
 1 : 2000 bichloride solution. The wound itself should be 
 
158 MINOR SURGERY. 
 
 next exposed as fully as possible, and any foreign bodies 
 which are found in it, or dirt, should be removed with 
 forceps and a stream of water ; it should next be thoroughly 
 irrigated with a 1 : 2000 bichloride solution, and then 
 should be drained, closed, and dressed as an operation 
 wound. 
 
 If suppuration is already present, after cleansing the 
 region surrounding the wound, it should be washed with 
 peroxide of hydrogen and then irrigated with a 1 : 2000 
 bichloride solution. If gangrenous tissues are present in 
 the wound, they should be removed w 7 ith the scissors and 
 curette, and, if it is found impossible to remove all infected 
 tissue in this manner, the affected parts should be touched 
 with a 30-grain solution of chloride of zinc applied by 
 means of a swab, and the wound should be finally irri- 
 gated with a 1 : 2000 bichloride solution. The wound 
 should then be wiped dry with gauze and dusted with 
 iodoform. 
 
 The introduction of drainage-tubes and sutures will 
 depend upon the character of the wound. Sutures cannot 
 often be used with advantage if much retraction of the 
 skin has occurred, and a drainage-tube is not required if 
 the wound is left open. The wound should next be loosely 
 packed with strips of iodoform gauze and covered with a 
 few layers of iodoform gauze, and the deep gauze dressing, 
 wrung out in a 1 : 2000 bichloride solution, is applied 
 over this, and the superficial gauze dressing and bichloride 
 cotton are next applied and secured by a bandage. 
 
 Infected wounds which are treated in this manner will 
 often be rendered aseptic, and in their subsequent course 
 will be perfectly satisfactory, both to the patient and to 
 the surgeon. 
 
 Materials Used in Surgical Dressings— Continued. 
 
 Lint. 
 
 This material is employed in surgical dressings, and is 
 of two varieties : the domestic lint, which consists of pieces 
 
OAKUM. 159 
 
 of old linen or muslin which have been thoroughly washed 
 or boiled and then dried, or the surgical lint which is 
 manufactured by machinery, and resembles Canton flannel 
 in appearance ; the latter is the best material, as it has a 
 greater absorbing capacity. 
 
 Lint is used as a material on which unctuous prepara- 
 tions are spread in the dressing of wounds, and is also 
 employed as a material for saturating with the various 
 solutions which are used in wet dressings, such as lead- 
 water and laudanum, or dilute alcohol ; the lint, after 
 being saturated with these solutions, is covered with rub- 
 ber tissue or oiled silk when applied, to prevent too rapid 
 evaporation of the solution. It is also one of the best 
 materials from which to construct compresses employed 
 in the treatment of fractures, to control hemorrhage, or to 
 make pressure for any purpose. 
 
 Paper-lint, made from old rags or wood pulp, has great 
 absorbing power for fluids, and may be used as a substi- 
 tute for surgical lint in the application of wet dressings to 
 surfaces when the skin is unbroken. 
 
 Oakum. 
 
 This material, made from old tarred rope, was formerly 
 much employed in the dressing of wounds before the intro- 
 duction of the antiseptic method of wound-treatment ; it 
 was supposed to possess some antiseptic properties due to 
 the tar with which it was impregnated. From its elas- 
 ticity it is found to be an excellent material for padding 
 splints or other surgical appliances. It is also employed 
 in the form of pads to place under patients to relieve por- 
 tions of the body from pressure, or to absorb discharges 
 which soak through the dressings. A mass of oakum 
 which has been well teased out and wrapped in a towel 
 forms an excellent pillow on which to support a stump. 
 The oakum seton is highly recommended by Dr. Sayre as 
 a means of making a direct application of ointments to 
 sinuses of bone ; the oakum is loosely twisted into a cord 
 and covered with any ointment desired and is passed 
 
160 MINOR SURGERY. 
 
 through the sinuses in the bone ; the position of the seton 
 is changed from time to time, fresh ointment being applied 
 before it is drawn through ; resin cerate is a favorite 
 application to these sinuses made in this manner. 
 
 Cotton. 
 
 Cotton is now employed in surgical dressings principally 
 as a material to pad splints or to relieve salient parts of 
 the skeleton from pressure in the application of splints or 
 bandages; for instance, in the application of the plaster- 
 of- Paris bandage, the bony prominences are generally 
 covered by small masses of cotton ; it possesses but little 
 absorbent power unless used in the form of absorbent cot- 
 ton, and is not much employed in surgical dressings except 
 for the purposes mentioned above. 
 
 Absorbent Cotton. 
 
 This material is prepared from ordinary cotton, which 
 is boiled with a strong alkali to remove the oily matter 
 which it contains. When so prepared it absorbs liquids 
 freely, and by reason of its great absorbing capacity it is 
 largely employed in surgical dressings. A small mass of 
 absorbent cotton wrapped upon the end of a probe or stick 
 is now generally employed to make applications to wounds, 
 and has taken the place of the sponge or brush which was 
 formerly employed for this purpose. On account of its 
 cheapness, after one application it can be thrown away 
 and a new piece can be used, and thus the danger of car- 
 rying infection from one wound to another by the appli- 
 cator is abolished. It is largely employed in gyneco- 
 logical practice for making applications to the female 
 genital organs. 
 
 It may be impregnated with various antiseptic sub- 
 stances, such as the bichloride of mercury, carbolic acid, 
 boric acid, and salicylic acid, and when thus treated forms 
 the bichloride, carbolized, borated, and salicylated cotton so 
 much employed in antiseptic dressings. 
 
RUBBER TISSUE. 161 
 
 Jute. 
 
 This substance is made from the fibre of the Corchorus 
 capsularis, which, on account of the character of its fibre, 
 possesses both elasticity and absorbing qualities ; it has 
 been employed for much the same purposes as oakum and 
 cotton, such as the padding of splints, etc., and is also used 
 as an external absorbing dressing. 
 
 Wood-wool. 
 
 AVood-wool made from wood-pulp, such as is employed 
 in the manufacture of paper, is also furnished in the shape 
 of lint, sponges, and pads, and may be used for the same 
 purposes as the ordinary surgical lint. 
 
 Oiled Silk or Muslin. 
 
 These materials are employed as an external covering 
 for moist dressings to prevent rapid evaporation from the 
 dressings ; they form excellent materials for this purpose, 
 but as they are quite expensive their use is limited. 
 
 Waxed or Paraffin Paper. 
 
 This dressing is prepared by passing sheets of tissue- 
 paper through melted wax or paraffin, and then allowing 
 them to dry for a few minutes. Paper thus treated forms 
 an excellent and cheap substitute for oiled silk or muslin, 
 and may be employed for the same purpose for which the 
 latter materials are used. 
 
 Rubber TrssuE. 
 
 This material, which is prepared by rubber manufac- 
 turers, consists of rubber run out into very thin sheets. 
 It has a glazed surface, is very pliable and at the same 
 time strong, forming, therefore, a cheap and satisfactory 
 substitute for oiled silk, and is employed for the same 
 purposes. In the moist method of antiseptic dressing it 
 
162 MINOR SURGERY. 
 
 may be used in place of the mackintosh, and indeed I 
 prefer it to the latter in this method of dressing. 
 
 Parchment Paper. 
 
 This paper is prepared so as to render it water-proof ; 
 it is employed in surgical dressings for the same purposes 
 as oiled silk and rubber tissue. 
 
 Compresses. 
 
 Compresses are prepared by folding pieces of lint, muslin, 
 linen, or flannel upon themselves, so as to form firm masses 
 of variable sizes ; oakum or cotton may also be used to 
 form compresses. Compresses are employed to make 
 pressure over localized portions of the body, as in the 
 treatment of fractures, or to make pressure upon vessels 
 for the control of hemorrhage. 
 
 Tampon. 
 
 A tampon is a form of compress which is employed in 
 cavities to make pressure, to control hemorrhage, or to 
 apply various medicines to the surface of the cavity. 
 Tampons used to control hemorrhage are generally made 
 of strips of bichloride or iodoform gauze or of pledgets of 
 bichloride cotton. In applying these, the strips of cotton 
 are packed into the cavity, and when the cavity is full a 
 compress is applied superficially and held in place by a 
 bandage. The application of a tampon to the vagina is a 
 favorite method of controlling uterine hemorrhage. 
 
 A glycerin tampon, made by pouring half an ounce of 
 glycerin on a piece of cotton or wool, and then turning up 
 the ends and securing them by a string, one end of which 
 is allowed to remain long enough to hang from the vagina, 
 to facilitate its removal ; it is a favorite application to the 
 os uteri. 
 
 Tent. 
 
 This consists of a small portion of lint, oakum, or 
 muslin rolled up into a conical shape, which is employed 
 
RETRACTORS. 
 
 163 
 
 to keep wounds open and to facilitate discharges. This 
 dressing is not much employed at the present time, its 
 use being largely superseded by the drainage tube. 
 
 Retractors. 
 
 Retractors are made by taking a piece of muslin four 
 inches wide and twelve to eighteen inches in length and 
 
 Fig. 103. 
 
 Fig 104. 
 
 Two-tailed retractor. 
 
 Three-tailed retractor. 
 
 splitting it as far as the centre, thus making a hvo-tailed 
 retractor. (Fig. 103.) A three-tailed retractor is made in 
 the same way, except that the muslin is slit twice instead 
 of once. (Fig. 104.) Retractors are used to retract the soft 
 parts in amputation, to prevent their injury by the saw in 
 the division of the bones. When one bone is sawed a two- 
 
164 MINOR SURGERY. 
 
 tailed retractor is used, and when two bones are sawed a 
 three tailed retractor is employed. 
 
 Plasters. 
 
 The varieties of plaster which are most commonly em- 
 ployed in surgical dressings are adhesive or resin plaster y 
 isinglass plaster and rubber adhesive plaster. 
 
 Resin Plaster. — This plaster, which is machine-spread, 
 is one of the most widely employed plasters in surgical 
 dressings ; the spread surface is covered with a layer of 
 tissue paper, which should be removed before it is used ; it 
 is cut into strips of the required width and length, and the 
 strips should be cut lengthwise from the roll of plaster, 
 as the cloth upon which it is spread stretches more trans- 
 versely than in a longitudinal direction. When heated 
 and applied to the surface it holds firmly; it is prepared 
 for application by applying the unspread side to a vessel 
 containing hot water, or it may be passed rapidly through 
 the flame of an alcohol lamp. 
 
 This is the variety of plaster which is generally used in 
 making the extension-apparatus for the treatment of frac- 
 tures, for strapping the chest in fractures of the ribs and 
 sternum, for strapping the pelvis in cases of fractures of 
 the pelvic bones, or for strapping the breast, the testicle, 
 ulcers, or joints. 
 
 Swan's-down Plaster. — This plaster is much the same as 
 resin plaster, but is spread upon a heavier material, and is 
 an excellent plaster to use for an extension-apparatus, 
 where it is to be worn for a long time. 
 
 Rubber Adhesive Plaster. — This plaster is made by 
 spreading a preparation of India-rubber on muslin, and 
 has the advantage over the ordinary resiu plaster that it 
 adheres without the application of heat. It is employed 
 for the same purpose as resin plaster, but when applied 
 continuously to the skin it is apt to produce a certain 
 amount of irritation, and for this reason when it is to be 
 continuously applied for some time, as in the case of an 
 
PL AS TEES. 165 
 
 extension-apparatus, it is not so comfortable a dressing as 
 that made from resin plaster. 
 
 Isinglass Plaster. — This plaster is made by spreading a 
 solution of isinglass upon silk or muslin, and it has been 
 found a most useful dressing in the treatment of superficial 
 wounds. It is made to adhere to the surface by moisten- 
 ing it, and when used in the treatment of wounds it should 
 be moistened with an antiseptic solution ; it is in this way 
 rendered aseptic, and may be used with safety in connec- 
 tion with other antiseptic dressings. The best variety of 
 this plaster is spread on muslin, and when properly ap- 
 plied adheres as firmly and possesses as much strength as 
 the ordinary resin plaster. 
 
 Before using any of these plasters upon parts which 
 contain hairs, the latter should be removed by shaving, 
 otherwise traction upon them, if the plaster be used for 
 the purpose of extension, will cause the patient discomfort, 
 and unnecessary pain will also be inflicted at the time of 
 its removal. 
 
 Soap Plaster. — Soap plaster for surgical purposes is 
 prepared by spreading emplastrum saponis upon kid or 
 chamois. It is not employed for the same purposes as the 
 resin or rubber plaster, as it has little adhesive power, and 
 is used simply to give support to parts or to protect salient 
 portions of the skeleton from pressure. It is found to be 
 a most useful dressing when applied over the sacrum in 
 cases of threatened bedsores, and may be applied for the 
 same purpose to other parts of the body where pressure- 
 sores are apt to occur. 
 
 In the treatment of sprains of joints a well-moulded 
 soap-plaster splint secured by a bandage will often be 
 found a most efficient dressing, and in the treatment of 
 fractures the comfort of the patient is often materially 
 increased by applying small pieces of soap plaster over 
 the bony prominences, upon which the splints, even when 
 well padded, are apt to make an undue amount of pressure. 
 
 Strapping, or applying pressure to parts by means of 
 strips of plaster firmly applied, is a procedure often em- 
 ployed in surgical practice. 
 
 8* 
 
166 
 
 MINOR SURGERY. 
 
 Stkapping the Testicle. 
 
 In strapping the testicle strips of resin plaster are usu- 
 ally employed ; a dozen or more strips one half an inch 
 wide and twelve inches in length will be required. 
 
 The scrotum, should be first washed and shaved, and the 
 surgeon next draws the skin over the affected organ tense 
 by passing the thumb and finger around the scrotum at 
 its upper portion, making circular constriction ; a strip of 
 plaster which has been heated is passed in a circular man- 
 ner around the skin of the scrotum above the organ, and 
 is tightly drawn and secured ; this isolates the part and 
 prevents the other strips from slipping. Strips are now 
 applied in a longitudinal direction, the first strip being 
 fastened to the circular strip and carried over the most 
 
 Fig. 105. 
 
 4fy 
 
 Strapping the testicle. (Smith.) 
 
 prominent part of the testicle, and is then carried back to 
 the circular strip and fastened. A number of these strips 
 are applied in an imbricated manner until the skin is 
 covered (Fig. 105), and the dressing is completed by pass- 
 ing transverse strips around the testicle from its lowest 
 portion to the circular strip ; care should be taken to see 
 that no portion of the skin is left uncovered. 
 
 Strapping the testicle is employed with advantage in 
 the subacute stage of orchitis or epididymitis, as the 
 swelling of the testicle diminishes the strips become loose, 
 and the part will require re-strapping. It will also be 
 found a useful means of applying pressure to the scrotum 
 after the injection-treatment of hydrocele. 
 
STRAPPING OF THE CHEST 
 
 167 
 
 Strapping the Breast. 
 
 To strap the breast, strips of resin plaster two inches 
 wide and long enough to pass from the opposite shoulder 
 under the breast to the point of starting are required. In 
 applying the strips the end of the strip is placed on the 
 spine of the scapula of the side opposite the diseased breast 
 and is carried forward over the shoulder and obliquely 
 downward under the breast and axilla, and then over the 
 back to the point of starting; the first strip being applied 
 in this manner, the next one is applied in the same direc- 
 tion overlapping about one- 
 third of the previous strip 
 (Fig. 106). These oblique 
 strips are applied in an im- 
 bricated manner until a suf- 
 ficient number have been 
 used to cover in the breast, 
 or the oblique strips may 
 be alternated with circular 
 strips pa-sing from the ster- 
 num over the breast to the 
 spine. A sufficient number 
 of strips are used to cover 
 the breast and to make firm compression upon it. Strap- 
 ping of the breast in this manner will be found a satis- 
 factory method of treatment in chronic inflammatory con- 
 ditions of the breast, w T here it is of advantage to support 
 the breast and make compression at the same time ; it has 
 the advantage over the use of a bandage to support and 
 compress the breast, that it does not interfere with the chest- 
 motions upon the opposite side of the body. 
 
 Strapping the breast. (Smith.) 
 
 Strapping of the Chest. 
 
 To strap one-half of the chest, strips of resin plaster two 
 and a half inches wide, and long enough to extend from 
 the spine to the median line of the sternum, are required — 
 
168 MINOR SURGERY. 
 
 eighteen to twenty inches in length. The first strip is 
 heated and one extremity is placed upon the spine opposite 
 the lower portion of the chest ; it is then carried over the 
 chest and its other extremity is fixed upon the skin in the 
 median line of the sternum. Strips are next applied from 
 below upward in the same manner, each strip overlapping 
 one-third of the preceding one, 
 FlG - 107 - until the axillary fold is reached 
 
 (Fig. 107) ; a second layer of strips 
 may be applied over the first, if 
 additional fixation is desired, or 
 a few oblique strips may be em- 
 ployed. 
 
 Adhesive straps applied in this 
 manner very materially limit the 
 motion of the chest-wall upon the 
 affected side, and are frequently 
 strapping the chest. empl oy ed in the treatment of frac- 
 
 tures and dislocations of the ribs, 
 in contusions of the chest, and in cases of plastic pleurisy 
 when the. motions of the chest walls are extremely painful 
 to the patient. 
 
 Strapping of Ulcers. 
 
 To strap ulcers of the leg, strips of resin plaster one and 
 a half inches wide, and long enough to extend two thirds 
 around the limb, are required. The ulcer should be thor- 
 oughly cleansed, and the skin surrounding it should be 
 well dried ; the first strip, being heated, is applied trans- 
 versely to the long axis of the leg about two inches below 
 the ulcer, and is carried two-thirds around the limb ; an- 
 other strip is applied to a corresponding point of the skin 
 above this one, so that it overlaps one-third of the first 
 applied strip, and it is carried two-thirds of the way 
 around the limb. Additional strips are thus applied until 
 the ulcer is covered in, and the strips are carried several 
 inches above the ulcer (Fig. 108). Care should be taken 
 to see that the strips are so applied as not to meet or 
 
STRAPPING OF ULCERS. 169 
 
 cover the entire circumference of the limb, as by so doing 
 injurious circular compression may result. Chronic ulcers 
 upon other portions of the body may be strapped in the 
 same manner. 
 
 Fig. 108, 
 
 Strapping of ulcer of leg. 
 
 Strapping of leg ulcers is usually reinforced by the 
 applications of a firmly applied spiral reversed or spica 
 bandage of the lower extremity. 
 
 Strapping of ulcers of the leg applied in the manner 
 described will be found a most satisfactory method of 
 treating chronic ulcers in this location in patients who 
 have to work during the course of treatment; the strips 
 
170 MINOR SURGERY. 
 
 need only be removed at intervals of a week, and, if well 
 applied, the dressing is generally a comfortable one to the 
 patient. 
 
 Strapping of Joints. 
 
 Strips of resin plaster two inches in width and long 
 enough to extend two-thirds around the joint are required. 
 The first strip is applied a few inches below the joint, and 
 strips are then applied over this, each strip covering in 
 two-thirds of the preceding one until the joint is covered 
 in and the dressing extends a few inches above the joint. 
 
 The ankle-joint is strapped by taking strips of resin 
 plaster one inch in width ; the first strip is placed over 
 the heel, and its ends are brought forward until they meet 
 over the dorsum of the foot ; a second strip encircles the 
 foot and secures the ends of the first strip. These strips 
 are alternately applied, each strip covering one-half of the 
 previous one until the foot and ankle are covered. 
 
 Strapping of joints will be found a satisfactory dressing 
 in the treatment of sprains of joints in their acute or 
 chronic state. 
 
 Strapping of a Carbuncle. 
 
 To strap a carbuncle strips of resin plaster one to one 
 and a half inches in width are required ; these strips are 
 applied at the margin of the swelling and are laid on con- 
 centrically until all except the central portion is covered. 
 If a number of openings exist, the strips are so placed as 
 not to cover these. Strapping applied in this manner in 
 the treatment of carbuncle is often a comfortable dressing 
 for the patient, and at the same time the concentric pressure 
 favors the extrusion of the slough. 
 
 Poultices. 
 
 This form of dressing was formerly much employed in 
 the treatment of inflammatory conditions and injuries as a 
 
POULTICES. 171 
 
 means of applying heat and moisture to the part at the 
 same time, and although the use of poultices is now very 
 much restricted since the introduction of the antiseptic 
 method of wound-treatment, yet I think there are still 
 conditions in which their employment is both useful and 
 judicious. 
 
 They are often employed with advantage in inflammatory 
 affections of the chest and of the abdominal organs, and in 
 inflammatory affections of the joints and of bone, com- 
 bined with rest, their action is most often satisfactory ; in 
 cases of gangrene their employment hastens the separation 
 of the sloughs. 
 
 They constitute a form of dressing which is conducive 
 to the comfort of the patient in cases of deep suppura- 
 tion by their relaxing effect upon the tissues, and their 
 previous use does not prevent the surgeon from using all 
 antiseptic precautions in the opening and drainage of these 
 abscesses and the employment of antiseptic dressings in 
 their subsequent treatment. 
 
 Flaxseed Poultice. 
 
 This poultice is prepared by adding first a little cold 
 water to ground flaxseed and then adding boiling water, 
 and stirring it in until the resulting mixture is of the con- 
 sistency of thick mush. A piece of muslin is next taken 
 which is a little larger than the intended poultice, and 
 this is laid upon the surface of a table and the poultice- 
 mass is spread evenly upon it with a spatula or knife 
 from one-quarter to one-half an inch in thickness ; a 
 margin of the muslin of one or one and a half inches is 
 left, which is turned over after the poultice is spread, and 
 serves to prevent it from escaping around the edges when 
 applied. The surface of the poultice may be thinly spread 
 over with a little olive oil, or may be covered with a layer 
 of thin gauze to prevent the mass from adhering to the skin. 
 
 It is now applied to the surface of the skin and is cov- 
 ered with a piece of oiled silk, rubber tissue, or waxed 
 paper, and held in position by a bandage or a binder. 
 
172 MINOR SURGERY. 
 
 Bread Poultice. 
 
 This poultice is prepared from stale wheaten bread, the 
 crusts being discarded and the crumb only being used ; 
 this is moistened with boiling water and allowed to soak 
 for a lew minutes, when the excess of water is poured off 
 and the mass is spread upon a piece of muslin or linen, as 
 before described. 
 
 Starch Poultice. 
 
 This poultice is prepared by mixing starch with cold 
 water until a smooth, creamy fluid results; boiling water 
 is then added, and it is heated until it becomes clear and 
 has about the same consistency as the starch used for 
 laundry purposes. When sufficiently cool it is spread 
 upon muslin, applied to the part, and covered with oiled 
 silk or waxed paper. This variety of poultice is princi- 
 pally useful in the treatment of diseases of the skin, espe- 
 cially those of the scalp accompanied by the formation of 
 scabs or crusts, to facilitate their removal and to afford a 
 clean surface for the application of ointments or wet 
 dressings. 
 
 Charcoal Poultice. 
 
 In preparing this poultice flaxseed-meal and powdered 
 charcoal in equal parts are mixed together, and by adding 
 boiling water a poultice-mass is produced, which is spread 
 upon muslin, as previously detailed. It is better to use 
 animal charcoal in making this poultice, as it possesses 
 greater disinfecting power than vegetable charcoal. This 
 poultice was formerly used as an application to gangrenous 
 parts, as it possesses marked disinfecting properties. 
 
 Fermenting Poultice. 
 
 This poultice may be prepared by adding yeast, two 
 tablespoon fuls, to a mixture of flaxseed with hot w^ater, 
 making a thin poultice-mass, and allowing it to stand for 
 a few hours in a warm place; it rises and becomes light, 
 and is then spread upon muslin and applied as required. 
 
HOT FOMENT A TIONS. 173 
 
 A few ounces of porter or a piece of yeast-cake may be 
 used as a substitute for the yeast in preparing this 
 poultice ; charcoal may also be added to it to increase its 
 disinfectant power. This poultice was formerly and is 
 still used as an application to gangrenous parts to hasten 
 their separation and to diminish the odor arising from 
 the necrosed tissues. 
 
 Oakum Poultice. 
 
 This is prepared by soaking a mass of loosely picked 
 oakum in hot water, wringing it out and covering it with 
 a layer of cheese-cloth or antiseptic gauze. It is next 
 applied to the part and covered with oiled silk or rubber 
 tissue, which may be held in place by a bandage. Such 
 a dressing will absord a considerable amount of discharge. 
 
 Before application it may be wrung out in a warm 
 bichloride solution or carbolic solution, and thus form an 
 antiseptic poultice. 
 
 Hot Fomentations. 
 
 Hot fomentations are employed to keep up the vitality 
 of parts which have been subjected to injury, as seen in 
 severe contusions resulting from railway or machinery 
 accidents; also to combat inflammatory action. Flannel 
 cloths, several layers in thickness, or surgical lint should 
 be soaked in water having a temperature of 120° ; these 
 are wrung out, placed over the part, and covered with waxed 
 paper or rubber tissue; a second cloth should be placed in 
 the hot water, ready to apply as soon as the first-applied 
 cloth begins to cool, and so by continuously reapplying 
 them the part is kept constantly covered by a hot dressing. 
 The use of these hot fomentations may in many cases 
 require to be continued for hours before the desired result is 
 obtained. Hot compresses applied in this manner are fre- 
 quently employed in treating inflammatory conditions of 
 the eye, and are also of the greatest service in keeping up 
 the vitality of parts which have been subjected to severe 
 
174 
 
 MINOR SURGERY. 
 
 injury interfering with their blood-supply. I have seen 
 contused limbs, which were cold and seemed to be doomed 
 to gangrene by reason of diminished blood-supply, have 
 their temperature and circulation restored by the patient 
 and persistent use of this dressing. After the vitality of 
 such a part is restored it should be covered with cotton 
 and a flannel bandage and surrounded by hot- water bags 
 or hot- water cans. 
 
 Irrigation. 
 
 This may be accomplished by allowing the irrigating 
 fluid to come in contact with the wound or inflamed part, 
 immediate irrigation, or by allowing the cold or warm 
 
 Fig. 109. 
 
 Apparatus for continuous irrigation. (Esmakch.) 
 
IRRIGATION. 
 
 175 
 
 fluids to pass through rubber tubes which are in contact 
 with or surround the part ; the latter method is known as 
 mediate irrigation. 
 
 Immediate Irrigation. 
 
 In employing immediate irrigation in the treatment of 
 wounds or in inflammatory conditions, a funnel-shaped 
 can with a stop-cock at the bottom, or a bucket, is sus- 
 pended over the part at a distance of a few inches (Fig. 
 109), or a jar with a skein of thread or lamp-wick ar- 
 ranged to act as a siphon may be employed. (Fig. 110.) 
 
 Fig. 110. 
 
 Irrigating-apparatus. (Erichsen. ) 
 
 The can or jar is filled with water, and this is allowed to 
 fall drop by drop upon the part to be irrigated, which 
 should be placed upon a piece of rubber sheeting so 
 arranged as to allow the water to run off into a receptacle 
 so as to prevent the wetting of the patient's bed. The 
 water employed may be either cold or warm, in accord- 
 ance with the indications in special cases. If it is de- 
 sired to make use of antiseptic irrigation, the water is 
 impregnated with carbolic acid or bichloride of mercury ; 
 a 1 : 5000 to 1 : 10,000 bichloride solution, or a 1 : 60 
 carbolic acid solution, being frequently employed with 
 good results. 
 
176 
 
 MINOR SURGERY. 
 
 Antiseptic irrigation employed in this manner will be 
 found a most useful method of treating lacerated and con- 
 tused wounds of the extremities in which the vitality of 
 the tissues is much impaired ; and in such cases warm 
 water should be preferred to cool water, the temperature 
 being from 100° to 110°. 
 
 Under the use of warm irrigation it is surprising to see 
 how tissues apparently devitalized regain their vitality ; 
 the absence of tension from the non-introduction of sutures 
 and firm dressings, and the warmth and moisture kept 
 constantly in contact with the wound by this method of 
 irrigation, are the important factors in the attainment of 
 this favorable result. 
 
 Mediate Irrigation. 
 
 In this method of irrigation cold or warmth is applied 
 to the surface by means of cold or warm water passing 
 through a rubber tube in contact with the part. A flexible 
 
 Fig. 111. 
 
 Cold coil applied to arm. (Esmarch.) 
 
COLD-WATER DRESSINGS. 177 
 
 tube of India-rubber half an inch in diameter, with thin 
 walls, and sixteen or twenty feet in length, is applied to 
 the limb like a spiral bandage, or is applied in a coil to 
 the head, breast, or joints, and held in place by a few turns 
 of a bandage ; the end of the tube is attached to a reser- 
 voir filled with cold or warm water above the level of the 
 patient's body, and the water is allowed to flow constantly 
 through the tubing and escape into a receptacle arranged 
 to receive it. (Fig. 111.) 
 
 Cold-water Dressings. 
 
 These dressings are applied by bringing the cold water 
 either directly in contact with the part or by applying it 
 by means of a rubber bag or bladder. 
 
 The temperature of the water may vary from cool water 
 to that of ice- water. 
 
 These dressings are employed in local inflammatory 
 conditions ; a favorite method for the employment of this 
 dressing is by means of cold compresses, which are made 
 of a few layers of surgical lint, dipped in water of the 
 desired temperature and applied to the part ; they are re- 
 newed as soon as they become warm. When it is desirable 
 to have the compresses very cold, they may be laid upon 
 a block of ice or in a basin with broken ice ; to obtain 
 the best results from their employment they should be 
 renewed at very short intervals. 
 
 A convenient method of applying cold without moisture 
 is by the use of the ice-bag. This is either a rubber bag 
 or bladder, which is filled with broken ice and applied to 
 the part. In using an ice-bag it is better to cover the part 
 first with a towel or a few layers of lint or muslin, which 
 prevents the surface from becoming wet by absorbing the 
 moisture which condenses upon the surface of the bag or 
 bladder, and thus renders the dressing more comfortable 
 to the patient. The ice-bag is often employed as an ap- 
 plication to the head in inflammatory conditions of the 
 brain or membranes, and is also used upon the surface of 
 the body to control internal hemorrhage. 
 
178 MINOR SURGERY. 
 
 Counter-irritation. 
 
 Counter-irritants are substances employed to excite ex- 
 ternal irritation, and the extent of their action varies 
 according to the material used and the duration of their 
 application ; superficial redness or complete destruction of 
 the vitality of the parts to which they are applied may 
 result. 
 
 The use of counter-irritants under favorable circum- 
 stances is found to have a decided effect in modifying 
 morbid processes, and they are widely employed as local 
 revulsants in cases of congestion or inflammation, and in 
 cases of collapse for their stimulating effect. 
 
 Rubefacients. 
 
 These agents, by reason of their irritating properties 
 when applied to the skin, produce intense redness and 
 congestion. 
 
 Hot Water. — When it is desired to make a prompt im- 
 pression upon the skin, the application of muslin or flannel 
 cloths wrung out in hot water and renewed as rapidly as 
 they become cool will soon produce a superficial redness of 
 the integument. 
 
 Spirits of Turpentine. — This drug applied to the skin is 
 a very active counter-irritant ; it may be rubbed upon the 
 surface of the skin until redness results. When used upon 
 patients whose skin is very delicate its action may be 
 modified by mixing it with equal parts of olive oil before 
 applying it; this will be found a useful precaution in 
 applying it as a rubefacient to the tender skins of young 
 children. 
 
 When redness of the skin has resulted from the appli- 
 cation, the skin should be wiped dry by means of a soft 
 towel „or absorbent cotton to remove any turpentine from 
 the surface, which by its continued contact may cause 
 vesication. 
 
 Turpentine is often employed as a rubefacient in the 
 form of the turpentine stupe, which is prepared by sprink- 
 
R UBEFA CI E NTS. 179 
 
 ling spirits of turpentine over flannel cloths which have 
 been wrung out in hot water, or by dipping hot flannel in 
 warm spirits of turpentine ; prepared in either way the 
 stupe should be squeezed as dry as possible to remove the 
 excess of turpentine before being applied to the surface of 
 the body. A turpentine stupe may cause vesication if 
 allowed to remain for too long a time in contact with the 
 skin ; its application for from five to ten minutes will 
 usually produce the desired effect ; it should be removed 
 after this time, and it can be reapplied if desired. 
 
 If the patient complains of severe burning of the skin 
 after the use of turpentine, the painful surface should be 
 freely smeared with vaseline or lard, which will relieve 
 the uncomfortable symptom. 
 
 Chloroform. — A few drops of chloroform applied to the 
 surface of the body by means of a piece of lint, muslin, or 
 flannel, and covered by oiled silk or rubber tissue, will 
 excite a rapid rubefacient effect. 
 
 3fustard. — Ground mustard or mustard flour prepared 
 from either Sinapis alba or Sinapis nigra is one of the most 
 commonly used substances to produce rubefacient action. 
 It is generally employed in the form of the mustard plaster 
 or sinapism, which is prepared by mixing equal parts of 
 mustard flour with wheat flour or flaxseed meal, and add- 
 ing to this enough warm water to make a thick paste ; 
 this is spread upon a piece of old muslin, and the surface 
 of the paste should be covered with some thin material, 
 such as gauze, to prevent the paste from adhering to the 
 skin. In making a mustard plaster for application to the 
 tender skin of a child, 1 part of mustard flour should be 
 mixed with 3 parts of wheat flour or flaxseed meal. 
 
 A mustard plaster or sinapism may be allowed to remain 
 in contact with the skin for a period varying from fifteen 
 to thirty minutes, the time being governed by the sensa- 
 tions of the patient ; if it is allowed to remain longer, it 
 may cause vesication, which is to be avoided, as ulcers 
 produced by mustard are very painful and extremely slow 
 in healing. After removing a sinapism the irritated sur- 
 face of the skin should be dressed with a piece of muslin 
 
180 MINOR SURGERY. 
 
 or lint spread with vaseline, boric acid or oxide of zinc 
 ointment. 
 
 To excite a rapid revulsive action the mustard foot-bath 
 is often employed ; it is prepared by adding two or three 
 tablespoonfuls of mustard flour to a bucket or foot-tub of 
 water at a temperature of 100° to 110°; in this the patient 
 is allowed to soak his feet for a few minutes. 
 
 Mustard Papers — Charta Sinapis, which can be obtained 
 in the shops ready for use, are a convenient means of 
 obtaining the rubefacient action of mustard. They are 
 dipped in warm water, and as they are generally very 
 strong, it is well to place a layer of muslin between the 
 surface of the plaster and the skin before applying it to 
 the surface. 
 
 Capsicum or Cayenne pepper is" also sometimes employed 
 as a rubefacient, but it is generally employed in combina- 
 tion with spices, forming the well-known spice plaster ; 
 this is prepared by taking equal parts of ground ginger, 
 cloves, cinnamon, and allspice, and adding to them one- 
 fourth part of Cayenne pepper ; these are thoroughly 
 mixed, enclosed in a flannel bag, and evenly distributed ; 
 a few stitches should be passed through the bag at differ- 
 ent points, to prevent the powder from shifting its posi- 
 tion ; before applying it, one side of the bag should be 
 wet with warm whiskey or alcohol. Capsine plasters are 
 also employed to obtain the rubefacient effect of Cayenne 
 pepper. 
 
 Aqua ammonia may also be employed for its rubefacient 
 action. A piece of lint saturated with the stronger water 
 of ammonia, placed upon the skiri and covered with 
 waxed paper, and allowed to remain for one or two minutes, 
 will produce a marked rubefacient effect. 
 
 Paquelin's Cautery. — By rapidly stroking the surface 
 of the skin with the point or button of Paquelin's cautery 
 at a black heat a marked counter-irritant action may be 
 produced. 
 
 Nitrate of silver, in a strong solution or in the form of 
 the solid stick, may be applied to the surface of the skin 
 to produce a counter-irritant effect. Nitrate of silver ap- 
 
VESICANTS. 181 
 
 plied by drawing the moist stick across the skin of the 
 scrotum at a number of points, was formerly a popular 
 form of treatment for acute epididymitis. 
 
 Caution should be exercised in applying counter-irri- 
 tants to patients w T ho are comatose or under the influence 
 of a narcotic, for here the sensations of a patient cannot 
 be used as a guide to their removal, and their too long con- 
 tinued application when the vitality of the tissues is im- 
 paired may result in serious consequences. 
 
 Vesicants. 
 
 Where it is desirable to make a more permanent counter- 
 irritant effect than that produced by rubefacients, sub- 
 stances are employed which by their action on the skin 
 cause an effusion of serum, or of serum and lymph, beneath 
 the cuticle, thus giving rise to vesicles or blisters ; they 
 are known as vesicants. 
 
 The substance most commonly employed to produce 
 vesication is Cantharis, or Spanish fly, and the prepara- 
 tion commonly used is the Ceratum cantharidis, which is 
 spread upon adhesive plaster, leaving a margin one-half 
 an inch in width uncovered, which will adhere to the skin 
 and hold the blister in position. The time required for a 
 fly blister to produce vesication is from four to six hours; 
 it should then be removed and the surface should be cov- 
 ered w T ith a flaxseed-meal poultice, or with a warm-w-ater 
 dressing. When the blister or vesicle is well developed, 
 it may be punctured at its most dependent part to allow 
 the serum to escape, and it should be dressed with vaseline 
 or boric ointment. If for any reason it is desired to keep 
 up continued irritation, after allowing the serum to escape, 
 the cuticle should be cut away and the raw surface should 
 be dressed with some stimulating material, such as the 
 compound resin cerate. 
 
 Cantharidal Collodion may also be employed to produce 
 vesication ; it is applied by painting several layers upon 
 the skin with a brush over the part on which the blister 
 
 9 
 
182 MINOR SURGERY. 
 
 is to be produced. It is a convenient preparation to use 
 when the patient would disturb the ordinary blister, as in 
 the case of a child or an insane patient, or where the 
 surface is so irregular that the ordinary blister cannot be 
 well applied. The after-treatment of blisters produced 
 by canthariclal collodion is similar to that previously 
 described. 
 
 In the treatment of chronic inflammation it is often 
 better to apply a number of small blisters at intervals than 
 one large blister producing an extensive vesication of the 
 surface. Caution should be observed in using blisters 
 upon the tender skins of children ; if employed, they should 
 be allowed to remain in contact with the skin for a short 
 time only. They are contraindicated in patients in whom 
 the vitality of the tissues is depressed by adynamic dis- 
 eases, and in aged persons. 
 
 A complication which sometimes occurs from the use of 
 cantharidal preparations as blisters is strangury, which is 
 shown by frequent and painful micturition, the urine often 
 containing blood. This accident should be treated by the 
 use of opium and belladonna by suppository, demulcent 
 drinks, and warm sitz-baths, and by leeches to the peri- 
 neum if the symptoms are very severe. 
 
 To avoid the development of strangury small blisters 
 should be employed, and should not be allowed to remain 
 too long in contact with the surface, and cantharidal prepa- 
 rations should not be employed in cases where renal or 
 vesical irritation has existed or is present. It is said that 
 strangury may also be avoided by incorporating opium 
 and camphor with the cantharidal cerate. 
 
 Aqua ammonia fortior and chloroform may be employed 
 to produce rapid vesication, a few drops being placed upon 
 the surface of the body and covered by an inverted watch- 
 glass for a few minutes, or lint saturated with aqua am- 
 monia or chloroform may be placed upon the skin and 
 covered with waxed paper or oiled silk. Either of these 
 agents applied in this manner, and allowed to remain in 
 contact with the skin for fifteen minutes, will produce 
 marked vesication. The blisters resulting from these 
 
ACUPUNCTURE. 
 
 183 
 
 agents are painful, and they are only to be used where a 
 rapid result is desired. 
 
 Acupuncture. 
 
 Counter-irritation is effected by this method by thrust- 
 ing steel needles deeply into the subcutaneous tissues. The 
 needles employed should be of steel, from two to four inches 
 in length, strong, highly polished, and sharp-pointed, and 
 should have round metallic heads or be fixed in handles. 
 (Fig. 112.) Before being used they should be allowed to 
 remain for a few minutes in boiling water or in a car- 
 bolized solution to sterilize them thoroughly. In perform- 
 ing the operation of acupuncture, local- 
 ities containing important organs, large fig. 112. 
 bloodvessels, the joints and viscera, 
 should be avoided. When introduced 
 the needles should be passed through 
 the skin with a rotary motion, the skin 
 being rendered tense between the thumb 
 and fingers, and pushed into the deep- 
 seated structures. They are allowed 
 to remain in position for a few moments 
 and are then withdrawn, the skin being 
 supported by the thumb and fingers. 
 
 Acupuncture has been found of ser- 
 vice in cases of deep-seated neuralgia, 
 obstinate rheumatic affections, and sci- 
 atica. 
 
 Issues. 
 
 Q 
 
 Acupuncture 
 needles. 
 
 Issues are ulcers made intentionally 
 by the application of caustics, the moxa, 
 or the knife. They are not often em- 
 ployed at the present time, but were formerly a popular 
 means of causing long-continued counter-irritation. In 
 making an issue, a region was selected where the subcuta- 
 neous cellular tissue was abundant, and which was free 
 from large bloodvessels and nerves, and not near the 
 
184 MINOR SURGERY. 
 
 joints. The plan usually adopted was to apply over the 
 surface of the skin a piece of adhesive plaster perforated 
 in the centre. A small piece of caustic potash or Vienna 
 caustic, mixed with water to make it a paste, was placed in 
 the hole in the adhesive plaster, and held in position by a 
 strip of adhesive plaster. In one or two hours the plaster 
 should be removed and the part should be washed with 
 dilute acid to prevent further action of the caustic ; a 
 poultice of flaxseed should next be applied, to hasten the 
 separation of the slough. The ulcer remaining after the 
 removal of the slough may be kept from healing by intro- 
 ducing into it a small wooden ball known as an issue pea, 
 or a glass bead or pebble held in place by a compress and 
 adhesive strap. 
 
 The Moxa was formerly used to make an issue ; it con- 
 sisted of a small mass of some combustible material, such 
 as punk, cotton, or lint, rolled into pyramidal 
 fig. 113. shape, which was placed upon the surface 
 of the body and ignited so as to produce an 
 eschar upon the skin. To facilitate the appli- 
 cation of the moxa an instrument called the 
 porte-moxa (Fig. 113) is employed. The 
 treatment of the eschar resulting from the 
 moxa is the same as that resulting from the 
 use of caustic potash. 
 
 The knife was also employed to establish an 
 issue, a crucial incision being made through 
 the skin and cellular tissues into the deep 
 tissues ; the objection to the use of the knife 
 in forming an issue was the difficulty in pre- 
 venting the wound from healing. 
 Porte-moxa. The Seton. — A seton is a subcutaneous 
 sinus, or an issue with two openings upon the 
 surface, which is prevented from healing by the introduc- 
 tion of a foreign body. It is established by introducing 
 a few strands of silk, a narrow strip of linen, or a rubber 
 ligature, by means of a seton-needle (Fig. 114), or by 
 means of a sharp-pointed bistoury and an eyed probe. 
 The seton-needle should be passed deeply into the super- 
 
SETON. 
 
 185 
 
 ficial fascia, care being taken to avoid important veins 
 and nerves. 
 
 A seton may also be established by pinching up a fold of 
 skin and transfixing its base with a narrow, sharp-pointed 
 
 Fig. 114. 
 
 Seton-needle. 
 
 bistoury (Fig. 115), and passing through the wound thus 
 made an eyed probe armed with a few strands of silk, a 
 strip of muslin, or an elastic ligature ; the probe is then 
 removed and the ends loosely tied together. The wound 
 
 Fig. 115. 
 
 Method of forming a seton. 
 
 should be dressed, and at each change of the dressing the 
 strip should be removed, or it may be smeared with some 
 stimulating ointment, which can thus be brought in con- 
 tact with the granulating surface by drawing it through 
 the wound. 
 
186 
 
 MINOR SURGERY. 
 
 Actual Cautery. 
 
 This method of counter-irritation is accomplished by 
 bringing in contact with the skin some metallic substance 
 brought to a high degree of temperature. This constitutes 
 one of the most powerful means of counter-irritation and 
 revulsion ; it is rapid in its action, and is not more painful 
 than some of the slower methods. The cauteries generally 
 employed are made of iron, and are fixed in handles of 
 wood or other non-conducting material, and have their 
 extremities fashioned in a variety of shapes (Fig. 116). 
 The irons are heated by placing their extremities in an 
 ordinary fire, or by holding them in the flame of a spirit- 
 
 Fig. 116. 
 
 Cautery irons. 
 
 lamp until they are heated to the desired point, either 
 a white or a dull-red heat. They are then applied to the 
 surface of the skin at one point, or drawn over the skin 
 in lines either parallel to or crossing one another. The 
 intense burning which follows the use of the cautery may 
 be allayed by placing upon the cautery-marks compresses 
 wrung out in ice- water or saturated with equal parts of 
 lime-water and sweet oil. 
 
 Where the ordinary cautery irons are not at hand, a 
 steel knitting-needle or iron poker heated in the flame of 
 a spirit-lamp or in a fire may be employed with equally 
 satisfactory results. Where the cautery iron is held in 
 
PAQUELIN'S THERMO-CAUTERY. 
 
 187 
 
 contact with the surface for some time to make a deep 
 burn, the pain of its application may be allayed by placing 
 a mixture of salt and cracked ice upon the spot to be 
 cauterized for a few minutes immediately before its appli- 
 cation. The cautery iron should not be placed over the 
 skin covering salient parts of the skeleton or over impor- 
 tant organs. 
 
 The actual cautery thus applied, in addition to its use 
 in producing counter-irritation and revulsion, is often 
 employed to control hemorrhage and to destroy morbid 
 growths. 
 
 Paquelin's Thermocautery. 
 
 A very convenient and efficient means of using the 
 thermo-cautery is the apparatus of Paquelin, which utilizes 
 
 Fig. 117. 
 
 Paquelin's cautery. 
 
 the property of heated platinum-sponge to become incan- 
 descent when exposed to the action of the vapor of benzole 
 
188 MINOR SURGERY. 
 
 or rhigolene. (Fig. 117.) The cautery is prepared for use 
 by attaching the gum tube to the receiver containing ben- 
 zole and heating the platinum knife or button, which is 
 also attached to the benzole receiver by a rubber tube, in 
 the flame of the alcohol lamp for a few moments, and 
 then passing the vapor of benzole through the platinum- 
 sponge, which is enclosed in the knife or button, by com- 
 pressing the rubber bulb. The points may be brought to 
 a high degree of heat, or may be brought only to a dull- 
 red heat. 
 
 This form of cautery may be employed for the same 
 purposes as that previously mentioned ; its great advantage 
 consists in the ease with which it can be prepared for use. 
 The knives heated to a dull-red heat will be found of 
 great service in operating upon vascular tumors, where 
 the use of an ordinary knife would be accompanied by 
 profuse or even dangerous hemorrhage. Wounds made 
 by the actual cautery are aseptic wounds, and when dusted 
 with iodoform will generally heal promptly under the 
 scab without suppuration. 
 
 Bloodletting. 
 
 This procedure is often resorted to to obtain both the 
 local and the general effects following the withdrawal of 
 blood from the circulation. Local depletion is accom- 
 plished by means of some one of the following pro- 
 cedures : scarification, puncturation, cupping and leeching, 
 and general depletion is effected by means of venesection 
 or by arteriotomy. 
 
 Scarification. 
 
 Scarification is performed by making small and not too 
 deep incisions into an inflamed or congested part with a 
 sharp-pointed bistoury ; the incisions should be in parallel 
 lines and should be made to correspond to the long axis 
 of the part, and care should be taken in making them to 
 
CUPPING. 189 
 
 avoid wounding superficial veins and nerves. Incisions 
 thus made relieve tension by allowing blood and serum to 
 escape from the engorged capillaries of the infiltrated 
 tissue of the part. Warm fomentations applied over the 
 incisions will increase and keep up the flow of blood and 
 serum. Scarification is employed with advantage in in- 
 flammatory conditions of the skin and subcutaneous cellular 
 tissue and in acute inflammatory swelling or oedema of the 
 mucous membrane ; for instance, of the conjunctiva, and 
 in acute inflammation of the tonsils, tongue, and epiglottis 
 it is au especially valuable procedure. A modification of 
 scarification known as deep incisions is practised in urinary 
 infiltration to establish drainage and to relieve the tissues of 
 the contained urine and to prevent sloughing ; in threatened 
 gangrene and phlegmonous erysipelas the same procedure 
 is adopted to relieve tension by permitting of the escape of 
 blood and serum, and its employment is often followed 
 bv most satisfactorv results. 
 
 PUNCTURATION. 
 
 This procedure consists in making punctures, which 
 should not extend deeper than the subcutaneous tissue, 
 into inflamed tissues with the point of a sharp-pointed 
 bistoury ; it is an operation similar in character to that 
 just described, its object being to relieve tension and bring 
 about depletion. It is employed in cases similar to those 
 in which scarification is indicated, and is resorted to in 
 cases of diffuse areolar inflammation or erysipelas. 
 
 Cupping. 
 
 Cupping is a convenient method of employing local 
 depletion by inviting the blood from the deeper parts to 
 the surface of the skin. Cupping is accomplished by the 
 use of icet or dry cups. When the former are used, no 
 blood is abstracted and the derivative action only is 
 obtained ; when wet cups are employed there is an actual 
 
 9* 
 
190 
 
 MINOR SURGERY. 
 
 Fig. 118. 
 
 abstraction of blood or local depletion as well as the 
 derivative action. 
 
 Dry Cupping. 
 
 Dry cups as ordinarily applied consist of small cup- 
 shaped glasses, which have a valve and stop-cock at their 
 summit ; these are placed upon the skin and an air-pump 
 is attached, and as the air is exhausted in the cup the con- 
 gested integument is seen to bulge into the cavity of the 
 cup. When the exhaustion is complete the stop-cock is 
 turned and the air-pump is removed, the cup being allowed 
 to remain in position for a few minutes, and 
 is then removed by turning the stop-cock and 
 allowing the air again to enter the cup. This 
 procedure is repeated until a sufficient number 
 of cups have been applied. (Fig. 118.) 
 
 In cases of emergency, when the ordinary 
 cupping-glasses and air-pump cannot be ob- 
 tained, a very satisfactory substitute may be 
 obtained by taking a wineglass and burning 
 in it a little roll of paper, or a small piece of 
 lint or paper wet with alcohol, and before the 
 flame is extinguished rapidly inverting it upon 
 the skin, or the air may be exhausted by the 
 introduction, for a moment or two, of the flame 
 of a spirit-lamp into the cup. Applied in this 
 manner cups will draw as well as when the 
 more complicated apparatus is used, and when 
 they are removed it is only necessary to press 
 the finger on the skin close to the edge of 
 the cup until air enters it, when it will fall 
 off. Although dry cups do not remove blood 
 directly, there is often an escape of blood from the capil- 
 laries into the skin and cellular tissue, as is evidenced by 
 the ecchymosis which frequently remains at the seat of 
 the cupmarks for some days. 
 
 Dry cups, as previously stated, are employed for their 
 derivative action in cases in which depletion is not indi- 
 cated. 
 
 Cupping- 
 glass and 
 air-pump. 
 
LEECHING. 
 
 191 
 
 Wet Cupping. 
 
 When the abstraction of blood as well as the derivative 
 action is desired wet cups are resorted to, and here it is 
 necessary to have a scarificator as well as the cups and 
 air-pump. (Fig. 119.) 
 
 Before applying wet cups the skin should be washed 
 carefully with a carbolic solution, and the scarificator 
 should also be dipped in a carbolic solution. A cup is 
 first applied to produce superficial congestion of the skin ; 
 this is removed and the scarificator is applied, and the 
 skin is cut by. springing the blades. The cups are im- 
 mediately applied and exhausted, and they are kept in 
 place as long as blood continues to 
 flow. When the vacuum is ex- fig. 119. 
 
 hausted and blood ceases to flow, 
 they should be removed and emp- 
 tied, and can be reapplied if it is 
 desirable to remove more blood. A 
 sharp-pointed bistoury which has 
 been sterilized may be employed to 
 make a few incisions into the skin 
 instead of the scarificator, and the 
 improvised cups may be employed 
 if the ordinary cupping-apparatus scarificator. 
 
 cannot be obtained. 
 
 After the removal of wet cups the skin should be 
 washed carefully with a bichloride or carbolic solution, 
 and an antiseptic dressing should be placed over the 
 wounds and held in place by a roller bandage. 
 
 Leeching. 
 
 In the abstraction of blood by leeching two varieties of 
 leeches are used — the American leech, which draws about 
 a teaspoonful of blood, and the Swedish leech, which draws 
 three or four teaspoonfuls. 
 
 Before applying leeches the skin should be carefully 
 washed, and the leech should be placed upon the part from 
 
192 MINOR SURGERY. 
 
 which the blood is to be drawn, and confined to this place 
 by inverting a tumbler or glass jar over him ; if he does 
 not bite or take hold, a little milk or blood should be 
 smeared upon the surface, which will generally secure the 
 desired result. As soon as the leech has ceased to draw 
 blood he is apt to let go his hold and fall off; if, however, 
 it is desired to remove leeches, they may be made to let go 
 their hold by sprinkling them with a little salt. After the 
 removal of leeches bleeding from the bites maybe encour- 
 aged, if desirable, by the application of warm fomenta- 
 tions. Leech-bites should be washed with a bichloride or 
 carbolic solution, and a compress of bichloride or iodoform 
 gauze should be placed over them and secured by a bandage. 
 
 It sometimes happens that free bleeding continues from 
 the leech-bite after the removal of the leeches ; in this 
 event, if a compress does not control the hemorrhage, the 
 bleeding point should be touched with a stick of nitrate of 
 silver or with the point of a steel knitting-needle heated 
 to a dull-red heat, and if this fails to control the bleeding 
 a delicate harelip pin should be passed through the skin 
 under the bite and a twisted suture should be thrown 
 around this; the wound should then be washed and 
 dressed as previously described. 
 
 In applying leeches in or near mucous cavities care 
 should be taken to see that they do not escape into the 
 cavities and pass out of reach. Leeches should not be 
 employed directly over inflamed tissue, but should be ap- 
 plied to parts surrounding it ; they should not be allowed 
 to take hold directly over a superficial artery, vein, or 
 nerve, and should never be applied to a part where there 
 is delicate skin and a large amount of loose cellular tis- 
 sue, as in the eyelid or scrotum, as unsightly ecchymoses 
 will result, which will persist for some time. Leeches 
 should not be used a second time. 
 
 Mechanical Leech. 
 
 The mechanical leech is an apparatus which has been 
 constructed to take the place of the leech ; it consists of a 
 
VENESECTION. 
 
 193 
 
 scarificator, cup, and exhausting- syringe or air-pump. 
 (Fig. 120.) In using this apparatus, after the scarificator 
 has been used the piston of the exhausting- 
 instrument should be drawn out slowly, fig. 120. 
 which secures a better flow of blood than if 
 a sudden vacuum is made. 
 
 The mechanical leech may be employed 
 when the natural leech cannot be obtained, 
 but possesses no advantage over the latter, 
 and is apt to get out of order if not in con- 
 stant use. 
 
 Venesection. 
 
 Venesection, as its name implies, consists 
 in the division of a vein, and it is the ordi- 
 nary operation by which general depletion 
 or bleeding is accomplished. Venesection 
 at the bend of the elbow is the operation 
 which is now usually resorted to for general 
 bloodletting ; the vein selected is the median 
 cephalic, which is further from the line of 
 the brachial artery than the median basilic 
 vein. (Fig. 121.) 
 
 To perform venesection the surgeon re- teech. 
 
 quires a bistoury or lancet — the spring lan- 
 cet was formerly much used, but it is not employed at 
 the present time — several bandages, a small antiseptic 
 dressing, and a basin to receive the blood. 
 
 The patient's arm should be carefully cleansed, washed 
 over with a bichloride solution, and a few turns of a roller 
 bandage should be placed around the middle of the arm, 
 being applied tightly enough to obstruct the venous circu- 
 lation and make the veins below become prominent, but 
 not tight enough to obstruct the arterial circulation. The 
 patient at the same time should be instructed to grasp a 
 stick or a roller bandage and work his fingers upon it. 
 The surgeon should next assure himself that there is no 
 abnormal artery beneath the skin, and having selected the 
 vein, the median cephalic by preference, he then steadies 
 
194 MINOR SURGERY. 
 
 the vein with his thumb and passes the point of the bis- 
 toury or lancet beneath it and cuts quickly outward, mak- 
 ing a free skin opening. The blood usually escapes freely, 
 and the amount withdrawn is regulated by the condition 
 of the pulse and the appearance of the patient. For this 
 reason it is better to have the patient sitting up or semi- 
 reclining when venesection is performed, as the surgeon 
 can judge better as to the constitutional effects of the loss 
 of blood while the patient is in this position. 
 
 When a sufficient quantity of blood has been removed, 
 the thumb is placed over the wounded vein and the 
 bandage is removed from the arm above. The wound is 
 next washed with a bichloride solution, and a compress of 
 
 Fig. 121. 
 
 Venesection. (Heath.) 
 
 antiseptic gauze is applied over the wound and held in 
 position by a bandage which should be so applied as to 
 envelop the limb from the fingers to the axilla. The 
 dressing need not be disturbed for five or six days, at 
 which time the wound is usually found to be healed. 
 
 Wounds of the brachial artery have occurred in opening 
 the vein at the bend of the elbow ; but if care is taken, this 
 accident should not take place. 
 
 Venesection may be practised on the external jugular 
 vein when, from excess of fat or in the case of children, the 
 veins at the bend of the elbow cannot be easily found. The 
 vein is rendered prominent by placing the thumb or a pad 
 over the vein at the outer edge of the sterno-cleido-mastoid 
 muscle just above the clavicle. The vein is next opened 
 
TRANSFUSION OF BLOOD. 195 
 
 over this muscle by an incision parallel to its fibres. After 
 a sufficient quantity of blood has escaped, the wound is 
 washed with an antiseptic solution and closed by a com- 
 press of antiseptic gauze held in position by a bandage 
 carried around the neck. 
 
 Bleeding from this vein has been advocated in cases of 
 apoplexy and cerebral inflammation, but it is questionable 
 whether any advantage is gained by opening the external 
 jugular vein rather than the vein at the bend of the elbow. 
 
 The internal saphenous vein is also sometimes selected for 
 venesection, and here care should be taken not to wound the 
 accompanying nerve which lies directly behind the vein. 
 
 Arteriotomy. 
 
 This operation is now scarcely ever performed, but if 
 done the vessel generally selected is the anterior branch of 
 the temporal artery. The position of the vessel is fixed by 
 the finger and thumb, and it is opened by a transverse in- 
 cision with a bistoury. After a sufficient quantity of blood 
 has escaped the wound is inspected, and if the vessel is not 
 completely divided, its division is completed and the ends 
 of the vessel should be secured with ligatures, and the 
 wound should be washed out with an antiseptic solution. 
 A gauze compress should next be applied and held in 
 position by a firmly applied bandage. 
 
 Transfusion of Blood. 
 
 This operation may be employed to introduce a certain 
 quantity of blood into the circulation of a patient who has 
 suffered from profuse hemorrhage. There are two methods 
 by which transfusion may be effected : the direct, by which 
 the blood is conveyed directly and without exposure to the 
 air from the bloodvessel of one person to that of another, 
 and the indirect, in which the blood is first drawn from 
 one person and is then injected into the veins of another, 
 being first deprived of its fibrin before being injected. 
 
196 MINOR S URGER Y. 
 
 Direct Transfusion of Blood. 
 
 This is best accomplished by using Aveling's apparatus, 
 which consists of a rubber tube, about eighteen inches in 
 length, with a small bulb in the centre, having metallic 
 extremities provided with stop-cocks, and two bevel-pointed 
 metallic canulse to be used to connect the tube with the 
 bloodvessels. In performing the operation of direct trans- 
 fusion the bulb and tube are first placed in a shallow basin 
 containing warm normal saline solution (0.7 percent.), and 
 the bulb and tube are filled with this solution to displace 
 any air which they may contain. The person supplying 
 the blood places his arm near the arm of the patient, and 
 the operator exposes a prominent vein on the patient's arm 
 at the bend of the elbow, opens it, and inserts into it one 
 of the canulse filled with saline solution, with the point 
 directed toward the body, and at the same time an assistant 
 should introduce the other canula into a vein at the bend 
 of the elbow of the party who supplies the blood. 
 
 The canulse are held in position by assistants, and the 
 tube is quickly connected with them, the stop-cocks being 
 closed before it is taken out of the saline solution, to pre- 
 vent the entrance of air ; then upon opening the stop-cocks 
 a direct communication is established between the circula- 
 tion of the patient and that of the person who supplies 
 the blood. (Fig. 122.) The introduction of the contents 
 of the bulb into the vein of the patient is effected by the 
 operator slowly compressing the bulb with one hand, while 
 he keeps the tube closed on the side of the donor with the 
 finger and thumb of the other hand. By relaxing the 
 pressure on the tube on the donor's side of the bulb and 
 closing it on the patient's side, blood will flow from the 
 donor's vein into the bulb as it slowly expands, and when 
 filled the communication with the patient's circulation is 
 again made, and the manipulation is repeated until a suffi- 
 cient quantity of blood has been introduced as indicated by 
 the condition of the patient's pulse. 
 
 The quantity of blood or saline solution introduced can 
 be calculated by remembering that at each emptying of 
 
TRANSFUSION OF BLOOD. 
 
 197 
 
 the bulb two drachms of fluid are introduced into the cir- 
 culation. When a sufficient quantity has been introduced 
 
 Fig. 122. 
 
 Apparatus for the direct transfusion of blood. 
 
 the canuke are removed and the wounds are dressed as 
 ordinary venesection-wounds. 
 
 Indirect Transfusion of Blood. 
 
 Indirect transfusion of blood is accomplished by with- 
 drawing from a vein of the donor by venesection about ten 
 ounces of blood, which is received in a clean glass or porce- 
 lain vessel, which is placed in water at a temperature of 
 110°. The blood thus kept warm is next defibrinated by 
 whipping it with a bundle of broom straws or a wire brush, 
 and after being filtered through a fine linen cloth or wire 
 strainer, it is injected by means of an ordinary syringe 
 attached to a canula which has previously been inserted 
 into a vein of the patient ; care should be taken that no 
 air is introduced with the blood. When a sufficient 
 quantity of blood has been introduced, the canula is re- 
 moved and the wound is dressed in the usual manner. 
 
198 
 
 MINOR SURGERY. 
 
 The success of this operation largely depends upon the 
 expedition with which it is performed ; to prevent the 
 coagulation of the blood not more than two minutes should 
 be allowed to intervene between the reception of the blood 
 in the syringe and its introduction into the patient's vein. 
 
 Fig. 123. 
 
 Apparatus for the indirect transfusion of blood. 
 
 Various forms of apparatus have been devised for the 
 operation of indirect transfusion of blood, and of these one 
 of the best is that devised by Dr. J. G. Allen and modified 
 by the late Dr. C. T. Hunter. (Fig. 123.) 
 
 Arterial Transfusion. 
 
 This procedure, which consists in injecting defibrinated 
 venous blood into an artery, is occasionally practised. An 
 artery, usually the radial at the wrist or the. posterior 
 tibial behind the inner malleolus, is exposed and secured 
 by a ligature ; it is then opened on the distal side of the 
 ligature and the point of a canula or the nozzle of a syrinze 
 is introduced, directed toward the distal extremity of the 
 limb, and blood, which has been previously defibrinated, 
 is slowly injected. When a sufficient quantity has been 
 introduced the canula is removed, and the division of the 
 artery is completed and its extremities are secured by liga- 
 tures, and the wound is closed and dressed. 
 
INTRA VENO US INJECTION OF SALINE SOL UTION 199 
 
 Auto-transfusion. 
 
 This procedure is recommended in cases of excessive 
 hemorrhage to support a moribund patient until other 
 means of resuscitation can be adopted. It consists in the 
 application of rubber bandages or of muslin bandages to 
 the extremities for the purpose of forcing the blood toward 
 the vascular and nervous centres. 
 
 Intravenous Injection of Saline Solution. 
 
 It has been proved by experiments and by clinical 
 experience that human blood is not more efficacious in 
 supplying volume to and restoring a rapidly failing circu- 
 lation than normal salt solution, and as the latter can be 
 
 Fig. 124. 
 
 Funnel and tube for intravenous injection. 
 
 obtained with much more ease than blood, its use has largely 
 superseded the former. The saline solution which is found 
 most satisfactory to employ for this purpose is known as 
 normal saline solution (0.7 per cent.). It is prepared by 
 adding sodii chloride, 5iss, sodii bicarb., grs. xv, to dis- 
 
200 MINOR SURGERY. 
 
 tilled water, Oij. In emergencies a solution prepared by 
 adding a drachm of common salt to a pint of water, which 
 has been sterilized by boiling, will be equally satisfactory. 
 
 The solution should be prepared with water which has 
 been boiled to sterilize it, and should be of a temperature 
 of about 100° when used. 
 
 A vein of the patient, at the elbow, should be exposed 
 and should have placed under it, about one-half inch apart, 
 two catgut ligatures ; the distal ligature is then tied and 
 an opening is made into the vein between the ligatures; a 
 canula is next inserted into the opening in the vein, and 
 is secured in position by tying the proximal ligature. The 
 canula is first filled with the saline solution, and is then 
 connected with a funnel by means of a rubber tube (Fig. 
 124), which is filled with saline solution to displace the 
 air, and upon raising the funnel above the part the solu- 
 tion enters the vein ; care should be taken to see that the 
 funnel is kept well supplied with solution until a sufficient 
 quantity has been introduced. The quantity introduced 
 is regulated by the condition of the patient's pulse. 
 
 Saline solution may also be introduced into a vein by 
 means of a syringe when the apparatus described cannot 
 be obtained, or normal salt solution may be introduced 
 into the cellular tissue by means of hypodermic injections, 
 or the needle may be introduced into the cellular tissue 
 and connected by a piece of rubber tubing with an irri- 
 gator containing normal salt solution held above the part, 
 and the solution allowed to find its way gradually into the 
 subcutaneous cellular tissue. A large quantity of fluid 
 may be introduced in this way. 
 
 Intravenous Injection of Milk. 
 
 The intravenous injection of cow's or goat's milk has also 
 been employed as a substitute for the transfusion of blood 
 in patients who have suffered from excessive hemorrhage 
 or from diseases which greatly deteriorate the quality of 
 the blood, such as pernicious anaemia, typhoid fever, and 
 in carbolic acid poisoning. In making one of these injec- 
 
ARTIFICIAL RESPIRATION. 201 
 
 tions the milk should be fresh and should be warmed and 
 strained through a fine wire or linen strainer. It should 
 then be introduced by means of a canula inserted into a vein 
 and secured in position by a ligature ; to this canula are at- 
 tached the rubber tubing and funnel, such as are employed 
 in the intravenous injection of saline solution. The 
 funnel and tube are next filled with milk prepared as 
 above described, and it is made to enter the vein of the 
 patient by turning the stop-cock and raising the funnel 
 above the patient' s body. This injection has been em- 
 ployed in the class of cases mentioned above with appar- 
 ently beneficial results. 
 
 Artificial Respiration. 
 
 This procedure is resorted to in cases of threatened 
 death from apnoea consequent upon drowning, profound 
 anesthetization or the inhalation of irrespirable gases, or 
 when from any cause there is interference with the func- 
 tion of breathing. Before resorting to artificial respiration 
 care should be taken to see that nothing is present in the 
 mouth or air-passages which will obstruct the entrance of 
 air into the lungs, such as mucus, foreign bodies or liquids, 
 and also that all tight clothing interfering with the free 
 expansion of the chest-walls should be removed from the 
 chest. 
 
 In cases where the apnoea is due to the presence of a 
 foreign body in the larynx or trachea it is evident that 
 no efforts at respiration can be successful until the air- 
 passages are freed from the occluding body ; and if it can- 
 not be removed through the mouth, tracheotomy should be 
 performed before artificial respiration is attempted ; the 
 tracheal wound should be held open by retractors, which 
 in a case of emergency can be made from bent hairpins, or 
 by a tracheotomy-tube, if one be at hand. 
 
 When artificial respiration is resorted to the operator 
 should persevere with it for some time, even when no 
 apparent spontaneous respiratory movements are excited ; 
 for resuscitation has been accomplished in seemingly hope- 
 
202 MINOR SURGERY. 
 
 less cases by patient perseverance with the manipula- 
 tions. 
 
 When the first natural respiratory movement is detected 
 the operator should not cease making artificial respiration, 
 but should continue these movements in such a way as to 
 coincide with the spontaneous inspiratory and expiratory 
 movements until the breathing has assumed its regular 
 character. 
 
 The temperature of the body should also be restored by 
 frictions to the surface of the body by the hands or by 
 rough towels and hot-water bottles, and warm coverings 
 should be applied for the same object. 
 
 Mouth-to-mouih Inflation. 
 
 This method of artificial respiration has been resorted 
 to in cases of great emergency, especially in very young 
 children. The operator draws the tongue forward, closes 
 the nostrils, and applies his mouth directly to the mouth 
 of the patient, and by a deep expiratory effort endeavors 
 to force air into the chest ; when this is accomplished the 
 air can be expelled from the lungs by pressure upon the 
 walls of the chest, and the procedure should be repeated 
 about sixteen times in a minute. The same object may be 
 accomplished by passing a flexible catheter into the trachea 
 through the mouth, or by passing an intubation-tube, to 
 the upper part of which a rubber tube is attached, into 
 the larynx ; this can be passed with the fingers without 
 difficulty, and the lungs can then be inflated by the opera- 
 tor blowing into the catheter or tube, or by attaching to 
 it a pair of bellows. 
 
 Inflation of the lungs through the nostrils has been 
 employed by Dr. Richardson, of London, who has devised 
 a pocket-bellows for this object. The apparatus consists of 
 two elastic bulbs, to which two rubber tubes are attached, 
 which terminate in a single tube. In using this bellows 
 the terminal tube is introduced into one nostril, the other 
 nostril and mouth being closed; air is forced into the 
 lungs by compressing one bulb, and withdrawn by com- 
 pressing the other bulb. (Fig. 125.) 
 
ARTIFICIAL RESPIRATION. 203 
 
 This bellows may also be attached to a catheter or in- 
 tubation-tube passed into the larynx, which would prevent 
 the possibility of air escaping into the oesophagus, a com- 
 
 FlG. 125. 
 
 Richardson's bellows for artificial respiration. 
 
 plication which is liable to occur in mouth-to -mouth infla- 
 tion or inflation through the nose. 
 
 Direct Method of Artificial Respiration (Howard's). 
 
 This method of artificial respiration is at the present time 
 considered the most efficacious, and is the one adopted by 
 the United States Life-saving Service, and although the 
 rules given are for the resuscitation of cases of apparent 
 drowning, the same procedures may be adopted in cases of 
 apnoea arising from other causes. 
 
 The rules laid down by Dr. How r ard are as follows : 
 
 Rule I. — " To expel water from the stomach and lungs, 
 strip the patient to the waist, and if the jaws are clenched 
 separate them and keep them apart by placing between the 
 teeth a cork or a small piece of wood. Place the patient 
 face downward, the pit of the stomach being raised above 
 the level of the mouth by a large roll of clothing placed 
 beneath it. (Fig. 126.) Throw your weight forcibly two 
 or three times upon the patient's back over the roll of 
 clothing so as to press all fluids in the stomach out of the 
 mouth. " 
 
 The first rule applies only to eases of drowning, and in 
 
204 
 
 MINOR SURGERY. 
 
 using Howard's method in apnoea from other causes it is 
 to be omitted. 
 
 Fig. 126. 
 
 First manipulation in Howard's method. 
 
 Rule II — " To perform artificial respiration, quickly 
 turn the patient upon his back, placing the roll of clothing 
 
 Fig. 127. 
 
 Direct method of artificial respiration. 
 
 beneath it so as to make the breast-bone the highest point 
 of the body. Kneel beside or astride of the patient's hips. 
 
ARTIFICIAL RESPIRATION. 205 
 
 Grasp the front part of the chest on either side of the pit 
 of the stomachy resting the fingers along the spaces between 
 the short ribs. Brace your elbows against your sides, and 
 steadily grasping and pressing forward and upward throw 
 your whole weight upon the chest, gradually increasing 
 the pressure while you count one — two — three. Then sud- 
 denly let go with a final push which springs you back to 
 your first position. (Fig. 127.) Rest erect upon your knees 
 while you count one — two ; then make pressure again as 
 before, repeating the entire motions at first about four or 
 five times a minute, gradually increasing them to about 
 ten or twelve times. Use the same regularity as in blowing 
 bellows and as seen in the natural breathing which you are 
 imitating. If another person is present, let him with one 
 hand, by means of a dry piece of linen, hold the tip of the 
 tongue out of one corner of the mouth, and with the other 
 hand grasp both wrists and pin them to the ground above 
 the patient's head." 
 
 This method may be employed in cases of still-birth, or 
 in young children, the operator holding the chest of the 
 child in his left hand and compressing it with the right 
 hand. 
 
 Sylvester's Method of Artificial Respiration. 
 
 In employing this method of artificial respiration the 
 patient should be placed on his back upon a firm, flat sur- 
 face ; a cushion of clothing is placed under the shoulders, 
 and the head should be dropped lower than the body by 
 tilting the surface on which he is laid. The mouth being 
 cleared of mucus or foreign substances, the tongue is 
 drawn forward and secured to the chin by a piece of tape 
 tied around it and the lower jaw, or may be pulled out of 
 the mouth and held by an assistant. The operator, stand- 
 ing at the patient's head, grasps the arms at the elbows 
 and carries them first outward and then upward until the 
 hands are brought together above the head ; they should 
 be kept in this position for two seconds, after which time 
 they are brought slowly back to the sides of the thorax 
 
 10 
 
206 
 
 MINOR SURGERY. 
 
 and pressed against it for two seconds. These movements 
 are repeated fifteen times in a minute until the breathing is 
 restored, or until it is evident that the case is a hopeless one. 
 
 Fig. 128. 
 
 Sylvester's method— Inspiration. (Esmarch.) 
 Fig. 129. 
 
 Sylvester's method— Expiration. (Esmarch.) 
 
ARTIFICIAL RESPIRATION. 207 
 
 Marshall HalPs Ready Method of Artificial Respiration. 
 
 In this method the mouth should first be freed from 
 mucus or foreign bodies, and the patient is turned upon 
 his face with one wrist under his forehead, and a roll of 
 clothing is placed beneath his chest. By turning the body 
 briskly on the side and a little beyond, and then on the 
 face, alternately, respiration is imitated. As the body is 
 brought in the prone position, compression is to be made 
 upon the posterior aspect of the chest. These manipula- 
 tions should be made fifteen times in a minute. 
 
 Laborde 1 s Method of Artificial Respiration by Rhythmical 
 Traction upon the Tongue. 
 
 Laborde has shown that systematic and rhythmic traction 
 upon the tongue is a powerful means of restoring the respi- 
 ratory reflex, and consequently the function of respiration. 
 The procedure is accomplished as follows : The body of 
 the tongue is seized between the thumb and fingers, and 
 traction is made upon it, with alternate relaxation fifteen 
 or twenty times a minute, imitating the function of respi- 
 ration, taking care to draw well on the tongue. When a 
 certain amount of resistance is felt it is a sign that the 
 respiratory function is being restored. Noisy respiration 
 first occurs, termed by Laborde " hoquet inspirateur " (in- 
 spiratory hiccough). Tongue forceps or dressing or haem- 
 ostatic forceps may be used in place of the fingers to 
 grasp the tongue. It is important to persist in the manipu- 
 lations for half an hour to an hour, unless the case is abso- 
 lutely hopeless. This procedure has been employed with 
 success in cases of drowning, toxic asphyxia, chloroform 
 asphyxia, and arrest of inspiration from electric shock. 
 
 Forced Respiration. 
 
 By this method of artificial respiration air is for- 
 cibly passed into the lungs. This procedure is strongly 
 
208 MINOR SURGERY. 
 
 advocated by Dr. George E. Fell, who has devised 
 an apparatus by which it may be satisfactorily accom- 
 plished. Prof. H. C. Wood has also made use of forced 
 respiration in the resuscitation of animals with an appa- 
 ratus somewhat similar to that devised by Dr. Fell with 
 good results, but has never applied it practically in the 
 case of the human subject. Wood's apparatus consists of 
 a pair of bellows, a few feet of rubber tubing and a face 
 mask of rubber, and one or two intubation-tubes; the 
 mask or intubation -tube is attached to one end of the rub- 
 ber tube and the bellows to the other end of the tube. 
 The mask is applied over the mouth, or, if this is not used, 
 the intubation-tube is introduced into the larynx, and air 
 is forced into the lungs by working the bellows. He also 
 advises that in the tubing a double metal tube be intro- 
 duced, with the openings so placed that their size can be so 
 regulated by turning the outer tube that the operator can 
 allow any excess of air thrown by the bellows to escape. 
 
 The apparatus of Fell, which he has used in a number 
 of cases with good results, consists of a tracheotomy-tube, 
 a tube connected with the air-control valve, which is 
 attached to an air-warming apparatus, which in turn is 
 connected with a bellows by another tube. By means of 
 this apparatus air is forced into the lungs and allowed to 
 escape when the lungs have been expanded by the elasticity 
 of the lung tissue and the chest walls. 
 
 Forced respiration will prove of value in cases of nar- 
 cotic poisoning and other accidents in which death is pro- 
 duced by paralysis of the respiratory centres. Dr. Fell 
 has reported a number of cases of narcotic poisoning in 
 which he has used his apparatus with the most satisfactory 
 results. 
 
 Aspiration. 
 
 This procedure is adopted to remove fluid from a closed 
 cavity without the admission of air, and the instrument 
 which is employed to accomplish this object is known as 
 an aspirator. The two forms of aspirator most generally 
 employed are those of Dieulafoy and Potain. 
 
ASPIRATION. 
 
 209 
 
 Potain's aspirator consists of a glass bottle, into the 
 stopper of which is introduced a metallic tube, which is 
 connected with two rubber tubes, one of which is con 
 nected with an exhausting-pump, and the other with a 
 delicate canula carrying a fine trocar ; the apparatus is 
 provided with stop-cocks to prevent the admission of air. 
 (Fig. 130.) In using this aspirator the air is exhausted 
 from the bottle by using the air-pump ; the canula enclosing 
 the trocar is next pushed through the tissues into the cavity 
 containing the fluid to be removed ; the trocar is then re- 
 
 FlG. 130. 
 
 Potain's aspirator. 
 
 moved, and upon opening the stop-cock the fluid is forced 
 out of the cavity by atmospheric pressure and passes into 
 the bottle or receiver. If the fluid contains masses of 
 lymph or clots which block the canula, interrupting the 
 flow of fluid, a stylet may be passed through the canula 
 to free it from the obstruction. 
 
 To diminish the pain produced in introducing the trocar 
 and canula, the skin at the point to be punctured may be 
 rendered less sensitive by holding in contact with it for a 
 few minutes a piece of ice wrapped in a towel, or a towel 
 
210 MINOR SURGERY. 
 
 containing broken ice and salt. Care should also be taken 
 to see that the trocar and canula are perfectly clean ; to 
 accomplish this it should be carefully washed and placed 
 in boiling water or a 5 per cent, carbolic solution before 
 being used. 
 
 In introducing the trocar and canula the operator should 
 be careful to avoid injuring any important veins, arteries, 
 or nerves. 
 
 After removiog the canula the small puncture should 
 be dressed with a compress of antiseptic or iodoform gauze 
 held in place by a bandage or adhesive straps. 
 
 The aspirator is frequently employed in cases of hydro- 
 thorax, empyema, and ascites, to evacuate the contents 
 of cold abscesses in diseases of the hip and spine, and to 
 remove the contents of a distended bladder until a more 
 radical operation can be performed. It is also a valuable 
 instrument for diagnostic purposes, being frequently used 
 to ascertain the character of the contents of deep-seated 
 tumors containing fluid. 
 
 The Stomach-tube. 
 
 This consists of a tube about twenty-eight inches in 
 length and three-eighths of an inch in diameter, which is 
 introduced while the patient is in the sitting posture, the 
 head being thrown backward so as to bring the mouth and 
 gullet as nearly as possible in the same line. The tube 
 being warmed and oiled, the surgeon standing in front ot 
 the patient passes it directly back to the pharynx, at the 
 same time introducing the index finger of the left hand to 
 guide its point over the epiglottis ; it is then passed gently 
 downward into the stomach. If any obstruction is met 
 with in its passage, it should be withdrawn a little way and 
 then pushed gently downward ; all manipulations should 
 be made without much force to prevent perforation of the 
 wall of the oesophagus. 
 
 The introduction of the stomach-tube may be required 
 for the evacuation of poisons from the stomach, or to wash 
 
THE STOMACH-PUMP. 211 
 
 out the cavity of this viscus. It may also be used to 
 introduce liquid nourishment into the stomachs of patients 
 who are unable or unwilling to swallow food. In the 
 recently introduced method of treating disorders of the 
 stomach and intestines by washing them out, lavage, the 
 introduction of a stomach-tube is required ; the tube here 
 employed is from twenty-four to thirty inches in length 
 (Fig. 131), and the fluid is introduced by means of a funnel 
 attached to its free extremity, or it may be attached to a 
 stomach-pump. In introducing liquid nourishment a 
 syringe or funnel is fitted to the exposed end of the tube 
 which has been passed into the stomach ; the syringe or 
 
 Fig. 131. 
 The stomach-tube. 
 
 funnel having been filled with milk or beef-tea or broth, 
 the contents are injected gently or allowed to run into the 
 stomach. 
 
 In cases of poisoning, where it is desirable to withdraw 
 the contents of the stomach and to wash out the organ, a 
 stomach-tube and syringe may be employed ; several 
 syringefuls of warm water are first thrown into the 
 stomach and then withdrawn by suction, but in such 
 cases the use of the stomach-pump will be found more 
 satisfactory. 
 
 The Stomach-pump. 
 
 This consists of a brass syringe, the nozzle of which is 
 connected with two tubes, one at the end, the other at the 
 side. The passage through the nozzle is regulated by a 
 valve controlled by a lever. The nozzle of the pump is 
 attached to a stomach-tube, and the end of the lateral tube 
 is placed in a pan of warm water. By raising the piston 
 and opening the valve, water may be drawn from the basin, 
 and by closing the valve and depressing the piston it is 
 
212 
 
 MINOR SURGERY. 
 
 passed through the stomach -tube into the stomach ; when 
 a sufficient quantity has been injected in this manner, by 
 reversing the action of the valve the fluid is drawn out of 
 the stomach and discharged through the lateral tube into 
 a basin. This manipulation is continued until the water 
 returns clear and the stomach has been completely washed 
 out. A less complicated instrument w r ill often serve as 
 well as that just described (Fig. 132). 
 
 Fig. 132. 
 
 Stomach-pump. 
 
 (Esophageal Bougie. — This instrument — which may be 
 passed through the oesophagus into the stomach for the 
 purpose of diagnosis, or for the purpose of dilating stric- 
 tures of the oesophagus — is passed in exactly the same 
 manner as the stomach-tube, and, as in the case of the 
 latter instrument, it should be introduced without the use 
 of much force, as perforations of the oesophagus have fol- 
 lowed the forcible introduction of such bougies. 
 
 Vaccination. 
 
 This is a minor surgical procedure which every physi- 
 cian is called upon to perform. The surface may be pre- 
 pared for the reception of the lymph by abrading the 
 
VACCINATION. 213 
 
 surface of the skin at one or two points with a dull lancet, 
 or by making several superficial incisions with a knife, or 
 by scratching the surface of the skin with the ivory-point 
 charged with lymph, in lines with crossing lines, cross- 
 scratch, until a little serum exudes. It is not advisable to 
 draw blood, which washes away the lymph, and for this 
 reason I prefer the abraded surface made by the dull knife 
 or the ivory-point. 
 
 The lymph used may be the humanized or the bovine. 
 The humanized lymph may be the viscid fluid taken from 
 the vaccine vesicle on the eighth or ninth day, or the dried 
 scab w r hich separates when the wound is about healed ; if 
 the latter is used, a small portion of it is rubbed up with 
 water until it forms a mixture of creamy consistence ; this 
 is rubbed into the abraded surface of the punctures. In 
 using humanized lymph care should be taken to see that 
 it is procured from a healthy subject. 
 
 Bovine lymph or virus, which is now most generally em- 
 ployed, is taken from the vaccine vesicles upon the udders 
 and teats of heifers ; ivory-points or quills are dipped into 
 this lymph and allowed to dry, and in using them they 
 are dipped in water for a moment, to moisten the lymph, 
 before being applied to the abraded surface. The ivory- 
 point is one of the most convenient means of vaccination, 
 as the surface may be abraded with it before the lymph is 
 applied. 
 
 It has recently been advised that antiseptic precautions 
 be exercised in performing vaccination, and although all 
 of the details cannot be carried out, I have found that the 
 exercise of care as regards cleanliness of the surface has 
 been followed by much fewer inflammatory complications 
 in vaccination-wounds. In an institution in which I 
 vaccinated yearly a large number of cases, since I have 
 adopted the following precautions I have had fewer bad 
 arms. 
 
 The surface to be abraded, usually the left arm below the 
 deltoid, is first washed with soap and water, and then with 
 a 1 : 2000 bichloride solution. Two points of this surface, 
 an inch apart, are then abraded by using a knife which has 
 
 10* 
 
214 MINOR SURGERY. 
 
 been washed or dipped in boiling water, or by using the 
 ivory-point which has been dipped in water which has 
 been boiled and cooled down. When the surface has been 
 prepared in the manner described, the moistened virus is 
 rubbed upon it and allowed to dry. Vaccination upon 
 the leg, which is practised by some physicians to prevent 
 the scar from showing, I think is not to be recommended, 
 and I never practise it in this situation, as it is more diffi- 
 cult to keep this part at rest, and I have seen some very 
 severe cases of cellulitis and phlebitis follow leg vaccination. 
 
 Hypodermic Injections. 
 
 The syringe used to make hypodermic injections is pro- 
 vided with a perforated needle, which is passed into the 
 cellular tissue. (Fig. 133.) Care should be taken to see 
 
 Fig. 133. 
 
 Hypodermic syringe and needles. 
 
 that the instrument and needle are perfectly clean before 
 being used; if a metallic syringe is employed, it should 
 be rendered aseptic by soaking it for a few minutes in 
 boiling water or in a five per cent, carbolic solution. 
 Hypodermic injections are generally made into parts in 
 which the cellular tissue is abundant, and great care should 
 be observed to avoid introducing the needle into a large 
 vein or artery, as by neglect of this precaution serious 
 symptoms have resulted, from the drug being thrown 
 
HYPODERMIC INJECTIONS. 215 
 
 rapidly into the circulation instead of being slowly ab- 
 sorbed from the subcutaneous cellular tissue ; the injury of 
 superficial nerves should also be avoided. Care should 
 also be taken to see that the solutions employed are 
 sterilized if possible, and freshly made solutions should be 
 preferred. 
 
 An unclean syringe or a solution which has not been 
 sterilized may give rise to a troublesome abscess at the site 
 of the injection. 
 
 To avoid using solutions for hypodermic use which un- 
 dergo change from being kept, it will be found convenient 
 to use the compressed pellets which are prepared by the 
 manufacturing chemists, the alkaloids being compressed 
 with a little sulphate of sodium, which increases their 
 solubility, the solution being prepared with boiled water 
 just before being used. 
 
 Fig. 134. 
 
 Method of giving a hypodermic injection. 
 
 The portions of the body usually selected for hypodermic 
 injection are the outer surface of the thighs or arms and 
 the anterior surface of the forearm. In making a hypo- 
 dermic injection the syringe is charged and the needle is 
 fastened to the nozzle of the syringe ; the skin is next 
 pinched up and the needle is quickly thrust through this 
 into the cellular tissue ; the syringe is then emptied by 
 pressing down the piston, and when the cylinder is empty 
 the needle is withdrawn ; the small puncture in the skin 
 resulting seldom bleeds and usually heals without diffi- 
 culty. (Fig. 134.) 
 
 In the treatment of disease by the injection of serum the 
 
216 
 
 MINOR SURGERY. 
 
 hypodermic method is made use of; in using antitoxin 
 injections in diphtheria the dose of the antitoxin is pro- 
 portionate to the age and weight of the patient as well as the 
 severity and duration of the disease. A child three years 
 old should be given 600-1000 units ; an adult, not less 
 than 1000 units, and the injection should be repeated in 
 twelve to twenty-four hours. Before employing the in- 
 iection the skin should be sterilized, and the best variety 
 of syringe to employ is one holding about 20 c.c. (Fig. 
 
 Fig. 135. 
 
 H. K. MULFORD CO., PHILADA. 
 
 Syringe for serum-injection. 
 
 135). It is well to have the needle connected with the 
 syringe by a short rubber tube, so that the needle will not 
 be broken if the patient straggles. The injections are 
 usually made below the angle of the scapula or in the 
 lumbar region, and the serum is introduced slowly to 
 avoid local reaction. 
 
 EXPLORING-NEEDLE. 
 
 This consists of a fine-grooved needle fitted into a handle 
 (Fig. 136), which is introduced into tumors or swellings 
 
 Fig. 136. 
 
 Exploring-needle. 
 
 to ascertain the nature of their contents, and its use is often 
 of service for purposes of diagnosis. The exploring-trocar 
 
SKIN-GRAFTING. 217 
 
 (Fig. 137) is employed for the same purpose, or the needle 
 of the hypodermic syringe or a fine needle attached to an 
 aspirator may be used for a like purpose. When either 
 the exploring needle or trocar is employed care should be 
 taken to see that it is rendered perfectly aseptic before 
 
 Fig. 137. 
 
 Exploring-trocar. 
 
 being used ; otherwise its employment is not without 
 danger, for I have seen the introduction of an exploring- 
 needle into an effusion in a joint for diagnostic purposes 
 followed by suppuration and destruction of the joint, which 
 subsequently necessitated its excision. 
 
 Skin-grafting. 
 
 This is a minor surgical procedure which may be em- 
 ployed to hasten cicatrization w T here large granulating 
 surfaces are exposed, such as result from extensive opera- 
 tions and from burns. 
 
 The operation consists in applying shavings of the epi- 
 dermis or of the epidermis and cutis together, to the granu- 
 lating surface and holding them in contact with it for a 
 few days ; the grafts often seem to disappear, but at the 
 end of a few days, if the part is closely inspected, bluish- 
 w T hite points will be seen to occupy the positions at which 
 the grafts are applied, which become converted into iso- 
 lated cicatrices from which the healing process rapidly 
 extends. To have a successful result follow the use of 
 skin-grafts the surface of the ulcer should be healthy, and 
 its surface as well as the surrounding skin should be 
 rendered aseptic, and the grafts should be applied at a 
 number of points. 
 
 The surface from which the grafts are to be taken should 
 also be rendered aseptic, and the skin should be removed by 
 
218 MINOR SURGERY. 
 
 scissors made for this purpose (Fig. 138), or by raising the 
 epidermis with a needle or with forceps and cutting out a 
 small portion of it with a sharp scalpel. The graft is 
 next applied to the granulating surface with its raw sur- 
 face in contact with the granulations ; after a sufficient 
 number of grafts have been applied, a piece of sterilized 
 protective is laid over them and is held in place by means 
 of a few strips of isinglass plaster. An ordinary anti- 
 septic or sterilized gauze dressing is next applied, and the 
 dressing is not disturbed for a week or ten days, at Avhich 
 time, if the grafts have taken, isolated cicatrices at the 
 points where the grafts were applied will be found to exist. 
 
 Fig. 138. 
 
 Scissors for skin-grafting. 
 
 Thiersch's Method. — In skin-grafting, according to this 
 method, the surface of the ulcer is rendered aseptic, and 
 all antiseptics are washed away with sterilized salt solution. 
 The surface of the ulcer is next curetted to remove soft 
 granulations, and it is then irrigated and covered with pro- 
 tective and a compress is applied to control all bleeding. 
 
 Shavings of skin are then removed from a surface — which 
 has been rendered aseptic — by means of a razor or section 
 knife. Each graft should be as long and broad as possi- 
 ble, and when cut it should he floated from the section 
 knife by a stream of salt solution and placed upon the pre- 
 pared surface of the ulcer and gently pressed into place. 
 
 After a sufficient number of grafts have been applied, 
 strips of protective are laid over the surface of the grafts, 
 and over these is placed a compress moistened with salt 
 
BONE-GRAFTING. 219 
 
 solution and covered by protective, and a few layers of 
 sterilized cotton are next applied over this, and the dress- 
 ing is held in position by a bandage. 
 
 The dressings need not be removed for a week or ten 
 days, and a second dressing should be applied in the same 
 manner until the grafts have become thoroughly vitalized. 
 
 The skin of the belly or backs of frogs, or the hairless 
 skin of young animals may be used in the place of human 
 skin. 
 
 Skin-grafting is sometimes accomplished by applying a 
 large piece of skin to a raw surface to fill a gap ; the graft 
 in such cases includes the whole thickness of the skin, but 
 has all of the cellular tissue removed from it, and is secured 
 in position by sutures. 
 
 Bone-grafting. 
 
 This procedure is resorted to to replace portions of bone 
 which have been separated, to fill up cavities in bone, or 
 to restore the continuity of the long bones. The bone to 
 be introduced should be rendered thoroughly aseptic and 
 should be placed in a sterilized salt solution at a tempera- 
 ture of 100°-105° F. ; it may be inserted in one piece or 
 broken into fragments and laid over the surface. 
 
 When it is desired to restore the continuity of one of 
 the long bones, after the surfaces of the bone have been 
 exposed and rendered aseptic, a bone is removed from a 
 freshly killed animal, is rendered aseptic, and is fitted into 
 the gap or is split into strips and packed into the cavity. 
 
 Bone-grafting may also be very satisfactorily accom- 
 plished by means of Sennas decalcified bone plates or chips, 
 which will be found useful in filling up the cavities result- 
 ing from the operation of trephining or for extensive re- 
 movals of bone in the operations for necrosis or caries. 
 
 In such cases, after the cavity has been sterilized, it is 
 dusted with iodoform and is then packed with bone chips ; 
 iodoform is next dusted over them and a piece of protec- 
 tive is placed upon them. A compress of iodoform gauze 
 
220 MINOR SURGERY. 
 
 and bichloride cotton is next applied, and the dressing is 
 held in position by a bandage. 
 
 When bone plates are employed they are cut to fit the 
 cavity, and provision should be made for drainage. 
 
 Preparation of Decalcified Bone Chips or Plates. — Take 
 the compact tissue of the fresh tibia or femur of an ox, 
 remove the periosteum and medullary tissue, and split in 
 pieces one-half an inch in width, and place them in a 15 
 per cent, watery solution of hydrochloric acid, allowing 
 them to remain in this for three weeks, changing the 
 solution daily. At the end of this time they should be 
 removed, thoroughly washed and cut in thin strips or 
 plates. They should then be washed in a weak solution 
 of caustic potash, and placed for forty-eight hours in a 
 1 : 1000 bichloride solution. 
 
 After this they may be kept in a solution of iodoform 
 in ether, or in a 1 : 500 solution of bichloride in alcohol 
 until required for use ; before being used they are soaked 
 in a 1 : 2000 bichloride solution. 
 
 Muscle-grafting and nerve-grafting are also occasionally 
 resorted to to supply deficiencies in muscles or nerves ; 
 fresh muscle or nerve tissue being employed to fill up the 
 gap. 
 
 Electeolysis. 
 
 Electrolysis, or the chemical decomposition induced by 
 electricity, is employed in surgery to destroy morbid prod- 
 ucts, tumors, or exudations. For this procedure a galvanic 
 or continuous-current battery is required, which is pro- 
 vided with electrodes and needles of suitable shapes. In 
 applying electrolysis to a tumor, for instance, the needle 
 connected with one of the poles of the battery is inserted 
 into the tumor and the other rheophore is applied to the 
 surface of the body, or two fine needles, carefully insulated 
 nearly to their extremities, are connected with both poles 
 of the battery by conducting cords ; these are introduced 
 into the tumor and a weak current is allowed to pass. The 
 strength of the current is gradually increased as the opera- 
 
GALVANO-CAUTERY. § 221 
 
 tion advances ; the current is passed for fifteen or twenty 
 minutes, and the procedure is repeated at intervals of 
 several days, until some decided change occurs in the 
 tumor. 
 
 Electrolysis has been applied with success in the treat- 
 ment of aneurism inaccessible to other operative procedures, 
 in malignant growths, in nsevi, goitres, cysts, and hydatids. 
 It is at the present time the most satisfactory method of 
 removing superfluous hairs from those portions of the body 
 in which their presence causes disfigurement. 
 
 Galvano-cautery. 
 
 Galvano-cautery batteries are constructed with plates of 
 large size, placed closely together, so that the internal re- 
 sistance is reduced and a current is quickly obtained which 
 will keep a metallic electrode at a w T hite heat. The ad- 
 vantage in the use of this form of cautery is that the elec- 
 trode can be introduced into the various cavities of the 
 body while cold and quickly heated to the desired tempera- 
 
 Ftg. 139. 
 
 Electrodes for galvano-cautery. 
 
 ture. The electrodes are made of various shapes and sizes, 
 according to the object desired (Fig. 139). The galvano- 
 cautery is applied for the same purpose as the actual 
 cautery, but, as previously stated, its use is more conve- 
 nient in the various cavities of the body, its action can 
 be more easily localized, and by its use hemorrhage is 
 avoided. It is frequently employed to destroy morbid 
 growths in the nasal passages, the throat, vagina, or uterus, 
 and also may be employed in the treatment of superficial 
 external growths; in using it for the removal of growths 
 
222 MINOR SURGERY. 
 
 from the mucous membrane its application may be ren- 
 dered practically painless by previously thoroughly cocain- 
 izing the parts. 
 
 Faradization. 
 
 The application of electricity in this form is often em- 
 ployed in surgical affections ; in cases of wasting of the 
 muscles following fractures or sprains, in some forms of 
 club-foot, and in lateral curvature of the spine the judi- 
 cious use of the faradic current will often be found to be 
 followed by the most satisfactory results. The current is 
 applied in such a manner as to bring about contraction of 
 the affected or wasted muscles, and thus improve their 
 nutrition. 
 
 Franklinization, or Statical Electricity. 
 
 The earliest application of electricity in the treatment 
 of disease was made by the use of statical electricity, and 
 although it fell into disuse it has recently, with the perfec- 
 tion of modern machines, been very widely revived. In 
 applying statical electricity the patient may be treated by 
 insulation, or the so-called dry electric bath. The second 
 method of using statical electricity is by sparks or shocks 
 from a Leyden jar which is charged from the prime con- 
 ductor of an electrical machine in motion, or by the electric 
 brush. McClure states that in the static induced current 
 we have means of producing muscular contractions when 
 failure results from the strongest faradic currents that can 
 be borne by the patient. 
 
 The Cystoscope. 
 
 This is an instrument employed for ocular examination 
 of the walls of the bladder, and is one of the most impor- 
 tant and useful of the electric-lamp instruments. A cysto- 
 scope consists of a beak-sound in which there is a telescopic 
 arrangement by which the inner surface of the bladder is 
 
THE URETHROSCOPE. 
 
 223 
 
 viewed through a small window of rock crystal. The lamp 
 is inclosed in the beak of the instrument and throws its 
 light through another window, also of crystal, upon any 
 part of the bladder wall. For examining the upper part 
 of the bladder, a separate instrument with a small reflect- 
 ing prism is used. The bladder must contain six or eight 
 ounces of clear urine or clear water if a proper view of 
 the walls is to be obtained. If the fluid present is turbid, 
 the view is very much obscured ; if too little fluid be 
 present in the bladder, the the beak of the instrument 
 
 Fig. 140. 
 
 Letter's cystoscope. 
 
 containing the lamp is likely to become buried in the folds 
 of mucous membrane and the light will be cut off, and, in 
 that case, the mucous membrane may be burned. A certain 
 amount of practice is required to use the cystoscope prop- 
 erly and to recognize the appearance of the raucous mem- 
 brane of the bladder in health and in its varied morbid 
 conditions. 
 
 The Urethroscope. 
 
 The urethroscope consists of a straight metal tube pro- 
 vided with an obturator of hard rubber which projects 
 slightly beyond the end of the tube. This tube is intro- 
 duced into the urethra until the bladder is reached, when 
 it is slightly withdrawn and the obturator is removed. 
 
224 
 
 MINOR SURGERY. 
 
 The instrument is then attached to a mirror or an electric 
 lamp, by which a strong light is thrown into the tube, and 
 as the tube is withdrawn various parts of the urethra are 
 
 Fig. 141. 
 
 The urethroscope. 
 
 exposed to the view of the surgeon. By means of the 
 urethroscope a very accurate inspection of all portions of 
 the urethra can be obtained. 
 
 The Panelectroscope. 
 
 This instrument, introduced by Leiter, consists of an 
 electric lantern with tubes and a mirror. The light from 
 a small incandescent lamp is projected by the mirror along 
 the tube, which is inserted into the part to be examined. 
 Tubes of various sizes are adapted to the instrument. It 
 is employed for endoscopy of the urethra, ear, pharynx, 
 and stomach. 
 
 Massage. 
 
 Massage consists in a variety of manipulations, such as 
 pinching up the integuments and muscles, and rolling them 
 between the thumb and fingers, in stroking or rubbing the 
 surface with the palm of the hand from the periphery 
 
PASSIVE MOTION. 225 
 
 toward the centre, to empty the distended veins and lym- 
 phatics ; rubbing the parts circularly with the extremities 
 of the fingers and thumb or the palm of the hand, or 
 kneading of the parts is another method of practising 
 massage. Massage may also be practised by tapping the 
 surface of the affected part with more or less force with the 
 tips of the fingers held in a row, or with the ulnar border 
 of the hand or with the palm of the hand. Before apply- 
 ing massage to an affected part, if there be a heavy growth 
 of hair, it should be carefully shaved off; otherwise the 
 manipulation may give the patient pain, and irritation of 
 the hair follicles resulting in abscesses will be apt to occur. 
 The part should also be rubbed over with olive oil, vase- 
 line, or cocoa-butter before and during the manipulations. 
 Massage is often employed with advantage in the treat- 
 ment of sprains and strains in their subacute and chronic 
 stages. It will also be found of great service in the later 
 treatment of fractures involving the joints or their vicinity, 
 in restoring the motion of the parts as well as in improv- 
 ing the nutrition of the muscles which have become wasted 
 from disuse. 
 
 Passive Motion. 
 
 This manipulation consists in alternately flexing and 
 extending or rotating the limb to imitate the normal joint- 
 movement. The motions should be carefully practised, 
 and in cases of fracture they should not be undertaken 
 until there is quite firm union at the seat of fracture, or if 
 for any reason passive motion is made use of before this 
 time the fragments should be firmly supported while it is 
 being employed. Other forms of massage, such as stroking 
 and kneading, may be employed in conjunction with pas- 
 sive motion in the treatment of the troublesome stiffness 
 of joints resulting from fractures, dislocations, and sprains; 
 passive motion applied in this manner will often restore 
 the function of a stiff joint more satisfactorily and with 
 less pain to the patient than the forcible manipulations of 
 the joint which are practised under an anaesthetic. 
 
226 MINOR SURGERY. 
 
 The Clinical Thermometer. 
 
 For clinical observations two thermometer scales are in 
 general use, the Centigrade and Fahrenheit ; the latter is 
 the one commonly employed in America and England. 
 This scale has a limited range above and below the normal 
 bodily temperature, which is 98 J- ° Fahrenheit or 36° 
 Centigrade. Thermometers are now made with a convex 
 surface, which serves to magnify the column of mercury, 
 and thus enables the observer without difficulty to note the 
 position of the index. (Fig. 142.) 
 
 Fig. 142. 
 
 110 J 
 
 9 5 100 
 
 Clinical thermometer. 
 
 The temperature of the body may be taken in the mouth, 
 axilla, vagina, or rectum ; the two former positions are 
 those generally employed. When taken in the axilla care 
 should be exercised to see that no clothing is interposed 
 between the skin and the instrument, and when the mouth 
 is used for thermometric observations the patient should 
 be instructed to keep his lips tightly closed and breathe 
 through his nose. The thermometer should be kept in 
 place for from three to five minutes. 
 
 Surface thermometers are sometimes employed, the in- 
 struments for this purpose having bulbs of a discoid shape, 
 or are drawn out in the form of a spiral or coil. (Fig. 
 143.) In using this form of thermometer to determine 
 
 Fig. 143. 
 
 Surface thermometer. 
 
 the amount of variation of the surface temperature, the 
 temperature of corresponding parts of the body on the 
 opposite side and the general temperature of the body 
 should be taken at the same time. 
 
RECTAL BOUGIES, 227 
 
 The Rectal Tube. 
 
 The introduction of the rectal tube is best accomplished 
 by placing the patient upon his left side, and the surgeon 
 should introduce his index finger well oiled into the rectum 
 and guide the tube upon this through the anus, and by 
 gentle pressure it is gradually passed into the rectum ; if 
 a stricture exists in the rectum within reach of the finger, 
 the latter should be used to guide the tube through the 
 opening in this ; if the tube becomes caught in a transverse 
 fold of the mucous membrane, and becomes doubled upon 
 itself, it should be withdrawn and a fresh attempt should 
 be made to pass it; in passing a rectal tube all manipula- 
 tions should be made with extreme gentleness, as it has 
 been shown that its passage is not without danger, perfora- 
 tions of the intestine having followed its use in some cases. 
 In cases of stricture of the rectum high up the operator 
 has to depend upon the sense of resistance experienced in 
 passing the tube, and in such cases the manipulations 
 should be most carefully made. When the rectal tube is 
 employed to introduce fluidsin to the large intestine the 
 fluids may be introduced by means of a syringe, or by 
 pouring them into a funnel attached to the free end of the 
 tube, or by attaching the tube to a fountain syringe, thus 
 allowing the liquid to pass slowly into the intestine. 
 
 The rectal tube is often employed with good results in 
 relieving the intestine of excessive flatus, and in intro- 
 ducing water or oil into the intestine in cases of intestinal 
 obstruction, and in those cases where the obstruction re- 
 sults from intussusception or fecal accumulations its use 
 will often prove satisfactory. 
 
 Rectal Bougies. 
 
 These instruments are made of the same material as the 
 English flexible catheter, and are of various sizes. They 
 should first be oiled, and carefully introduced in the same 
 manner as the rectal tube. They are generally employed 
 
228 MINOR SURGERY. 
 
 in cases of stricture of the rectum, and they should be used 
 with great care to avoid perforating the wall of the rec- 
 tum. A very satisfactory substitute for a rectal bougie 
 is a tallow candle, one end of which is melted or rubbed 
 down to a conical shape. 
 
 Enemata. 
 
 These may be administered by means of the ordinary 
 syringe, or by means of a gravity or fountain syringe; the 
 precautions which should be observed are to introduce the 
 nozzle of the syringe gently and in the right direction, as 
 perforation of the lower portion of the rectum has taken 
 place from the careless and forcible introduction of the 
 nozzle of the enema-syringe ; the fluid should also be in- 
 jected slowly, as by so doing there is less resistance and 
 less tendency for the patient to pass the fluid before the 
 desired quantity has been introduced. 
 
 The enema most commonly employed to empty the lower 
 bowel is made by adding a tablespoonful of sweet oil and 
 two teaspoonfuls of spirits of turpentine to one or two 
 pints of warm water in which a little castile soap has been 
 dissolved ; warm water and sweet oil are also frequently 
 used for the same purpose. 
 
 Glycerin Enema. — One or two teaspoonfuls of glycerin 
 injected into the rectum, or a suppository made of gly- 
 cerin, will often be found an efficient substitute for the 
 larger enemata of water. 
 
 Nutritious Enemata. 
 
 When it is found necessary to resort to feeding by the 
 rectum, the substances employed should be injected into 
 the rectum by means of a syringe, and care should be 
 taken to see that the quantity is not too large, and that it 
 is of such a nature as not to cause any irritation of the 
 walls of the rectum, or it will not be retained ; two ounces 
 in the case of an adult are generally a sufficient quantity 
 to inject at one time. 
 
LOCAL ANESTHESIA. 229 
 
 Peptonized milk or beef juice, or the yolk of an egg 
 beaten up with milk, is often employed, and any unirri- 
 tating drugs may be mixed with the enema and adminis- 
 tered at the same time. 
 
 Ansesthetics. 
 
 The substances which are employed at the present time 
 to produce either local or general anaesthesia are ice, co- 
 caine, rhigolene, nitrous oxide, chloroform, and ether. 
 
 Local Anesthesia. 
 
 Cold. 
 
 Local anaesthesia may be produced by the application of 
 cold, either by a piece of ice or a mixture of ice and salt 
 held in contact with the part for one or two minutes, or 
 by directing a spray of rhigolene or sulphuric ether upon 
 the surface of the part whose sensibility is to be obtunded. 
 (Fig. 144.) 
 
 Fig. 144. 
 
 Application of rhigolene spray. 
 
 Chloride of Ethyl is also used to produce local anaesthesia, 
 and is conveniently furnished in glass tubes, one end of 
 which is drawn out into a fine point and hermetically 
 sealed. When used the end of the tube is broken off and 
 a fine jet of ethyl is projected upon the surface, the warmth 
 of the hand being sufficient to force the fluid from the tube. 
 
 11 
 
230 MINOR SURGERY. 
 
 This form of local anaesthesia is made use of in minor 
 surgical procedures, such as aspiration , the opening of ab- 
 scesses, and the removal of superficial tumors. 
 
 Rapid Respiration, 
 
 Rapidly repeated deep inspirations kept up for a few 
 minutes will produce insensibility to pain, but sensibility 
 to contact is not obliterated. This form of anaesthesia 
 may be made use of in slight operations, such as the open- 
 ing of an abscess. 
 
 Cocaine. 
 
 Local anaesthesia produced by the employment of an 
 aqueous solution of the hydrochlorate of cocaine, in strength 
 from 1 to 10 per cent., is often made use of in minor sur- 
 gical procedures. Where the mucous membrane is to be 
 operated upon or growths removed from it, analgesia is 
 produced by brushing the surface over with the solution 
 of cocaine, or by applying a compress of absorbent cotton 
 saturated with the solution to the part for a few minutes ; 
 in mucous cavities the latter method of application will be 
 found most convenient. In using a solution of cocaine to 
 produce anaesthesia in operations upon the eye a 2 or 4 per 
 cent, solution is dropped into the eye, and the application 
 is repeated until the analgesia is complete. 
 
 In applying cocaine to the urethra a 1 to 10 per cent, 
 solution is injected into the urethra, and is allowed to re- 
 main for two or three minutes ; more than one or two 
 grains should not be injected at one time, as fatal results 
 have followed the injection of larger quantities ; this is 
 especially the case in using cocaine in the urethra and 
 the rectum, and in these situations great caution should be 
 exercised in its use. 
 
 Experience has proved that there is always danger in 
 the use of the stronger solutions of cocaine, so that it is 
 now considered wise not to use a solution stronger than 1 
 or 2 per cent., as the full analgesic effect can be obtained 
 by a solution of this strength. 
 
LOCAL ANESTHESIA. 231 
 
 When it is desired to produce local anaesthesia of the 
 skin or deeper tissues the application of the solution of 
 cocaine to the surface is not satisfactory, and it should in 
 such cases be injected hypodermically into the deeper 
 layers of the skin and into the cellular tissue of the parts 
 to be operated upon ; to avoid multiple punctures the needle 
 is not completely withdrawn from the wound, but its di- 
 rection is changed and the solution is thrown into different 
 portions of the tissues. It is well in situations where it 
 can be accomplished to cut off the circulation from the 
 part to be operated upon by placing around it a rubber 
 strap or tube, which prevents the rapid absorption of the 
 cocaine into the general blood-current. 
 
 Some persons also have an idiosyncrasy for cocaine, and 
 children seem more susceptible to its constitutional effects 
 than adults. I have seen several instances in children in 
 which marked symptoms of cocaine- poisoning resulted from 
 the application of a 4 per cent, solution to the nasal mucous 
 membrane. 
 
 In minor surgical operations, such as amputations of the 
 finger, circumcision, opening of abscesses, and removal of 
 superficial tumors, cocaine-anaesthesia may be employed 
 with advantage ; but its utility is most marked in opera- 
 tions upon the eye and upon the mucous membranes of 
 the nose, throat, rectum, vagina, and urethra. Applied 
 for a few minutes to the surface of an ulcer which is to 
 be cauterized, it will render the operation almost painless 
 to the patient. 
 
 Infiltration Ancesthesia. 
 
 It has been shown by Liebreich that the injection of 
 simple water into the tissues in such a way as to produce 
 an artificial oedema induces a transitory anaesthesia. 
 
 Schleich found that the combination of a minute quan- 
 tity of cocaine and morphine with a weak salt solution, 
 when injected hypodermically, produced a local anaesthesia 
 of longer duration. 
 
 The anaesthesia is produced by the artificial ischaemia, 
 by the pressure of the injected fluids upon the nerves, and 
 
232 MINOR SURGERY. 
 
 by the direct action of the anaesthetic substances on the 
 nerves. 
 
 A solution of 1 part of cocaine to 1000 parts of steril- 
 ized water may be used, or the following solution may be 
 employed : 
 
 Cocaine hydrochlor gr. iss. 
 
 Morphise hydrochlor. gr. y^. 
 
 Sodii chloridi gr. iij. 
 
 Aquae Siijss. 
 
 The injection should be first made into the substance of 
 the skin itself, and then into the cellular tissues and deeper 
 structures as desired. 
 
 Nitrous Oxide Gas. 
 
 This gas is administered for the purpose of producing 
 anaesthesia, and the apparatus best suited for its adminis- 
 tration consists of a cylinder of metal in which the gas is 
 compressed ; this is attached to a rubber bag which has a 
 mouthpiece fastened to it ; this is provided with a double 
 valve, which prevents the expired air from passing back 
 into the bag. The mouthpiece is adjusted over the mouth, 
 and after removing any false teeth, or foreign bodies, from 
 the mouth, the patient is instructed to take deep, full 
 breaths, and in from one-half to one minute the face be- 
 comes congested and dusky, and the breathing becomes 
 stertorous, indicating that the patient is fully under the 
 influence of the gas. The anaesthesia from nitrous oxide 
 cannot be prolonged for more than a few minutes, so that 
 it can only be employed in operations which take a short 
 time for their performance, such as the extraction of teeth, 
 the opening of abscesses, and the reduction of dislocations 
 or fractures. In England nitrous oxide is frequently used 
 to produce anaesthesia, and when this result is accomplished 
 the anaesthesia is kept up by the administration of ether 
 by the employment of a special apparatus devised for this 
 purpose. Nitrous oxide gas is most commonly employed 
 in dental surgery to produce anaesthesia for the removal of 
 teeth, but is also occasionally employed in minor surgical 
 
ETHER. 233 
 
 operations ; but from the fact that the apparatus for its 
 administration is a bulky one, its use is not so convenient 
 as ether or chloroform, and in this country it is not much 
 employed in general surgery. 
 
 Ether. 
 
 Sulphuric ether is one of the most widely employed 
 substances in surgery to produce anaesthesia ; it is probably 
 the safest of all anaesthetics, except nitrous oxide gas, and 
 for this reason should be given the preference over all 
 others. 
 
 A patient should be prepared for the administration of 
 ether by not allowing him to have any solid food for at 
 least six hours before its inhalation ; he should be in the 
 recumbent posture, and any garments about the chest or 
 neck should be loosened so that the respiratory movements 
 are not interfered with. The surgeon should also see that 
 any false teeth or foreign bodies which may be present in 
 the mouth are removed before the administration of the 
 drug is begun. As the vapor of ether often causes irrita- 
 tion of the mucous membrane of the lips and nasal pas- 
 sages, it is well to anoint these parts with a little vaseline 
 or cold-cream before administering the ether. 
 
 It should also be borne in mind that the vapor of ether 
 is very inflammable, and that it is heavier than the air, so 
 that lights brought near the patient while being etherized 
 should be held at a higher level than the ether-can or 
 inhaler. 
 
 For the administration of ether a towel folded into a 
 cone or one of the various ether inhalers may be employed. 
 The best of these is Allis's inhaler (Fig. 145), which con- 
 sists of a metallic framework covered with leather, which 
 carries a number of folds of a roller bandage, giving a 
 large surface for the rapid evaporation of the drug. 
 
 If a towel folded into a cone is used, a few layers of stiff 
 paper interposed between the outer layers of the towel will 
 keep the cone in shape and will prevent the evaporation 
 of the ether from its external surface. 
 
234 
 
 MINOR SURGERY. 
 
 In debilitated patients or those who are weak from the 
 loss of blood the administration of half an ounce to an 
 ounce of whiskey from fifteen to thirty minutes before the 
 anaesthetic is given is often advisable. 
 
 For the administration of an anaesthetic the patient 
 should be in the recumbent posture and the head should 
 be turned to one side, as in this position mucus is less apt 
 to collect in the pharynx and interfere with the breathing. 
 
 Fig. 145. 
 
 Allis's ether inhaler. 
 
 In administering ether, half an ounce of ether is poured 
 over the inner surface of the towel or inhaler and it is 
 brought near the mouth of the patient, and he is requested 
 to take deep breaths or to blow the ether away, and as soon 
 as he has become accustomed to the irritating qualities of 
 the ether vapor the cone or inhaler is held firmly over 
 the mouth and nose, and the vapor is administered in as 
 concentrated a form as possible ; if the respiration and 
 circulation are good, there is no disadvantage in pushing 
 the ether. When the conjunctiva is insensible to the touch 
 of the finger, and the muscular relaxation is complete, and 
 the breathing tends to become stertorous, the stage of com- 
 plete anaesthesia has been reached, and the ether should 
 be withdrawn for a time or should be given only in such 
 quantities as suffice to keep the patient in this condition. 
 
ETHER. 235 
 
 The first effect from the inhalation of ether is to produce 
 acceleration of the pulse and respiration ; the mucous mem- 
 brane of the air-passages is irritated and coughing often 
 occurs ; there is also in this stage a disposition to muscular 
 movements, and it is frequently necessary to restrain the 
 patient ; the brain is also excited and the patient is apt to 
 cry out. These symptoms call for a continuance of the 
 administration of the ether and not for its withdrawal. 
 Succeeding this stage, if the ether is pushed, profound 
 anaesthesia takes place, as is evidenced by loss of conscious- 
 ness, relaxation of the muscular system, moistened skin, 
 loss of the special senses, contracted pupils, and slow and 
 deep respiration tending to become stertorous. 
 
 Under the name of first insensibility from ether there 
 exists early in the course of the administration of ether a 
 primary anaesthesia, which lasts for a minute or so, and 
 which may be taken advantage of to perform such minor 
 surgical operations as the opening of an abscess or the 
 reduction of a dislocation or the drawing of a tooth. The 
 recovery from this condition is usually very prompt, and 
 it is not followed by nausea and the after-effects which 
 attend the prolonged administration of ether. During the 
 administration of ether, particularly in the early stage, 
 the patient may stop breathing, the face at the same time 
 becoming cyanosed ; this condition calls for the withdrawal 
 of the ether, and if a deep inspiration does not quickly 
 follow, pressure should be made upon the front of the 
 chest, and when this is relaxed a deep inspiration usually 
 takes place and no further difficulty is experienced. 
 
 If the patient has eaten solid food shortly before the 
 etherization, vomiting is apt to occur ; when this takes 
 place the ether inhaler should be removed and the head 
 should be turned to one side, or the patient should be 
 rolled upon his side, the mouth being kept open to facili- 
 tate the escape of the vomited matters. The breathing 
 also sometimes becomes obstructed by the accumulation of 
 mucus in the fauces ; this should be removed by small 
 sponges securely fastened to sponge-holders. 
 
 When the anaesthesia is profound it sometimes happens 
 
236 
 
 MINOR SURGERY. 
 
 that the muscular relaxation is so complete that the tongue 
 falls backward and the glottis is closed, the face becomes 
 cyanosed and the pulse frequent and irregular, and death 
 is threatened from asphyxia ; in this event the head should 
 be extended and the lower jaw should be pressed forward 
 by the fingers placed beneath the ramus of the inferior 
 maxillary bone. (Fig. 146.) This manipulation is usually 
 sufficient to re-establish the respiratory movements, but if 
 so fortunate a result does not take place, artificial respira- 
 tion should be practised — Laborde's, Sylvester's, or How- 
 ard's method being given the preference — the patient's 
 
 Fig. 146. 
 
 Pushing the lower jaw forward. (Esmakch.) 
 
 head being placed upon a lower level than the body, the 
 tongue brought forward, and the fauces being cleared of 
 mucus. The respiratory action should also be stimulated 
 by the use of electricity — one sponge-electrode being placed 
 over the sternum, the other being applied to the epigas- 
 trium during an inspiratory effort. 
 
 If artificial respiration is not satisfactorily applied in 
 this way, forced respiration applied by means of a mask 
 with tube and bellows attached (Fell's apparatus), or an 
 intubation-tube with a rubber tube attached, which is 
 
ETHER. 237 
 
 connected with a bellows, may be slipped into the larynx, 
 and air may thus be directly forced into the lungs, or 
 the trachea should be opened. Tracheotomy is especially 
 to be recommended if the asphyxia has resulted from 
 blood or vomited matters having entered the larynx. 
 After opening the trachea and introducing a tracheal 
 canula, a rubber tube and bellows are connected with this 
 and respiratory movements are simulated by forcing air 
 directly into the trachea. 
 
 The hypodermic injection of strychnia, atropia, or digi- 
 talis is also recommended, and the intravenous injection of 
 ammonia is said to have been followed by good results. 
 
 Efforts at resuscitation in these cases should be per- 
 severed in for at least half an hour, as apparently hopeless 
 cases have been saved by the persistent use of these means. 
 
 The person intrusted with the administration of the 
 anaesthetic should watch the patient closely and should not 
 have his attention diverted by the operation ; he should 
 carefully watch the pulse, respiration, and the color of the 
 patients face, and be ready to withdraw the ether upon 
 the development of any symptom of danger, and to meet 
 such symptoms, should they arise, by the use of some of 
 the means previously mentioned. 
 
 The administration of ether vapor by the rectum was a 
 few years ago employed in many cases, and although anaes- 
 thesia w r as quickly produced, dangerous symptoms some- 
 times followed its employment, so that this method of 
 administration has been abandoned. 
 
 Vomiting after the administration of ether is very com- 
 mon, and if it persists after a few hours, it may be relieved 
 by the administration of the fourth of a grain of cocaine 
 with crushed ice, repeated two or three times, or by the 
 use of crushed ice with champagne or brandy, and in some 
 cases the swallowing of a few mouthfuls of very warm 
 water will relieve this condition. 
 
 An anaesthetic should never be given to a woman with- 
 out the presence of a third person, as in some cases these 
 agents give rise to erotic dreams, and it may be difficult 
 to disabuse the patient's mind of the idea that an assault 
 
 11* 
 
238 MINOR SURGERY. 
 
 has been committed unless the evidence of eye-witnesses 
 at the time of the anesthetization can be brought forward 
 to prove that such was not the case. 
 
 Chloroform. 
 
 A patient is prepared for the administration of chloroform 
 as in the case of ether, the same precautions being taken as 
 regards the removal of false teeth or foreign bodies from 
 the mouth, and to see that the clothing about the chest and 
 neck does not restrict the circulation or respiratory move- 
 ments. Chloroform is certainly a much more dangerous 
 anaesthetic than ether, and although it is widely used in 
 the British Islands and upon the Continent, it is not used 
 in this country except in certain districts — as in the 
 southern and southwestern districts of the United States, 
 and here its use is followed by fewer fatalities than in the 
 northern districts, so that it is possible that its use is safer 
 in warm climates. Clinical experience has demonstrated 
 the fact that chloroform can be used in aged and very 
 young subjects and in puerperal patients with comparative 
 safety ; it is also to be preferred to ether in patients suffer- 
 ing from emphysema of the lungs, bronchitis, and vascular 
 degeneration of the kidneys. It is also employed instead 
 of ether in operations upon the mouth when the actual 
 cautery is employed, on account of its less inflammable 
 character. 
 
 The result of clinical experience and the deductions from 
 physiological experiments seem conclusively to point to 
 the fact that chloroform is a direct depressant and paraly- 
 zant of the heart muscle. 
 
 Chloroform is administered by pouring a drachm of the 
 drug upon a folded towel, which is first held a few inches 
 from the mouth and nose and gradually brought nearer, 
 but is not allowed to come in contact with the face, as from 
 its local irritating action it will blister the surface ; the 
 ansesthetizer should remember that one of the dangers in 
 the administration of chloroform is the risk of too great 
 
CHLOROFORM. 
 
 239 
 
 concentration of its vapor, so that he should see that a 
 sufficient admixture of atmospheric air takes place. Pro- 
 found anaesthesia is evidenced by insensibility of the con- 
 junctiva to the touch, by complete muscular relaxation, 
 and by the absence of reflexes ; the pupils in chloroform- 
 anaesthesia are usually contracted. Various inhalers have 
 been devised to regulate the amount of chloroform admin- 
 istered and to secure the proper admixture of atmospheric 
 air, and the best of these is probably Mr. Clover's appa- 
 ratus. (Fig. 147.) This consists of a bag holding 8000 
 
 Fig. 147. 
 
 Clover's chloroform apparatus. (Eeichsen.) 
 
 cubic inches of air connected with a face-piece by a flexible 
 tube. The bag is charged by means of a bellows (Fig. 
 147, 1) measuring 100 cubic inches ; and the air is passed 
 through a box warmed with hot water, into which is intro- 
 duced at each filling of the bellows as much chloroform as 
 is required for 1000 cubic inches of air. This is done 
 with a syringe (Fig. 147, 2); the amount of chloroform 
 required is usually from 30 to 40 minims. When the 
 bag is full the tube is removed from the evaporator and 
 the mouthpiece (Fig. 147, 3) is fitted to it. Additional 
 air may be admitted by regulating the size of the opening 
 
240 MINOR SURGERY. 
 
 in the mouthpiece ; the patient, however, cannot receive a 
 larger proportion of chloroform than the air in the bag is 
 charged with. 
 
 Death from the administration of chloroform results 
 from cardiac syncope or from respiratory arrest, and the 
 dangerous symptoms develop so rapidly that the greatest 
 promptness is required to meet them. The person ad- 
 ministering chloroform should constantly watch both the 
 pulse and the respiration, and should not for a moment 
 have his attention diverted from the patient ; great vigi- 
 lance is here, if possible, more important than during the 
 administration of ether. 
 
 When dangerous symptoms arise they are to be treated 
 by lowering the patient's head, and if respiratory arrest 
 has occurred, the same means to bring about respiratory 
 action should be employed as for a . similar condition 
 during ether narcosis. Cardiac syncope is treated by the 
 use of electricity, the electrodes with a rapidly interrupted 
 current being swept over the chest ; hypodermics of digi- 
 talis and strychnia and atropia may be employed to stimu- 
 late the heart and respiration, and as in ether narcosis the 
 efforts should not be desisted from for some time, as by the 
 persistent employment of these means apparently hopeless 
 cases have been resuscitated. 
 
 The A.-C.-E. Mixture. 
 
 This mixture, which consists of 3 parts of chloroform, 
 1 part of ether, and 1 part of alcohol, has been employed 
 by some surgeons in the place of ether or chloroform, with 
 the idea that the dangers of chloroform are diminished by 
 its combination with ether and alcohol. Clinical ex- 
 perience, however, has not proved this view to be correct, 
 and I see no advantage in the use of this combination over 
 that of ether or chloroform. If administered with as much 
 care as chloroform, its administration is accompanied with 
 the same safety. It should be administered upon a towel 
 in the same manner as chloroform, and the patient should 
 be watched as carefully during its inhalation as during the 
 
TBUSSES. 241 
 
 administration of the latter drug, any complication occur- 
 ring should be treated in the same manner as those arising 
 during the use of chloroform. 
 
 Bromide of Ethyl. 
 
 This drug was introduced as an anaesthetic some years 
 ago, but as a number of deaths followed its use, it was 
 abandoned. The time required to produce anaesthesia is 
 shorter than for ether, but there is often induced violent 
 muscular spasm, which renders it an unsuitable anaesthetic 
 in many cases. 
 
 Bromide of ethyl has again been revived as an anaes- 
 thetic, but clinical experience has found that its use is not 
 devoid of danger, that it is not as safe an anaesthetic as 
 ether, and that it possesses no advantages in point of safety 
 over chloroform. When used it should be administered 
 by pouring a drachm or two upon an inhaler or a towel, 
 and the patient should be watched with the same care as 
 during the administration of chloroform. 
 
 Trusses. 
 
 A truss for the palliative treatment of hernia is a me- 
 chanical contrivance with one or more pads and a strap ; 
 these are held in position by a spring to which they are 
 attached, which holds the pad in contact with the skin 
 over the hernial ring. 
 
 They are applied in all cases of reducible hernia, and 
 are used in the treatment of hernia at all ages ; in infants 
 and young children the continued use of a properly fitting 
 truss is often followed by a radical cure of the hernia. 
 
 Trusses are made with steel or rubber rings and with 
 pads of wood, rubber, celluloid, or horsehair, covered with 
 chamois, and their shape and the pressure which they 
 should exert vary with the variety of hernia for which 
 they are applied. 
 
 A firm compress applied over the inguinal canal or crural 
 
242 MINOR SURGERY. 
 
 ring, secured in position by a firmly applied spica-of-the 
 groin bandage, forms a very satisfactory temporary means 
 of preventing the descent of a hernia. 
 
 A properly fitting truss should be worn without discom- 
 fort to the patient — that is, should not make too much 
 pressure upon the skin at the points where the pads are 
 applied — and should absolutely prevent the descent of the 
 hernia. In testing the adequacy of a truss, after appli- 
 cation, to prevent the escape of the hernia, the patient 
 should be instructed to separate his legs, bend forward 
 over the back of a chair, and cough or strain deeply ; if 
 this does not bring the hernia down, its control of the rup- 
 ture may be considered satisfactory. 
 
 Trusses should be applied after the complete reduction 
 of the hernia, while the patient is in the recumbent pos- 
 ture. When first applied the truss should be worn both 
 during the night and day, and if the skin becomes tender 
 at the points of pressure, it should be sponged with alcohol 
 and alum, then dried and dusted with powdered starch or 
 lycopodium. Patients at first sometimes complain of dis- 
 comfort in wearing a truss, but they soon become accus- 
 tomed to its presence. After a truss has been worn for 
 some time its use at night, while the patient is in bed, 
 may be dispensed with, but the patient should not remove 
 it until he is in bed in the recumbent posture, and he should 
 reapply it before he rises in the morning. In children it 
 is better to have the truss worn continuously, and if it is 
 removed for bathing the nurse should be instructed to 
 place her finger over the ring to prevent the descent of the 
 hernia until the truss is reapplied. In applying trusses 
 to male children care should be taken not to make pressure 
 upon an undescended testicle. 
 
 Trusses for Inguinal Hernia. 
 
 In measuring a patient for this form of truss the cir- 
 cumference of the body midway between the crest of the 
 ilium and the great trochanter should be taken, and the 
 
TRUSSES FOR FEMORAL HERNIA. 
 
 243 
 
 distance from the symphysis pubis to the anterior superior 
 spinous process of the ilium may also be given, as half of 
 this distance corresponds to the position of the internal 
 abdominal ring. In reducible inguinal hernia the truss- 
 pressure should be exerted upon the inguinal canal and 
 
 Fig. 148. 
 
 Truss for inguinal hernia. 
 
 directly backward. To control this variety of hernia a 
 single-spring truss (Fig. 148) may be employed, or the use 
 of a truss having a double spring with flat pads on each 
 side of the spine attached to the springs, and a smaller 
 pad over the inguinal canal on the unaffected side, with a 
 
 Fig. 149. 
 
 Hood's truss. 
 
 full pad on the side of the hernia, will often be found 
 most satisfactory. This, which is known as Hood's truss, 
 is one w^hich will be found a very satisfactory instrument 
 both in inguinal and femoral hernia. (Fig. 149.) 
 
 Trusses for Femoral Hernia. 
 
 In measuring a patient for this variety of truss, the cir- 
 cumference of the body midway between the crest of the 
 ilium and the great trochanter should be taken ; the dis- 
 
244 
 
 MINOR SURGERY. 
 
 tance of the saphenous opening from the symphysis pubis, 
 as well as from the anterior iliac spine, should also be 
 taken. In reducible femoral hernia the truss-pressure 
 should be directed backward against the femoral canal, 
 and the pad should be large enough to make pressure upon 
 the adjacent tissues through which the hernia passes, as 
 well as upon the relaxed tissues covering the femoral canal. 
 As in inguinal hernia, either a single or a double spring 
 truss may be employed (Fig. 150). 
 
 In applying a truss for femoral hernia, care should be 
 taken to see that the pad does not rest upon the pubis, and 
 thus remove the pressure from the crural ring and adja- 
 cent tissues and prevent the proper control of the hernia. 
 
 Trusses for Umbilical Hernia. 
 
 In measuring a patient for this variety of truss, the cir- 
 cumference of the body over the umbilicus should be taken. 
 
 Fig. 150. 
 
 Fig. 151. 
 
 Hood's truss for femoral hernia. 
 
 Truss for umbilical hernia. 
 
 In reducible umbilical hernia the truss-pressure should 
 be directed backward, and the pad should bear rather on 
 the tendinous margins of the ring than on the hernial 
 opening. A truss for this variety of hernia should have a 
 flat or slightly convex pad, which is held in position over 
 the umbilical ring by means of springs having counter- 
 pads on either side of the spine attached to their extremi- 
 ties ; these are fastened together by a strap (Fig. 151). 
 
 A simple and satisfactory truss for umbilical hernia in 
 infants consists of a penny covered by adhesive plaster, 
 held over the umbilical ring by one or two strips of adhe- 
 sive plaster about two inches in width, and should be 
 
USE OF CATHETERS AND BOUGIES. 245 
 
 applied so as to cover in about the anterior two-thirds of 
 the body. A penny, or a small, flat, compress of linen, 
 will be found much more satisfactory than the conical 
 rubber or cork pad which is often recommended. 
 
 Trusses for Irreducible Hernia. 
 
 The application of a truss to this variety of hernia 
 secures the hernia from injury and prevents the further 
 protrusion of the hernia ; such trusses are secured in the 
 same way as those for reducible hernia, but the pads are 
 made concave or cup-shaped, or may have an air-cushion 
 attached to the pad. 
 
 Use of Catheters and Bougies. 
 
 Catheters are hollow tubes, made either of metal, India- 
 rubber, or other flexible substances. 
 
 Metallic catheters are made of silver, or, if constructed 
 of other metals, they should be plated with silver or nickel, 
 to give them a smooth, bright surface which can easily be 
 kept perfectly clean ; and their shape should conform to 
 that of the normal urethra (Fig. 152). The shape of the 
 metallic catheter is sometimes changed to meet certain 
 indications ; for instance, the metallic catheter for use in 
 cases of enlarged prostate is longer and has a larger curve 
 than the ordinary instrument (Fig. 153). The metallic 
 female catheter is shorter and has a much smaller curve 
 than the instrument used for the male urethra. 
 
 Flexible Catheters. — The most commonly used variety of 
 flexible catheter is that known as the English catheter, 
 which is made of linen and shellac, and is provided with 
 a stylet ; it can be moulded into any shape desired by dip- 
 ping it into hot water, which renders it very flexible, and, 
 after moulding it to the proper curve, this can be fixed by 
 immersing it in cold water, which hardens it again. 
 
246 
 
 MINOR SURGERY. 
 
 The French flexible catheters are made of India-rubber, 
 or a combination of this material with other substances. 
 
 Fig. 153. 
 
 Fig. 152. 
 
 Metallic catheter. 
 
 Prostatic catheter. 
 
 These instruments are conical toward their extremities, and 
 terminate in an olive-shaped point; they are provided 
 with one or two smoothly finished eyes near their vesical 
 extremities (Fig. 154). 
 
 Another form of flexible catheter, known as the elbow T - 
 catheter or Mercier's catheter (Fig. 155), has an angle or 
 
BOUGIES AND SOUNDS. 
 
 247 
 
 elbow near its vesical extremity ; this is often found a 
 satisfactory instrument to use in cases of enlarged prostate. 
 
 Fig. 154. 
 
 French flexible catheters. 
 Fig. 155. 
 
 Mercier's elbowed catheter. 
 
 A variety of flexible catheter made of soft India-rubber 
 is also sometimes employed. (Fig. 156.) 
 
 Fig. 156. 
 
 Soft rubber catheter. 
 
 Catheters and bougies are made according to a certain 
 scale. The English scale runs from l.to 12; the American 
 from 1 to 20 ; and the French from 1 to 30. 
 
 Bougies and Sounds. 
 
 Bougies are flexible instruments which correspond in 
 size and shape to the English and French catheters, and 
 besides there are the acorn-pointed bougie (Fig. 157) and 
 
248 
 
 MINOR SUBGERY. 
 
 the filiform bougie, which is made of whalebone or of the 
 same material as the ordinary French bougie and catheter. 
 These instruments are of very small size and can often be 
 
 Fig. 157. 
 
 Bulbous or acorn-pointed bougies. 
 Fig. 159. 
 
 Fig. 160. 
 
 Fig. 158. 
 
 {/ 
 
 Filiform bougies. 
 
 Steel sound. 
 
 Sound for dilating meatus. 
 
INTRODUCTION OF A CATHETER. 249 
 
 passed through strictures which will admit no other form 
 of instrument. (Fig. 158.) 
 
 Sounds. — These are solid instruments usually made of 
 steel with a smooth surface and plated with nickel ; they 
 correspond in size and have the same curve as the metallic 
 catheter ; the handle is flattened to allow the operator to 
 grasp them firmly ; they are employed in the treatment of 
 strictures by dilatation. (Fig. 159.) The sound used in 
 dilating strictures of the meatus is straight and is shorter 
 than the sound employed in the treatment of urethral 
 strictures. (Fig. 160.) 
 
 Introduction of a Catheter. 
 
 The passing of a catheter is a minor surgical procedure 
 which every practitioner is at times called upon to employ, 
 and its passage through a healthy urethra is a matter of 
 little difficulty. For the introduction of a catheter the 
 patient may be in the standing, sitting, or recumbent pos- 
 ture, and the latter is the best in most cases ; he should 
 rest squarely on his back and have the thighs a little flexed 
 and separated. 
 
 Before passing a metallic catheter the surgeon should 
 see that it is perfectly clean, and after warming and oiling 
 it he stands upon the left side of the patient and grasps 
 the penis with the left hand, and turns it over the pubis 
 and introduces the beak of the catheter into the meatus, 
 and gently passes it along the urethra until its point passes 
 beneath the symphysis pubis ; at this point the handle is 
 elevated and gently depressed between the thighs, and the 
 beak will pass into the bladder. (Fig. 161.) 
 
 When the prostatic region is reached difficulty is some- 
 times experienced in the further passage of the instrument ; 
 this may be overcome by introducing the finger into the 
 rectum and guiding the catheter through the prostatic 
 urethra, or if the prostate is found much enlarged, the 
 catheter should be withdrawn, and a prostatic catheter 
 (Fig. 153) should be substituted for it. 
 
250 
 
 MINOR SURGERY. 
 
 The same manipulation is made use of in passing 
 metallic sounds. 
 
 Flexible catheters and bougies are passed by grasping 
 the penis and holding it in such a position that it is at a 
 right angle to the axis of the body, and the catheter or 
 
 Fig. 161. 
 
 Introduction of a catheter. (Voillemiee.) 
 
 bougie is passed into the meatus and carried through the 
 urethra into the bladder by gently pushing the instrument 
 downward. 
 
 In this variety of catheter, which has no curve, the sur- 
 geon has no means of guiding the. point of the instrument, 
 and if an obstruction is met, he should withdraw the instru- 
 
TYING THE MALE CATHETER IN THE BLADDER. 251 
 
 ment slightly and make another attempt ; all manipulations 
 should be extremely gentle. 
 
 The same manipulations are employed in passing 
 bougies through the urethra. 
 
 Passing the Female Catheter. 
 
 This should be introduced without exposure of the 
 patient, she being in bed with the thighs slightly flexed 
 and separated from each other. The surgeon introduces 
 
 Fig. 162. 
 
 Method of holding the female catheter. 
 
 the forefinger of the left hand between the nymphse, bring- 
 ing it from behind forward until he touches the space 
 between the entrance of the vagina and the orifice of the 
 urethra ; the catheter is then introduced with the right 
 hand held as shown in Fig. 162, and guided by the left 
 forefinger is passed through the orifice of the urethra into 
 the bladder. 
 
 Tying the Male Catheter in the Bladder. 
 
 When it is desirable to retain a catheter for some time 
 in the male bladder, it is necessary to secure it to prevent 
 its slipping out. Either a metallic or flexible catheter 
 may be employed, but, as a rule, the flexible instrument is 
 to be preferred ; there are several methods of securing it 
 in the bladder. 
 
 By one method two narrow strips of tape or two or 
 
252 MINOR SURGERY. 
 
 three strong silk ligatures are attached to the rings at the 
 end of a metallic catheter, or are securely fastened around 
 
 the end of the flexible instru- 
 FlG - 163 - ment ; these are next brought 
 
 backward, one on each side of 
 the penis, and the skin is drawn 
 forward and a strip of adhesive 
 plaster half an inch in width 
 is passed over the strings or 
 tapes and carried three or four 
 times around the body of the 
 
 Tying in catheter. (Bryant.) penis just behind the position 
 
 of the glans penis. If the skin 
 has been brought well forward before the strips have been 
 applied, the ligatures are tightened as it slips back, and 
 the catheter has not too much play. (Fig. 163.) 
 
 Another method consists in fastening a strong silk liga- 
 ture around the catheter just in advance of the meatus ; 
 the two ends are next brought backward and tied in a 
 knot behind the corona glandis ; the ends are then carried 
 around behind the corona and tied on one side of the 
 frsenum ; the foreskin is slipped forward and covers the 
 ligatures, 
 
 A catheter may also be secured in the bladder by tying 
 the ends of the silk ligatures, which are attached to the 
 instrument in advance of the meatus, to tufts of pubic hair. 
 
 A simpler method of securing the catheter is to perforate 
 the free end with a needle armed with a double ligature 
 of silk or hemp ; the needle being removed, two loops are 
 made of the proper length, and these are passed through 
 the ends of a T-bandage, which is secured around the 
 waist, the tails being brought up on either side of the 
 scrotum and secured to the body of the bandage passing 
 around the waist. 
 
 In the female bladder, when it is desirable to keep the 
 bladder empty, the self-retaining catheter is usually em- 
 ployed, which consists of a catheter with a bulb at its 
 vesical extremity, or an ordinary catheter with silk loops 
 
URETHRAL INJECTIONS. 253 
 
 and a T-bandage may be employed in the same manner as 
 in securing a male catheter. 
 
 Washing out the Bladder. 
 
 This procedure may be required in the treatment of 
 cystitis, and it is accomplished by passing a flexible 
 catheter with a large eye into the bladder, or a double 
 
 Fig. 164. 
 
 Rubber bag with stopcock, for washing out the bladder. 
 
 catheter may be employed. A syringe, or better a rubber 
 bulb holding about a pint, having a nozzle and stopcock 
 (Fig. 1 64), is filled with warm water, or with any medi- 
 cated solution which is desired, and it is then attached to 
 the free end of the catheter and the contents are gently 
 injected into the bladder ; care should be taken that the 
 bladder is not too much distended. When the desired 
 amount of fluid has been injected, it is allowed to run out 
 of the catheter, and the procedure may be repeated until 
 the solution comes away perfectly clear. 
 
 Care should be taken to see that the bladder is perfectly 
 emptied of the solution, and in cases of paralysis of the 
 bladder gentle pressure should be made upon the abdomen 
 over the pubis to accomplish this object. Solutions of 
 boric acid, permanganate of potassium, and weak solutions 
 of carbolic acid and of nitrate of silver are often employed 
 in washing out the bladder in cases of chronic cystitis. 
 
 Urethral Injections. 
 
 In the treatment of urethral inflammations the injection 
 of medicated solutions is generally made use of, and as 
 
 12 
 
254 
 
 MINOR SURGERY. 
 
 ,165. 
 
 these injections are usually made by the patient himself, 
 he should be shown or instructed how to employ them. 
 A rubber syringe having a conical nozzle and 
 holding about two or three drachms is the 
 best instrument to employ for this purpose. 
 (Fig. 165.) The syringe having been filled 
 with the solution, the patient sits upon the 
 edge of a hard chair, with the thighs sepa- 
 rated, grasps the syringe between the thumb 
 and middle finger of the right hand, the tip of 
 the index finger resting upon the end of the 
 piston, and inserts its conical end from a quarter 
 to half an inch within the meatus, which is held 
 open by the thumb and finger of the left hand. 
 After the introduction of the nozzle of the 
 syringe the tissues should be drawn tightly 
 around it, the pressure being made laterally so 
 shape ot ag ^ Q narrow ^he urethral opening; instead of 
 
 nozzle of ^ 
 
 urethral broadening it, as is the case when the compres- 
 
 syringe. sion is in an antero-posterior direction. After 
 
 the fluid has been thrown into the urethra in 
 
 this manner the syringe is removed, and the patient is 
 
 instructed to hold the lips of the meatus together for one 
 
 or two minutes to prevent the escape of the fluid. 
 
 Sutures. 
 
 A variety of materials are employed for sutures, such as 
 silk, catgut, silver or iron wire, silkworm-gut, kangaroo- 
 tail tendon, and horsehair ; the material most frequently 
 employed at the present time is either catgut, silk, or silk- 
 worm-gut, although some surgeons still prefer silver wire. 
 Catgut and kangaroo-tail tendon are practically the only 
 substances employed as sutures which are absorbable ; the 
 other varieties of suture require removal after their appli- 
 cation, although some sutures, such as the silk, when 
 employed in subcutaneous w 7 ounds may be cut short, as 
 they are apt to become encysted and produce no trouble. 
 
SURGICAL NEEDLES. 255 
 
 It matters little what variety of material be employed for 
 suturing if the surgeon is careful to see that it is rendered 
 thoroughly aseptic before being brought in contact with 
 the wound. 
 
 Sutures of Relaxation are those which are entered and 
 brought out at some distance from the edges of the wound, 
 and are employed to prevent dangerous tension upon the 
 sutures which approximate the edges of the skin. This 
 form of suture is employed by the use of the quilled, 
 button, or plate suture. 
 
 Sutures of Coaptation. — These are superficial sutures 
 applied closely together and include only the skin \ they 
 are employed to secure accurate apposition of the cutaneous 
 surface of wounds. 
 
 Sutures of Approximation are those which are applied 
 deeply into the tissue to secure approximation of the deep 
 portions of a wound ; this object is accomplished by the 
 use of the quilled, button, or plate suture. 
 
 Secondary Sutures. — These sutures are applied when the 
 surfaces of the wound are covered by granulations, when 
 the primary sutures have failed to secure apposition of the 
 edges of the wound, or in cases of secondary hemorrhage 
 where the opening of the wound has been necessitated to 
 turn out the blood-clot and secure the bleeding vessel, or 
 in plastic operations where the primary sutures have failed 
 to secure adhesions of the edges of the flaps. They are 
 also employed with advantage in cases in which it is neces- 
 sary to pack a wound with antiseptic gauze, or to allow 
 haemostatic forceps to remain clamped upon bleeding tissues 
 in a wound at the time of operation. The sutures should 
 in such a case be introduced and loosely tied at this time, 
 and when the packing or forceps is removed at the end 
 of two or three days the sutures are tightened so as to 
 secure apposition of the edges of the wound. 
 
 Surgical Xeedles. 
 
 Xeedles for surgical use are of different sizes and shapes 
 (Fig. 166) ; straight needles are the ones most commonly 
 
256 MINOR SURGERY, 
 
 employed, but curved needles will be found most con- 
 venient for the introduction of sutures in wounds of certain 
 
 Fig. 166. 
 
 <z^gs^ 
 
 Surgical needles. 
 
 locations. Hagedorn needles, which are flat and have sharp- 
 cutting edges, make a narrow linear wound in the tissues 
 
 Fig. 167. 
 
 Mounted needle. 
 
 and are useful in some cases. Tubular needles are often 
 employed in introducing sutures in wounds in which the 
 
 Fig. 168. 
 
 Needle-holder. 
 
 use of an ordinary needle is difficult : for instance, in the 
 operation for cleft palate, and for the introduction of sutures 
 
SECURING SUTURES AND LIGATURES. 257 
 
 in deep wounds, a mounted needle will often be found very 
 useful (Fig. 167). Xeedles should be sharp and clean and 
 should be rendered thoroughly aseptic before being used. 
 A needle-holder is often required for the satisfactory intro- 
 duction of sutures in wounds of certain localities (Fig. 
 168) ; if this is not at hand the needle may be held by a 
 pair of dressing forceps or a pair of haemostatic forceps. 
 
 Method of Securing Sutures and Ligatures. 
 
 Metallic sutures are usually secured by twisting the 
 ends together or by passing the ends through a perforated 
 shot and clamping the shot with a shot-compressor, which 
 securely fixes them. 
 
 Sutures and ligatures of catgut, silk, silkworm-gut, 
 kangaroo-tail tendon, or horsehair are secured by tying, 
 and several different knots are employed to secure them. 
 
 Reef or Flat Knot 
 
 Fig. 169. 
 
 Reef or flat knot. 
 
 This is one of the best forms of knot to use in securing 
 sutures or ligatures, and it is made by passing one end of 
 the thread over and around the other end, and the knot 
 thus formed is tightened ; the ends of the thread are next 
 carried toward each other and the same end is again car- 
 ried over and around the other, and when the loop is drawn 
 tight we have formed the reef or flat knot (Fig. 169). 
 
258 MINOR SURGERY. 
 
 Surgeon s Knot 
 
 This knot is formed by carrying one end of the thread 
 twice around the other end (Fig. 170) ; and after tighten- 
 
 FlG. 170. 
 
 Surgeon's knot. 
 
 ing this loop the same end is carried over and around the 
 other end as in the case of the final knot of the reef or flat 
 
 Fig. 171. 
 
 Surgeon's knot and reef knot combined. 
 
 knot. The surgeon's knot and reef knot combined is one 
 of the best methods of securing sutures or ligatures of 
 catgut or silk, as the first knot is not apt to relax before 
 the second knot is applied. (Fig. 171.) 
 
 Granny Knot. 
 
 This method of tying the ligature or suture should not 
 be employed, as the resulting knot is not as secure as the 
 reef knot and is apt to relax ; it differs from the latter in 
 the fact that one end of the thread having been carried 
 across and around the other end, the knot is completed by 
 ca^ying the same end under and around the other end ot 
 tho thread (Fig. 172). 
 
VARIETIES OF SUTURE. 259 
 
 The Staffordshire knot, which is much used to secure the 
 pedicle in the removal of the ovaries or ovarian tumors, is 
 applied as follows : A handled needle armed with a stout 
 silk ligature is passed through the pedicle, and then with- 
 
 FiG. 172. 
 
 Granny knot. 
 
 drawn so as to leave a loop on the distal side ; this loop is 
 drawn over the ovary or tumor and one of the free ends 
 is passed through it so that one end is above while the 
 other end is below the retracted loop. (Fig. 173). The 
 
 Fig. 173. 
 
 Staffordshire knot. 
 
 ends are then seized and drawn through the pedicle ; at the 
 same time the thumb and forefinger are pressed against it 
 until sufficient constriction is made, and the ends are finally 
 secured by tying as in the securing of an ordinary ligature. 
 
 Varieties of Suture. 
 
 The Interrupted Suture. 
 
 This variety of suture is the one most usually emplcved 
 in the apposition of wounds, which consists of a nun. >er 
 
260 MINOR SURGERY. 
 
 of single stitches, each of which is entirely independent of 
 those on either side. In applying this suture the surgeon 
 holds the edge of the wound with the fingers or forceps 
 and thrusts the needle, previously threaded, through the 
 skin three or four lines from the edges of the wound. He 
 then passes the needle from within outward through the 
 tissues of the opposite flap at the same distance from the 
 edge of the wound. (Fig. 174.) Each stitch is secured 
 
 Fig. 174. 
 
 The interrupted suture. 
 
 as soon as it is passed — by tying if a silk, catgut or silk- 
 worm-gut suture be used, or by twisting if a silver-wire 
 suture is employed. A suture may be used with a needle 
 threaded on each end, in which case both needles are 
 passed from within outward. The sutures may be secured 
 as soon as applied, or they may be left unsecured until a 
 sufficient number have been introduced, and then they may 
 be secured by tying or twisting. Care should be taken to 
 see that they make no tension on the edges of the wound 
 and that they are so introduced as to make the best possi- 
 ble apposition of the parts. 
 
 Buried Sutures. 
 
 In extensive and deep wounds it may be found neces- 
 sary to introduce both deep and superficial sutures, the 
 former bringing about apposition of the muscles and deep 
 
VARIETIES OF SUTURE. 
 
 261 
 
 fascia, the superficial layer bringing together the superficial 
 fascia and skin. 
 
 The deep or buried sutures are often employed to unite 
 fascia, muscles, or tendons, and the best material for this 
 variety of suture is either catgut, silk, silkworm-gut, or 
 kangaroo-tail tendon. 
 
 Continued or Glover's Suture. 
 
 This variety of suture is applied in the same manner as 
 the interrupted suture, but the stitches are not cut apart 
 and tied ; it is made with silk or catgut and is secured by 
 drawing it double through the last stitch and using the 
 
 Fig. 175. 
 
 Continued or glover's suture ; method of securing. 
 
 free end to make a knot with the double portion attached 
 to the needle. (Fig. 175.) This suture is generally em- 
 ployed in intestinal sutures, but also may be employed in 
 bringing about apposition of the edges of wounds 
 tissues of loose structure. 
 
 12* 
 
 in 
 
262 
 
 MINOR SURGERY. 
 
 Subcuticular Suture. 
 
 Halstead has introduced a suture in which the needle is 
 introduced on the under surface of the skin on one side, 
 and brought out just beneath the cut edge ; it is then entered 
 in the reverse direction below the epidermic surface oppo- 
 site ; when tied it will lie wholly out of sight. The object 
 of this variety of suture is to avoid infection of the wound 
 by the skin coccus which may be introduced by the suture 
 if passed from without inward. Fine silk or catgut should 
 be used for this variety of suture, which may become en- 
 cysted, absorbed, or gradually cast off after a few weeks. 
 
 The Twisted or Hare-lip Suture. 
 
 This is a very useful form of suture where great accuracy 
 and firmness of apposition of the edges of the wound are 
 desired. It is applied by thrusting pins or needles deeply 
 through both lips of the wound, the edges being kept in 
 contact over the wound by figure-of-eight turns with silk 
 or wire. (Fig. 176). The ends of the pins should be cut 
 
 Fig. 176. 
 
 Fig, 177. 
 
 Twisted or hare-lip suture. 
 
 India-rubber suture. 
 
 off by pin-cutters after the sutures are applied, or should 
 be protected by pieces of cork or plaster to prevent them 
 from injuring the skin of the patient and causing him 
 pain. 
 
 The twisted or hare-lip suture is frequently employed 
 in plastic operations about the face and in other parts ot 
 the body where accurate apposition of the flaps is desired. 
 
VARIETIES OF SUTURE. 
 
 263 
 
 The India-rubber Suture. 
 
 This is applied by first passing the pins or needles 
 through the edges of the flaps, and instead of the twisted 
 figure- of-eight suture of silk, delicate rings of India-rubber 
 are employed. (Fig. 177.) 
 
 Tlie Quilt Suture. 
 
 This variety of suture is made with silk or catgut, and 
 is employed in wounds to effect very close approximation 
 
 Fig. 178. 
 
 The quilt suture. 
 
 of the parts and to prevent bagging ; it is often employed 
 in connection with the continued suture, and is applied as 
 shown in Fig. 178. 
 
264 
 
 MINOR SURGERY. 
 
 The Quilled Suture. 
 
 In making use of this suture a needle armed with a 
 double thread of wire or silk is passed through the tissues 
 as in applying the interrupted suture, but at a greater dis- 
 tance from the edges of the wound. Into the loops on one 
 side of the wound is inserted a quill or piece of a flexible 
 catheter or bougie, and on the opposite side the free ends 
 of the sutures are tied around a similar object after being 
 tightened. (Fig. 179.) This form of suture makes deep 
 and equable pressure along the whole line of the wound. 
 
 Fig. 179. 
 
 
 The quilled suture. (Smith.) 
 
 In applying this suture it may be found advisable in some 
 cases to introduce a few superficial interrupted sutures 'along 
 the line of the wound to secure accurate approximation ot 
 the skin. 
 
 This form of suture was formerly much employed in 
 cases of deep wounds to secure accurate apposition of the 
 deep portions of the wound, but recently the introduc- 
 tion of buried catgut sutures has supplanted the use of 
 this variety of suture. 
 
 Button or Plate Suture. 
 
 This suture is applied by passing a needle armed with 
 a double thread as in the case of the quilled suture, the 
 
VARIETIES OF SUTURE. 
 
 265 
 
 Fig. 180. 
 
 ends of the suture being passed through the eyes of a 
 button or through perforations in a lead plate before 
 being threaded in the eye of the needle. 
 After the suture prepared in this way 
 has been passed through both sides of the 
 wound, the needle is removed and the 
 free ends of the suture are passed through 
 the eyes of a button or the perforations 
 in a lead plate on the opposite side of the 
 wound, and are tightened and secured. 
 (Fig. 180.) This form of suture may be 
 employed in deep wounds to accomplish 
 the same purpose as the quilled suture. 
 It allows the cutaneous margins of the 
 wound to remain free from compression, 
 and here, as in the case of the quilled 
 suture, a few interrupted sutures may be introduced be- 
 tween the button or plate sutures to secure accurate appo- 
 sition of the skin surfaces it desired. 
 
 Button suture. 
 (Smith.) 
 
 Fig. 181. 
 
 Tongue-and-groove Suture. 
 
 This variety of suture, devised by the late Dr. Joseph 
 Pancoast, consists in slipping the margin of the flap which 
 has been bevelled into a groove, 
 made by dissecting up the mar- 
 gin of the skin surrounding 
 the raw surface which is to be 
 covered. In applying this su- 
 ture the wire or thread used 
 has a needle applied on each 
 end, and after passing the su- 
 tures so as to secure the flaps 
 the free ends are secured over a pad of adhesive plaster or 
 a disk of lead or through the eyes of a button. (Fig. 181.) 
 
 Shotted Sutures. 
 
 This suture receives its name not from any special 
 method of application, but solely from the way in which it 
 
 Tongue-and-groove suture. 
 
266 MINOR SURGERY. 
 
 is secured ; any of the previously mentioned varieties of 
 sutures may be employed. The material used in applying 
 this suture may be catgut, silver wire, silkworm-gut, silk, or 
 horsehair, and after the suture has been passed the needle 
 is removed, and the ends are passed through a perforated 
 shot ; the ends are then drawn upon to bring the edges of 
 the wound in contact, and the shot is pressed down to the 
 skin and clamped by means of a shot-compressor. The 
 suture is then cut off' flush with the surface of the shot. 
 
 This method of securing sutures is especially useful in 
 closing wounds in the mucous cavities, such as the vagina, 
 rectum, and mouth, where the knot or twist of the wire 
 might cause irritation of the surface or pain to the 
 patient • it is also a useful method of securing sutures in 
 plastic operations ; it also facilitates the removal of the 
 sutures, as the shot is not apt to be obscured by the 
 swollen tissue, and is easily seized by forceps when the 
 loop is divided. 
 
 Removal of Sutures. 
 
 Where sutures are buried in the tissues or used to ap- 
 proximate parts in cavities which are subsequently closed, 
 such materials should be used for sutures as will be ab- 
 sorbed in a few days, or will become encysted and remain 
 harmless in the tissues — such as catgut, silkworm-gut, or 
 silk — and it is needless to state that sutures used with this 
 end in view should be rendered perfectly aseptic before 
 being employed. 
 
 Catgut sutures, when well prepared and used for sutures 
 in external wounds, usually undergo absorption in from 
 ten to fifteen days ; the loop buried in the tissues is 
 absorbed and the knot may be removed from the surface 
 with forceps or it may come off with the dressings. 
 
 The other substances, such as silk, silkworm-gut, silver 
 wire, and horsehair, are removed by cutting one side of 
 the loop and making traction upon the knot of the suture 
 with forceps, or in the case of the wire suture, after divid- 
 ing the loop and straightening out one end of it, the wire 
 should be withdrawn in a curved direction. 
 
VARIETIES OF SUTURE. 
 
 267 
 
 Sutures which are not causing any irritation should be 
 allowed to remain in position until the wound is solidly 
 healed. The time usually required for their retention in 
 cases of aseptic wounds is from eight to twelve days. 
 
 Lemberfs Suture. 
 
 Lembert's suture is used in wounds of the viscera 
 covered by the peritoneum, with the object of bringing in 
 contact the peritoneal surfaces. This form of suture is 
 
 Fig. 182. 
 
 Lemberfs suture. (Bryant.) 
 
 usually employed in closing wounds of the intestine, blad 
 der or stomach. (Fig. 182.) 
 
 Fig. 183. 
 
 Lembert's suture, a, serous ; b, muscular ; and, c, mucous coat. (Smith.) 
 
 A needle armed with a fine catgut or silk thread is 
 passed, and it is better to employ a round needle, such as 
 
268 MINOR SURGERY. 
 
 the ordinary sewing-needle, in preference to the bayonet- 
 pointed needle, as there results by its use less bleeding 
 from the punctures. The needle is first carried through 
 the peritoneal and muscular coats of the intestine a short 
 distance from the wound, and it is then carried across the 
 wound and passed through the same portions of the 
 intestine a short distance from the edge of the wound on 
 the opposite side, and when the suture is tightened the 
 peritoneal surfaces of the intestine are inverted and 
 brought into contact with each other (Fig. 183) ; the in- 
 terrupted or continued suture may be employed in mak- 
 ing this form of suture. 
 
 Halstead's Quilt Suture. 
 
 This is a modification of Lembert's method. The needle 
 penetrates the superficial coats of the gut twice on each side 
 of the wound, and is then tied. (Fig. 184.) 
 
 Fig. 184. 
 
 Halstead's quilt suture for intestines. 
 
 GMy's Suture. 
 
 In applying this form of suture in intestinal wounds a 
 ligature armed with a fine needle at each end is employed, 
 
VARIETIES OF SUTURE. 
 Fig. 185. 
 
 269 
 
 Gely's suture. 
 
 and the punctures should be about five millimetres apart; 
 the method of applying the suture is shown in Fig. 185. 
 
 Bouisson's Suture. 
 
 This method of suturing intestinal wounds, which is 
 more complicated than either of the previously mentioned 
 methods and possesses no advantage over them, is applied 
 
 Fig. 186. 
 
 Bouisson's suture. 
 
 by passing a delicate pin in and out along each side of the 
 wound as shown in Fig. 186, and drawing them together 
 laterally by ligatures passed through the intervals, one 
 end of each ligature being cut short and the other end 
 
270 MINOR SURGERY. 
 
 being brought out at the lower angle of the external wound ; 
 a thread is also tied under the head of each pin and brought 
 out at the upper angle of the wound, and at the end of 
 three or four days the pins are removed by means of the 
 threads attached to them, and at the same time the sutures, 
 having been freed by the removal of the pins, are withdrawn. 
 
 Czerny Suture. 
 
 This suture is applied in intestinal wounds by passing 
 the needle armed with a catgut or silk thread through the 
 serous membrane on one side of the wound of the intestine 
 and out at the wound surface so as not to include the 
 mucous membrane ; the needle is then passed through the 
 wound surface on the opposite side, avoiding the mucous 
 membrane, and brought out through the serous membrane 
 a short distance from the edge of the wound. By this 
 suture the lips of the wound are approximated. For 
 additional security in preventing the escape of the contents 
 of the intestine and to secure approximation of the serous 
 surfaces a few Lembert sutures should be introduced. 
 
 Joberfs Suture. 
 
 This suture, which has been employed in transverse 
 wounds of the intestine which completely or incompletely 
 
 Fig. 187. 
 
 Jobert's suture. 
 
 divided the gut, is introduced after turning the lower end 
 of the bowel in upon itself. When the division of the gut 
 
VARIETIES OF SUTURE. 
 
 271 
 
 was incomplete Jobert employed only one suture, when 
 complete tw r o ; the ends of the sutures were brought out of 
 the external wound. (Fig. 187.) By this method of suture 
 the two serous surfaces are brought into contact. 
 
 Sutures Employed in Intestinal Anastomosis. 
 
 When it is desired to form a permanent orifice between 
 two portions of the gut, the ends of the gut are closed and 
 
 Fig. 188. 
 
 Method of applying Senn's decalcified bone plates. (Geeig Smith 
 
 an opening is made in each portion of the gut, and the walls 
 of the gut surrounding the openings are held in contact 
 with each other by sutures attached to perforated plates of 
 decalcified bone ; this is the method devised by Senn. The 
 manner of using the bone plates and sutures is shown in 
 Figs. 188 and 189. To accomplish the same purpose 
 rubber rings or perforated plates of rubber have been em- 
 
272 MINOR SURGERY. 
 
 ployed, also rings made from catgut, to which the sutures 
 are attached, are applied in the same manner as Sennas 
 plates. In using the rubber rings or plates it is well to 
 divide them at one or two points and unite them by catgut 
 sutures which will soften and be dissolved in a few days 
 and allow the ring or plate to change its shape and 
 facilitate its passage through the bowels ; if catgut rings 
 are employed these will be softened and dissolved in a 
 short time so as to be passed without difficulty. 
 
 Fig. 189. 
 
 WALL OF 
 
 INTESTINE 
 
 TURNED IN AND 
 
 SECURED BY , 
 
 LEMBERT STITCHES 
 
 Diagram showing position of bone plates in intestinal anastomosis after 
 resection of the bowel. (Roberts.) 
 
 At the present time many surgeons in performing in- 
 testinal anastomosis dispense with the use of bone plates 
 or rings and make use of Abbe's long incision, in which, 
 after closing the two ends of the gut, the two portions are 
 laid alongside of each other and two rows of continuous 
 Lembert sutures are applied, a quarter of an inch apart 
 and an inch longer than the proposed cut. The bowel is 
 then opened for four inches a fourth of an inch from the 
 sutures, both rows being to one side of the cut ; the op- 
 posite portion of the bowel is then opened in the same 
 manner, and the adjacent edges of the bowel are united by 
 a continuous suture. The two free cut edges are then 
 hemmed to secure any bleeding that may be present, after 
 which the serous surfaces on the opposite sides of the 
 
VARIETIES OF SUTURE. 273 
 
 opening are approximated and secured by two rows of 
 continuous Lembert sutures. 
 
 Intestinal anastomosis may be employed instead of 
 Jobert's suture or the circular suture in wounds com- 
 pletely dividing the intestine and after resection of the 
 gut for the removal of growths or for stricture. 
 
 Sutures Employed in Gastrostomy. 
 
 In this operation, when the wall of the stomach has 
 been exposed, two hare-lip pins should be thrust through 
 the integument and tissues near the edge of the wound 
 and then through the peritoneal and muscular coats of the 
 stomach, to bring the surface of the stomach in contact 
 with the peritoneum covering the inner surface of the 
 abdominal walls in the region of the wound ; a few sutures 
 of silk may also be introduced to secure the wall of the 
 stomach to the edges of the wound. The opening of the 
 stomach is postponed for four or five days if possible, 
 until the adhesion between its walls and the abdominal 
 parietes is secure, and at this time the sutures and the pins 
 are removed. 
 
 When immediate opening of the stomach is required for 
 any reason, after the wall of the stomach has been exposed 
 two silver-wire sutures are passed through the peritoneal 
 and muscular coats of the viscus by means of a needle; 
 these sutures should be placed transversely to the external 
 abdominal wound and serve to draw the wall of the 
 stomach in contact with the inner margins of the abdom- 
 inal incision. 
 
 A long silk suture is next passed through the outer 
 coats of the stomach so that the loops project upon the 
 external surface of the organ. A needle, having a hook 
 near its extremity, is passed through the abdominal wall 
 and engages the loop and draws it to the surface of the 
 abdomen near the edge of the abdominal wound ; the same 
 manipulation is repeated until all of the loops have been 
 brought to the surface. (Fig. 190.) 
 
 A piece of rubber tube is carried around the external 
 
274 
 
 MINOR SURGERY. 
 
 wound and slipped through the loops which project upon 
 the surface of the abdomen, and by drawing the loops 
 tight over the rubber tube and tying the ends of the suture 
 the stomach wall is secured in contact with the inner mar- 
 gins of the abdominal wound, and it may be safely opened 
 after being thus fixed. 
 
 Fig. 190. 
 
 Sutures for immediate gastrostomy. (Roberts .) 
 
 In the operation of gastrostomy, where the stomach has 
 been exposed and opened and the foreign body removed, 
 or its cavity has been explored, or its orifices dilated, as 
 the case may be, the wound in the wall of the stomach is 
 closed with Lembert's sutures, silk or catgut being the 
 material employed for this purpose. The abdominal wound 
 is next closed with deep sutures which include the parietal 
 peritoneum. 
 
 Ligatures Used in the Treatment of Vascular Growths. 
 
 Various forms of ligature are used for the strangulation 
 of vascular growths ; the material used for ligatures is 
 usually strong silk or hemp thread, catgut, or silver wire. 
 
LIGATURES USED IN VASCULAR GROWTHS. 275 
 
 The Single Ligature with a Pix. 
 
 This is applied by first inserting a hare lip pin through 
 the skin near the edge of the growth, passing it under the 
 growth and bringing its point out through the skin at a 
 point opposite the point of entry ; a strong silk or hemp 
 ligature, which has been well waxed, is passed under the 
 ends of the pin surrounding the base of the tumor and is 
 drawn tight enough to strangulate the growth, and is 
 secured by two knots (Fig. 191). If the growth is of 
 
 Eig. 191. 
 
 Vascular tumor strangulated with pin and ligature. (Roberts.) 
 
 considerable size it is better before applying this ligature 
 to introduce a second pin at right angles to the first one, 
 and then secure the ligature under the pins. In applying 
 these forms of ligatures to healthy skin the patient is 
 saved much pain, and the separation of the mass is 
 hastened, by cutting a groove in the skin with a sharp 
 knife at the point where the ligature is to be applied ; the 
 ligature when tied is buried in the groove thus made. 
 
 Double Ligature in Vascular Growths. 
 
 This ligature is applied by passing a needle or a needle 
 with a handle, armed with a double ligature, through the 
 skin near the growth, and then passing it under the tumor 
 and bringing it out through the skin at a point directly 
 opposite the point of insertion ; the ligature is then divided 
 and the needle removed. The tumor is strangulated by 
 tying firmly the corresponding ends of the ligature on each 
 side of the tumor, each ligature including one-half of the 
 growth (Fig. 192). 
 
276 
 
 MINOR SURGERY. 
 
 The double ligature may also be applied by first passing 
 a pin under the growth and then passing a needle armed 
 
 Fig. 192. 
 
 Method of applying double ligature. (Roberts.) 
 
 with a double thread under the tumor at right angles to 
 the pin, and after removing the needle the ends of the 
 
 Fig. 193. 
 
 Method of applying double ligature and pin. (Bryant.) 
 
 ligature are tied and the tumor is strangulated in two 
 sections. (Fig. 193.) 
 
 Quadruple Ligature. 
 
 In applying this ligature two needles carrying a double 
 thread are passed under the growth at right angles to 
 
LIGATURES USED IN VASCULAR GROWTHS. 277 
 
 each other, or if the handled needles be used they may be 
 first passed in this manner, and then threaded with double 
 ligatures, which are carried under the growth as they are 
 
 Fig. 194. 
 
 Method of applying quadruple ligature. (Liston.) 
 
 withdrawn. The needles being removed, the surgeon ties 
 two ends of the ligature together,, and repeats this pro- 
 cedure until the growth has been strangulated in four sec- 
 tions. (Fig. 194.) 
 
 Subcutaneous Ligature. 
 
 This is applied by introducing a needle armed with a 
 ligature through the skin near the growth, and carrying it 
 through the subcutaneous tissues around the part to be con- 
 stricted for a short distance, then bringing it out through 
 
 13 
 
278 
 
 MINOR SURGERY. 
 
 the skin. The needle is again introduced through the same 
 puncture, and is again brought out through the skin at 
 some distance from the first point of exit. It is next intro- 
 duced through this puncture and brought out at a more 
 distant point. In this way the growth is completely en- 
 circled by a subcutaneous ligature, which is finally brought 
 out at the point of entrance ; the tumor is strangulated by 
 firmly tying together the ends of the ligature. (Fig. 195.) 
 
 Fig. 195. 
 
 Method of applying subcutaneous ligature. (Holmes.) 
 
 If a needle armed with a double ligature is first passed 
 under the growth the ligature is divided, and by passing 
 each end of the divided ligature subcutaneously around 
 the growth it may be strangulated subcutaneously in two 
 sections. 
 
 Erichsen's Ligature. 
 
 This ligature is employed to strangulate tumors of 
 irregular shape in a number of sections. A strong silk 
 or hemp ligature three yards in length, one-half of which 
 is stained black, is carried by a needle as a double ligature 
 under the growth at various points so as to leave a series 
 
ELASTIC LIGATURES. 
 
 279 
 
 of loops about nine inches long on each side of the tumor 
 (Fig. 196); the black loops being cut on one side, the 
 
 Fig. 196. 
 
 Method of applying Erichsen's ligature. (Erichsex.) 
 Fig. 197. 
 
 Erichsen's ligature applied. 
 
 white on the other, the ends are then firmly tied so as to 
 strangulate the growth in sections. (Fig. 197.) 
 
 Elastic Ligatures. 
 
 Ligatures made of India-rubber varying from half a 
 line to several lines in thickness are often made use of in 
 surgery. They may be employed to strangulate growths 
 such as moles or nsevi, or in the treatment of fistulse, and 
 
280 MINOR SURGERY. 
 
 are especially useful in the treatment of those cases of 
 fistula-in-ano in which the internal opening into the bowel 
 is situated high up, as the division of such fistulse by this 
 means is accomplished without hemorrhage and with less 
 risk than by the employment of the knife. In applying 
 elastic ligatures in such cases the ligature, after being 
 passed through the fistula by means of a probe, is carried 
 out through the internal opening ; the anus is next well 
 stretched, and the elastic ligature is then firmly tied with 
 two or three knots ; the greater the tension made before 
 the ligature is tied the more rapidly will it cut its way out. 
 The smaller sizes of rubber drainage-tubes may be sub- 
 stituted for the solid rubber ligatures. 
 
 Treatment of Hemorrhage. 
 
 The surgeon may be called upon to treat the following 
 varieties of hemorrhage : arterial, venous, or capillary ; and 
 these again are classified according to the time of their 
 occurrence, as primary, that is, bleeding which occurs at 
 the time the wound is inflicted ; intermediary or consecutive, 
 that which occurs within twenty-four or forty-eight hours 
 after the reception of the injury, which generally takes 
 place during the period of reaction ; and secondary, which 
 takes place after forty-eight hours, and may occur at any 
 time subsequent to this period until the wound is healed. 
 The treatment of hemorrhage is either constitutional or 
 local. 
 
 The constitutional treatment of hemorrhage consists in 
 keeping the patient in the recumbent posture and avoiding 
 any sudden elevation of the head or arms which might 
 induce fatal syncope. Opium is a valuable remedy and 
 should be freely used. Ergot, gallic acid, acetate of lead, 
 and tincture of iron may also be employed, and stimulants 
 and food should be carefully administered, and in extreme 
 cases auto-transfusion or the transfusion of blood or normal 
 salt solution, as described on page 196 may be resorted to. 
 
 In the local treatment of hemorrhage various measures 
 
CONTROL OF ARTERIAL HEMORRHAGE. 
 
 281 
 
 may be adopted which may be either temporary or perma- 
 nent in their action. 
 
 Temporary Control of Arterial Hemorrhage. 
 
 This may be effected by pressure applied directly to the 
 bleeding vessel in the wound or by pressure applied indi- 
 rectly to the main artery between the point of its injury 
 and the centre of the circulation, and this pressure may be 
 made by the fingers, digital compression, by compresses, or 
 by means of tourniquets. 
 
 Digital Compression. 
 
 This constitutes one of the most valuable means em- 
 ployed in the temporary control of hemorrhage ; the finger 
 is pressed directly upon the bleeding vessel, in the wound, 
 or is used to make pressure upon the artery from which 
 
 Fig. 198. 
 
 Digital compression of the femoral artery. 
 
 the bleeding arises at some point between the wound and 
 the centre of the circulation. (Fig. 198.) Control of 
 hemorrhage by digital pressure can only be mantained for 
 a few minutes, for the fingers of the surgeon or assistant 
 
282 MINOR SURGERY. 
 
 soon become tired, so that it is only employed until means 
 are adopted for the permanent arrest of the bleeding. 
 Digital compression of the radial and ulnar arteries is 
 frequently resorted to for the control of hemorrhage dur- 
 ing amputations of the fingers, also of the axillary and 
 femoral arteries in amputations at the shoulder- and hip- 
 joints. 
 
 It is also used to control hemorrhage from wounds, 
 either the result of accident or those made by the knife 
 of the surgeon, in which case the finger is placed directly 
 upon the divided vessel, or is employed to hold a sponge 
 or compress firmly in the wound. 
 
 Compresses. 
 
 By the use of compresses placed directly in the wound 
 or applied to the vessel between the wound and the centre 
 of the circulation, the temporary control of hemorrhage 
 may be very satisfactorily accomplished. Where it is pos- 
 sible, the compress which is applied in the wound should 
 be made of antiseptic or aseptic gauze, thereby diminish- 
 ing the chances of wound-infection. 
 
 The compress should be held in position by a bandage 
 firmly applied, and is generally employed only as a tem- 
 porary expedient until a more permanent means of con- 
 trolling the bleeding is adopted. 
 
 Tourniquets. 
 
 These instruments, which are employed for the tempo- 
 rary control of hemorrhage from wounds, are of many 
 different kinds. 
 
 Petit's tourniquet, which is the best for ordinary use, 
 consists of two metal plates connected by a strong linen or 
 silk strap, with a buckle — the distance between the plates 
 being regulated by a screw. (Fig. 199.) In applying this 
 tourniquet a compress or roller bandage is placed directly 
 over the artery to be compressed and may be held in posi- 
 tion by a few turns of the roller bandage. The lower plate 
 
CONTROL OF ARTERIAL HEMORRHAGE. 
 
 283 
 
 of the tourniquet is placed directly over this pad and the 
 strap is tightly secured around the limb to keep the instru- 
 ment in place. The screw is then turned so as to separate 
 the plates and tighten the strap, thus forcing the compress 
 or pad upon the artery and controlling its circulation. This 
 
 Fig. 199. 
 
 Petit' s tourniquet. 
 
 instrument is very generally employed for the control of 
 hemorrhage in wounds of the extremities, and is especially 
 useful in amputation of these parts, being placed over the 
 main artery some distance above the seat of operation. 
 
 The Spanish Windlass. 
 
 An improvised tourniquet, known as the Spanish 
 windlass, may be employed in cases of emergency ; it is 
 prepared by folding a handkerchief or piece of muslin 
 into a cravat and placing a compress or smooth pebble on 
 the body of the cravat ; this is placed over the artery to 
 
284 
 
 MINOR SURGERY. 
 
 Fig. 200. 
 
 be controlled, and the ends of the handkerchief are tied 
 loosely around the limb ; a short stick is passed through 
 
 this loop, and by twisting the 
 stick the loop is tightened and 
 the compress is forced down upon 
 the artery (Fig. 200). 
 
 Many other forms of tourni- 
 quet have been devised which 
 have the pad and counter-pad 
 arranged to make pressure upon 
 the vessel desired, such as Lister's 
 aorta compressor (Fig. 201 ), which 
 is employed in the treatment of 
 aneurism of the iliac vessels and 
 for the control of hemorrhage 
 in amputation at the hip-joint. 
 Hoey's clamp (Fig. 202) and 
 Signorini's tourniquet (Fig. 203) 
 are constructed upon the same 
 principle, and are frequently em- 
 ployed to control the circulation 
 in the femoral artery in cases of 
 operations on the thigh and leg, 
 and in the treatment of femoral 
 or popliteal aneurism. 
 The elastic tube, or strap of EsmarcNs apparatus (Fig. 
 204) may also be employed for the temporary control of 
 arterial hemorrhage, being applied above the wound, and 
 if this is not at hand, any strong rubber cord, or a piece of 
 large-sized drainage-tube may be used as a substitute. In 
 hemorrhage from wounds of the hands and feet, especially 
 in children, and in controlling hemorrhage from wounds 
 of the penis, a piece of drainage-tube, firmly applied above 
 the wound, may be employed with advantage. This tube 
 or strap, although generally employed to control hemor- 
 rhage from vessels of the extremities, may be used to 
 control the femoral artery as it crosses the brim of the 
 pelvis, by placing a compress over the artery in this posi- 
 tion, and then applying the elastic band to secure it with 
 
 The Spanish windlass. 
 
CONTROL OF ARTERIAL HEMORRHAGE. 
 
 285 
 
 a figure-of-eight turn, passing it under the thigh, crossing 
 over the pad, and then carrying the ends around the 
 pelvis, and securing them. 
 
 Fig. 201. 
 
 Lister's aorta compressor. 
 
 Fig. 203. 
 
 Fig. 202. 
 
 Hoey's clamp. 
 
 Signorini's tourniquet. 
 
 To make pressure on the axillary artery, a compress 
 should be placed in the axilla, and the middle of the tube 
 
 13* 
 
286 MINOR SURGERY. 
 
 placed over this to hold it in position ; the ends of the tube 
 are then carried over the shoulder where they are crossed, 
 and then carried to the opposite axilla and secured. 
 
 Fig. 204. 
 
 Elastic strap of Esmarch's apparatus. 
 
 In amputation at the shoulder-joint, to make pressure 
 upon the subclavian artery, which it is difficult to compress 
 by an ordinary tourniquet, the handle of a large key well 
 padded may be used ; it is firmly pressed against the vessel 
 above the clavicle, and held by an assistant, and will prove 
 a very satisfactory means of controlling the circulation in 
 this vessel. 
 
 Hcemostatie Forceps. 
 
 The temporary control of arterial hemorrhage by the 
 use of haemostatic forceps is now very generally employed 
 in surgical operations, and their use has done much to 
 diminish the shock following operations from the loss of 
 blood. The haemostatic forceps in general use is self- 
 retaining ; it is clamped upon the bleeding vessel, and is 
 allowed to remain until the operation is completed, when 
 the vessel is secured permanently by the application of a 
 ligature, and the forceps is removed. The use of these 
 forceps will be found very satisfactory in controlling 
 hemorrhage during the removal of tumors, in cases of 
 amputation, and for the temporary control of bleeding 
 during the operation of tracheotomy they will be found 
 most efficient, as also in abdominal operations, in which 
 their utility was first demonstrated. (Fig. 205.) 
 
ESMARCWS BANDAGE AND TUBE. 
 
 287 
 
 Esmarch's Bandage and Tube. 
 
 This apparatus, which is applied to the limbs to render 
 them bloodless during operations, consists of a rubber 
 bandage two and a half 
 inches in width and three fig. 205. 
 
 or four yards in length, and 
 a rubber tube two yards in 
 length, to one end of which 
 is attached a chain and to 
 the other a hook, or better 
 a rubber strap, one inch in 
 width and one and a half 
 yards in length with a hook 
 and chain. The bandage is 
 applied to the extremity of 
 the limb and is carried up 
 the limb to a point some 
 distance above the seat of 
 proposed operation ; the 
 bandage is applied firmly, 
 each turn overlapping one- 
 fourth of the preceding one, 
 and when the last turn has 
 been made the rubber tube 
 or strap is wound firmly 
 around the limb and secured 
 by fastening the hook into 
 one of the links of the 
 chain. (Fig. 206.) After securing the tube or strap the 
 rubber bandage is removed from the limb and if the tube 
 has been firmly enough applied the limb will be found to 
 be blanched, and should be free from blood during the 
 operation. Care should be taken not to apply the tube or 
 strap too tightly in poorly developed limbs, or on parts of 
 the limb where large nerve trunks approach the surface, 
 as they may be subjected to an amount of pressure which 
 will interfere w T ith their functions subsequently. I have 
 knowledge of one case of this nature in which permanent 
 
 Haemostatic forceps. 
 
288 
 
 MINOR SURGERY. 
 
 paralysis of the limb followed the use of Esmarch's 
 apparatus ; the tube should be applied with just enough 
 firmness to control the circulation. 
 
 As the strap, when firmly applied, completely cuts off 
 the circulation of the parts below, it should be applied for 
 as short a time as possible, as gangrene has resulted from 
 its prolonged use. 
 
 After the removal of the tube there is generally quite 
 free capillary hemorrhage, due to paralysis of the vasomotor 
 nerves from pressure, but this in a short time stops. This 
 
 Fig. 206. 
 
 Esmarch's bandage and tube applied. 
 
 apparatus is of the greatest service in controlling hemor- 
 rhage at the time of operation, and in amputations and 
 removal of vascular tumors from the limbs will be found 
 most satisfactory. In operations upon bone, either oste- 
 otomy or sequestrotomy, it is especially useful, as it allows 
 the surgeon to have a view of the parts unobscured by 
 hemorrhage. I have found its use most satisfactory in 
 operations for the removal of foreign bodies, such as 
 needles imbedded in the hands or feet or extremities. 
 
 Permanent Control of Arterial Hemorrhage. 
 
 To secure this end the surgeon may resort to the use of. 
 position, cold, heat, styptics, pressure, cauterization, liga- 
 tion, torsion, or acupressure. 
 
CONTROL OF ARTERIAL HEMORRHAGE. 289 
 
 Position. 
 
 In arterial hemorrhage from wounds of the extremities 
 elevation of the part will be found to materially diminish 
 the amount of bleeding ; in hemorrhage from wounds of 
 the arteries of the hand, forearm, foot, or leg, forcible 
 flexion of the forearm on the arm or of the leg on the 
 thigh will be found useful in diminishing the force of the 
 blood-current. 
 
 Gold. 
 
 The application of cold by means of a stream of cold 
 water or an ice-bag or pieces of ice will often be found an 
 efficient means of controlling hemorrhage from vessels of 
 small calibre ; it is especially applicable to hemorrhage 
 from wounds of the vessels of the mouth, nostrils, vagina, 
 or rectum. 
 
 Hot Water. 
 
 Hot water will be found a very efficient means of con- 
 trolling hemorrhage from small vessels, and it may be 
 used in the form of a hot antiseptic solution. It is of 
 especial value in capillary or parenchymatous hemorrhage, 
 and is employed in the form of a douche or by means of 
 sponges dipped in the hot solution and packed into the 
 wound. The injection of hot w T ater is a most satisfactory 
 method of controlling uterine hemorrhage. 
 
 Styptics. 
 
 These agents are sometimes employed to control capil- 
 lary bleeding or hemorrhage from small vessels, and 
 although their use is often satisfactory as regards the 
 control of the bleeding, they have the disadvantage of 
 interfering with the primary union in wounds, and since 
 the value of asepsis in wound treatment has been demon- 
 strated they are now very seldom employed. The most 
 valuable styptics which are used are alcohol, alum, oil of 
 
290 MINOR SURGERY. 
 
 turpentine, perchloride of iron, and persulphate of iron or 
 MonseFs solution, acetic acid, and vinegar. 
 
 Pressure. 
 
 For the permanent control of arterial hemorrhage 
 pressure may be applied directly to the bleeding-point or 
 surface by means of a compress of antiseptic gauze or by 
 strips of gauze packed firmly into the cavity from whose 
 surface the bleeding arises. 
 
 Compresses are used with the best results where the 
 proximity of a bone gives a firm substance upon which 
 the vessel may be compressed, as is the case in the vessels 
 of the scalp. Pressure applied by means of packing with 
 strips of gauze will be found most efficient in controlling 
 hemorrhage from cavities such as the nose, vagina, or 
 rectum, and in the cavities resulting from the removal of 
 necrosed or carious bone. Pressure may be indirectly 
 applied by flexing the proximal joint over a compress or 
 by firm bandaging of the limb. 
 
 In controlling bleeding from a divided artery in a bony 
 cavity, such as the inferior dental, a piece of catgut liga- 
 ture may be forced into the canal, and will control the 
 bleeding in a most satisfactory manner, or by forcing a 
 small piece of Horsley's wax into the opening in the bone ; 
 this wax is composed of wax, 7 parts]; oil, 2 parts ; and 
 carbolic acid, 1 part. 
 
 Halstead has introduced a material known as gut wool, 
 which is prepared from the same material from which cat- 
 gut is made. This is cut into fine shreds and is used to 
 control hemorrhage from bone, being pressed into the open- 
 ing or cavity in the bone from which the bleeding arises. 
 
 The troublesome hemorrhage sometimes occurring after 
 the removal of a tooth may be controlled by packing the 
 alveolar cavity with a strip of iodoform gauze, or by 
 introducing a wedge-shaped piece of cork and holding 
 it in place by fastening the jaws together by means of a 
 bandage. 
 
CONTROL OF ARTERIAL HEMORRHAGE. 
 
 291 
 
 Cauterization. 
 
 The use of cauterization by means 
 of a hot iron is a satisfactory method 
 of arresting hemorrhage. Care should 
 be taken to have the iron only of a 
 dull-red or black heat, as the result 
 desired is not the destruction of the 
 tissues, but the coagulating effect of 
 heat upon them. The form of cau- 
 tery iron employed will depend upon 
 the position of the vessel. Paque- 
 lin's cautery is also a satisfactory 
 apparatus to use for the control of 
 hemorrhage. 
 
 The control of arterial bleeding 
 by cauterization is often resorted to 
 in operations upon the jaws and in 
 the removal of tumors from the 
 mouth or pharynx or of the tonsils ; 
 it is also frequently employed to con- 
 trol hemorrhage in operations upon 
 the uterus and the rectum, and also 
 that resulting from the removal of 
 abdominal tumors, where the appli- 
 cation of a ligature is difficult and 
 often impossible. 
 
 Torsion. 
 
 This method of controlling arte- 
 rial hemorrhage consists in seizing 
 the end of the artery, drawing it 
 slightly out of its sheath and twist- 
 ing it ; it may be accomplished with 
 a single pair of forceps or by two 
 pairs of forceps. In the latter method 
 the vessel is held by one pair of 
 forceps and is twisted by the second 
 pair. 
 
 Fig. 207. 
 
 o o 
 
 Hewson's torsion 
 forceps. 
 
292 MINOR SURGERY 
 
 Torsion of arteries in accidental wounds is quite com- 
 mon, and in many cases controls the hemorrhage until 
 surgical aid is rendered. I have seen the femoral artery 
 in Scarpa's triangle completely controlled in this manner 
 in a case of avulsion of the thigh from a railway injury. 
 
 In vessels of moderate size it may be practised with one 
 pair of forceps, and the ordinary double-spring artery for- 
 ceps (Fig. 208) will be found satisfactory for such cases. 
 
 Fig. 208. 
 
 Double-spring artery forceps. 
 
 In larger arteries two forceps should be employed, or some 
 of the numerous forms of torsion forceps which have been 
 devised for this purpose. (Fig. 207). 
 
 Constriction or Crushing of Arteries for the Arrest of 
 Hemorrhage. 
 
 This procedure has been adopted for the closure of arte- 
 ries without the use of ligatures or other foreign substance 
 to be left in the wound. It was employed by the use of 
 an instrument known as the artery constrictor, which 
 grasped the artery and constricted it in such a way that 
 the inner and middle coats were lacerated, but the external 
 coat was preserved intact. 
 
 Arteriversion. 
 
 This method of controlling hemorrhage consists in con- 
 stricting the mouths of the arteries divided in wounds and 
 amputations by turning over the cut ends with a little 
 instrument called an arteriverter ; with this instrument 
 the ends of the divided artery may be retro verted, and the 
 cut extremity of the artery is reinforced by the duplica- 
 ture of its walls, thus surrounding its open mouth with 
 
CONTROL OF ARTERIAL HEMORRHAGE 
 
 293 
 
 such a quantity of arterial, muscular, and elastic fibres 
 as to effectually close it. 
 
 Ligation. 
 
 The use of the ligature is by far the most generally em- 
 ployed method of controlling arterial hemorrhage. The 
 materials used for ligature are silk, hemp thread, catgut, 
 horsehair, iron or silver wire. Catgut or silk is the mate- 
 rial generally employed. The vessel is seized with a pair of 
 artery or haemostatic forceps or a tenaculum (Fig. 209) and 
 
 Fig. 209. 
 
 Tenaculum. 
 
 drawn out of its sheath, and a ligature of prepared catgut 
 is thrown aronnd it and secured by a surgeon's knot, or 
 by a reef knot and a surgeon's knot combined, and when 
 firmly tied the ends of the ligature are cut short in the 
 wound. Silk ligatures which have been rendered aseptic 
 
 Fig. 210. 
 
 Aneurism needle armed with ligature. 
 
 are applied in the same manner, and the ends may be cut 
 short in the wound. 
 
 When ligatures are applied to vessels in their continuity 
 they may be threaded into an eyed probe or aneurism 
 needle (Fig. 210) and carried around the vessel and se- 
 
294 MINOR SURGERY. 
 
 cured. A convenient method of applying a ligature to a 
 bleeding- point in a deep wound, or to a vessel in tissues 
 which are of such a nature as not to permit of the isola- 
 tion of the vessel, is to use a curved needle threaded with 
 a catgut ligature, which is passed deeply into the tissues 
 near the vessel and brought oat on the opposite side ; the 
 ligature thus placed is then firmly tied, and the ends are 
 cut short in the wound. (Fig. 211.) 
 
 Fig. 211. 
 
 Artery occluded by suture. (Esmarch.) 
 
 Acupressure. 
 
 In this method of controlling arterial hemorrhage a 
 needle or pin is used, which is thrust through the tissues 
 in such a way as to compress the artery. There are a 
 number of methods of using the needle or pin, and a few 
 of these will be described. 
 
 First Method of Acupressure. 
 
 In this method the surgeon places a finger of his left 
 hand upon the mouth of the bleeding vessel and with his 
 right hand introduces the needle from the cutaneous sur- 
 face and passes it through the thickness of the flap until its 
 point projects for a couple of lines or so from the surface of 
 the wound a little to the right side of the tube of the vessel. 
 By forcibly inclining the head of the needle toward his 
 
CONTROL OF ARTERIAL HEMORRHAGE. 
 
 295 
 
 right he brings the projecting portion of its point firmly 
 down on the side of the vessel, and after seeing that it oc- 
 cludes the artery he makes it re-enter the flesh as near as 
 
 Fig. 212. 
 
 Fig. 213. 
 
 Acupressure— first method ; raw 
 surface. (Emchsen.) 
 
 Acupressure— first method ; cutaneous 
 surface. (Erichsen.) 
 
 possible to the left side of the wound and pushes the needle 
 through the flesh until its point comes out again at the cuta- 
 neous surface. (Figs. 212 and 213.) 
 
 Second Method of Acupressure. 
 
 A straight needle threaded with a short piece of iron or 
 silver wire, for the purpose of afterward retracting and 
 removing it, is passed down through the soft parts a little 
 to one side of the vessel ; its point is then raised up and 
 passed over the artery and is then turned down again and 
 thrust into the soft tissues on the other side of the vessel. 
 (Fig. 214.) 
 
 Third Method of Acupressure. 
 
 In this method the point of the needle is passed into the 
 tissues a few lines to one side of the vessel, then passed 
 under it and afterward pushed on, so that the point again 
 emerges a few lines beyond the vessel. A loop of wire is 
 next passed over the point of the needle, and then after 
 being carried over the vessel and passed around the oppo- 
 site end of the needle it is drawn sufficiently tight to close 
 
296 
 
 MINOR SUEGEEY. 
 
 the vessel, and the ends of the wire are secured by making 
 a twist around the stem of the needle. (Fig. 215.) 
 
 Fig. 214. 
 
 Fig. 215. 
 
 Acupressure— second method. 
 (Erichsen.) 
 
 Acupressure— third method. 
 (Erichsen.) 
 
 Fourth Method of Acupressure. 
 
 This method is identical with the third, except that a 
 long pin is used in place of the needle, the head of the 
 pin remaining outside the wound. 
 
 Fifth Method of Acupressure. 
 
 This method is identical with the third, except that a 
 long pin is used in place of the needle, the head of the 
 pin remaining outside the wound. 
 
 Acupressre— fifth method. (Erichsen.) 
 
 This method consists in passing a pin or needle through 
 the soft tissues close to the artery, and by giving the pin 
 a quarter or half rotation twisting the vessel upon itself, 
 
TREATMENT OF VENOUS HEMORRHAGE. 297 
 
 and fixing the pin by thrusting its point deeply into the 
 tissues beyond. (Fig. 216.) 
 
 Sixth Method of Acupressure. 
 
 This method consists in applying the pin as in the 
 fourth method, but differs from it in crossing the ends of 
 the wire behind the pin so as to embrace the mouth of the 
 vessel between them. 
 
 Seventh Method of Acupressure. 
 
 This method consists in passing a long needle or pin 
 through the cutaneous surface deeply into the soft parts at 
 some distance from the vessel, making it emerge near the 
 vessel, bridging over the artery and then thrusting it down 
 into the soft parts on the other side of the vessel and 
 making its point emerge again from the integument. 
 
 Treatment of Venous Hemorrhage. 
 
 Bleeding from small veins often stops spontaneously 
 unless there is some pressure upon the wounded veins 
 upon the cardiac side of the wound. It is, however, very 
 satisfactorily controlled by position or by the application 
 of a compress and bandage, or by the use of a ligature ; 
 if the divided vein be a large one it is well to secure both 
 ends by ligatures. The free bleeding arising from rup- 
 tured varicose veins of the leg is easily controlled by the 
 application of a compress and bandage, while hemorrhage 
 from the larger veins, such as the jugular, should be con- 
 trolled by the application of ligatures as in the case of 
 wouuded arteries. The application of the lateral ligature 
 to small wounds of veins of large size, such as the femoral, 
 or to wounds of venous sinuses, has been recommended 
 and employed with good results, this procedure consists 
 in pinching up the wall of the vein so as to include the 
 orifice of the wound and throwing a delicate ligature 
 around it. 
 
298 MINOR SURGERY. 
 
 The use of the actual cautery may also be required for 
 the control of venous hemorrhage in positions in which 
 its arrest by pressure or the ligature is not feasible. 
 
 TREATMENT OF CAPILLARY HEMORRHAGE. 
 
 Capillary or parenchymatous hemorrhage is usually 
 arrested spontaneously by the exposure of the injured 
 surface of the wound to the air, but it is often so profuse 
 that its arrest becomes a matter of importance. To con- 
 trol this form of bleeding, pressure may be applied to the 
 bleeding surface for a short time, and if this fails to arrest 
 it, sponging the surface with dilute alcohol will sometimes 
 prove satisfactory ; but the best application to arrest hem- 
 orrhage of this nature is hot water, which may be used in 
 the form of a hot bichloride solution. Acetic acid and 
 vinegar are also sometimes employed for the same purpose. 
 In cases where the means mentioned above fail to control 
 the bleeding, it may be necessary to pack the wound with 
 strips of antiseptic gauze ; this dressing is most service- 
 able when the hemorrhage comes from cavities such as 
 result from the removal of tumors or excisions of joints, 
 and for the control of bleeding following the removal of 
 necrosed or carious bone. To control hemorrhage from 
 the mucous cavities, such as the nose, rectum, and vagina, 
 this method of treatment is frequently resorted to. 
 
 Treatment of Secondary Hemorrhage. 
 
 Secondary hemorrhage following the use of the ligature 
 or other means of controlling bleeding is, since the adop- 
 tion of the antiseptic method of wound-treatment, a much 
 less frequent complication of wounds. The treatment of 
 this complication is both constitutional and local ; the con- 
 stitutional treatment consists in the use of those remedies 
 which were mentioned as serviceable in primary hemor- 
 rhage, and the drugs upon which the most reliance is to 
 be placed are opium and ergot. 
 
TREATMENT OF SECONDARY HEMORRHAGE. 299 
 
 The local treatment of this form of hemorrhage consists 
 in the use of the various means of controlling hemorrhage 
 which have been mentioned before, such as the ligature, 
 hot water, pressure, or the actual cautery. If possible, it 
 is well to secure the vessel from which the bleeding arises 
 in the wound ; if for any reason this cannot be done, the 
 main artery should be ligated above the wound if the 
 hemorrhage be arterial. 
 
 Rules for Ligating Wounded Arteries, 
 
 The following rules for the application of ligatures to 
 wounded arteries are laid down by Ashhurst : 
 
 1. In cases of primary hemorrhage, no operation should 
 be performed upon an artery, unless it is at the moment 
 actually bleeding. The exception to this rule is in the 
 cases where the vessel is seen to pulsate in the wound or 
 where the wound involves the region of a large artery and 
 the patient has to be transported or may be in such a posi- 
 tion that it will be impossible to receive surgical aid sub- 
 sequently if needed ; under these circumstances, the vessel 
 should be tied or the wound should be explored to ascer- 
 tain the fact that no important vessel has been injured. 
 
 2. In applying a ligature to a wounded artery, the sur- 
 geon should cut down directly upon it at the point from 
 which it bleeds and secure it in the wound. 
 
 This rule holds good for both primary and secondary 
 hemorrhage. 
 
 3. Two ligatures should be applied, one to each end of 
 the artery if it be completely divided, and one on each 
 side of the wound if the latter has not completely severed 
 the coats of the artery. This procedure is adopted for the 
 reason that the arterial anastomosis is so free that the 
 proximal ligature will not always, even temporarily, arrest 
 the bleeding ; and if it does accomplish this object at the 
 time, after the collateral circulation is established, bleeding 
 is apt to occur from the distal extremity of the divided 
 vessel. If the coats of the artery are not completely sev- 
 ered their division should be completed, either before or 
 
300 MINOR SURGERY. 
 
 after the application of the proximal and distal ligatures, 
 thereby favoring the contraction and retraction of the 
 ends of the divided vessel. 
 
 Control of Hemorrhage from Special Parts. 
 
 Epistaxis or hemorrhage from the nose may be so pro- 
 fuse as to require surgical interference. To control this 
 form of hemorrhage the application of iced compresses to 
 the surface of the nose may first be made use of, and if 
 this fails to control the bleeding, the surgeon or the patient 
 should grasp the cartilaginous portion of the nose with his 
 thumb and forefinger in such a manner as to keep the nos- 
 trils tightly closed, which will prevent the passage of air 
 through the nose and thus permit clots to form, arresting 
 the flow of blood. Bleeding from the nose often arises 
 from the erosion of a small artery low down upon the 
 septum ; it can be freely exposed by introducing a nasal 
 speculum, and the bleeding point can be touched with a 
 cautery iron, avoiding the necessity of plugging the nares. 
 If these simple means fail to arrest the bleeding the nasal 
 cavity or cavities may be packed with strips of antiseptic 
 gauze introduced into the anterior nares, and pushed back- 
 ward by a director or probe; this will often be found a 
 perfectly satisfactory means of arresting the bleeding. 
 This method may be supplemented by a plug of antiseptic 
 cotton introduced into the posterior nares with the fingers. 
 The use of a rubber tampon, consisting of a rubber bag, 
 introduced into the nares in an empty state and afterward 
 inflated, has also been recommended for the control of this 
 variety of hemorrhage. 
 
 Another method of controlling hemorrhage from the 
 nose consists in introducing a small piece of sponge, tied 
 to a strong silk ligature, into the anterior nares and push- 
 ing it back along the floor of the nose to the posterior 
 nares ; a small piece of sponge about the size of a marble 
 with a hole in the centre is threaded on the ligature and 
 pushed back until it comes in contact with the first piece 
 
HEMORRHAGE FROM SPECIAL PARTS. 
 
 301 
 
 of sponge introduced, and thus by introducing a number 
 of pieces of sponge in this way the nasal cavity may 
 be completely filled up and the bleeding arrested. Care 
 should be taken to see that the sponge has been rendered 
 aseptic before being introduced, and the nasal cavity should 
 also be washed out with an antiseptic solution before its 
 introduction. The sponges may be allowed to remain in 
 place for twenty-four to forty-eight hours. (Fig. 217.) 
 
 Fig. 217. 
 
 Plugging the nares from the front. (Roberts.) 
 
 Plugging the nares by means of Bellocq's canula is also 
 employed to arrest hemorrhage from the nasal cavities; the 
 canula, armed with a strong ligature, is passed along the 
 floor of the nose until it reaches the pharynx, when the 
 spring being protruded, the ligature is seized and brought 
 out of the mouth and secured to a plug of lint or antiseptic 
 gauze of the required size, and upon withdrawing the in- 
 strument the plug is brought into position in the posterior 
 
 14 
 
302 
 
 MINOR SURGERY. 
 
 Dares and the end of the ligature is allowed to protrude 
 from the mouth to facilitate its removal. (Fig. 218.) An 
 ordinary flexible catheter may be employed in place of 
 Bellocq's canula for the introduction of the ligature. 
 
 Fig. 218. 
 
 Plugging the nares with Bellocq's canula. (Fergusson.) 
 
 Hemorrhage from the Urethra. 
 
 In hemorrhage from the urethra, if profuse, the blood 
 will trickle from the meatus, or if efforts at micturition 
 are made the first gush of urine will contain blood, but 
 afterward will be clear, and the last urine will contain a 
 few drops of pure blood. 
 
 This variety of bleeding, if it proceeds from the anterior 
 portion of the urethra, may be controlled by the introduc- 
 tion of a catheter and the application of a bandage around 
 the penis, carefully applied so as to make only moderate 
 pressure. 
 
 If the bleeding comes from the posterior portion of the 
 urethra, it will often be controlled by the application of 
 cold or pressure to the perineum, or by the introduction of 
 
HEMORRHAGE FROM SPECIAL PARTS. 303 
 
 a cold steel bougie, or by the injection of a solution of 
 tannic acid. 
 
 Hemorrhage from the Bladder. 
 
 In this variety of hemorrhage the first portion of the 
 urine may be blood-stained and the last portion will con- 
 tain more blood and clots as the organ contracts, which 
 distinguishes it from hemorrhage from the kidneys, in 
 which the admixture of blood with the urine renders it of 
 a smoky color or dark-red if the bleeding is profuse. 
 
 To control bleeding from the bladder a catheter should 
 be introduced and the urine and clots withdrawn ; the 
 bladder should next be washed out with a warm or cold 
 boric acid solution. In severe cases weak astringent 
 solutions, such as tannic acid or alum, may be employed. 
 The application of ice to the perineum and supra-pubic 
 regions may also be employed with advantage. 
 
 Hemorrhage from the Rectum. 
 
 This variety of bleeding may be controlled by the in- 
 jection of cold or astringent enemata. If the bleeding be 
 profuse a speculum should be introduced, and when the 
 source of the bleeding has been discovered the actual cau- 
 tery or a ligature should be applied. If this is not feasible 
 the rectum may be plugged with strips of antiseptic gauze, 
 or a piece of a rubber catheter of large calibre may be 
 wrapped with gauze and introduced into the rectum, the 
 end of the catheter being allowed to protrude; by using 
 this tube flatus can escape, and if the bleeding is not con- 
 trolled blood will escape through the tube, preventing the 
 risk of concealed hemorrhage. If the bleeding arises from 
 hemorrhoids or polypus of the rectum the operative treat- 
 ment of these conditions should be undertaken to perma- 
 nently control the bleeding. 
 
304 MINOR SURGERY. 
 
 Opening and Dressing of Abscesses. 
 
 In operations for the evacuation of the contents of ab- 
 scesses, care should be taken to observe every precaution 
 to prevent a new infection of the wound or abscess cavity; 
 the skin over the abscess should be carefully cleaned to 
 make it aseptic, the hands of the surgeon and the instru- 
 ments to be brought in contact with it should also be 
 aseptic. These precautions should be especially observed 
 in the opening of chronic abscesses when a new variety of 
 infection is liable to be set up if aseptic precautions are 
 not rigidly observed. 
 
 Acute abscesses, as a rule, should be opened by incision, 
 and this is best done with a straight, narrow, sharp-pointed 
 bistoury ; the incision should be deep enough to freely 
 expose the cavity of the abscess, and should be so planned 
 as to be parallel with and not across important structures, 
 and it should also be made at as dependent a portion as 
 possible. Abscesses of the limbs are opened by a longi- 
 tudinal incision, and those in the region of the anus and 
 breast by an incision radiating from the anus or nipple. 
 
 In deep-seated abscesses in the region of important 
 structures the method of opening suggested by Mr. Hilton 
 may be employed with advantage ; it consists in making 
 a small incision through the skin and cellular tissue ; a 
 director is next pushed through the tissues into the abscess 
 cavity, which will be shown to have been reached by the 
 escape of a little pus along the director; a dressing forceps 
 with the blades closed is now pushed along the director 
 into the abscess cavity, and when this has been accom- 
 plished the director is withdrawn and the forceps is re- 
 moved with the blades expanded so as to dilate the wound 
 and allow the pus to escape. 
 
 The cavity of the abscess having been emptied of pus, it 
 should be irrigated with a stream of carbolic acid solution 
 1 : 40, or bichloride solution, and if the cavity is not very 
 large or deep no drainage-tube need be introduced, and a 
 small piece of protective may be placed between the lips of 
 
OPENING AND DRESSING OF ABSCESSES. 305 
 
 the wound to prevent their adhesion ; but if, on the other 
 hand, the cavity is extensive and deeply situated, a rubber 
 drainage-tube or a strip of iodoform gauze should be 
 introduced to the bottom of the cavity to secure free 
 drainage, and fixed at the surface of the skin by a safety- 
 pin. A piece of protective which has been dipped in 
 bichloride solution is next placed over the wound, and 
 over this is laid a gauze dressing, consisting of a number 
 of layers, which has been moistened in carbolic or bi- 
 chloride solution ; this is covered by a number of layers 
 of dry gauze which is in turn covered by a piece of rubber 
 tissue. The latter may be omitted, and over this is placed 
 a few layers of bichloride cotton, and the dressing is finally 
 secured by a roller bandage. The dressing is removed at 
 the end of two or three days, the cavity being washed out 
 with one of the antiseptic solutions previously mentioned. 
 The drainage-tube may then be shortened or removed, and 
 the dressings reapplied as at the primary dressing. Under 
 this method of treatment acute abscesses usually heal more 
 promptly and with less suppuration than under the older 
 methods of treatment in which poultices were applied. 
 
 Chronic or tuberculous abscesses, which occur chiefly in 
 connection with diseases of the bones or joints or of the 
 lymphatic system, and are generally tubercular in their 
 origin, may be opened in various ways, the time at which 
 this should be done depending upon the size and situation 
 of the abscesses and the amount of constitutional and 
 local disturbance which the patients experience from their 
 presence. 
 
 A tuberculous abscess may be evacuated by means of the 
 aspirator ; the pus being withdrawn as far as possible, the 
 puncture is sealed with a small piece of gauze covered 
 with iodoform collodion. Reaccumulation of the pus 
 often takes place, and the aspiration has to be repeated a 
 number of times. The greatest difficulty in the successful 
 removal of the contents of cold abscesses by means of 
 aspiration is the presence of masses of lymph in the pus 
 which occlude the canula and often prevent the complete 
 emptying of the cavity. 
 
306 MINOR SURGERY. 
 
 These abscesses may also be evacuated by making a 
 puncture through the skin and overlying tissues with a 
 narrow bistoury, the surface having been previously thor- 
 oughly w r ashed with soap and water and with a carbolic 
 or bichloride solution ; a director is next pushed through 
 this small wound into the cavity of the abscess, and the 
 pus is allowed to escape by stretching the wound by the 
 director ; when the cavity is emptied of pus it is washed 
 out with a carbolic or bichloride solution introduced into 
 it by pushing the nozzle of a syringe into the cavity, and 
 this is allowed to escape in the same way as the pus 
 previously did. When the irrigating solution has all 
 escaped the cavity may be injected with an emulsion com- 
 posed of iodoform one part, glycerin ten parts ; after this 
 has been introduced the small wound is closed by a com- 
 press of antiseptic gauze held in place by a compress of 
 bichloride cotton and a bandage or by strips of adhesive 
 plaster. The injection of the iodoform emulsion need not be 
 repeated as long as iodoform continues to be excreted with 
 the urine. Tuberculous abscesses are also treated by making 
 a free incision into the abscess cavity with full antiseptic 
 precautions, and after the escape of the purulent matter 
 the walls of the abscess should be thoroughly scraped with 
 a curette, and after the cavity has been freely washed out 
 with a carbolic or bichloride solution large drainage-tubes 
 are introduced and an antiseptic dressing is applied to the 
 wound. The dressings are removed as soon as they become 
 soaked, aud the drainage-tubes are shortened or removed 
 as the discharge diminishes and the cavity contracts. 
 
 In evacuating tuberculous abscesses by means of the 
 aspirator or by a small puncture, there is absence of shock, 
 and the loss of blood is insignificant, so that these pro- 
 cedures should generally be first employed, and the more 
 radical operation of incision and curetting of the cavity 
 of the abscess, which is accompanied with a certain amount 
 of shock and hemorrhage, should be reserved for those 
 cases in which the less severe operations have failed to be 
 followed by a satisfactory result. 
 
 Diffused suppuration is treated by numerous punctures 
 
DRESSING OF WOUNDS. 307 
 
 or incisions, which allow the purulent matter to escape, 
 and where sloughs are present free incisions may be re- 
 quired to give exit to the necrosed tissues ; the introduc- 
 tion of drainage tubes may also be required. The wounds 
 and the cavities, as far as possible, should be washed out 
 with a carbolic or bichloride solution, and an antiseptic 
 gauze dressing should be applied. 
 
 Sinuses resulting from abscesses, if superficial, should 
 be laid open freely and their surfaces should be scraped 
 with a curette, and they should then be lightly packed 
 with strips of bichloride or iodoform gauze and should be 
 covered by an antiseptic dressing. If they are too deep 
 to be treated by incision their healing may be facilitated 
 by the injection of stimulating solutions introduced by 
 means of a syringe ; the employment of solutions of 
 chloride of zinc, nitrate of silver, and sulphate of copper 
 varying in strength from five to twenty grains to the 
 ounce of water will often prove satisfactory. 
 
 Dressing of Wounds. 
 
 Incised wounds present the conditions favorable for 
 prompt healing, and they should first be carefully irrigated 
 wdth an antiseptic solution to remove any blood-clots or 
 foreign bodies, and after any hemorrhage which is present 
 is controlled by the use of ligatures, if the wound be an 
 extensive or deep one, provision should be made for drain- 
 age by introducing a drainage-tube or a few strands of 
 sterilized catgut at the bottom of the wound, allowing the 
 extremity to project from the most dependent portion of 
 the wound. In superficial incised wounds, after the hem- 
 orrhage has been controlled, it is not usually found neces- 
 sary to make any provision for drainage. If the wound 
 be a deep one, involving the muscles and deep fascia, 
 buried sutures of catgut should be applied to approximate 
 the muscles and fascia, and if important nerves or tendons 
 have been divided their ends should be brought into appo- 
 sition by sutures of catgut or sterilized silk ; the superficial 
 portions of the wound should next be brought together by 
 
308 MINOR SURGERY. 
 
 the introd action of a number of interrupted sutures, catgut, 
 silkworm-gut, silver wire or silk being employed for this 
 purpose ; the accurate apposition of the edges of wounds 
 of this variety is secured by the introduction of a number 
 of sutures placed closely together. 
 
 After a wound of this variety has been closed the sub- 
 sequent dressing is accomplished by dusting the surface of 
 the wound with iodoform or aristol, and a piece of pro- 
 tective a little larger than the wound, which has been 
 dipped in a 1 : 40 carbolic solution, is placed over it ; over 
 this is placed a pad of antiseptic gauze, composed of ten 
 or twelve layers, which has been soaked in a 1 : 40 carbolic 
 solution or a 1 : 2000 bichloride solution, and over this is 
 laid a pad of dry antiseptic gauze of the same thickness, 
 overlapping the wet gauze by a few inches in all directions ; 
 a few layers of bichloride cotton are next applied over the 
 gauze dressings and the whole dressing is secured in posi- 
 tion by the application of an antiseptic gauze bandage. 
 Under this form of dressing prompt healing of incised 
 wounds is the rule, and the wound need not be re-dressed 
 for a week or ten days unless some indications exist for 
 the change of dressing at an earlier period. Dry or moist 
 sterilized dressings may also be employed. At the time 
 of the first dressing the catgut drain or the drainage-tube 
 is usually removed, and if the adhesion of the edges of 
 the wound is firm the sutures may also be removed. An 
 antiseptic dressing is usually next applied and allowed to 
 remain in position for a few days longer. 
 
 Lacerated wounds present edges which are torn and not 
 sharply cut, and the vitality of the injured parts is often 
 so seriously impaired that prompt union in this variety of 
 wounds is not, as a rule, to be looked for. Wounds of this 
 nature should first be irrigated with an antiseptic solution, 
 as in the case of incised wounds, and blood-clots and for- 
 eign bodies should be removed. If the wounds be deep, 
 drainage-tubes should be introduced ; on the other hand, 
 if they be superficial, or if the edges are not closely ap- 
 proximated, provision for drainage may be omitted. The 
 torn or irregular edges of the wound should next be 
 
DBESSIXG OF WOUNDS. 309 
 
 brought into apposition at a few points, by the introduc- 
 tion of catgut or silkworm-gut sutures, applied not very 
 closely together ; and if the edges are discolored and their 
 vitality seems markedly impaired, it is better not to use 
 sutures, but rest satisfied by bringing them as nearly as 
 possible in contact by the use of a few strips of isinglass 
 plaster moistened with a bichloride solution. If the edges 
 of the wound are so much crushed as to have their vitality 
 destroyed, they may be trimmed away with scissors until 
 a surface possessing fair vitality is secured. The evil 
 results arising from the introduction of sutures into this 
 variety of wounds, with the idea of closely approximating 
 their edges, are so common that the surgeon who dispenses 
 with the use of sutures entirely errs upon the safe side. 
 The use of many sutures in wounds of this nature often 
 causes marked tension in the wound, which is frequently 
 followed by impairment of the vitality of the injured tis- 
 sues, and sloughing results. 
 
 The wound should next be dressed antiseptically, and if 
 it runs a favorable course it need not be re-dressed for a 
 week or ten days ; the time required for the repair of a 
 wound of this nature is longer than that for an incised 
 wound, and more frequent dressing may be required. 
 
 In lacerated wounds of the extremities continuous irri- 
 gation of the wound by a warm bichloride or carbolic' 
 solution, applied as described (page 174), is often followed 
 by the most satisfactory results ; wounds produced by 
 machinery and railway accidents, in which the vitality of 
 the tissues is much impaired, are particularly favorable 
 cases for this method of treatment, and here the same caution 
 should be exercised as regards the introduction of sutures. 
 
 Contused Wounds. — This variety of wounds possesses 
 many characteristics in common with lacerated wounds ; 
 the edges are bruised and the injury of the subcutaneous 
 tissue is often more extensive than the size of the external 
 wound would lead one to suspect. They are dressed in 
 the same manner as lacerated wounds, and the same objec- 
 tion here exists to the use of sutures as in the latter class 
 of injuries. 
 
 14* 
 
310 MINOR SURGERY. 
 
 Punctured Wounds. — These wounds are inflicted by 
 sharp-pointed instruments, and it often happens that a 
 portion of the vulnerating body remains in the wound, as 
 is frequently the case in wounds produced by needles ; and 
 another complication in this variety of wound is the injury 
 of vessels, giving rise to concealed hemorrhage, or of nerves, 
 resulting in neuritis. Simple punctured wounds should be 
 carefully washed with an antiseptic solution and covered 
 by an antiseptic gauze dressing, and if no complication 
 exists their healing is usually very rapid. 
 
 When, however, a foreign body remains in the wound, 
 as it often happens in punctured wounds produced by 
 needles and pins, the punctured wound should be con- 
 verted into an incised wound, and the body should be 
 searched for and removed if possible, and in doing this in 
 the case of wounds of the extremities the operation is much 
 facilitated by the employment of Esmarch's bandage and 
 strap. After the removal of the foreign body the wound 
 is treated as an incised wound, and an antiseptic dressing 
 should be applied. When concealed hemorrhage occurs 
 after a punctuted wound, the wound should be laid open 
 and the bleeding vessel searched for and ligatured if possi- 
 ble, and the wound should afterward be dressed as an 
 incised wound. 
 
 Poisoned Wounds. — These wounds are caused by the 
 absorption, by means of a cut or abrasion in the skin, of 
 fluids from a dead body in making dissections or post- 
 mortem examinations or in operating upon living subjects, 
 and often result in serious consequences. Such wounds, 
 as soon as possible after their reception, should be care- 
 fully washed out with a solution of bichloride of mercury, 
 1 : 2000, or a 30-grain solution of chloride of zinc, and 
 then dressed with an antiseptic dressing. If, however, this 
 precaution is not taken or the wound has escaped notice, 
 and in a few hours becomes inflamed and painful, and 
 evidences of lymphatic involvement show themselves, 
 the wound should be opened and its surface should be 
 thoroughly washed out with a 30-grain solution of chlo- 
 ride of zinc, and finally with a 1 : 2000 bichloride solution, 
 
DRESSING OF WOUNDS. 311 
 
 and it should then be dressed with an antiseptic gauze 
 dressing. Under this method of dressing the poisoned 
 wound is often converted into a healthy one, even after 
 the lymphatic involvement is well marked, and it usually 
 heals promptly without further constitutional disturbance. 
 
 Gunshot Wounds. — These wounds are produced by small 
 shot, balls, or fragments of shells, and are of the nature of 
 contused and lacerated wounds, and the vulnerating body 
 as well as portions of the clothing are often imbedded in 
 the tissues. 
 
 In dressing these wounds any foreign bodies, if they can 
 be located, should be removed, and in the search for and 
 removal of balls from the extremities the application of 
 the Esmarch bandage and strap will be found most useful. 
 The wound should next be thoroughly washed out with a 
 1 : 2000 bichloride solution, and an antiseptic dressing ap- 
 plied as in the case of other contused and lacerated wounds. 
 
 Powder burns resulting from the explosion of powder, 
 in addition to the burning and laceration of the tissues, 
 are accompanied by the introduction of grains of unburnt 
 powder into the skin, which, if not removed, leave perma- 
 nent points of pigmentation. These wounds should first 
 be washed with an antiseptic solution, and upon the face, 
 to avoid unsightly pigmentation of the skin, care should 
 be taken to pick out the small masses of powder with a 
 needle or the sharp point of a tenotomy knife. The sur- 
 face should then be dressed with antiseptic gauze or with 
 lint spread with an ointment of boric acid or an ointment 
 of aristol, consisting of half a drachm or a drachm of 
 aristol to an ounce of vaseline, this dressing being covered 
 by a few layers of bichloride or borated cotton, held in 
 place by a roller bandage. 
 
 Contusions or bruises differ from contused wounds in the 
 fact that the skin is not broken, though in spite of this 
 fact there may exist very extensive laceration of the sub- 
 cutaneous tissues, accompanied by more or less extravasa- 
 tion of blood from the injured vessel. When not severe 
 enough to require operative treatment they should be 
 dresssed by applying over them several layers of lint satu- 
 
312 MINOR SURGERY. 
 
 rated with lead-water and laudanum, and over this dress- 
 ing is placed a layer of waxed paper or rubber tissue, and 
 the dressing is secured by a roller bandage. 
 
 Brush-barn. — This is a form of contused wound which 
 is produced by violent friction applied to the surface of 
 the body, and is often produced by coming in contact with 
 rapidly revolving wheels or the belting of machinery, or 
 by the body being rapidly propelled over an uneven sur- 
 face, or by a rope being rapidly drawn through the closed 
 hands. The injury may vary from a superficial abrasion to 
 the absolute destruction of the skin. The surface of the 
 brush-burn should be cleansed by a stream of sterilized 
 water or 1 : 2000 bichloride solution, and should then be 
 dressed with a powder of iodoform and boric acid, equal 
 parts, and a sterilized gauze dressing should be applied ; 
 if suppuration occurs, a dressing of boric ointment should 
 be applied. 
 
 A solution which I find most satisfactory in the dress- 
 ing of contusions is as follows : 
 
 Ammonii chloridi grs. xx. 
 
 ScotJns} -ch . . m- 
 
 Aquae q. s. ad fsj. 
 
 Several layers of lint saturated with this solution are 
 laid over the contused tissues, and are covered with waxed 
 paper, oiled silk, or rubber tissue. 
 
 Extensive collections of blood following contusions often 
 remain in the tissues for some time, but usually are ab- 
 sorbed. If this result does not follow, or an abscess forms, 
 the blood or pus should be removed by aspiration or by 
 incision with full antiseptic precautions. 
 
 Burns and Scalds. 
 
 The dressings employed in the treatment of burns and 
 scalds are similar, as the injury to the tissues is practically 
 the same in both classes of injuries. Superficial burns or 
 scalds, in which the effect of the heat has only extended 
 to the superficial layer of the skin, may be treated by the 
 
BURNS AND SCALDS. 313 
 
 application of lint saturated with a solution of carbonate 
 of sodium, a drachm to an ounce of water ; this dressing 
 rapidly relieves the pain, and is a satisfactory application 
 in this variety of burns and scalds. In cases in which 
 the effects of heat have extended to the deeper tissues, the 
 affected surface may be dressed with carron oil, which is 
 prepared by rubbing together lime-water and linseed oil 
 until a thick creamy paste results ; lint is saturated with 
 this mixture and laid over the surface of the burn or scald. 
 The dressing is a comfortable one to the patient, but soon 
 becomes offensive, and for this reason requires frequent 
 renewal. 
 
 The disadvantage met with in the antiseptic method of 
 dressing burns and scalds is the fact that the raw surface 
 presented offers the most favorable conditions for the ab- 
 sorption of the antiseptic substances employed in the dress- 
 ings, and for this reason the use of bichloride of mercury, 
 carbolic acid, and iodoform is not to be recommended in 
 burns or scalds involving a large extent of surface, on 
 account of the toxic symptoms which may result from their 
 employment. 
 
 A recent burn or scald, by reason of the heat employed 
 in its production, is practically an aseptic wound, and it 
 may be dressed by covering it with a number of layers of 
 sterilized gauze and cotton, and with boric acid ointment, 
 and placing over this a number of layers of borated or 
 salicylated cotton, and holding the dressings in position 
 by a bandage. 
 
 If, however, a full antiseptic dressing is employed, the 
 injured surface should first be irrigated with a 1 :60 car- 
 bolic or 1 : 4000 bichloride solution, and then covered with 
 protective or rubber tissue which has been sterilized, and 
 over this a dressing of carbolized or bichloride gauze and 
 bichloride cotton should be applied. 
 
 Aristol, as a substitute for iodoform, may be employed 
 in the dressing of burns or scalds, being either dusted 
 over the surface or used in the form of an ointment, and 
 over this application should be placed a few layers of 
 borated or salicylated cotton. 
 
314 MINOR SURGERY. 
 
 When blebs are present upon the surface of the burn or 
 scald, they should be opened to allow the serum to escape. 
 If suppuration occurs, or the tissues become necrosed by 
 reason of the severity of the injury, the surface of the burn 
 may be washed with a 1:60 carbolic solution or 1 : 4000 
 bichloride solution, and the same dressing should then be 
 applied. 
 
 The ulcers resulting from the separation of the dead 
 tissues should be touched with a solution of nitrate of 
 silver, four grains to the ounce of water, and dressed with 
 lint spread with an ointment of boric acid or aristol. In 
 the dressing of extensive burns or scalds of the neck, face, 
 and region of the joints, the possibility of serious deformity 
 from contraction of the tissues in healing should not be 
 lost sight of, and position, splints, and bandages should be 
 employed to prevent, as far as possible, this complication. 
 
 Bedsores. 
 
 These sores usually occur over the sacrum or hips in 
 patients who are confined to bed for a considerable time, 
 as the result of a long-continued pressure, or in those cases 
 where the vital powers are depressed by adynamic diseases, 
 and are also a frequent and troublesome complication in 
 spinal injuries, in which cases they result from trophic 
 disturbances. Their formation may be prevented in 
 many cases by the use of air-cushions or of a water mat- 
 tress and by keeping the parts exposed to pressure scrupu- 
 lously clean and frequently bathing them with stimulating 
 lotions, such as alcohol, olive oil and alcohol equal parts, 
 or soap liniment. The parts should also be protected from 
 pressure by the application of adhesive plaster, or, still 
 better, soap plaster spread upon chamois. When a bed- 
 sore has actually formed, and in many cases its formation 
 is very rapid and the slough will be found to involve a 
 large surface of the skin over the sacrum, and to extend 
 down to the bone, we have present a very serious compli- 
 cation, and one which requires most careful treatment. 
 
SPRAINS. 315 
 
 The dressing of a bedsore before the separation of the 
 slough consists in relieving the part from pressure by the 
 use of an air cushion placed under the buttocks, and the 
 application of a fermenting poultice until the slough has 
 separated. When the slough has become detached the 
 ulcer remaining should be well washed with a carbolic or 
 bichloride solution, and the granulations should be touched 
 with a 5-grain solution of nitrate of silver; and resin 
 cerate, iodoform, aristol, or boric acid ointment, spread 
 upon lint, should be applied to the surface of the ulcer, 
 and a piece of soap plaster a little larger than the ulcer 
 should be placed over this dressing and held in place by 
 broad strips of adhesive plaster. This dressing should be 
 renewed every day or every other day, and means should 
 be adopted to protect the parts from further pressure, and 
 the constitutional condition of the patient should be im- 
 proved by the administration of a nutritious diet, tonics, 
 and stimulants. The application of the galvanic current 
 has been employed with good results to promote the heal- 
 ing of the ulcer in obstinate cases. 
 
 Sprains. 
 
 Sprains of joints from twists or other external violence 
 resulting in the stretching or laceration of the ligaments 
 are injuries which require careful dressing. 
 
 Sprains may be first treated by the application of cold- 
 or hot-water dressings for a few hours, or by the applica- 
 tion of lead-water and laudanum, the joint being kept at 
 rest by the use of a splint or by confining the patient in 
 the recumbent posture in the case of sprains of the joints 
 of the lower extremities. 
 
 After a few days' use of the lead-water and laudanum 
 dressing the swelling usually subsides and the joint may 
 be fixed by the application of a moulded soap-plaster splint 
 or felt splint held in place by a firmly applied roller ban- 
 dage, which should be worn for a week or ten days ; in 
 ordinary cases after this time the splint may be removed 
 
316 MINOR SURGERY. 
 
 and the patient should be encouraged to use the joint. In 
 cases of severe sprains, on the other hand, the pain and 
 swelling persist for some time, and here the fixation of 
 the joint by a soap plaster, or better by a plaster-of-Paris 
 bandage, will be found useful for a few weeks. If upon 
 the removal of this dressing the parts are still painful 
 and swollen, the swollen tissues should be painted with 
 tincture of iodine ; or the method of applying tincture of 
 iodine recommended by Mr. Jordan, that is, the applica- 
 tion of the iodine in a broad band around and not over 
 the swollen tissues, may be employed. The joint should 
 next be surrounded by a piece of lint spread with an 
 ointment composed of equal parts of ointment of mercury 
 and ointment of belladonna, and a moulded soap-plaster 
 splint being fitted to the joint, it is held in place by a 
 firmly applied bandage. This will be found a most satis- 
 factory dressing in the treatment of sprains after they 
 have passed their acute stage. The dressing is removed 
 at intervals of three or four days, the joint is sponged off 
 with alcohol, and a similar dressing is reapplied ; and this 
 method of dressing may have to be continued for some 
 weeks, but the results obtained by its continuous use are 
 often most satisfactory. An ointment of ichthyol one part 
 to lanolin three parts may also be used in the same manner 
 as the ointment of belladonna and mercury with good re- 
 sults in the treatment of these injuries. 
 
 The treatment of sprains which I have found the most 
 satisfactory, both in the acute and chronic stage, consists 
 in the use of strapping. Strips of rubber adhesive or ad- 
 hesive plaster one and a half inches in width are applied 
 around the joint, and are made to extend some distance 
 above and below it, and a gauze bandage is next applied 
 over the straps, and the patient is allowed to use the part 
 as soon as he can do so without discomfort. 
 
 In the chronic stage of a sprain, after all dressings have 
 been removed, the methodical use of massage is often most 
 beneficial; and after the parts have been thoroughly 
 manipulated a flannel bandage should be applied which, by 
 its elasticity, gives a certain amount of support to the parts. 
 
SPEAINS. 317 
 
 Sprain-fracture. — Under this name Mr. Callender has 
 described an injury which consists in the separation of a 
 ligament or tendon from its point of insertion, with the 
 detachment of a thin shell of bone; this injury is apt to 
 occur about the ankle-, knee , elbow-, and wrist-joints, and 
 the treatment is the same as that of an ordinary fracture 
 in the same locality. This injury is probably much more 
 common than is generally supposed in connection with 
 sprains of the joints, and is, I think, in many cases the 
 cause of the tardy restoration of the function of sprained 
 joints, this injury being overlooked and the injury simply 
 being treated as a sprain, and the patient being encouraged 
 to use the part before the union of the bone has been 
 accomplished. 
 
 Strains of muscles and fascia varying in severity from 
 simple stretching of the fibres to absolute rupture are 
 treated by putting the parts at rest and by the application 
 of pressure by means of adhesive straps or of a bandage; 
 in strains of the muscles and fascia of the back the use of 
 broad strips of adhesive plaster, applied as in cases of 
 fracture of the ribs, will be found most satisfactory, and in 
 the treatment of the latter stages of the injury the employ- 
 ment of massage will often be followed bv good results. 
 
PAET III. 
 
 FRACTURES. 
 
 In the following article the author has endeavored to 
 confine himself simply to a description of the varieties of 
 fracture and to their dressing and treatment, and he has 
 tried as far as possible to avoid the multiplication of dress- 
 ings, being satisfied to describe a few of the methods of 
 dressing most frequently employed. He has also avoided 
 the description of complicated splints and dressings, by 
 the use of which in certain fractures most excellent results 
 are obtained, but has preferred to recommend the employ- 
 ment of simple splints and dressings, which can be obtained 
 by physicians practising in districts remote from large 
 cities where the services of an instrument-maker cannot 
 be obtained to construct special apparatus for the treat- 
 ment of these injuries. 
 
 Varieties of Fracture. 
 
 A complete fracture is one in which the line of separa- 
 tion completely traverses the bone, involving the entire 
 thickness of the bone. 
 
 An incomplete fracture is one in which there is only a 
 partial separation of the bone-fibres (Fig. 219), under 
 which name are included partial or " green-stick" fracture, 
 in which some of the bone-fibres have given way, while 
 the remaining fibres have been bent by the force and have 
 not been broken. (Fig. 220.) Fissured, punctured, in- 
 
VARIETIES OF FBACTUBE. 
 
 319 
 
 dented, and perforating fractures are also included in the 
 class of incomplete fractures. (Fig. 221.) 
 
 A simple or closed fracture is a fracture in which there 
 are but two fragments, and the seat of injury in the bone 
 
 Fig. 219. 
 
 Fig. 220. 
 
 Fig. 221. 
 
 Incomplete fracture 
 of femur. 
 
 Partial or green-stick 
 fracture of radius. 
 
 Fissured fracture 
 of the humerus. (Gurlt.) 
 
 does not communicate w r ith the external air by a wound in 
 the soft parts. 
 
 Compound or open fractures are fractures in which the 
 seat of injury in the bones communicates with the external 
 air by a wound in the soft parts. 
 
 Comminuted fractures are those in which there are more 
 than two fragments, the lines of fracture intercommuni- 
 cating with each other. (Fig. 222.) 
 
 A multiple fracture is one in which a bone is the seat of 
 
320 
 
 FRACTURES. 
 
 two or more distinct fractures at different points, the lines 
 of fracture not necessarily communicating with each other. 
 Complicated fractures are such as are accompanied by 
 some serious injury of the parts in the region of the frac- 
 ture — as, for instance, the laceration of important blood- 
 vessels or nerves, contusion or laceration of the muscles, 
 or dislocation of a neighboring joint. 
 
 Fig. 222. 
 
 Fig. 224. 
 
 Comminuted fracture 
 of patella. 
 
 Fig. 223. 
 
 Impacted fracture. 
 
 Transverse fracture 
 of femur. (Gurlt.) 
 
 Impacted fractures are those in which one fragment is 
 driven into and fixed in the other, the impaction taking 
 place at the time of fracture, or being caused by a force 
 subsequently applied. (Fig. 223.) 
 
DIRECTION OF FRACTURE. 
 
 321 
 
 Direction of Fracture. 
 
 A transverse fracture is one in which the geueral line of 
 division of the bone is at right angles with the long axis 
 of the bone. (Fig. 224.) Transverse fractures of the long 
 bones are rarely met with, the line of fracture usually being 
 more or less oblique 
 
 Fig. 225. 
 
 Fig. 226. 
 
 Oblique fracture of humerus. 
 (Stimson.) 
 
 Longitudinal fracture of tibia. 
 (Stimson.) 
 
 An oblique fracture is one in which the line of separa- 
 tion is oblique to the long axis of the bone. This is one 
 of the most common directions of the line of fracture. 
 (Fig. 225.) 
 
 A longitudinal fracture is one in which the line of sepa- 
 ration runs in the general direction of the long axis of the 
 
322 FRACTURES. 
 
 bone. (Fig. 226.) This form of fracture is rare, but is 
 sometimes met with in the long bones as the result of gun- 
 shot injury. 
 
 Epiphyseal fracture or separation occurs before complete 
 ossification has taken place between epiphysis and diaphy- 
 sis, and is rarely seen after the twentieth year of life ; 
 the direction of the epiphyseal separation is transverse. 
 (Fig. 227.) 
 
 Fig. 227. 
 
 Epiphyseal fracture of the head of the humerus. (Moore.) 
 
 The deformity or displacement in fractures is either 
 angular, transverse, longitudinal, or rotary. 
 
 Repair of Fractures. 
 
 The process of repair in cases of fracture is concisely 
 stated by Ashhurst as follows: "The traumatic irritation 
 propagated from the broken bone causes swelling of the 
 periosteum, active proliferation, and formation of a sheath 
 of new bone around the seat of fracture; this is the 
 
EXAMINATION OF CASES OF FRACTURE. 323 
 
 ensheathing or ring callus of surgical writers. At the 
 same time, the medulla feels the effect of the irritation, 
 becomes hardened, and partially ossified ; this constitutes 
 the interior or pin callus. Lastly, the osseous tissue itself 
 undergoes cell-proliferation, and union of the fragments 
 takes place — mutatis mutandis — precisely by the same pro- 
 cess that we have already studied in considering wounds of 
 the soft tissues. The new material which is thus devel- 
 oped between the fragments themselves, constitutes what 
 Dupuytren called the intermediate, permanent, or definitive 
 callus, in contradistinction to the ensheathing and interior 
 forms of callus, which are temporary or provisional." 
 
 Examination of Cases of Fracture. 
 
 In examining a case of fracture to locate the nature and 
 seat of the injury, the clothing should be removed from the 
 part with as little disturbance as possible, and it is better, 
 in most cases, to cut or rip the clothing, rather than to 
 attempt to remove it in the ordinary manner. The surgeon 
 should first inspect the injured part, and, where possible, 
 compare it with its fellow, as in the case of injuries of the 
 extremities; much valuable information is also derived 
 from the patient or his friends as to the manner in which 
 the injury was produced. The part should next be care- 
 fully examined by the surgeon ; if it be one of the ex- 
 tremities which is injured, it should be gently lifted, firm 
 extension being made at the same time, the surgeon by his 
 touch and by gentle movements seeking to locate the seat 
 of fracture ; and he may, by his manipulation, at the same 
 time develop crepitus. 
 
 All manipulations should be made with care, and with 
 the greatest gentleness, not only to save the patient from 
 pain, but also to prevent the soft parts in the region of 
 the fracture from being injured by the rough or sharp 
 fragments of the bone. Rough handling of fractures may 
 increase the muscular spasm by the irritation caused by 
 the sharp fragments of the bones, and may also result in 
 
324 FRACTURES. 
 
 the injury of important vessels and nerves, and indeed a 
 simple fracture may be converted into a compound one by 
 forcible and injudicious manipulations. 
 
 The sooner the examination is made after the fracture 
 has occurred the better, for at this time there is less swell- 
 ing in the region of the injury, and the surgeon can locate 
 the bony prominences with much more ease, and can often 
 discover the exact seat of the fracture with the least 
 amount of manipulation of the parts. When a case of 
 suspected fracture is not subjected to examination for 
 several days after the reception of the injury, the parts in 
 the region of the supposed fracture are often so much 
 swollen that it is impossible to accurately locate its seat, 
 and in such a case it is often necessary to wait until the 
 swelling has subsided before the position of the fracture 
 can be satisfactorily fixed, the case being treated in the 
 meantime as one of fracture. 
 
 Ancesthetics may be employed to relieve the patient from 
 pain and to obliterate muscular spasm in the examination 
 of fractures. Their employment is often of the greatest 
 service in the diagnosis of obscure or complicated frac- 
 tures, especially those in the neighborhood of joints ; but 
 the surgeon should remember that all manipulations should 
 be made with the same gentleness as when the examination 
 is conducted without anaesthesia, for there is the same risk 
 of injury to the surrounding structures by the fragments ; 
 this precaution is often neglected when an anaesthetic has 
 been given, the surgeon often being inclined to handle the 
 parts more roughly than he otherwise would ; such practice 
 cannot be too severely condemned. 
 
 Provisional Dressings in Cases of Fracture. 
 
 It generally happens that fractures occur at localities 
 more or less distant from the point where the treatment 
 of the fracture is to be conducted, and the transportation 
 of the patient and the temporary dressing of the fracture 
 are, therefore, matters of the first importance. In frac- 
 
PROVISIONAL DRESSINGS IN FRACTURE. 325 
 
 Fig. 228. 
 
 tures of the upper extremities, if the fracture be simple, 
 the clothing need not be removed, and the arm should be 
 bound to the side by some article of clothing, or supported 
 in a sling made from handkerchiefs or the clothing, and 
 the patient can usually walk or ride for a short distance 
 without much injury to the parts in the region of the 
 fracture or inconvenience to himself. When the bones ot 
 the lower extremities or the trunk are the parts involved, 
 the transportation of the patient 
 is a matter of more difficulty. 
 When the bones of the trunk 
 are involved the part should 
 be surrounded by a binder 
 firmly pinned or tied, made 
 from the clothing or from 
 towels, or sheets or other strong 
 materials which are at hand. 
 When the bones of the lower 
 extremity are involved if the 
 fracture be a simple one, the 
 clothing need not be removed, 
 and the motion of the frag- 
 ments should be prevented by 
 applying to the sides of the 
 limb, extending above and be- 
 low the seat of fracture, strips 
 of wood, shingles, pasteboard, 
 bundles of straw, strips of bark 
 taken from trees, or bundles of 
 twigs, these being held in place 
 by handkerchiefs or strips torn 
 from the clothing. Umbrellas 
 or canes, or broomsticks (Fig. 
 228), applied in the same man- 
 ner, may be employed, the object of any of these dressings 
 being to secure temporary fixation of the fragments of 
 bone during the transportation of the patient. 
 
 If the fragments are not fixed in some way, but are 
 allowed to move about during the transportation of the 
 
 15 
 
 Provisional dressings for fracture 
 of the leg. (Esmarch.) 
 
326 FRACTURES. 
 
 patient, much damage may result to the soft parts sur- 
 rounding the fractured bones, and simple fractures may 
 become compound ones by the bones being forced through 
 the skin, the discomfort of the patient at the same time 
 being much increased. 
 
 Having applied any dressing to bring about fixation of 
 the fragments, the patient should next be placed upon a 
 broad board or settee ; if a mattress cannot be obtained, 
 the fractured limb should be laid upon a mass of clothing, 
 or upon some straw, and he should be placed in a wagon 
 or carried to the point where the subsequent treatment of 
 the fracture is to be conducted. 
 
 Reduction or Setting of Fractures. 
 
 This should be effected as soon as possible after the 
 occurrence of the injury and as soon as the surgeon is 
 prepared to apply the dressings to keep the parts in their 
 proper position; reduction at an early period is less painful 
 to the patient and is accomplished with more ease to the 
 surgeon than at a later period, when marked swelling and 
 inflammation are present at the seat of fracture. Reduction 
 consists in bringing the fragments, by manipulation, as 
 nearly as possible in their normal position, and it is accom- 
 plished by extension and manipulation with the hands, care 
 being taken to use as little force as possible to attain the 
 object. Very little force is required if the surgeon places 
 the part in such a position as to relax the muscles which 
 produce the displacement; when this is accomplished the 
 fragments can usually be pressed into position by the 
 fingers without the application of any considerable force. 
 When the reduction of a fracture has been accomplished 
 the fragments are retained in position by the application 
 of various splints or dressings which serve to prevent their 
 displacement. 
 
FRACTURE DRESSINGS. 327 
 
 Materials and Appliances Used in the Dressing 
 of Fractures. 
 
 The Fracture Bed. 
 
 Many ingenious forms of beds have been devised for 
 the use of patients suffering from fractures of the bones 
 of the trunk and lower extremities, but a simple bedstead 
 provided with a firm hair mattress having a perforation 
 near its centre, into which is fitted a firm pad, and pro- 
 vided with a pan which slides in a framework beneath a 
 corresponding opening in the bedstead, will prove a useful 
 appliance. The mattress is covered by a sheet perforated 
 to correspond to the opening in the mattress, and when 
 the pad is removed the evacuations of the patient are 
 passed into the pan. 
 
 In fractures of the trunk or lower extremities it will be 
 found more convenient in handling the patient to use a 
 single bed not over thirty-two or thirty-six inches in 
 width, and it is not essential that the mattress be perfor- 
 ated, as a bed-pan can usually be slipped under the patient ; 
 the mattress should be a firm one stuffed with hair. The 
 use of an ordinary tin pie-plate covered w x ith a piece of 
 old muslin to receive the fecal evacuations may be substi- 
 tuted for the bed -pan and will be found in many cases 
 more satisfactory, especially in the case of children suffer- 
 ing from fracture of the lower extremity. 
 
 Splints.. 
 
 After the reduction or setting of the fragments in cases 
 of fracture they are usually retained in position until 
 union occurs by the use of splints held in position by 
 means of bandages or strips of muslin. Splints may be 
 made of wood, or of tin, lead, copper or wire, binder's 
 board, leather, felt paper, or gutta-percha. 
 
 Wooden splints. — The simplest and best splints are made 
 from wood — white pine, w r illow or poplar being the best 
 material to employ for their construction, being sufficiently 
 
328 FRACTURES. 
 
 strong to give fixation to the parts and at the same time 
 being light. Splints made from smooth white pine, willow 
 or poplar boards from one-eighth to one-half an inch in 
 thickness may be employed in the form of straight or 
 angular splints, and their preparation is a matter of little 
 difficulty. 
 
 Wooden splints before being applied to the part should 
 be well padded with cotton, wool, oakum, or hair, and 
 where lateral wooden splints, are employed in the treat- 
 ment of fractures of the lower extremity it is usual to 
 place bandages or junk-bags between the limb and the 
 splint. The carved wooden splints which are sold by the 
 instrument-makers are not to be recommended, as a rule, 
 for unless the surgeon has a large number to select from 
 it is rare that a splint can be obtained to accurately fit any 
 individual case. 
 
 Binder's board or pasteboard, is an excellent material 
 from which to construct splints ; it is first soaked in boil- 
 ing water, and when sufficiently soft is padded with cotton 
 or a layer of lint and moulded to the part. It may be 
 secured in position by a bandage ; as it becomes dry it 
 hardens and retains the shape into which it was moulded. 
 
 Undressed leather is also an excellent material from 
 which to construct splints ; it is applied by first soaking 
 the leather in boiling water, and after padding it with 
 cotton or lint it is moulded to the part and retained in 
 position by a bandage. 
 
 Felt made from wool saturated with gum shellac, pressed 
 into sheets, is also a good material from which to con- 
 struct splints. This material is prepared for application 
 to the surface by heating it before a fire until it becomes 
 pliable, or by dipping it into boiling water. 
 
 Gutta-pereha splints made from sheets of this material, 
 in thickness from -^ to ^ of an inch, may often be em- 
 ployed with advantage ; it is prepared for use by immers- 
 ing it in hot water, when it becomes soft and can be 
 moulded to the surface. Care should be taken that it is 
 not allowed to become too soft by too long immersion to 
 permit of its being conveniently handled. 
 
FRAC1 UBE DRESSINGS. 
 
 329 
 
 Paper splints made from layers of manilla paper stiffened 
 with starch constitute a very fair substitute for some of the 
 varieties of splints previously mentioned. 
 
 Flaster-of- Paris, starch, chalk and gum, silicate of potas- 
 sium or sodium may be employed for the construction of 
 splints, either movable or immovable, in the treatment of 
 fractures ; their method of preparation and application is 
 described (p. 101 et seq.); the plaster-of-Paris dressing is 
 the one which is most generally used at the present time. 
 
 Fracture-box. — This is a form of splint used in the 
 treatment of fractures of the lower extremity, and con- 
 sists of a piece of board eighteen to twenty inches in 
 length, with a foot-board firmly secured at its lower 
 
 Fig. 229. 
 
 Fracture-box with movable sides. 
 
 extremity ; the sides are secured by hinges which allow 
 them to be raised or lowered (Fig. 229). A fracture-box 
 of greater length is required for the treatment of fractures 
 about the knee-joint. 
 
 Bran, Sand, or Junk Bags. 
 
 These are constructed by taking a piece of unbleached 
 muslin five feet in length and fourteen and one-half inches 
 in width, doubling it and securing the free margins, except 
 at the mouth, by stitches so as to form a bag ; the bag is 
 then inverted so that the edges of the seams are brought 
 in the inner surface of the bag. The bags are next filled 
 w^ith dry sand, bran, or hair, or with straw, and the mouth 
 of the bag is closed by stitches or by being tied with a 
 string. Bran bags with splints or sand bags are fre- 
 quently employed in the treatment of fractures of the 
 femur. 
 
330 FBACTURES. 
 
 Bandages made of muslin are used to retain splints in 
 the treatment of fractures, and are also sometimes applied 
 directly to the injured part before the application of splints 
 to control muscular spasms and limit the amount of swell- 
 ing ; when a bandage is so used it is known as a "primary 
 roller. The use of the primary roller is sometimes of the 
 greatest service in the dressing of fractures ; but its use in 
 inexperienced hands has often been followed by such un- 
 fortunate results in the early treatment of fractures, or in 
 cases which are not under constant observation, that I 
 think it is a safe rule of practice to discard entirely the 
 use of the primary roller. 
 
 Compresses made from a number of folds of lint, or ot 
 cotton or oakum, are often employed to retain fragments 
 in position or to make localized pressure upon certain 
 points in the treatment of fractures. The compresses are 
 held in position by strips of adhesive plaster, by a few 
 turns of a roller bandage, or by the splints. Compresses 
 are sometimes employed to protect bony prominences of 
 the skeleton from the pressure of the splints; but this 
 purpose is often better effected by the use of small pieces 
 of soap plaster spread on chamois skin fitted over the 
 prominent points. 
 
 Fig. 230. 
 
 Rack for supporting bed-clothes in fracture of the lower extremity. 
 
 A rack or cradle, made of wire or wooden hoops, is often 
 employed to support the weight of the bed-clothes in the 
 treatment of fracture of the lower extremity (Fig. 230). 
 
 Use of Evaporating Lotions in Cases of 
 Fracture. 
 
 The employment of evaporating lotions such as lead- 
 water and laudanum, or muriate of ammonia and lauda- 
 
FRACTURE OF THE NASAL BONES. 331 
 
 num, to the skin in the region of fractures is highly recom- 
 mended by many surgeons, especially in fractures involv- 
 ing or situated near joints. It is here employed to relieve 
 pain, to limit inflammatory swelling, and to hasten the 
 absorption of the blood and serum at the seat of fracture. 
 Many surgeons, on the other hand, think that their use 
 causes irritation of the skin and delays the process of 
 repair in the union of the fracture, and so strongly con- 
 demn their employment. I personally have never seen 
 any bad results arising from their use, and have generally 
 employed them in fractures near or involving the joints, 
 but I do not consider their employment absolutely essen- 
 tial, and when I use them I only do so for two or three 
 days. In cases of fractures accompanied with much pain 
 and swelling, when the surgeon does not wish to use any 
 of the lotions before named, an ointment of ichthyol one 
 part, lanoline three parts, spread on lint and wrapped 
 around the limb, will often prove a satisfactory dressing, 
 or a layer of cotton may be simply wrapped around the 
 part before the application of the splints. 
 
 Dressing of Special Fractures. 
 Fracture of the Nasal Bones. 
 
 Fractures of the nasal bones are often accompanied with 
 fractures involving the septum, the nasal process of the 
 maxillary bone, and the nasal spine of the frontal bone. 
 
 The treatment consists in replacing the fragments, if 
 displacement exists, by manipulation with the fingers over 
 the seat of fracture and by pressure made from within the 
 nostrils by a probe or a steel director. When the displace- 
 ment is ouce corrected it is not apt to recur, and in the 
 majority of cases no dressing is required. Before resort- 
 ing to any manipulation within the nasal cavities the 
 mucous membrane should be thoroughly cocainized to 
 render the operation painless to the patient. When there 
 is depression of the fragments or displacement of the 
 
332 
 
 FRACTURES. 
 
 septum after correcting the deformity by raising the de- 
 pressed fragment or bending the septum into place by a 
 director, the parts may be held in position by packing the 
 nasal cavity firmly with a strip of antiseptic gauze. 
 
 In lateral displacements of the nasal bones from frac- 
 ture, after reducing the displacement, a small compress 
 held over the fragment by strips of adhesive plaster will 
 be the only dressing required. 
 
 Fig. 231. 
 
 Mason's dressing for fractures of the nasal bones. 
 
 Mason transfixes the nose, after reduction of the frag- 
 ments, with a stout needle, and steadies the pieces with a 
 strip of plaster crossing the bridge of the nose and fastened 
 to the ends of the needle. The needle is kept in position 
 for eight or ten days (Fig. 231). Roberts, in cases in 
 which there is a displacement of the cartilaginous portion 
 of the nose, after reducing the deformity, holds the parts 
 in position by transfixing them with steel pins. 
 
 Profuse hemorrhage sometimes occurs after fracture of 
 
FRACTURE OF THE UPPER MAXILLA. 333 
 
 the nasal bones and may require plugging of the nares to 
 control it. 
 
 Fractures of the nasal bones are usually firmly united 
 in from ten to twelve days, and dressings may be dispensed 
 with after this time. 
 
 Fracture of the Malar Bone and Zygoma. 
 
 These fractures are usually the result of direct force ; 
 the displacement is upward or backward, and w r hen the 
 zygomatic arch is broken the fragments from pressure 
 upon the masseter muscle or on the tendon of the temporal 
 muscle may interfere with the movement of the lower jaw 
 in mastication. This displacement is corrected by cutting 
 down upon the fragment and elevating it or by passing a 
 tenaculum into the fragment and raising it. 
 
 Outward displacements may be corrected by pressure 
 and the application of a compress. The dressing of these 
 fractures after the correction of the deformity consists in 
 the application of a compress of lint over the seat of frac- 
 ture, held in position by strips of adhesive plaster or a 
 bandage. There is little tendency to recurrence of the 
 deformity after it has been corrected, and union at the seat 
 of fracture is usually firm at the end of three weeks. 
 
 Fracture of the Upper Maxilla. 
 
 These fractures may involve the body, the nasal pro- 
 cesses, or the alveolar processes. The displacement should 
 be corrected, and if any teeth have been displaced they 
 should be replaced ; if there is comminution of the alveolus 
 the teeth in the separate fragments may be fastened together 
 by fine wire to fix the fragments and hold them in place ; 
 and the teeth of the lower jaw should be brought up in 
 contact with those of the upper jaw, and the jaws should 
 be secured together by the application of a Barton's or a 
 Gibson's bandage (Fig. 232). Inter-dental splints, made 
 of cork, with grooves to fit the teeth, or of gutta-percha, 
 are also employed in the dressing of these fractures. The 
 
 15* 
 
334 FRACTURES. 
 
 patient should not be allowed to move the jaw in mastica- 
 tion, and should be nourished by liquid and semi-solid 
 food which can be taken without removing any teeth to 
 give space for its introduction. 
 
 Fig. 232. 
 
 Dressing for fracture of the upper jaw. 
 
 The bandage should be removed every second or third 
 day, and after the face and neck have been sponged off 
 with alcohol it should be reapplied. 
 
 These fractures are usually firmly united at the end of 
 four or five weeks, and dressings may be dispensed with 
 at this time. 
 
 Fracture of the Lower Maxilla. 
 
 The lower jaw may be broken at or near the symphysis, 
 the most usual seat of fracture being near the mental fora- 
 men ; it is often broken at two places at once, and the frac- 
 tures are in many cases rendered compound by laceration 
 of the mucous membrane, or the injury may consist in a 
 separation of a portion of the alveolar process of the bone. 
 The dressing of a fracture of the lower jaw, after reduc- 
 ing the displacement and replacing any loosened or de- 
 tached teeth, consists in applying a pad of lint under the 
 
FRACTURE OF THE LOWER MAXILLA. 335 
 
 Fig. 233. 
 
 
 Dressing for fracture of the lower jaw. 
 Fig. 234. 
 
 Four-tailed bandage applied for fracture of the lower jaw. (Hamilton.) 
 
336 
 
 FRACTURES. 
 
 chin and bringing the jaw up against the upper jaw, hold- 
 ing the compress in place, and securing the jaws firmly 
 in contact by applying a Barton (Fig. 233), modified 
 Barton or Gibson's bandage. The bandage should be re- 
 moved and reapplied at the end of the second or third 
 day, and at like intervals during the course of treatment. 
 The patient should be fed upon a liquid or semi-solid 
 diet, not being allowed to chew any solid food until the 
 union at the seat of fracture has become firm. 
 
 Fig. 235. 
 
 Fig. 236. 
 
 Shape of splint before being fitted to chin. (Roberts.) 
 
 A very satisfactory temporary dressing for fracture of 
 the lower jaw consists in the application of a four-tailed 
 sling. (Fig. 234.) 
 
 Some surgeons prefer to use an external splint moulded 
 from pasteboard or gutta percha fitted to the chin in the 
 dressing of this fracture, this being padded with cotton and 
 held in place by a Barton or Gibson 
 bandage. (Fig. 236.) Where there is 
 much difficulty in keeping the frag- 
 ments in position the wiring together 
 of the teeth may be employed, or the 
 fragments may be perforated with a 
 drill and held in place by a strong 
 silver - wire suture ; inter - dental 
 splints of metal or gutta-percha are 
 also sometimes used for this pur- 
 pose. During the course of the 
 treatment in fracture of the jaws the mouth often becomes 
 very offensive from the fermentation of the saliva and dis- 
 
 Splint moulded to fit chin. 
 (Roberts.) 
 
FRACTURE OF THE LARYNX OR TRACHEA. 337 
 
 charges, and it is well to use frequently a mouth-wash of 
 chlorate of potash, tincture of myrrh, glycerin, and water. 
 
 The dressings for fracture of the lower jaw are usually 
 applied for four or six weeks, the union usually being 
 quite firm at the end of this time. 
 
 Fracture of the Hyoid Bone. 
 
 In fracture of the hyoid bone, if displacement exists, its 
 reduction is facilitated by pressure made with the finger 
 in the pharynx. 
 
 The treatment consists in enforced quiet and the use of 
 opium if cough is a prominent symptom, and the inflam- 
 matory symptoms may require the employment of active 
 local treatment. A dressing may sometimes be employed 
 with advantage, consisting of a splint of pasteboard or 
 leather moulded to the anterior portion of the neck. 
 
 Fracture of the Larynx or Trachea. 
 
 In fractures of the larynx or trachea where there is little 
 displacement and dyspnoea is not marked, the parts should 
 be supported by the application of compresses of lint held 
 in place by strips of adhesive plaster. If, on the other 
 hand, the respiration is embarrassed or there is free expec- 
 toration of blood, tracheotomy should be performed, and 
 if the injury be seated in the larynx the displacement of 
 the fragments may be overcome by manipulation with the 
 finger or a director through the tracheal wound, or the 
 larynx may be packed with a strip of antiseptic gauze to 
 control hemorrhage or hold the fragments in position, the 
 patient in the meantime breathing through a tracheotomy- 
 tube secured in the tracheal wound ; the packing should 
 be removed in a few days, the tracheotomy-tube being 
 permanently removed as soon as the patient can breathe 
 comfortably through the larynx with the tracheal wound 
 closed. In fractures of the trachea the opening into the 
 trachea should be below or at the seat of injury. 
 
338 
 
 FBACTURES. 
 
 Fractures of the Trunk. 
 
 Fig. 237. 
 
 Fractuke of the Ribs. 
 
 Fractures of the ribs are more frequent than fractures 
 of any other bones of the trunk; the ribs most commonly 
 broken are those from the fourth to the tenth ; the most 
 common seat of fracture is near the junction of the costal 
 cartilages or at the angle. The dressing of fractures of the 
 ribs is best accomplished by envel- 
 oping the side of the chest on which 
 the rib or ribs are broken with 
 broad straps of adhesive plaster. 
 The adhesive straps should be two 
 and a half inches in width and 
 long enough to extend from the 
 spine to the middle of the sternum. 
 The straps are warmed and the 
 first strap is firmly applied a short 
 distance below the seat of fracture, 
 extending from the spine to the 
 mid-sternal line ; a number of as- 
 cending straps are applied in this 
 way, each strap overlapping the 
 preceding one by about one- third of its width until half 
 the chest is covered in. (Fig 237.) This dressing usu- 
 ally gives the patient much comfort, and the straps need 
 not be renewed until they become slightly loosened, usu- 
 ally at the end of a week or ten days ; they should then 
 be renewed in the same manner. 
 
 The dressings for fractures of the ribs are usually dis- 
 pensed with at the end of three or four weeks, as repair 
 of the fracture is generally well advanced by this time. 
 
 A satisfactory temporary dressing for fractures of the 
 ribs consists in surrounding the chest by a broad binder of 
 stout linen or muslin ; indeed, some surgeons prefer to 
 employ this dressing during the course of treatment, but 
 as a rule I think it is not as good a dressing as the adhe- 
 
 Adhesive plaster dressing 
 for fracture of the ribs. (Ham- 
 ilton.) 
 
FRACTURE OF THE STERNUM. 339 
 
 sive plaster dressing, as the former confines the move- 
 ments of both sides of the chest. 
 
 Fracture of the Costal Cartilages. 
 
 These fractures often take place at the junction of the 
 cartilages with the ribs or in the body of the cartilages, 
 and the union of the fracture usually takes place by the 
 production of a mass of bone at the seat of fracture. The 
 dressing for fractures of the costal cartilages consists in the 
 application of strips of adhesive plaster applied in the 
 same manner as for fracture of the ribs, and the dressing 
 should be retained for about the same time. 
 
 Fracture of the Sternum. 
 
 Fractures of the sternum are rare injuries, but diastasis 
 of the bones of the sternum is a more common accident. 
 The dressing for either variety of injury is the same, and 
 
 Fig. 238. 
 
 Adhesive plaster dressing for fracture of the sternum. 
 
 consists in the application of a compress over the seat of 
 fracture held in place by a broad bandage, or, better, by 
 strips of adhesive plaster (Fig. 238), applied so as to cover 
 and fix the anterior portion of the chest, covering the 
 
340 FRACTURES. 
 
 entire length of the sternum. This dressing should be 
 retained for at least four weeks, being renewed if it be- 
 comes loose at the end of a week or ten days. 
 
 Fracture of the Pelvis. 
 
 These fractures are often serious injuries from implica- 
 tion of the pelvic viscera. The reduction of the displace- 
 ment should be first accomplished as far as possible by 
 external manipulation, together with internal manipula- 
 tion by the fingers introduced into the rectum, or into the 
 vagina in the female. The patient should be placed upon 
 a firm bed on his back, with the knees slightly flexed over 
 a pillow, and the parts should be kept at rest by surround- 
 ing the pelvis with broad straps of adhesive plaster or a 
 stout muslin binder, or by a firmly applied padded pelvic 
 belt. The hip-joints should be kept at rest by the applica- 
 tion of pasteboard splints or by sand-bags. The dressings 
 should be retained for a period of at least six weeks. 
 
 When these fractures are complicated by injury of the 
 pelvic viscera various operative procedures may be re- 
 quired, which will compel the surgeon to modify the 
 method of dressing. 
 
 Fracture of the Sacrum and Coccyx. 
 
 The dressing of fractures of the sacrum, after effecting 
 reduction of the fragments as far as possible by pressure 
 from within the rectum, consists in the application of 
 broad adhesive straps around the pelvis, and the patient 
 should be kept at rest in bed. When the coccyx only is 
 fractured, after reduction of the displacement the patient 
 should be confined to bed and the bowels should be kept 
 at rest by the use of opium by suppository. The patient 
 should be kept at rest for three or four weeks, and, in 
 case of fracture of the sacrum, the dressings should be 
 retained for this time. 
 
FRACTURE OF THE VERTEBRM 341 
 
 Fracture of the Vertebrae. 
 
 Fractures of the vertebrae are always most serious in- 
 juries, not only from the injuries of the bones themselves, 
 but also from the damage to the spinal cord, membranes, 
 and nerves, which often accompanies them. 
 
 In transporting, or turning in bed, a patient suffering 
 from fracture of the vertebrae, great care should be exer- 
 cised, for rough or sudden motions might cause a displace- 
 ment of the fragments which might, by injury of, or 
 pressure upon, the spinal cord, rapidly prove fatal. 
 
 In the treatment of fractures of the spine, if the de- 
 formity is marked, efforts should be made to reduce it by 
 extension and counter-extension, and the result may be 
 successful, especially if the fracture be associated with a 
 dislocation of the vertebrae. In some cases the use ot 
 permanent extension by means of weights attached to the 
 legs, shoulders, and chest by adhesive plaster and bandages 
 has been successful in reducing the deformity. 
 
 The patient should be placed upon his back upon a bed 
 with a hair mattress, or better, if it can be obtained, a 
 water-bed, which consists of a rubber mattress filled with 
 water, which distributes the weight of the patient's body 
 evenly over the surface. Whatever form of bed be used, 
 the greatest care should be exercised to keep the patient 
 absolutely clean, and the parts of the body or limbs which 
 are exposed to pressure should be frequently bathed with 
 alcohol or soap liniment ; and to distribute the pressure, 
 small pads should be placed under the parts and changed 
 at intervals. These precautions are necessary to prevent, 
 if possible, the formation of extensive bedsores, w 7 hich are 
 a frequent and troublesome complication of these injures. 
 
 The bowels should be carefully watched, and, if con- 
 stipation is present, it should be relieved by the use of 
 enemata ; and, as it is not desirable to lift the patient to 
 slip a bed-pan under him, the discharges can be received 
 in a flat tin plate pushed under the thighs and buttocks, 
 or on pads of oakum or old muslin. 
 
 The care of the bladder is also a matter of the greatest 
 
342 FRACTURES. 
 
 importance ; the retention which at first exists should be 
 relieved by the use of a flexible catheter introduced with 
 great gentleness, and when incontinence supervenes the 
 catheter should also be used at intervals ; the employment 
 of a soft instrument, if used with care, is not apt to pro- 
 duce any injury to the urethra or bladder. 
 
 The employment of a plaster-of-Paris jacket has been 
 followed, in some cases, by good results, and it may be 
 applied early in the case, or it may be used after the 
 patient has been kept in the recumbent posture for some 
 weeks ; by its use it is often possible to get the patient out 
 of bed and allow him to sit in a chair. 
 
 In fractures involving the cervical vertebrae, care should 
 be exercised in lifting or moving the head, and it is often 
 of advantage in these cases to apply short sand-bags to the 
 sides of the neck and head, to give additional fixation to 
 the parts while the patient is in the recumbent posture, 
 or, if he is allowed to get out of bed, to apply a moulded 
 leather or pasteboard splint to the neck, shoulders, and 
 back of the head for the same purpose. 
 
 Trephining of the spine in cases of fracture of the 
 vertebrae, to remedy the displacement and relieve the cord 
 from pressure, has been recommended and employed in 
 some cases, and although the operation under strict anti- 
 septic methods is not attended with much risk, the results 
 obtained up to the present time scarcely seem to warrant 
 its performance. 
 
 The course of treatment in cases of fractures of the ver- 
 tebrae, if the patient does not succumb to the injury in a 
 few days or weeks, often extends over many months, and 
 recovery is often more or less incomplete as regards the 
 function of the parts below the seat of fracture. 
 
 Fracture of the Skull. 
 
 The treatment of fractures of the skull, whether simple 
 or compound, depends largely upon the nature of the in- 
 jury and the condition of the cranial contents. In simple 
 fractures unaccompanied with cerebral symptoms no 
 
FRACTURE OF THE CLAVICLE 343 
 
 special dressing is required, but in compound fractures 
 where loose fragments are present, these should be re- 
 moved ; and if there is no depression of the fragments, 
 and if no cerebral symptoms are present, the wound 
 should be drained, carefully closed and dressed antisep- 
 tically, the dressings being held in place by a recurrent 
 bandage of the head. 
 
 The patient should be put to bed, and the use of an ice- 
 cap to the head is often of service. The diet should be 
 restricted, while calomel and opium or bromide of potas- 
 sium should be administered ; it is well to keep the patient 
 for a few weeks in a quiet and darkened room. Where 
 cerebral symptoms are present, either in simple or com- 
 pound fractures, and trephining is resorted to, the dressing 
 of the wound is similar, and the same general treatment 
 should be adopted. In all cases of fracture of the skull, 
 whether subjected to operative treatment or not, it is well 
 to keep the patient at rest in bed for three or four weeks, 
 and he should be cautioned to avoid excesses, and should 
 not resume active work for some months. 
 
 Fractures of the Upper Extremity. 
 
 Fracture of the Clavicle. 
 
 Fractures of the clavicle may be complete or incomplete, 
 and in the latter variety of injury the deformity is not 
 usually very marked. The indications for treatment in 
 complete fractures of the clavicle are to relax the sterno- 
 cleido-mastoid muscle, to prevent the weight of the arm 
 on the injured side from dragging down the outer fragment 
 of the clavicle, and, by fixing the scapula, to carry the 
 attached external fragment outward and forward. A large 
 number of dressings have been devised and used to accom- 
 plish these objects. The treatment of fractures of the 
 clavicle by position is accomplished by placing the patient 
 in bed on his back upon a firm mattress with a low pillow 
 under his head, and the arm on the side of injury should 
 
344 
 
 FRACTURES. 
 
 be fastened to the side of the chest by a few circular turns 
 of a bandage passing around the arm and chest ; the de- 
 formity is usually very satisfactorily reduced upon the 
 patient assuming this position, and after three weeks' rest 
 in this position the union is generally sufficiently firm to 
 allow the patient to get out of bed and be about with the 
 arm bound to the side or carried in a sling or with a Vel- 
 peau bandage applied without any recurrence of the de- 
 formity. 
 
 A satisfactory temporary dressing for fractures of the 
 clavicle consists in the application of a four-tailed ban- 
 dage ; the bandage is made from a piece of muslin two 
 
 Fig. 239. 
 
 Four-tailed bandage for fracture of clavicle. (Stimson.) 
 
 yards in length and fourteen inches in width ; a hole is 
 cut in its centre about four inches from its margin, to re- 
 ceive the point of the elbow ; the bandage is then split 
 into four tails in the line of the hole and to within six 
 inches of it ; the body of the bandage should be applied so 
 that the point of the elbow rests in the hole, and a folded 
 towel being placed in the axilla, the lower tails should be 
 carried, one anteriorly, the other posteriorly, diagonally 
 across the chest and back to the neck on the side opposite 
 the seat of fracture, and secured ; the remaining tails are 
 
FRACTURE OF THE CLAVICLE. 
 
 345 
 
 next carried around the lower part of the chest and secured 
 so as to fix the arm to the side of the body. (Fig. 239.) 
 
 In some cases the deformity is corrected by the applica- 
 tion of a posterior figure-of-eight bandage, the forearm on 
 the side of injury being carried in a sling. (Fig. 240.) 
 
 Fig. 240. 
 
 Posterior figure-of-eight dressing for fracture of the clavicle. (Hamilton.) 
 
 Say re's dressing for fracture of the clavicle consists of 
 two strips of adhesive plaster three and a half inches wide 
 and two yards in length. The first strip is looped around 
 the arm just below the axillary margin, and is pinned or 
 sewed with the loop sufficiently open not to constrict the 
 arm. The arm is then drawn downward and backward 
 until the clavicular portion of the pectoralis major muscle 
 is put sufficiently upon the stretch to overcome the action 
 of the sterno-cleido-mastoid muscle, and in this way draw T s 
 the sternal fragment of the clavicle down to its pace. The 
 strip of plaster is then carried completely around the body 
 and pinned or stitched to itself on the back. (Fig. 241.) 
 The second strip is next applied, commencing upon the 
 front of the shoulder of the sound side ; thence it is car- 
 ried over the top of the shoulder diagonally across the 
 
346 
 
 FRACTURES. 
 
 back, under the elbow, diagonally across the front of the 
 chest to the point of starting, where it is secured by 
 pinning or sewing. A slit is made in this strip to receive 
 the point of the elbow. Before the elbow is secured by 
 the plaster it should be pressed well forward and inward. 
 (Fig. 242.) 
 
 Fig. 241. 
 
 Fig 242. 
 
 Say re's dressing for fracture of the 
 clavicle. First strip applied. 
 
 Sayre's dressing for fracture of the 
 clavicle. Second strip applied. 
 
 Velpeau's dressing may also be used in the treatment of 
 fractures of the clavicle. (Fig. 243.) A compress may 
 also be secured by the vertical turns of this bandage over 
 the seat of fracture if needed. The application of the 
 bandage is described (p. 68). 
 
 In any form of dressing in which the arm is held against 
 the side of the chest, it is well to apply a folded towel or 
 piece of lint between the arm and chest to prevent the 
 surfaces from becoming excoriated. 
 
FRACTURE OF THE CLAVICLE. 
 
 347 
 
 Fig. 243. 
 
 Velpeau's dressing for fracture 
 of the clavicle. 
 
 A modified form of the Velpeau dressing for fracture 
 of the clavicle is applied as follows : A soft towel or piece 
 of lint is placed agaiust the side 
 of the body and over the front 
 of the chest, and held in position 
 by a strip of adhesive plaster; 
 the arm is next placed in the 
 Velpeau position, a good-sized 
 pad of lint is next applied over 
 the scapula, and this is held in 
 place by a broad strip of adhesive 
 plaster two and a half inches in 
 width and one and a half yards 
 in length ; this strip is continued 
 downward and forward so as to 
 pass over the point of the elbow, 
 and is carried diagonally across 
 the chest to the shoulder of the 
 opposite side, and is secured, a 
 slit being cut in it to receive the 
 point of the elbow; a compress of lint is next placed over 
 the seat of fracture and held in place by a strip of ad- 
 hesive plaster ; an additional strip of plaster is next car- 
 ried from the spine around the arm and chest and secured 
 on the opposite side of the chest ; circular turns of a roller 
 bandage are then passed around the chest, including the 
 arm from below upward until the arm is securely fixed 
 to the body, and the dressing is finished by making one 
 or two turns of the third roller of Desault. (Fig. 244.) 
 Or the turns of the third roller of Desault may be applied 
 first, and the dressing may be finished by circular turns 
 of a roller passing around the arm and chest, extending 
 from the elbow to the shoulder. 
 
 In the treatment of fractures of the clavicle in children 
 the Velpeau or modified Velpeau dressing will be found 
 to be the most satisfactory dressing to employ, and as these 
 patients are particularly apt to disarrange their dressings 
 it is well to render the dressing additionally secure by 
 applying a few broad strips of adhesive plaster over the 
 
348 FRACTURES. 
 
 turns of the roller bandage, the strips following the turns 
 of the bandage. 
 
 The removal of dressings and their reapplication will 
 depend upon the comfort of the patient and the manner 
 in which they keep their position. As a rule, in fractures 
 of the clavicle the dressings are removed at the end of the 
 second or third day, the parts are inspected, and the skin 
 is sponged off with dilute alcohol or whiskey ; the dress- 
 ings are then reapplied, and if the patient is comfortable 
 
 Fig. 244. 
 
 Modified Velpeau dressing for fracture of the right clavicle. 
 
 and the parts are in good position, the dressings are made at 
 less frequent intervals until union is completed at the seat 
 of fracture. 
 
 Union in cases of fracture of the clavicle is generally 
 quite firm at the end of four or five weeks, and at this 
 time the dressings may be removed, and the patient should 
 carry the arm of the affected side in a sling for several 
 weeks, and should not undertake any work requiring 
 forcible movements of the arm until eight or ten weeks 
 have elapsed from the receipt of the injury. 
 
FRACTURE OF THE SCAPULA. 
 
 349 
 
 The time required for union in fractures of the clavicle 
 in children is somewhat shorter; the dressings may be 
 removed at the end of three weeks. 
 
 Fracture of the Scapula. 
 
 Fractures of the scapula may involve the body, neck, 
 acromion or coracoid process of the bone. Fractures of 
 this bone are quite rare. 
 
 Iracture of the Body of the Scapula. 
 
 In dressing this fracture, if deformity is present, it is 
 reduced by manipulation, and compresses of lint are 
 placed above and below the seat of fracture and held in 
 place by adhesive strips; the arm is next fixed to the side 
 of the body by spiral turns of a roller bandage passing 
 around the arm and chest, and the forearm is supported 
 in a sling. 
 
 Fracture of the Neck, Acromion or Coracoid Process 
 of the Scapula. 
 
 Fig. 245. 
 
 Velpeau dressing for fracture of the scapula. 
 16 
 
350 
 
 FRACTURES. 
 
 These fractures may be dressed by placing a pad of 
 lint or a folded towel in the axilla and binding the arm 
 to the body by spiral turns of a roller bandage passing 
 around the arm and chest and supporting the forearm in 
 a sling. Or these fractures of the scapula may be dressed 
 by first placing a pad of lint or a folded towel in the 
 axilla and then securing the arm in the Velpeau position 
 by the application of a Velpeau's bandage. (Fig. 245.) 
 In fractures of the acromion or coracoid processes the 
 union is usually fibrous. In the treatment of fractures of 
 the scapula the dressing should be retained for about four 
 weeks. 
 
 Fbacture of the Humerus. 
 
 Fractures of the humerus may involve the upper ex- 
 tremity, the shaft or the lower extremity of the bone. 
 
 Fractures of the Upper Extremity of the Humerus include 
 fractures of the head and anatomical neck of the bone, 
 fractures through the tuberosities, fractures through the 
 surgical neck of the humerus, and epiphyseal fracture or 
 disjunction of the upper epiphysis of the 
 humerus. 
 
 The most satisfactory dressing for all 
 fractures of the humerus above the upper 
 third of the bone is applied as follows : A 
 primary roller should be evenly applied 
 from the tip of the fingers to the seat of the 
 fracture, the arm being flexed at the elbow 
 before the bandage is carried above this 
 point, to prevent the dangerous constriction 
 which might result if the bandage were 
 applied with the arm in the straight posi- 
 tion, and it were afterward flexed at the 
 elbow. A folded towel or a thin pad of 
 lint should next be placed in the axilla and 
 over the outer surface of the chest, to fur- 
 nish a firm basis of support for the humerus 
 and also to prevent excoriation from the contact of the 
 skin surfaces. A splint of pasteboard, felt or leather (Fig. 
 
 Fig. 246. 
 
 Moulded splint for 
 shoulder and arm. 
 
FRACTURE OF THE HUMERUS. 
 
 351 
 
 246) is next moulded to the shoulder and arm ; this should 
 be long enough to extend some distance below the seat of 
 fracture and wide enough to cover in about one-half of the 
 circumference of the arm, and is padded with cotton and 
 fitted to the shoulder and arm. The splint and arm are next 
 secured to the side of the body by spiral turns of a roller 
 bandage including the arm and chest in its turns and applied 
 from the elbow to the top of the shoulder. The forearm 
 is carried in a narrow sling suspended from the neck (Fig. 
 247). This dressing should be removed at the end of 
 
 Fig. 247. 
 
 .Dressing for fracture of the upper extremity ol the humerus. 
 
 twenty-four or forty-eight hours, and after the parts have 
 been inspected and sponged over with alcohol, the dress- 
 ings should be reapplied in the same manner, and if the 
 patient is comfortable they need not be disturbed again 
 for three or four days, subsequent dressings being made 
 at the same intervals. Union in fractures of the upper 
 extremity of the humerus, except in intra-capsular fract- 
 ure, in which bony union is the exception, is usually quite 
 firm at the end of five or six weeks, and the dressings can 
 be dispensed with at this time. 
 
352 
 
 FRACTURES. 
 
 Fracture of the Shaft of the Humerus. 
 
 The dressing consists in the application of a primary 
 roller from the tips of the fingers to the seat of fracture ; 
 a short well-padded wooden splint extending from the 
 axilla to a point a little above the internal condyle is next 
 placed on the inner surface of the arm and against the 
 chest ; a moulded pasteboard or felt splint, fitted to the 
 shoulder and outer side of the arm and extending a short 
 distance below the seat of fracture, is padded with cotton 
 and applied to the shoulder and arm. The splints are 
 held in position by the turns of a bandage, and the arm 
 is secured to the body by spiral turns of a roller bandage 
 
 Fig. 243. 
 
 Internal angular splints. 
 
 carried around the chest and arm, and the forearm is 
 carried in a sling suspended from the neck. The dressing 
 is much the same as that for fracture of the upper part of 
 the humerus, with the addition of the short internal splint. 
 Fracture of the shaft of the humerus may also be 
 dressed by first applying a primary roller and then plac- 
 ing the forearm and arm upon a well-padded internal 
 angular splint. (Fig. 248.) Care should be taken to see 
 that the end of the splint extends only to the axilla and 
 does not press upon the brachial veins. A pasteboard or 
 felt moulded splint is next applied to the shoulder and 
 outer side of the arm, which should be long enough to 
 
FRACTURE OF THE HUMERUS. 353 
 
 extend below the seat of fracture. The splints are held 
 in position by turns of a roller bandage beginning at the 
 fingers and carried up to the shoulder, and finished with a 
 few spica-of-the-shoulder turns. (Fig. 249.) The arm is 
 supported by a sling applied at the wrist, and sometimes 
 for additional security the arm is bound to the side of the 
 body by spiral turns of a bandage carried around the arm 
 and chest. The after-treatment of these fractures as re- 
 
 FlG. 249. 
 
 Dressing for fracture of the shaft of the humerus with internal angular splint 
 and external splint of binder's board. 
 
 gards the removal and renewal of the dressings is the same 
 as in cases of fracture of the upper portion of the humerus. 
 In fractures of the shaft of the humerus the dressings 
 should be retained for five or six weeks. 
 
 Fracture of the Lower Extremity of the Humerus. 
 
 These include fractures at the base of the condyles, 
 splitting fractures between the condyles or those of the 
 internal or external condyle, and epiphyseal fracture or 
 disjunction of the lower epiphysis of the humerus. 
 
354 
 
 FRACTURES. 
 
 In dressing fractures of the lower extremity of the 
 humerus, if a primary roller is employed it should be 
 carried up only to the elbow. The displacement is reduced 
 by extension and manipulation, and before applying any 
 splint it is well in many cases to apply over the region of 
 
 Anterior angular splint. 
 
 the fracture several folds of lint saturated with lead- water 
 and laudanum, and to cover this dressing with waxed 
 paper or rubber tissue to diminish as far as possible the 
 swelling, which is very marked after these injuries. The 
 use of this lotion may be omitted, and a layer of cotton 
 
 Fig. 251. 
 
 Dressing for fracture of the lower extremity of the humerus with anterior 
 angular splint. 
 
 may be placed around the joint in its place. An anterior 
 angular splint (Fig. 250) well padded with cotton or 
 oakum is next applied and held in position by the turns 
 of a roller bandage applied from the fingers to the upper 
 portion of the splint. (Fig. 251.) These fractures may 
 
FRACTURE OF THE HUMERUS. 355 
 
 also be dressed with a well-padded internal angular splint, 
 this splint being substituted by an anterior angular splint 
 at the end of ten days or two weeks. 
 
 These fractures may also be dressed by placing the arm 
 in a posterior angular trough (Fig. 252) made of paste- 
 board or leather. Some surgeons prefer to dress fractures 
 of the condyles of the humerus with the arm in the ex- 
 tended position upon a straight an- 
 
 m. M. O "Fir" 9^9 
 
 terior splint, or with short, narrow 
 
 pasteboard splints applied around 
 
 the joint, as favoring more accurate 
 
 coaptation of the fragments. If 
 
 this position is employed a straight 
 
 wooden splint is applied to the 
 
 anterior surface of the arm and 
 
 forearm, or moulded splints of Posterior angular trougK 
 
 pasteboard may be used, and after 
 
 the union is moderately firm, at the end of two weeks, the 
 
 elbow should be flexed and kept in this position during 
 
 the remaining time of the treatment. 
 
 When fractures of the lower extremity of the humerus 
 involve the elbow-joint a certain amount of impairment of 
 joint-motion is apt to occur either from ankylosis or from 
 displacement of the fragments which in many cases it is 
 impossible to completely reduce, so that flexion and exten- 
 sion of the joint are restricted. Bearing these facts in mind, 
 it is well to make passive motion in these cases as early 
 as the second or third week. It is well to explain to the 
 patient or his friends that impairment of joint-motion may 
 result in these fractures in spite of the greatest skill and 
 care in the treatment. In a case of fracture in the region 
 of the condyles of the humerus the dressings should be 
 removed in twenty-four hours, and it should be re-dressed 
 in the same manner, and if the swelling does not increase 
 and the dressing is comfortable to the patient it should 
 afterward be dressed at less frequent intervals ; the union 
 is generally quite firm at the end of four w T eeks, and the 
 splint may be removed at this time. Fractures of the 
 condyles of the humerus are very common in children, 
 
356 FRACTURES. 
 
 and epiphyseal disjunctions of the lower epiphysis of the 
 humerus are also met with ; the dressing of these injuries 
 in this class of patients is similar to that described for 
 fractures of the condyles of the humerus. 
 
 Fracture of the Olecranon Process of the 
 Ulna. 
 
 Fractures of the olecranon may consist in simply a 
 separation of the cortical layer of bone over the summit 
 of the process to which the triceps is principally attached, 
 or the line of fracture may pass through the sigmoid fossa. 
 
 Fractures of the olecranon are dressed with the arm 
 slightly flexed at the elbow, or with it completely extended, 
 
 Fig. 253. 
 
 Adhesive strap applied to draw fragment downward. 
 
 the former position is possibly a little less irksome to the 
 patient. The separation of the fragment by the action of 
 the triceps muscle is usually not very marked ; but, if the 
 displacement is considerable, it may in a measure be over- 
 come by the use of a compress above the fragment, over 
 which figure-of-eight strips of adhesive plaster are fastened 
 to draw it down into position (Fig. 253.) The ends of the 
 strap are then attached to a well-padded straight splint 
 which should be long enough to extend from the upper 
 third of the arm to the ends of the fingers, which is 
 secured in position by the turns of a roller carried from 
 the fingers to the upper extremity of the splint, with figure- 
 
FRACTURE OF THE OLECRANON. 357 
 
 of-eight turns at the elbow to reinforce the action of the 
 strips of plaster. 
 
 This fracture may also be dressed by first applying a 
 primary roller up to the elbow, and then placing the arm 
 upon a well-padded anterior obtuse-angled splint, or a 
 straight splint with a good-sized pad of lint or oakum 
 fastened at a point corresponding to the position of the 
 flexure of the elbow. When either of these splints is 
 placed upon the arm a position of moderate flexion is 
 obtained. A compress of lint is next placed above the 
 fragment, if there is a displacement, and one or two narrow 
 strips of adhesive plaster are fastened over this and passed 
 obliquely downward and attached to the splint on either 
 side. The splint is then securely fastened to the arm by 
 the turns of a roller bandage applied from the fingers to 
 the upper end of the splint. (Fig. 254.) 
 
 Fig. 254. 
 
 Fracture of olecranon dressed in the extended position. 
 
 The dressings in a case of fracture of the olecranon 
 should be removed at the end of twenty-four or thirty-six 
 hours, or sooner if there is evidence of swelling of the 
 tissues in the region of the fracture, and they should be 
 reapplied in the same manner. If the dressing is com- 
 fortable to the patient, and there is no evidence of swell- 
 ing, the subsequent dressings should be made at less frequent 
 intervals ; the dressings are usually retained in this frac- 
 ture for five or six weeks. Passive motion should not be 
 made until this time, as flexion of the elbow tends to 
 separate the fragments, unless union has taken place. The 
 repair of a fracture of the olecranon is, in most cases, by 
 
 16* 
 
358 FRACTURES. 
 
 fibrous union, but in a few instances bony union has been 
 found to have taken place. 
 
 Fracture of the Coronoid Process of the Ulna. 
 
 Fractures of the coronoid process are rarely met with, 
 and their dressing is accomplished by placing the arm in 
 a flexed position and applying a well-padded internal 
 right-angled splint, or a posterior right-angled splint, and 
 securing it to the arm by the turns of a roller bandage. 
 A moulded pasteboard or leather gutter may be substituted 
 for the angular splints. The dressings should be changed 
 at intervals, and after their removal, at the end of three or 
 four weeks, passive motion should be practised. 
 
 Fracture of the Head and Neck of the Radius. 
 
 These fractures are also quite rare, and, when met with, 
 should be dressed, after reducing the fragments by manipu- 
 lation, by flexing the elbow and keeping it in this position 
 by the application of a well-padded anterior right-angled 
 splint, the splint being firmly secured in position by the 
 turns of a roller bandage applied from the tips of the 
 fingers to the upper end of the splint. The splint should 
 be changed at intervals, and should not be permanently 
 removed for four weeks, at which time passive motion, 
 consisting in flexion and extension at the elbow and 
 pronation and supination of the forearm, should be made. 
 (Fig. 251.) 
 
 An internal angular splint applied to the inner surface 
 of the forearm and arm may also be used in the treatment 
 of these fractures. (Fig. 249.) 
 
 Fracture of Both Bones of the Forearm. 
 
 These fractures are often met with as the result of direct 
 or indirect violence, and after reducing the displacement, 
 which is always marked when both bones are broken, and 
 
FRACTURE OF BOTH BONES OF THE FOREARM. 359 
 
 is not so marked when one bone only is broken, by making 
 extension from the hand and by manipulation ; the forearm 
 is placed in the supine position or in a position between 
 pronation and supination. The supine position is, as a 
 rule, to be preferred in any fracture of the radius, as the 
 upper fragment is supinated by the action of the biceps 
 and supinator brevis muscles, and, therefore, unless the 
 lower fragment be placed in the supine position, union 
 with the rotary deformity will almost inevitably ensue. 
 
 Two straight wooden splints, well padded, a little wider 
 than the forearm, are employed. The anterior splint 
 
 Fig. 255. 
 
 Dressing for fracture of both bones of the forearm. 
 
 should be long enough to extend from the elbow to the 
 tips of the fingers, and the posterior splint should extend 
 from the elbow to the wrist. A primary roller should 
 never be applied to the forearm in dressing these fractures, 
 as its application diminishes the interosseous space, and its 
 use has been followed by gangrene of the hand and fore- 
 arm. In applying the anterior splint to the palmar surface 
 of the forearm and hand, care should be taken to see that 
 the upper end of the splint does not press upon the bra- 
 chial artery and basilic vein at the elbow when the forearm 
 is flexed ; the posterior splint is next applied from the 
 elbow to the wrist, and the splints are held in position by 
 the turns of a bandage carried from the fingers to the 
 elbow. (Fig. 255.) 
 
360 FRACTURES. 
 
 In dressing this fracture a posterior splint equal in 
 length to the anterior splint may be used in place of the 
 short posterior splint extending from the elbow to the wrist. 
 
 In fracture either of the shaft of the radius or of the 
 ulna alone, the deformity is usually not so marked as when 
 both bones are broken at the same time, the unbroken 
 bone acting as a splint ; the dressing for these fractures is 
 the same as for fracture of both bones of the forearm. 
 
 The dressing should be removed in twenty-four or thirty- 
 six hours, and after inspecting the parts and sponging 
 them with dilute alcohol the splints should be replaced in 
 the same manner and secured. The dressing should be 
 removed and renewed at intervals of two or three days for 
 two weeks at least, and after this time the dressings should 
 be made at less frequent intervals. The time required for 
 union in these fractures is usually five or six weeks, and 
 the splints should be retained for this time. 
 
 Fractures of the forearm should be seen by the surgeon 
 frequently for the first two weeks of the treatment, for it 
 is in these fractures that the most unfortunate results have 
 occurred from neglect of this precaution. 
 
 In children incomplete or green-stick fracture of the 
 bones of the forearm are very common ; their dressing, 
 after reducing the deformity, which consists in bending 
 the bones back into place, often converting the incom- 
 plete fracture into a complete one, is accomplished in the 
 same manner as described above. In these patients there 
 is a great tendency to displace the splints or rather to draw 
 the forearm out of the splints, and to prevent this I often 
 employ an anterior angular splint, in place of the straight 
 anterior one, the upper portion of which, being fastened 
 to the arm, prevents the child from dragging the arm out 
 of the dressings. 
 
 Fracture of the Lower End op the Radius. 
 
 The most common fracture of the radius is one situated 
 from one-half of an inch to one and one-half inches above 
 
FRACTURE OF THE LOWER END OF THE RADIUS. 361 
 
 the lower articular surface of the bone, the line of fracture 
 being more or less transverse, although it may in some 
 cases be slightly oblique ; the characteristic deformity in 
 this fracture is represented in Fig. 256. 
 
 Fig. 256. 
 
 Fracture of the radius near its lower extremity. 
 
 The most important point in the treatment of this frac- 
 ture is to effect complete reduction before the application 
 of any splint ; this is done by making extension from the 
 hand, and, at the same time, by extending and flexing the 
 wrist and by manipulation, the deformity can usually be 
 completely reduced. The arm should then be brought 
 
 Fig. 257. 
 
 Position of compresses in Colles's fracture. 
 
 into the position of supination, and a firm compress of lint 
 is next placed over the lower end of the upper fragment 
 on the palmar surface of the forearm ; a second compress 
 is then placed over the upper end of the lower fragment 
 (Fig. 257), and a well-padded Bond splint (Fig. 258) is 
 applied to the palmar surface of the arm and held in place 
 by the turns of a roller bandage. (Fig. 259.) 
 
362 FRACTURES. 
 
 Many surgeons treat this fracture with the hand in a 
 position between pronation and supination, the thumb 
 pointing upward. A substitute for Bond's splint may be 
 
 Fig. 258. 
 
 Bond's splint. 
 Fig. 259. 
 
 Dressing for fracture of the lower end of the radius. 
 Fig. 260. 
 
 Substitute for Bond's splint. 
 
 prepared by fastening a roller bandage obliquely upon 
 a straight wooden splint as suggested by Dr. Hays. 
 (Fig. 260.) 
 
FRACTURE OF THE CARPAL BONES. 363 
 
 Two straight splints with compresses are also employed 
 in the treatment of this fracture, and a vast number of 
 splints have been devised ; among these may be mentioned 
 those of Gordon, Coover, and the metal splint of the late 
 Dr. R. J. Levis. The most important point in the treat- 
 ment of this fracture is the complete reduction of the 
 deformity at the first dressing, and if this has been satis- 
 factorily done almost any splint may be used with a good 
 result, and indeed some surgeons use no splint, applying 
 only a compress over the palmar fragment, held in place 
 by a strip of plaster, the arm being carried in a sling. 
 
 The after-treatment of these fractures consists in remov- 
 ing the splint and compresses after twenty-four or thirty- 
 six hours and in sponging the surface of the skin with 
 dilute alcohol, and the compresses and splint should then 
 be reapplied in the same manner ; the fracture should be 
 dressed every second or third day for the first two weeks, 
 and after this time it should be dressed at less frequent 
 intervals. Union is usually quite firm at the end of four 
 weeks, and the splint should be dispensed with at this 
 time. A certain amount of stiffness of the wrist and 
 fingers is apt to follow this fracture, which is usually 
 soon overcome by passive motion and physiological use of 
 the parts. 
 
 In children epiphyseal separations or fractures of the 
 lower epiphysis of the radius are often met with, and their 
 treatment is similar to that described above ; a Bond splint 
 w T ith compresses or two straight splints with compresses 
 being the most satisfactory dressing to employ in this 
 injury, the dressings being retained for three weeks. 
 
 Fracture of the Carpal Bones. 
 
 These fractures are usually compound or open fractures, 
 and are so frequently associated with extensive laceration 
 of the arm and hand that operative measures have to be 
 resorted to ; but if such is not the case they are dressed, 
 when compound, with an antiseptic dressing, and the hand 
 and forearm are supported upon a well-padded palmar 
 
364 
 
 FRACTURES. 
 
 splint held in place by a roller bandage ; more or less im- 
 pairment in the motion of the wrist is apt to follow these 
 fractures. In simple fractures of the carpal bones the use 
 of an evaporating lotion for a few days, in connection with 
 the splint just mentioned, will be found useful. The 
 dressings should be retained for three or four weeks, and 
 after their removal passive motion should be employed to 
 overcome as far as possible the joint-stiffness resulting. 
 
 Fracture of the Metacarpal Bones. 
 
 These fractures are often met with as the result of direct 
 or indirect force applied to the metacarpal bones. The 
 
 Fig. 261. 
 
 Agnew's splint for fracture of the metacarpal bones. 
 
 treatment of fractures of the metacarpal bones consists in 
 first reducing the deformity, which is usually an angular 
 
 Fig. 262. 
 
 Dressing for fracture of the metacarpal bones. 
 
 one, the projection of the angle being toward the back of 
 the hand ; this is reduced by pressure with the fingers, 
 and the hand and forearm should then be placed upon a 
 
FRACTURE OF THE PHALANGES. 
 
 365 
 
 palmar splint (Fig. 261) with a pad of oakum or cotton 
 under the palm ; a compress of lint is next placed over the 
 seat of fracture, and the hand and forearm are bound to 
 the splint by the turns of a roller bandage. (Fig. 262.) 
 At the end of three weeks union at the seat of fracture is 
 usually quite firm, and the splint should be dispensed 
 with at this time. 
 
 Fractuee of the Phalanges. 
 
 The treatment of fractures of the phalanges consists in 
 reducing the displacement by extension and manipulation, 
 
 Fig. 263. 
 
 Gutta-percha splint for fracture of phalanx. (Hamilton.) 
 Fig. 264. 
 
 Dressing for fracture of phalanx with anterior and posterior splints. 
 
 and in placing the finger in a moulded gutta-percha or 
 pasteboard splint (Fig. 263), and securing the splint in 
 
366 FRACTURES. 
 
 position by the turns of a roller bandage. When the 
 proximal phalanx is fractured a narrow, padded, wooden 
 splint extending from the end of the finger to the wrist 
 should be applied upon the palmar surface of the finger and 
 hand, and a short dorsal splint should also be used ; if there 
 is a tendency to lateral displacement short lateral splints 
 should also be employed, and the splints should be held in 
 place by strips of plaster or by a roller bandage. (Fig. 264.) 
 Union in fractures of the phalanges is usually quite firm 
 at the end of three weeks, and the splints can be dispensed 
 with at that time. 
 
 Fractures of the Lower Extremity. 
 
 Fkacture of the Femuk. 
 
 Fractures of the upper extremity of the femur are those 
 Involving the neck, great trochanter, and upper end of the 
 shaft of the bone. 
 
 In dressing fractures of the upper extremity of the femur 
 the patient should be placed in bed upon a firm mattress, 
 and an extension apparatus made from adhesive plaster 
 should be applied to the leg, extending as far as the knee- 
 joint. The extension apparatus is constructed by taking 
 a piece of adhesive plaster two and a half inches in width 
 and long enough to extend from the outer side of the knee 
 to four inches below the sole of the foot, and from this 
 point back to the inner side of the knee ; in the centre of 
 this strip is placed a block of wood, two and a half inches 
 wide and four inches in length, with a perforation in its 
 centre ; the block and the inner surface of the strip on 
 each side are next faced with a similar strip of adhesive 
 plaster to a point about an inch above each malleolus ; a 
 few straps are next wound around the wooden block to 
 fix the previously applied straps ; the strip of plaster is 
 next warmed and applied to the sides of the leg and held 
 in position by three strips of adhesive plaster carried around 
 the leg at intervals (Fig. 265), and the plaster is made 
 
FRACTURE OF THE FEMUR. 
 
 367 
 
 additionally secure by the application of a roller bandage 
 applied to the foot and leg and carried up to the knee- 
 Through the perforation in the block or stirrup is fastened 
 a cord which passes over a pulley attached to the bed, 
 and to this cord is attached the extending weight. The 
 extension apparatus being applied, lateral support is given 
 to the leg and thigh by sand-bags applied on either side ; 
 the outer sand-bag should extend from the foot to the 
 
 Fig. 265. 
 
 Adhesive plaster extension apparatus applied to limb. (Ashhurst.) 
 
 axilla, and the inner one from the foot to the groin. A 
 weight of five or ten pounds is attached to the extending 
 cord, and the lower feet of the bed should be raised on 
 blocks a few inches high to prevent the patient from slip- 
 ping down in bed ; a pad of oakum or cotton should also 
 be placed under the tendo-Achillis to relieve the heel from 
 pressure. This dressing is kept in place for from four to 
 six weeks, and if union has occurred the patient is kept 
 in bed for a few weeks longer and is then allowed to be 
 about using crutches. In the majority of cases of fracture 
 of the neck of the femur fibrous union only takes place, 
 and after employing the dressing before described for six 
 weeks the patient is allowed to get up and go about on 
 crutches. It often happens that the subjects in whom 
 these fractures occur are old and feeble, and if it is found 
 that restraint in bed with the dressings here described is 
 not well borne, under such circumstances they should be 
 
368 
 
 FRACTURES. 
 
 discarded and the patient should be allowed to sit up in 
 bed with the limb resting on a pillow, or in a chair, the 
 treatment of the local condition having to be disregarded, 
 attention being given to the patient's constitutional con- 
 dition. 
 
 Fig. 266. 
 
 Plaster- of-Paris bandage applied to thigh. (Hamii/i on. ) 
 
 Fig. 267. 
 
 ^X 
 
 a 
 
 Smith's anterior splint for fracture of the femur. 
 
 1 
 
 The application of a plaster-of-Paris bandage to the leg, 
 thigh, and pelvis is also sometimes made use of in the 
 
FRACTURE OF THE FEMUR. 
 
 369 
 
 treatment of fractures of the upper extremity of the 
 femur; extension should be made from the foot while the 
 bandage is being applied. (Fig. 266,) In fractures of 
 the neck of the femur and of the upper part of the shaft 
 
 Fig. 268. 
 
 iirii;illiiiii.ii[|ll|]'\Hlllli|||!!li , ^ N ^ v — iNiilllllllllllll : 
 
 Dressing for fracture of the femur with extension upon an inclined plane. 
 (Agnew.) 
 
 of the bone the anterior wire splint of Prof. N. R. Smith 
 is sometimes used with advantage; the limb being swung 
 from the splint the patient is able to move in bed without 
 causing him pain or disturbing the fragments. (Fig. 267.) 
 In fractures in the upper portion of the femur where there 
 
 Fig. 269. 
 
 Double inclined fracture-box. 
 
 is marked tilting forward of the upper fragment Prof. 
 Agnew employed extension made from the thigh and 
 placed the limb upon a double inclined plane, maintaining 
 this position during the treatment of the case. (Fig. 268.) 
 With the same object in view, in place of the double in- 
 
370 FRACTURES. 
 
 clined plane a double inclined fracture-box may be em- 
 ployed, extension being made from the thigh by means of 
 adhesive plaster strips applied above the knee, to which a 
 weight is attached. (Fig. 268.) 
 
 Fracture of the Shaft of the Femur. 
 
 In the treatment of fractures of the shaft of the femur 
 the dressings are applied to diminish as far as possible the 
 shortening and to prevent angular or rotary displacement 
 of the fragments. In dressing these fractures the patient 
 should be placed upon a fracture-bed or an ordinary bed 
 with a firm hair mattress ; an extension apparatus of ad- 
 hesive plaster is applied and extension is made by a weight 
 attached to this as previously described. Lateral support 
 is given to the limb by the application of two wooden 
 splints — the outer or long one extending from the axilla 
 to the foot, the inner or short one extending from the groin 
 to the foot. The splints at their upper extremity should 
 be about six inches in width and at their lower extremity 
 about three and a half inches. The splints are wrapped 
 in a splint cloth which extends from the foot to the groin, 
 and after this has been placed under the limb the splints 
 are fixed in their proper positions, the short one to the 
 inner side, the long one to the outer side of the limb. 
 Between the limb and the splints are interposed bran- 
 bags ; the outer bag should be long enough to extend from 
 the axilla to the foot, the inner one from the groin to the 
 foot. The splints and bran-bags are held in place by five 
 or six strips of bandage passing under the limb and body 
 and around the splints and bran-bags at intervals. The 
 heel is saved from pressure by placing a wad of oakum or 
 cotton under the tendo-Achillis, and after the splints have 
 been brought into place the strips of bandage are firmly 
 tied to secure them, and a weight of ten or twelve pounds 
 is attached to the extending cord. The foot of the bed is 
 raised to prevent the patient from slipping downward and 
 to allow the weight of the body to act as a counter- extend- 
 ing force. After the application of the dressings the thigh 
 
FRACTURE OF THE FEMUR. 
 
 371 
 
 should be slightly adducted. During the after-treatment 
 of these fractures the surgeon should see that the splints 
 and bran-bags are kept firmly in place and that the foot 
 does not roll outward ; this is accomplished by untying 
 the strips and readjusting the bags and then bringing up 
 the splints and securing them in position by fastening the 
 strips. (Fig. 270.) The extension apparatus usually does 
 not require renewal during the course of treatment. The 
 extension and splints are kept in place for four or six weeks, 
 and at this time union at the seat of fracture is usually 
 quite firm, so that they may be removed, and the fracture 
 is then supported by moulded pasteboard splints or by the 
 
 Fig. 270. 
 
 Dressing for fracture of the shaft of the femur with lateral splints and bran-bags. 
 (Ashhtjrst.) 
 
 application of a plaster-of-Paris splint for several weeks 
 longer, and at the end of eight weeks it is safe to allow 
 the patient to be up and around on crutches. 
 
 Many surgeons, in fracture of the shaft of the femur, 
 prefer to use a long external sand-bag and a shorter in- 
 ternal one in place of the corresponding long and short 
 splints and bran-bags, and, if care is observed to see that 
 the sand-bags are kept accurately in contact with the limb 
 and body, excellent results may be obtained by this form 
 of dressing. After considerable experience with both 
 methods of furnishing lateral support in the dressing of 
 fractures of the shaft of the femur, I am well satisfied 
 
372 FRACTURES. 
 
 that angular deformity is less likely to result where the 
 splints and bran-bags are employed. 
 
 The plaster-of-Paris dressing, including the foot, leg, 
 thigh, and pelvis, is employed by some surgeons in the 
 early treatment of fracture of the shaft of the femur, the 
 limb being kept well extended until the plaster has thor- 
 oughly set. This dressing is applied in the ambulant 
 method of treating fractures of the femur. The double 
 inclined plane and the anterior angular wire splint are 
 also sometimes employed in the dressing of fractures of 
 the shaft of the femur. 
 
 Fracture of the Shaft of the Femur in Children. 
 
 The treatment of these fractures in young children by 
 extension by a weight and pulley and lateral splints is 
 often unsatisfactory on account of the difficulty in keeping 
 the patient quiet upon his back, and from the soiling of 
 the dressings by the feces and the urine. In children two 
 years of age and over I have never found much trouble 
 in employing extension and lateral support by splints and , 
 bran-bags or sand-bags, and in these cases I make addi- 
 tional fixation at the seat of fracture, and guard against 
 displacement of the fragments by the child sitting up in 
 bed when not watched, by carefully moulding external 
 and internal pasteboard or felt splints to the thigh, and 
 holding them in place by the turns of a bandage. I have 
 employed this form of dressing even in children under 
 two years of age with the most satisfactory results. 
 
 In cases of fracture of the femur in children from a few 
 months to a year or eighteen months of age, in whom it 
 is difficult to obtain quietude, or who have to be moved to 
 give them nourishment if they are taking the breast, the 
 dressing which I have found most satisfactory consists in 
 first applying a roller bandage from the foot to the groin, 
 and then moulding to the outer half of the foot, leg, thigh, 
 and also to half of the pelvis, a pasteboard or felt splint 
 which is well padded with cotton, and held in position 
 by the turns of a bandage carried from the foot to the 
 
FRACTURE OF THE FEMUR. 
 
 373 
 
 Fig. 271. 
 
 pelvis and finished with circular turns about the pelvis. 
 The splint should be so moulded as to include a little 
 more than one-half of the circumference of the thigh and 
 leg. If this splint becomes soiled it is easily replaced by 
 a fresh one, and its removal and renewal are much easier 
 than that of the plaster-of- Paris splint which is recom- 
 mended by some surgeons in these cases. 
 
 In young children fractures of the femur are often 
 incomplete or green-stick fractures; and even when com- 
 plete, the shortening is usually not marked, as the line of 
 fracture is apt to be transverse, the periosteum often not 
 being completely ruptured, which tends 
 to hold the fragments in position. 
 
 In green-stick fractures the deform- 
 ity should be reduced by manipulation, 
 even if it is necessary to convert the 
 incomplete fracture into a complete one 
 to accomplish this object. 
 
 Mr. Bryant recommends that fract- 
 ures of the femur in young children be 
 treated in the vertical position; the 
 injured limb, together with the sound 
 one, is flexed at a right angle to the 
 pelvis and fixed with a light splint, and 
 attached to a cradle or bar abovefthe 
 bed. (Fig. 271.) 
 
 If the plaster-of-Paris dressing is 
 used, the limb should be first enveloped 
 from the foot to the pelvis with a flan- 
 nel bandage, and extension should be 
 made while the plaster-of-Paris bandage 
 is being applied and should be kept up until the bandage 
 has become fixed. The plaster bandage should extend 
 from the toes to the pelvis, and it is well to fix the 
 hip-joint by carrying several turns of the bandage about 
 the pelvis. To prevent the splint from absorbing the 
 discharges and becoming offensive, the upper portion of 
 it may be coated with shellac. 
 
 The time required for union in fractures of the femur 
 
 17 
 
 Fracture of the fe- 
 mur treated by vertical 
 extension. (Bryant.) 
 
374 FRACTURES. 
 
 in children is about four weeks, and the dressings may 
 be removed at this time, but the child should not be 
 allowed to use the limb for several weeks after this period. 
 
 Fracture of the Lower End of the Femur. 
 
 The fractures met with in this portion of the femur are 
 supra-condyloid fractures, or those in which one condyle 
 is separated, or comminuted fractures in which both con- 
 dyles are separated ; epiphyseal disjunctions of the lower 
 end of the femur, met with in young subjects, may also 
 be classed with fractures at this portion of the bone. 
 
 The dressing of supra-condyloid fractures, if there is 
 shortening, should be similar to that employed in fractures 
 of the shaft of the femur, consisting in the application of 
 an extension apparatus and bran-bags and splints or sand- 
 bags to give lateral support ; if, however, there is no 
 marked shortening the dressing employed should be the 
 same as that applied in fractures involving one or both 
 condyles or epiphyseal separations. 
 
 The dressing employed in fracture of one or both con- 
 dyles or in epiphyseal disjunction of the lower end of the 
 femur consists in placing the limb in a long fracture-box 
 extending from the foot to the upper third of the thigh, 
 the box being well padded with a soft pillow, or a well- 
 padded posterior splint, or a moulded pasteboard or felt 
 gutter may be employed ; if either of these dressings is 
 employed, the splint or gutter should be long enough to 
 extend from the lower part of the leg to the upper part of 
 the thigh. 
 
 If there is much effusion into the joint or soft parts, 
 lead-water and laudanum should be applied over the 
 region of the injury for some days, until the swelling has 
 subsided. At the end of two weeks it is well to place the 
 limb in a plaster- of-Paris dressing extending from the 
 foot to the upper part of the thigh. This dressing should 
 be retained for four weeks, and at the end of this time the 
 dressing should be removed, and if the union is suffi- 
 ciently firm to allow the patient to go about on crutches, 
 
FRACTURE OF THE PATELLA. 375 
 
 a fresh plaster-of-Paris splint should be applied extending 
 from the middle of the leg to the middle of the thigh, or 
 lateral splints of pasteboard may be substituted for the 
 plaster dressing. 
 
 A certain amount of permanent impairment of the joint 
 motion is apt to follow fractures involving one condyle or 
 both condyles of the femur. 
 
 Feacture of the Patella. 
 
 The dressing of fractures of the patella consists, first, 
 in the application of a roller bandage from the toes to the 
 upper part of the leg; a well-padded posterior wooden 
 splint long enough to extend from the middle of the leg 
 to the middle of the thigh, or an Agnew splint, which is 
 provided with pegs for the attachment of strips of adhe- 
 sive plaster (Fig. 272) is next placed under the limb. A 
 
 Fig. 272. 
 
 Agnew' s splint for fracture of the patella. 
 
 small compress of lint is next placed above the upper 
 fragment, and a similar compress is placed below the lower 
 fragment ; a strip of adhesive plaster one and a half inches 
 in width and twenty- four inches in length has its middle 
 portion applied over the compress, and its ends are then 
 brought obliquely downward and fastened to the splint, 
 or to the pegs if Agnew's splint be used ; this may be re- 
 inforced by a second or third strip. The object of these 
 strips is to bring the upper fragment down in contact with 
 the lower fragment. A strip of plaster with the ends 
 passing in the opposite direction is next placed over the 
 
376 
 
 FRACTURES. 
 
 lower compress, and the ends are fastened to the splint or 
 pegs ; this strip serves only to steady the lower fragment, 
 as it cannot be drawn upward to meet the upper fragment 
 by reason of the inextensibility of its ligamentous attach- 
 ment. (Fig. 273.) If the Agnew splint is employed the 
 strips of plaster may be tightened by turning the pegs to 
 which they are fastened without removing the splint. 
 
 Fig. 273. 
 
 *fck... f.lnliu.u;. 
 
 \3MMMhihk 
 
 iin.lillk.juim:.. J 
 
 Agnew 's splint applied. 
 
 The splint is next firmly fixed in contact with the limb 
 by the turns of a roller bandage extending from the lower 
 to the upper end of the splint. The limb should next be 
 placed upon an inclined plane or in a long fracture-box 
 with its foot elevated to relax the quadriceps femoris 
 muscle. This dressing should be removed and reapplied 
 in a few days, as the dressings become loose as the swelling 
 about the seat of injury subsides, and after this disappears 
 the dressings require renewal at less frequent intervals, and 
 usually at the end of three weeks the splint may be re- 
 moved and a plaster-of-Paris bandage may be applied 
 extending from the middle of the leg to the middle of the 
 thigh. At the end of six weeks the patient may be allowed 
 to walk upon the limb, the knee-joint being fixed with a 
 plaster-of-Paris or pasteboard splint. 
 
 It is well, after the removal of the splints, for the 
 patient to wear for some months a laced muslin knee- 
 supporter, which gives some support to the knee-joint. 
 
 The union in fractures of the patella is usually fibrous, 
 although in rare cases bony union has occurred. 
 
FRACTURE OF THE BONES OF THE LEG. 377 
 
 A great variety of splints have been devised and used 
 in the treatment of fractures of the patella, the main object 
 of which is to fix the knee-joint and bring the fragments 
 as nearly as possible in apposition. Malgaigne's hooks or 
 Levis's modification of the same are employed by some 
 surgeons to secure close apposition of the fragments. The 
 method of treatment in fractures of the patella, which con- 
 sists in exposing the fragments by an incision, and drilling 
 and suturing them with catgut or silver wire sutures, is also 
 employed at the present time, the strictest antiseptic pre- 
 cautions being taken to prevent infection of the wound. 
 
 In cases of rupture of the fibrous union after fracture 
 of the patella, which is not an uncommon accident, the 
 treatment of the case should be the same as that for a 
 recent fracture of the patella. 
 
 Fracture of the Bones of the Leg. 
 
 In fractures of both bones of the leg the displacement is 
 usually very marked ; when one bone only is broken, the 
 sound bone, acting as a splint, prevents much deformity, 
 
 Fig. 274. 
 
 Fracture-box with movable sides. 
 
 except in case of fracture at the lower end of the fibula, 
 when the foot inclines to the injured side. 
 
 The dressing for fractures of both bones of the leg or 
 for fracture of the tibia or fibula alone, except in cases 
 where the lower portion of the fibula is the seat of injury, 
 is best accomplished by the use of a fracture-box. (Fig. 
 274.) The displacement being overcome as far as possible 
 by extension and manipulation, the leg is placed in a 
 fracture-box, which is prepared for the reception of the 
 
378 
 
 FRACTURES 
 
 limb by having the sides let down and having a soft pillow 
 laid in it ; the foot is next secured to the footboard by a 
 loop of bandage passed around the foot, the ends being 
 tied after passing through the slots in the footboard ; a 
 pad of oakum or cotton is placed under the tendo Achillis 
 to relieve the heel from pressure, and a similar pad is 
 placed between the sole of the foot and the footboard. 
 (Fig. 275.) The sides of the box are then brought up and 
 secured by two or three strips of bandage tied around the 
 box. In Vising a fracture-box in the treatment of fractures 
 of the bones of the leg, the surgeon should see that the foot 
 
 Fig. 275. 
 
 Application of the fracture-box. 
 
 is kept well down to the footboard and is at a right angle 
 with the leg, that there is no eversion of the knee, and 
 that the pillow is full enough to make equable pressure 
 upon the leg when the sides of the box are secured, and 
 that the heel is not subjected to undue pressure — the use 
 of a pad of oakum or cotton under the tendo Achillis being 
 employed to prevent this complication. Where there is a 
 tendency to tilting upward of the lower end of the upper 
 fragment the lower fragment can be brought in line with 
 this by raising the foot by a mass of oakum or cotton 
 placed under the tendo Achillis and heel, and so overcom- 
 ing the deformity. In some cases division of the tendo 
 
FRACTURE OF THE BONES OF THE LEG. 379 
 
 Achillis may be required before this deformity can be 
 corrected. 
 
 The subsequent dressings of the case are conducted by 
 letting down the sides of the box and correcting any dis- 
 placement, if present, by adjusting the limb and pads in 
 their proper position, and again bringing up the sides of 
 the box and securing them. At the end of two weeks the 
 fracture-box may be removed and a plaster-of-Paris dress- 
 ing may be applied to the limb, which will allow the patient 
 more freedom of movement in bed, or permit of his sitting 
 up without disturbing the fragments (Fig. 276). 
 
 Fig. 276. 
 
 4 
 
 r~ ■ ■ 
 
 Plaster bandage applied to fracture of the leg. 
 
 Union in fractures of the bones of the leg is usually 
 quite firm in six weeks, but the patient should not be 
 allowed to put his weight upon the limb in walking for 
 at least eight weeks. 
 
 If the patient is restless, and finds his position with the 
 fracture-box resting upon the bed irksome, the fracture- 
 box may be swung from a frame fastened over the bed 
 (Fig. 277). _ 
 
 The application of a plaster-of-Paris dressing as a 
 primary dressing — the ordinary plaster of-Paris bandage 
 or the Bavarian dressings being applied — in fractures of 
 the bones of the leg, is adopted by some surgeons, and, if 
 employed, the case should be under constant supervision 
 
380 
 
 FRACTURES. 
 
 for a few days, so that the dressing can be removed if a 
 dangerous amount of swelling takes place. Moulded 
 splints of felt or pasteboard are also sometimes applied in 
 the treatment of these cases. (Fig. 278.) 
 
 Fig. 277. 
 
 Fracture-box suspended. (Agnew.) 
 
 The ambulant method of treatment of fractures of the 
 bones of the leg and femur, which has recently been in- 
 troduced, consists in applying a plaster-of-Paris bandage 
 in case of fracture of bones of the leg from the toes to 
 the middle of the thigh. The region of the ankle should 
 be well padded with cotton, and the plaster bandage should 
 be applied so as to form a very firm, thick dressing over the 
 
FRAC1TJRE OF THE BONES OF THE LEG, 
 
 381 
 
 foot, ankle, and lower part of the leg ; the region of the 
 knee should also be well padded. When employed for frac- 
 tures of the femur the bandage should be applied in the 
 same manner, but it should be carried high enough to 
 obtain points of support upon the pelvis, at the tuberosity 
 of the ischium and outer surface of the ilium, these parts 
 
 Fig. 278. 
 
 Moulded binder' s-board splints for fracture of the leg. 
 
 being well padded and the turns of the bandage being 
 carried around the pelvis. In the ambulant method ot 
 treatment, the patient, as soon as the bandage has become 
 firm, is allowed to walk about, first with crutches or a cane, 
 and finally bearing his weight upon the injured limb. 
 
 In patients suffering with delirium tremens, or in 
 maniacal patients, the use of a fracture-box in the treat- 
 ment of fractures of the bones of the leg is often not 
 
382 FRACTURES. 
 
 satisfactory on account of the difficulty in restraining the 
 movements of the patient and the consequent displace- 
 ment of the fragments. In such cases it is well to apply 
 a few strips of binder's-board, well padded with cotton, 
 to the limb, extending above and below the seat of the 
 fracture, holding them in place by a few turns of a roller, 
 and then to wrap the limb and foot in a soft pillow, and 
 hold this in place by the turns of a roller bandage applied 
 with moderate firmness. This dressing allows the patient 
 to move the limb without serious disturbance of the frag- 
 ments, and, after the patient recovers from his attack, the 
 leg may be placed in the fracture-box or in a plaster-of- 
 Paris dressing. 
 
 In fractures of the bones of the leg in young children 
 the same difficulty is often experienced in keeping them 
 quiet, and for this reason a fracture-box cannot be used 
 with satisfaction. In dressing these cases, two lateral 
 splints of pasteboard, moulded to the foot and leg and 
 well padded with cotton, may often be employed with the 
 best results. The splints should not be wide enough to 
 meet on the anterior or posterior surface of the leg or foot. 
 The splints, after being carefully adjusted, are held in 
 place by the turns of a roller bandage ; and, after these 
 splints have been applied for two weeks, and all swelling 
 has subsided at the seat of fracture, a plaster-of- Paris 
 bandage may be substituted for them, which should be 
 worn for three weeks ; at the expiration of this time union 
 is usually firm enough to dispense with all dressings. 
 
 Fkactuee of the Fibula. 
 
 In fractures of the fibula, with the exception of that 
 fracture occurring at the lower end of the bone, the de- 
 formity is not marked, and they are usually dressed with 
 a fracture-box applied as in the dressing of fractures of 
 both bones of the leg, and at the end of two weeks a 
 plaster-of-Paris dressing should be applied, and the patient 
 may be allowed to get out of bed and move about on 
 
FRACTURE OF THE FIBULA. 383 
 
 crutches. The union in a fracture of the fibula is usually 
 quite firm at the end of five weeks, and all dressings may 
 be dispensed with at that time. 
 
 Fracture of the Lower End of the Fibula. 
 
 This fracture usually occurs in the lower fifth of the 
 bone, and is often associated with a laceration of the in- 
 ternal lateral ligament of the ankle-joint or a sprain-frac- 
 ture of the internal malleolus, and is usually accompanied 
 by marked eversion of the foot. This fracture is com- 
 monly known as Pott's fracture. 
 
 In this fracture, after reducing the displacement by ex- 
 tension and manipulation, the limb should be placed in a 
 fracture-box provided with a soft pillow, the foot should 
 be secured to the footboard, and a pad of oakum or cotton 
 should be placed under the tendo Achillis ; before bring- 
 ing up the sides of the box and securing them two firm 
 compresses of lint or oakum should be placed in contact 
 with the leg, one just above the inner malleolus, the other 
 just below the outer malleolus. The sides of the box are 
 next brought up and secured, and by the pressure of these 
 compresses the foot is brought into an inverted position 
 and the deformity is corrected. 
 
 The after-dressing of this fracture consists in letting 
 down the sides of the box, and in inspecting the parts to 
 see that the foot is kept in the proper position, and care 
 should be taken to see that undue pressure is not made 
 upon the skin by the compresses, which might result in 
 ulceration ; this may be avoided by sponging the skin 
 with alcohol and changing the positions of the compresses 
 slightly at each dressing. At the expiration of ten days 
 the fracture-box and compresses may be removed and the 
 limb maybe put up in a plaster-of-Paris dressing, including 
 the foot and leg up to the knee. The patient may then 
 be allowed to go about on crutches, and at the end of five 
 weeks all dressings may be dispensed with. A certain 
 amount of stiffness and even permanent impairment in 
 the motion of the ankle-joint often results from these 
 
384 
 
 FRACTURES. 
 
 fractures. This fracture is also dressed by means ot 
 Dupuy trends splint, which consists of a straight wooden 
 splint long enough to extend from the condyles of the 
 femur to the end of the toes ; this splint is provided with 
 padding, the thickest part of which, several inches in 
 thickness, should rest upon the skin just above the inner 
 malleolus when the splint is applied to the inner side of 
 the leg. The splint is applied to the inner surface of the 
 leg with the thickest part of the pad resting upon the skin 
 just above the inner malleolus, and is secured in position 
 by the turns of a roller applied over the foot and at the 
 upper part of the leg. (Fig. 279.) After using this dress- 
 
 FlG. 279. 
 
 Dupuytren's splint applied. 
 
 ing for a few days if the displacement is satisfactorily 
 corrected the splint may be removed and the leg may be 
 placed in a fracture-box or in a plaster-of-Paris dressing. 
 This splint, when applied with sufficient firmness to 
 correct the displacement, is not, as a rule, a comfortable 
 dressing to the patient, so that in practice the use of the 
 fracture-box and compresses will be found a more com- 
 fortable dressing and one equally satisfactory in correcting 
 the deformity. 
 
 Fractures of the Bones of the Foot. 
 
 Fracture of the Tarsal Bones. 
 
 The calcaneum and astragalus are the tarsal bones most 
 frequently fractured. The dressing of fractures of the 
 calcaneum after reducing the displacement, which is not 
 
FRACTURE OF THE TARSAL BONES. 
 
 385 
 
 usually marked unless the posterior portion of the bone 
 is involved by manipulation, consists in placing the leg 
 and foot in a fracture-box, and care should be taken to 
 see that the foot is kept at a right angle to the leg. When 
 the fracture involves the posterior portion of the bone 
 and there is displacement by the action of the muscles 
 inserted into the fragment, the leg should be flexed upon 
 the thigh and the foot should be extended ; this position 
 may be maintained by applying a well-padded curved 
 splint to the anterior portion of the leg and foot and 
 securing it in position by a bandage, or the same result 
 may be obtained by applying a band or padded collar 
 around the thigh, which is made fast by a cord or strap to 
 the heel of a slipper applied to the foot. (Fig. 280.) 
 
 Fig. 280. 
 
 Apparatus for fracture of posterior portion of the calcaneum. (Hamilton.) 
 
 Fractures of the astragalus, after reducing any deform- 
 ity which is present by extension and manipulation, are 
 dressed by placing the foot and leg in a fracture-box, care 
 being taken to see that the foot is kept at a right angle to 
 the leg. This precaution is important, as ankylosis not 
 infrequently occurs after this fracture, and if the foot is in 
 the proper position it is much more useful to the patient. 
 
 As soon as the swelling, which is usually very marked 
 after fracture of the calcaneum or astragalus, subsides, the 
 foot and leg should be put up in a plaster-of-Paris ban- 
 
386 FRACTURES. 
 
 dage. The amount of tension and the inability to reduce 
 the displacement in cases of fracture of the astragalus may 
 be indications for excision of the fractured bone. The 
 time required for union in fractures of the tarsal bones is 
 from five to six weeks. 
 
 Fracture of the Metatarsal Bones. 
 
 These fractures are dressed by placing the foot upon a 
 well-padded plantar splint, and using compresses to hold 
 the fragments in place if there is much displacement, the 
 splint and compresses being held in position by a bandage ; 
 or they may be treated by placing the foot and leg in a 
 fracture- box, the footboard of the box acting as a plantar 
 splint ; the plaster-of-Paris dressing may also be used in 
 these cases. The time required for union in fracture ot 
 the metatarsal bones is from three to four weeks. 
 
 Fracture of the Phalanges of the Toes. 
 
 These fractures are often compound and attended with 
 so much laceration of the soft parts that immediate ampu- 
 tation is required ; when, however, the fractures are sim- 
 ple, or in compound fractures where amputation is not 
 required, the dressing consists in applying a plantar splint 
 of wood or binder' s-board, extending beyond the toes and 
 securing it in position by the turns of a roller bandage. 
 When a single toe only is broken a moulded splint of 
 gutta-percha or binder's-board may be applied, and a 
 portion of the splint should extend some distance upon 
 the sole of the foot, to fix the proximal joint and also to 
 give it a firm point of fixation ; the moulded splint should 
 be held in position by a narrow roller bandage or by 
 strips of adhesive plaster. The time required for union 
 in fractures of the phalanges of the toes is about three 
 weeks. 
 
DRESSING OF COMPOUND OB OPES FRACTURES 387 
 
 Dressing of Compound or Open Fractures. 
 
 In the dressing of compound or open fractures the same 
 dressings and splints which are generally used in the 
 treatment of simple or closed fractures may be employed : 
 the wound in the soft parts requires a special dressing and 
 this should be so arranged as to secure free drainage and 
 promote its prompt healing. In some cases of compound 
 fracture the treatment of the injuries of the soft parts de- 
 mands attention first, and in such cases the injury to the 
 bones is for a time disregarded, care being taken to see 
 that the fragments are kept quiet, so as to prevent further 
 damage to the soft parts until the wound is in such a 
 condition that the proper manipulation to reduce the dis- 
 placement and fix the fragments by splints and suitable 
 dressings can be undertaken without interfering with the 
 repair of the wound. 
 
 Fig. 251. 
 
 Method of reducing a compound fracture. (Ha^jiltox.) 
 
 In the dressing of compound or open fractures the skin 
 surrounding the wound should be first carefully cleansed 
 and the wound should next be thoroughly irrigated with 
 a 1 : 2000 bichloride solution or a 1 : 40 carbolic solution. 
 and any foreign bodies or loose fragments of bone should 
 be removed, and if there is hemorrhage it should be con- 
 trolled by securing the bleeding vessels with ligatures. 
 The reduction of the displacement should next be accom- 
 
388 FRACTURES. 
 
 plished by making extension and by manipulation (Fig. 
 281); if the fragments project from the wound, before this 
 can be satisfactorily accomplished it may be necessary to 
 enlarge the wound and to resect one or both ends of the 
 fractured bones, and in some cases it may be necessary to 
 drill the ends of the fragments and introduce a strong 
 wire or catgut suture, or a metallic nail or screw, to hold 
 them in their proper positions. After reduction of the 
 displacement the wound should again be thoroughly irri- 
 gated with the antiseptic solution, and after making pro- 
 vision for drainage by the introduction of a drainage-tube 
 or tubes, counter-openings being made to secure free drain- 
 age if necessary, the dressings should be applied. 
 
 The wound, if a small one, need not be closed with 
 sutures; but if extensive, a few catgut, silk, or silkworm- 
 gut sutures may be applied to bring the edges of the wound 
 into apposition, care being taken to avoid making undue 
 tension ; if the soft parts have been much lacerated or con- 
 tused, it is better to introduce no sutures. A final irriga- 
 tion of the wound through the drainage-tube is next made, 
 and the wound is covered by a piece of protective, and the 
 ordinary gauze dressing should be applied and covered 
 by a number of layers of bichloride cotton, the whole 
 dressing being held in position by a gauze bandage applied 
 with moderate firmness. 
 
 The reduction of the fragments and the dressing of the 
 wound having been accomplished as has been described, 
 the splints and dressings appropriate for a similar fracture, 
 if it were a simple or closed one, are next applied. If the 
 surgeon has been able to render the wound aseptic, and 
 has applied an antiseptic dressing, the compound fracture 
 is often soon converted into a simple one, by the prompt 
 healing of the wound, and the patient may exhibit no 
 more constitutional disturbance than he would have with 
 a similar simple or closed fracture. The re-dressing of a 
 compound fracture dressed in this way need not be made 
 for a week or ten days, unless there is a rise in the patient's 
 temperature or the dressings become soaked with dis- 
 charges from the wound, or they become uncomfortable to 
 
DRESSING OF COMPOUND OR OPEN FRACTURES. 389 
 
 the patient by reason of swelling of the soft parts in the 
 region of the wound. When the re-dressing of the frac- 
 ture becomes necessary, the dressings are removed, and 
 the drainage-tubes may be removed if no longer needed ; 
 the wound being re-dressed with an antiseptic dressing, 
 the splints are reapplied, and, after the wound is healed, 
 the subsequent dressing of the fracture should be the same 
 as that of a simple fracture. The time required for union 
 in a compound fracture is usually much longer than in a 
 corresponding simple fracture. 
 
 Many ingenious splints have been devised for the dress- 
 ing of special compound fractures, but these were princi- 
 pally used before the introduction of the antiseptic method 
 of wound-treatment, and as the treatment of these cases 
 has been much simplified by its use, they possess no special 
 advantage over the ordinary splints and dressings used in 
 simple fractures. 
 
 Fig. 282. 
 
 Fenestrated plaster dressing for compound fracture of the leg. (Stimson.) 
 
 The plaster- of -Par is dressing may be used as a primary 
 dressing in compound fractures ; the displacement being 
 reduced and the wound being dressed with an antiseptic 
 gauze dressing, a plaster-of- Paris bandage is applied to the 
 parts so as to firmly fix the fragments ; the joints on either 
 side of the fracture should be fixed by the bandage, and 
 the parts should be held in position until the plaster has 
 
390 FRACTURES. 
 
 set firmly After the plaster has become firm, a fenestrum 
 should be made over the position of the wound, so that it 
 can be inspected or dressed through this when necessary. 
 The ends of a piece of stout wire, bent into a semicircle, 
 may be incorporated in the turns of the plaster bandage 
 above and below the position of the fenestrum, to give it 
 additional strength after the removal of a portion of the 
 bandage to make the fenestrum. (Fig. 282.) 
 
 If the plaster-of-Paris dressing is applied as a primary 
 dressing in compound fractures the case should be care- 
 fully watched for a few days, and if much swelling occurs 
 at the seat of fracture its removal and renewal are indicated ; 
 profuse discharge of serum may also soak the dressings 
 and bandage so that its renewal is necessitated. Some 
 surgeons, therefore, prefer to defer the application of the 
 plaster-of-Paris dressing in compound fractures for a few 
 weeks until the swelling has diminished and the wound is 
 nearly or quite healed ; the wound being covered with an 
 antiseptic dressing the plaster bandage is applied and a 
 fenestrum is made over the position of the wound if 
 required. 
 
 Binder' s-board or felt splints may also be employed in 
 the dressing of compound fractures, being moulded to the 
 parts after an antiseptic dressing has been applied to the 
 wound, and held in position by the turns of a roller 
 bandage. 
 
 The principal advantage in the use of these splints is 
 the ease with which they can be removed and reapplied if 
 frequent dressings of the fracture are necessary for any 
 reason. They may be used during the course of treatment, 
 or, after a few weeks when the swelling has diminished at 
 the seat of fracture and the wound is well advanced toward 
 repair, they may be discarded and a plaster-of-Paris dress- 
 ing substituted. In compound fractures of the bones of 
 the leg, after reducing the displacement and applying an 
 antiseptic dressing to the wound, I usually apply moulded 
 binderVboard splints to either side of the leg, including 
 the foot, and place the leg in a fracture-box for additional 
 
DRESSING OF COMPOUND OB OPEN FRACTURES. 391 
 
 security, and after a few weeks I discard the binder's- 
 board splints and apply a plaster of- Paris dressing. 
 
 Bran dressing for compound fractures was formerly a 
 popular dressing in this city, especially for compound 
 fractures of the leg and thigh. It was applied by placing 
 a piece of muslin or rubber cloth over the bottom and 
 sides of a fracture-box, and upon this was placed a layer 
 of bran ; the fractured leg was next placed in the box 
 upon the layer of bran, the foot was then fastened to the 
 footboard, and the sides of the box were brought up and 
 secured ; bran was next poured into the box and firmly 
 packed around and over the limb. The bran absorbed the 
 discharges which escaped from the wound, and at the sub- 
 sequent dressings the soiled bran was renewed without 
 disturbing the limb, and fresh bran was packed about the 
 limb. 
 
 Sawdust which has been saturated with a solution of 
 bichloride of mercury and dried may be used in the same 
 manner as bran in the dressing of compound fractures, and 
 the former, which has been rendered antiseptic, has decided 
 advantages over the bran dressing. 
 
 Continuous irrigation of compound fractures by a warm 
 antiseptic solution either of bichloride of mercury 1 : 4000 
 or of carbolic acid 1 : 60, in cases in which so much contu- 
 sion or laceration of the soft parts exists that the applica- 
 tion of the ordinary dressings would be attended with the 
 risk of gangrene, will be found a most satisfactory method 
 of treatment. This dressing is applied by supporting the 
 injured extremity upon a splint laid on a pillow covered 
 by a rubber cloth, and a can or jar with a nozzle contain- 
 ing the solution is placed over the part, and the irrigation 
 is accomplished by allowing the fluid to run continuously 
 over the wound ; this irrigation may be kept up for days 
 or weeks, and when the vitality of the parts is assured an 
 antiseptic dressing with the ordinary splints or a plaster- 
 of- Paris bandage may be applied. 
 
 A method of dressing compound fractures which has 
 recently been introduced consists in rendering the skin in 
 
392 FRACTURES. 
 
 the region of the wound aseptic and removing any foreign 
 bodies from the wound, then rendering it as far as possible 
 aseptic; iodoform is then dusted thickly over the wound 
 at intervals and, mixing with the blood and serum from 
 the wound, is allowed to dry, forming an antiseptic scab, 
 the wound being exposed to the air, and the fragments are 
 retained in position by splints or by a fracture-box. 
 
PAET IT. 
 
 DISLOCATIONS. 
 
 A dislocation is the displacement of the articular sur- 
 faces of bones which enter into the formation of a joint. 
 
 Dislocations may be complete, partial, simple, compound, 
 and complicated, and they are also known as recent and old 
 dislocations, the latter terms being used not entirely with 
 reference to the length of time the displacement of the 
 articular surfaces of the bones has existed. 
 
 A complete dislocation is one in which no portions of the 
 articular surfaces of the bones remain in contact with each 
 other. 
 
 A partial dislocation is one in which portions of the 
 articular surfaces of the bones still remain in contact with 
 each other. 
 
 A simple dislocation is one in which there exists dis- 
 placement in the relation of the articular surfaces of the 
 bones with little injury to the soft parts adjacent to the 
 joint, and the displaced ends of the bones do not com- 
 municate with the air by a wound in the soft parts. 
 
 A compound dislocation is one in which there exists dis- 
 placement of the articular surfaces of the bones which 
 communicate with the air through a wound in the soft 
 parts. 
 
 A complicated dislocation is one in which, in addition to 
 the displacement of the articular surfaces of the bones, 
 there exists a fracture, or a laceration of important blood- 
 vessels, nerves, or muscles in proximity to the dislocation. 
 
394 DISLOCATIONS. 
 
 A recent dislocation is one in which the displacement of 
 the articulating surfaces of the bones has existed for such 
 a period that time has not been afforded for inflammatory 
 changes to take place in the articular surfaces of the bones 
 or in the adjacent tissues which would seriously inter- 
 fere with their reduction. 
 
 An old dislocation is one in which the displacement of 
 the articulating surfaces of the bones has existed for some 
 time, and in this variety of dislocation the displaced bones 
 often form firm adhesions to the surrounding tissues. 
 
 Treatment of Dislocations. 
 
 The first indication in the treatment of dislocations is to 
 return the displaced articular surfaces of the bones to their 
 normal position and to retain them in this position by the 
 use of suitable dressings. The return of the articular sur- 
 faces of the bones to their normal position or the reduction 
 of the dislocation is accomplished by manipulation, exten- 
 sion, and counter-extension. The reduction of dislocations 
 should be attempted as soon as possible after they have 
 occurred. 
 
 The principal obstacles to the reduction of dislocations 
 are muscular resistance and the anatomical peculiarities of 
 the joints. The former is best overcome by the use of an 
 anaesthetic given to the point where complete muscular 
 relaxation is produced. The resistance offered by the 
 changed relations of the articular surfaces and the liga- 
 ments is to be overcome by the surgeon making such 
 manipulations, founded upon his knowledge of the anatomy 
 of the parts, as will make the ligaments, muscles, and 
 bones assist in the reduction of the dislocation. 
 
 In recent dislocations by the use of extension and ma- 
 nipulation, especially if an anesthetic be employed, the 
 reduction is usually accomplished without the use of much 
 force ; but in old dislocations, where absolute muscular 
 shortening has taken place, the use of extending bands is 
 often required, and in securing these bands to the limb 
 the clove-hitch knot is useful. (Fig. 283.) 
 
DISLOCATIONS OF THE VERTEBRAE. 395 
 
 The treatment of dislocations after reduction consists in 
 placing the joint at complete rest by the application of 
 suitable splints and bandages, and in treating any inflam- 
 matory complications if they arise, by the application of 
 
 Fig. 283. 
 
 Clove-hitch knot applied. (Erichsen ) 
 
 evaporating lotions, and in a week or two after the injured 
 ligaments have been repaired passive motion should be 
 resorted to for restoring the function of the joint. 
 
 Special Dislocations. 
 
 Dislocations of the Vertebra. 
 
 Dislocations of the lumbar and dorsal vertebrce, as simple 
 dislocations, are extremely rare accidents ; they are occa- 
 sionally met with , but are more often associated with frac- 
 tures of the vertebrae in these regions ; their occurrence in 
 the cervical vertebrae is more common. The treatment of 
 dislocations of the vertebrae, whether complicated w T ith 
 fracture or not, consists in attempting reduction by mak- 
 ing extension and counter-extension with manipulation, 
 and by this means in many cases the luxations can be 
 reduced. Jf, however, the efforts at reduction are unsuc- 
 cessful, permanent extension should be applied by means 
 of a weight-extension apparatus from both legs and from 
 the shoulders and head. The after-treatment consists in 
 
396 
 
 DISLOCATIONS. 
 
 keeping the patient at rest upon his back in bed upon a 
 firm mattress, and if the cervical vertebrae have been in- 
 volved the head and neck should be supported by short 
 sand-bags, and in case of the vertebrae below this point, 
 the application of a plaster-of-Paris jacket may be used to 
 give support and fixation to the parts. The general man- 
 agement of the case as regards complications is similar to 
 that in cases of fracture of the vertebrae. 
 
 Dislocations of the coccyx are reduced by manipulations 
 with the finger in the rectum and external manipulation 
 at the same time. The only after-treatment required is 
 rest in bed for a few days and the administration of 
 opium to keep the bowels quiet. 
 
 Dislocation of the Jaw. 
 
 This dislocation may consist in the displacement of one 
 or both condyles of the jaw from the glenoid fossae, consti- 
 
 FlG. 284. 
 
 Bilateral dislocation of the jaw. (Ashhurst.) 
 
DISLOCATION OF THE JAW. 
 
 397 
 
 tutiug the unilateral or bilateral dislocation of the jaw ; 
 the latter is the more common form of dislocation of the 
 jaw met with, and the deformity resulting is shown in 
 Fig. 284. 
 
 The reduction of a dislocation of the lower jaw is accom- 
 plished as follows : The surgeon placing his thumbs, well 
 protected by strips of bandage or a towel, on the molar 
 teeth or behind them, presses the angles of the jaw down- 
 ward while he elevates the chin with his fingers, and by 
 this manipulation the condyles of the jaw usually slip 
 
 Fig. 285. 
 
 Method of reducing dislocation of the lower jaw. (Hamilton.) 
 
 back into place with a snap. After reduction of the dis- 
 location the jaw should be fixed for a week or ten days 
 by the application of a Barton's bandage or a four-tailed 
 sling. (Fig. 285.) 
 
 Dislocation of the Hyoid Bone. 
 
 A few cases of dislocations of the hyoid bone have been 
 recorded ; the treatment consists in throwing back the 
 head as far as possible, to place the muscles of the neck 
 upon the stretch, depressing the lower jaw and pressing 
 the luxated bone into position. 
 
 18 
 
398 DISLOCATIONS. 
 
 Dislocation of the Ribs. 
 
 The ribs may be dislocated at their vertebral articula- 
 tions or at the junction with their costal cartilages. The 
 treatment of these dislocations consists in reducing the 
 displacements by manipulation and pressure and then in 
 fixing the chest to secure immobility of the ribs by strap- 
 ping the affected side with strips of adhesive plaster, the 
 same dressing being applied as in cases of fracture of the 
 ribs, the dressing being retained for three or four weeks. 
 
 Dislocation of the Sternum. 
 
 Dislocation or diastasis of the sternum may occur at the 
 junction of the manubrium and gladiolus or at the junc- 
 tion of the ensiform cartilage and gladiolus. The reduc- 
 tion is effected by extension of the chest by bending the 
 dorsal spine over a firm cushion placed under the back 
 and by pressure upon the projecting bone ; when the dis- 
 placed bone has been reduced a compress should be placed 
 over the seat of injury, and held in place by broad strips 
 of adhesive plaster, or by a bandage to keep the parts at 
 rest. The dressing should be retained for three or four 
 weeks. 
 
 In the few examples of dislocations of the ensiform 
 cartilage which have been reported, the displacement of 
 the cartilage has in some cases given rise to persistent 
 vomiting, which was relieved by reduction of the displace- 
 ment ; it is, however, almost impossible to keep the frag- 
 ment in place after reduction, and the vomiting gradually 
 disappears after a time in those cases where it is impos- 
 sible to keep the cartilage in its normal position. 
 
 Dislocation of the Pelvis. 
 
 Dislocations or diastasis of the bones of the pelvis may 
 occur at the pubic or sacro-iliac symphyses. 
 
 These are generally serious injuries, as they are apt to 
 be complicated by lesions of the pelvic viscera. 
 
DISLOCATIONS OF THE CLAVICLE. 
 
 399 
 
 The reduction of these dislocations is effected by pressure 
 and manipulation, and after reduction the parts should be 
 supported by a compress held in place by a stout binder 
 or by broad strips of adhesive plaster, the patient being 
 kept quiet in bed, and the pelvis being supported by 
 means of sand-bags. The dressings should be retained 
 for from four to six weeks. 
 
 Dislocations of the Clavicle. 
 
 Dislocations of the clavicle may occur either at the 
 sternal or acromial end, and the latter injury some writers 
 describe as a dislocation of the scapula, following the gen- 
 eral rule that the distal bone is the one dislocated. 
 
 Dislocations of the sternal end of the clavicle may occur 
 in a forward, backward, or upward direction, and the dis- 
 placement is generally well marked. (Fig. 286.) The 
 
 Fig. 286. 
 
 Dislocation of sternal end of clavicle 
 forward. (Bryant.) 
 
 Dislocation of clavicle at acromial 
 end. (Bryant.) 
 
 reduction of this dislocation is effected by placing the 
 knee against the spine, and drawing the shoulders outward 
 and backward and pressing the displaced end of the 
 clavicle into place. The reduction is generally easy, but 
 it is often difficult to keep the end of the bone in its 
 proper position. To accomplish this, a compress should 
 
400 DISLOCATIONS. 
 
 be placed over the end of the bone, and this should be 
 secured in place by broad strips of adhesive plaster ; the 
 shoulders should be brought well backward and secured 
 by a posterior figure-of-eight bandage of the chest, and the 
 arm of the injured side should be fastened to the sid^ of 
 the chest by spiral turns of a bandage. In some cases, in 
 addition to the compress over the end of the bone, secur- 
 ing the arm of the injured side in the Velpeau position 
 will be found all that is necessary to retain the bone in 
 position. 
 
 Dislocation of the acromial end of the clavicle may be 
 upward, downward, or backward. (Fig. 287.) The re- 
 duction is effected by manipulation of the arm and scapula 
 and by pressure over the displaced end of the clavicle. 
 The displacement is usually reduced without much trouble, 
 but it is often a matter of difficulty to keep the end of the 
 bone in its proper place. 
 
 The dressing consists in placing a compress over the 
 acromial end of the clavicle and holding it in place by 
 broad strips of adhesive plaster ; the arm should at the 
 same time be fixed in the Velpeau position. These dress- 
 ings after reduction of dislocations of the clavicle should 
 be kept in place for at least three weeks. Although in 
 many cases a certain amount of deformity persists, the 
 disability resulting from the injury is not often marked. 
 
 Dislocations of the Scapula. 
 
 Dislocation of the acromion process of the scapula from 
 the outer end of the clavicle, which has been described 
 under dislocation of the acromial end of the clavicle, is 
 classed by some writers as a scapular dislocation. 
 
 Dislocation or projection of the inferior angle of the 
 scapula , due to its escape from under the latissimus dorsi 
 muscle or relaxation of this muscle and of the serratus 
 magnus, is sometimes described as a dislocation of the in- 
 ferior angle of the scapula. The reduction of this deformity 
 consists in the employment of manipulation and pressure 
 to overcome the displacement, and the use of a compress 
 
DISLOCATIONS OF THE SHOULDER. 
 
 401 
 
 held in place by broad strips of adhesive plaster to secure 
 the bone in its proper position. 
 
 Dislocations of the Shoulder. 
 
 The head of the humerus may be dislocated downward, 
 forward, or backward. 
 
 Subglenoid or downward dislocation of the head of the 
 humerus is that variety of dislocation in which the head 
 of the bone rests in the axilla. (Fig. 288.) 
 
 FIG. 288. 
 
 Subglenoid dislocation of the shoulder. (Stimson.) 
 
 Subcoracoid or forward dislocation of the head of the 
 humerus is that variety of dislocation in which the head 
 
402 
 
 DISLOCATIONS. 
 
 of the humerus rests beneath the coracoid process of the 
 scapula. ((Fig. 289.) 
 
 /Subclavicular dislocation of the head of the humerus may 
 be considered an aggravated form of the latter variety of 
 dislocation ; the head of the humerus in this variety of 
 dislocation rests beneath the clavicle. 
 
 Fig. 289. 
 
 Subcoracoid dislocation of the shoulder. (Stimson.) 
 
 Subspinous or backward dislocation of the head of the 
 humerus is that variety of dislocation in which the head 
 of the humerus rests beneath the spine of the scapula. 
 (Fig. 290.) 
 
 The reduction of dislocations of the humerus is effected 
 by manipulation, by extension and counter-extension, and 
 by a combination of these methods. 
 
 Manipulation in the reduction of subglenoid dislocation 
 
DISLOCATIONS OF THE SHOULDER. 
 
 403 
 
 of the humerus is practised by first flexing the forearm 
 
 upou the arm to relax the long head of the biceps muscle; 
 
 the elbow is next seized and abducted so as to bring it to 
 
 the side of the patient's head, thus relaxing the deltoid 
 
 and supra spinous muscles ; the surgeon or an assistant 
 
 next places his hand upon 
 
 the head of the humerus FlG - m 
 
 in the axilla, and, as the 
 
 arm is drawn outward to 
 
 a right angle with the 
 
 body by the other hand, 
 
 he pushes the head of 
 
 the bone into the glenoid 
 
 cavity. 
 
 In the reduction of sub- 
 glenoid and subclavicular 
 dislocations the manipula- 
 tions are the same except 
 that the arm is to be ro- 
 tated outward before being 
 carried downward. 
 
 In the reduction of sub- 
 spinous dislocations after 
 the arm has been abducted 
 it should be rotated inward 
 and direct pressure should be made upon the head of the 
 bone as the arm is adducted. Reduction may also be 
 effected by extension and counter- extension as in Cooper's 
 method, where extension is made from the arm downward 
 and counter-extension is made by the heel in the axilla. 
 (Fig. 291.) 
 
 Subspinous dislocation of the head of the 
 humerus. (Erichsen.) 
 
 Kocher's Method of reduction of dislocations of the 
 shoulder consists in flexing the elbow at a right angle and 
 pressing it closely against the side, the forearm at the same 
 time being turned as far as possible away from the trunk. 
 While the external rotation is being maintained the elbow 
 is carried well forward and upward and the arm is rotated 
 inward and the elbow is lowered. 
 
404 
 
 DISLOCATIONS. 
 
 Reduction may also be accomplished by extension made 
 upward, as in Mothers method, the scapula being fixed 
 
 Fig. 291. 
 
 Reduction of shoulder by heel in the axilla. (Erichsen.) 
 Fig. 292. 
 
 Reduction of shoulder by extension upward. 
 
 by the foot or hand placed over the acromion process. 
 (Fig. 292.) 
 
DISLOCATIONS OF THE ELBOW. 405 
 
 After reduction of dislocations of the head of the 
 humerus the arm should be bound to the side of the body 
 by the turns of a spiral bandage of the chest, or should 
 be held against the side by the application of a Velpeau 
 bandage (Fig. 59, p. 68) ; this dressing should be removed 
 at intervals of a few days, and after ten days or two weeks 
 all dressings should be dispensed with, passive motion 
 should be employed, and the patient allowed to move the 
 arm. 
 
 Dislocations of the Elbow. 
 
 Dislocation of the Bones of the Forearm. 
 
 Dislocations of the bones of the forearm at the elbow 
 may either be backward, forward, or lateral. The back- 
 ward dislocation is the most common form. (Fig. 293.) 
 
 Fig. 293. 
 
 Dislocation of "both bones of the forearm backward. (Liston.) 
 
 The reduction of backward dislocations is effected by 
 making traction upon the forearm and at the same time 
 making pressure upon the lower end of the humerus as 
 the forearm is flexed upon the arm. 
 
 Or the reduction may be accomplished by bending the 
 arm slowly and forcibly over the knee placed upon the 
 inner surface of the elbow so as to press upon the radius and 
 ulna, separating them from the humerus and freeing the 
 coronoid process from its abnormal position. (Fig. 294.) 
 
 Lateral dislocations of the bones of the forearm at the 
 elbow are reduced by making extension from the forearm, 
 
 18* 
 
406 
 
 DISLOCATIONS, 
 
 and at the same time making direct pressure on the dis- 
 placed bones and counter-pressure on the lower end of the 
 humerus. 
 
 Fig. 294. 
 
 Reduction with the knee in the bend of the elbow. (Hamilton.) 
 
 Forward dislocations of the bones of the forearm at the 
 elbow are reduced by making forced flexion at the elbow, 
 together with extension or counter-extension, or by mak- 
 ing forced extension of the forearm at the elbow, pressing 
 the humerus backward and suddenly flexing the forearm. 
 
 The dressing, after the reduction of dislocations at the 
 elbow, consists in the application of a well-padded anterior 
 right- or slightly obtuse-angled splint, to keep the forearm 
 in a flexed position — the dressing being practically the 
 same as that for fractures of the lower end of the humerus, 
 with an anterior angular splint (Fig. 295). This dressing 
 
DISLOCATION OF THE RADIUS. 407 
 
 should be retained for two or three weeks, being removed 
 at intervals of several days ; after the removal of the splint, 
 
 Fig. 295. 
 
 Dressing after reduction of dislocation of the elbow. 
 
 passive motion should be practised, to prevent stiffness of 
 the elbow r -joint. 
 
 Dislocation of the Head of the Radius. 
 
 The head of the radius may be displaced forward, out- 
 ward, or backward, the forward dislocation being the most 
 frequent. (Fig. 296.) The reduction of these disloca- 
 tions is effected by making extension from the forearm 
 and counter-extension from the lower end of the humerus, 
 and at the same time the head of the bone is pressed into 
 its proper position. The dressing after reduction of the 
 displacement consists in the application of a compress over 
 the head of the bone, and the arm and forearm should 
 be placed upon a well-padded anterior angular splint, 
 which is secured by a roller bandage. The dressing is 
 similar to that employed in fractures of the lower end of 
 the humerus, in which an anterior angular splint is em- 
 ployed (Fig. 251, page 354). Difficulty is sometimes ex- 
 perienced in keeping the head of the bone in position after 
 reduction, so that the use of the compress in addition to 
 the use of the splint is often required. The arm should 
 
408 
 
 DISLOCATIONS. 
 
 be kept upon the splint for three weeks, being re-dressed 
 at intervals. 
 
 Fig. 296. 
 
 Dislocation of head of the radius forward. (Liston.) 
 
 Dislocation of the Upper End of the Ulna. 
 
 The upper end of the ulna may be displaced backward, 
 the olecranon projecting beyond the condyles of the 
 humerus, while the head of the radius occupies its normal 
 position. The reduction of this displacement is effected 
 in the same manner as that of both bones of the forearm 
 backward, and the dressing after reduction is similar to 
 that employed when both bones have been displaced. 
 
DISLOCATIOXS OF THE WRIST. 
 
 409 
 
 Dislocations of the Wrist. 
 
 The lower end of the ulna may be dislocated from the 
 radius forward, backward, or inward. The reduction of 
 these displacements is effected by fixing the radius and 
 pushing the ulna back into place. The dressing after 
 reduction consists in placing the wrist-joint at rest by the 
 application of well-padded anterior and posterior straight 
 splints. The splints should be retained for three or four 
 weeks, dressings being made at intervals of two or three 
 days. 
 
 Dislocations of the carpus upon the bones of the forearm 
 may be forward (Fig. 297), or backward (Fig. 298). The 
 
 Fig. 297. 
 
 Fig. 298. 
 
 Dislocation of the carpus forward. 
 (Hamilton.) 
 
 Dislocation of the carpus backward. 
 (Hamilton.) 
 
 reduction in either variety of displacement is effected by 
 extension from the hand and by pressure. After reduc- 
 tion of the displacement, which does not tend to recur, 
 the hand and the forearm should be placed upon a well- 
 padded straight splint applied to the palmar surface of the 
 hand and forearm. The splint should be retained for ten 
 days or two weeks. 
 
410 DISLOCATIONS. 
 
 Dislocations of the Bones of the Carpus. 
 
 The displacement of the individual bones of the carpus 
 occasionally takes place, the os magnum, the semilunar and 
 pisiform being the bones most usually displaced, although 
 other bones of the carpus are sometimes dislocated. Re- 
 duction is effected by means of extension and pressure, 
 and the part should afterward be dressed with a palmar 
 splint and compresses. 
 
 Dislocations of the Metacarpal Bones. 
 
 The metacarpal bones may be dislocated upon the 
 carpus ; the bones most commonly displaced are those of 
 the thumb and of the index and middle fingers ; the latter 
 are usually displaced backward, while the metacarpal bone 
 of the thumb may go either backward or forward. 
 
 Reduction is effected by extension and pressure. The 
 dressing after reduction consists in the application of a 
 palmar splint to the hand and forearm and a compress 
 over the displaced bone. The dressings should be retained 
 for two weeks. 
 
 Dislocations of the Fingers. 
 
 Dislocations of the phalanges of the fingers usually take 
 place at the metacarpophalangeal junction, but sometimes 
 occur at the inter-phalangeal joints. The reduction is 
 usually easily effected by extension (Fig. 299), or by push- 
 ing the phalanx back until it stands perpendicularly upon 
 the metacarpal bone, when by strong pressure upon its 
 base, from behind forward, it is readily carried by flexion 
 into its natural position. 
 
 Where difficulty is experienced in making extension in 
 the reduction of these dislocations, the ingenious apparatus 
 of the late Dr. Levis (Fig. 300), or the " Indian puzzle " 
 apparatus (Fig. 301), may be employed with success. 
 
DISLOCATIONS OF THE FINGERS. 
 
 411 
 
 In dislocations of the proximal phalanx of the thumb 
 backward (Fig. 302), great difficulty in reduction is often 
 
 Fig. 299. 
 
 Backward dislocation of phalanx. Reduction by extension. (Hamilton.) 
 
 experienced from the head of the metacarpal bone slipping 
 between the two heads of the short .flexor muscle, or 
 
 Fig. 300. 
 
 Levis's apparatus for dislocation of the phalanges applied. 
 
 between the lateral ligaments. The interposition of the 
 external sesamoid bone is considered by some surgeons 
 
 Fig. 301. 
 
 Extension by Indian puzzle. (Bryant.) 
 
 to be the cause of difficulty in the reduction of this dis- 
 placement. 
 
 In this dislocation reduction is effected by firmly press- 
 ing the metacarpal bone of the thumb strongly toward the 
 palm of the hand to relax the two portions of the short 
 flexor muscle. The thumb is next extended upon the 
 
412 
 
 DISLOCATIONS. 
 
 wrist until its tip points to the elbow. An assistant now 
 places his finger behind the proximal phalanx to prevent 
 its slipping backward, and by bringing the thumb down 
 to the flexed position the bone slips into place. It some- 
 times happens that all efforts at reduction fail, and in such 
 cases it may be necessary to divide one head of the short 
 flexor muscle subcutaneously or through an open wound 
 before the displacement can be relieved. 
 
 Fig. 302. 
 
 Dislocation of proximal phalanx of thumb backward. (Farabeuf.) 
 
 The dressing of dislocations of the phalanges after re- 
 duction consists in the application of splints of wood, or 
 moulded splints of binder's-board, or gutta-percha, to fix 
 the joint, which should be retained for ten days or two 
 weeks. 
 
 Dislocations of the Hip. 
 
 The head of the femur is most frequently dislocated 
 backward, downward, or upward, although it may assume 
 other positions in exceptional cases. 
 
 Posterior or backward dislocations of the head of the 
 femur are either backward and upward, when they are 
 described as iliac or dorsal, the bone resting upon the dor- 
 sum of the ilium (Fig. 303) ; or the dislocation may be 
 backward, the head of the bone resting upon the ischiatic 
 notch ; these are known as ischiatic dislocations, or dislo- 
 
DISLOCATIONS OF THE HIP. 
 
 413 
 
 cations of the femur dorsal below the tendon (of the ob- 
 turator interims), according to Bigelow (Fig. 304). 
 
 The reduction of the posterior dislocations of the femur 
 can generally be effected by manipulation. The patient 
 
 Fig. 303. 
 
 Fig. 304. 
 
 Backward and upward dislo- 
 cation of femur. (Cooper.) 
 
 Backward dislocation of femur. 
 (Cooper.) 
 
 being anaesthetized and placed upon his back, the surgeon 
 grasps the leg at the ankle and knee, flexes the leg upon 
 the thigh, and the thigh upon the pelvis ; he then abducts 
 the limb and rotates it outward, bringing it in a broad 
 sweep across the abdomen, and by bringing it down to its 
 natural position the head of the bone will slip into the 
 acetabulum. (Fig. 305.) 
 
 Downward Dislocation of the Head of the Femur, or 
 
414 
 
 DISLOCATIONS. 
 
 Downward and Forward Dislocation. — In this variety of 
 dislocation the head of the bone rests upon the thyroid fora- 
 
 Fig. 305. 
 
 Fig. 306. 
 
 Downward and forward dislocation 
 of femur. (Cooper.) 
 
 Reduction of backward dislocation of 
 femur. (Bigelow.) 
 
 men ; this form of displace- 
 ment is sometimes spoken of 
 as a thyroid dislocation. (Fig. 
 306.) 
 
 The reduction of downward 
 and forward dislocations of 
 the head of the femur is ef- 
 fected by flexing the leg and 
 thigh and bringing the limb 
 into a position of abduction ; it is then adducted and ro- 
 tated inward in a broad sweep across the abdomen and 
 brought down to its natural position, and the head of the 
 bone slips into the acetabulum. (Fig. 307.) 
 
 In making these manipulations the head of the bone 
 sometimes slips back upon the dorsum of the ilium, con- 
 verting the downward dislocation into a posterior one ; if 
 this accident occurs the displacement should be remedied 
 by making the manipulations appropriate for the reduction 
 of the latter dislocation. 
 
DISLOCATIONS OF THE HIP. 
 
 415 
 
 Upward Dislocation, or the Dislocation Forward and 
 Upward, of the Head of the Femur. — In this variety of 
 
 Fig. 308. 
 
 Reduction of downward and forward dis- 
 location of the femur. (Bigelow.) 
 
 dislocation the head of the bones 
 rest upon the pubis ; this form of 
 displacement is also spoken of as 
 a pubic dislocation. (Fig. 308.) 
 The reduction of forward and 
 upward dislocations of the head 
 of the femur is effected by much 
 the same manipulation as is em- 
 ployed in the reduction of down- For ward and upward dislocation 
 
 ward and forw r ard dislocations, of the femur. (Cooper.) 
 except that in the pubic disloca- 
 tion the flexed limb should be carried across the sound 
 thigh at a higher point. The thigh being flexed the head 
 of the bone is drawn down from the pubis ; it is then semi- 
 abducted and rotated inward to disengage the bone com- 
 pletely. While rotating inward and drawing on the thigh 
 the knee should be carried inward and downward to its 
 place by the side of its fellow, and the head of the bone 
 w r ill usually slip into the acetabulum. 
 
 As before stated various anomalous displacements of the 
 
416 
 
 DISLOCATIONS. 
 
 Fig. 
 
 head of the femur occasionally occur ; the head of the bone 
 may pass directly upward, or downward between the sciatic 
 notch and thyroid foramen, or downward and backward 
 on the body of the ischium, or downward and backward 
 into the lesser sciatic notch, or downward, inward, and 
 forward into the perineum. These anomalous displace- 
 ments usually occur where there has been extensive lacera- 
 tion of the capsular and Y-ligaments. 
 
 The dressing of cases, after reduction of dislocations of 
 the head of the femur, consists in keeping the patient at 
 
 rest in bed upon his back, and 
 the limb should be kept at rest 
 by sand-bags applied to either 
 side of the limb, or the knees 
 should be tied together. 
 
 The patient should be kept 
 at rest for two or three weeks, 
 and at the end of this time may 
 be allowed to get out of bed 
 and go about on crutches. 
 
 Dislocations of the 
 Patella. 
 
 The patella may be dislocated 
 outward, inward, or upward, or 
 it may be rotated upon its own 
 axis. The outward dislocation 
 is the displacement most usually 
 seen. (Fig. 309.) 
 
 Upward dislocation of the 
 patella can only result from 
 laceration of the ligamentum 
 patellae, and the treatment in 
 such cases is similar to that for fracture of the patella. 
 
 The reduction of dislocations of the patella is effected 
 by extending the leg upon the thigh, and flexing the thigh 
 upon the pelvis to relax the quadriceps femoris muscle, 
 when the patella can usually be forced back into place ; in 
 
 Outward dislocation of the 
 patella. (Duplay.) 
 
DISLOCATIONS OF THE KNEE. 417 
 
 some cases alternate flexion and extension of the leg will 
 accomplish the same result. 
 
 The dressing after reduction of the displacement con- 
 sists in the application of a posterior straight splint or 
 a moulded binderVboard or felt splint to keep the joint 
 at rest; the splint should be worn for a week or ten days. 
 
 Dislocations of the Knee. 
 
 The head of the tibia may be dislocated forward, back- 
 ward, or laterally ; the latter dislocations are always incom- 
 plete, forward dislocation being the variety of displacement 
 most commonly met with. (Fig. 310.) 
 
 The reduction of dislocations of the knee is effected by 
 extension and counter-extension with forced flexion of the 
 
 External condyle of femur 
 Forward dislocation of the knee. (Bryant.) 
 
 knee with pressure, aided by rocking movements. The 
 treatment of cases of dislocation of the knee after reduc- 
 tion consists in fixing the knee-joint by the application of 
 a straight posterior splint or a moulded splint of binder's- 
 board. As there is usually marked swelling following 
 these injuries from violence to the joint-structures, the 
 application of evaporating lotions for a few days will be 
 found useful. As soon as the swelling has subsided the 
 joint should be put up in a plaster-of- Paris dressing, and 
 this should be retained for four weeks. 
 
418 DISLOCATIONS. 
 
 Dislocation of the Semilunar Cartilages. 
 
 The displacement here consists in the slipping forward 
 or backward and wedging of the semilunar cartilages be- 
 tween the femoral condyles and the tibia. 
 
 Reduction of the displaced cartilages can usually be 
 effected by hyper-flexion of the knee followed by sudden 
 full extension, or by alternately flexing and extending the 
 joint. Excision of the displaced cartilages is sometimes 
 required in cases in which they cannot be reduced by 
 manipulation. 
 
 The dressing of these cases after reduction of the dis- 
 placed cartilages consists in the application of a posterior 
 straight splint or a plaster-of- Paris dressing to fix the 
 knee-joint ; the splint should be worn for three or four 
 weeks, and if there is a tendency to redisplacement the 
 patient should wear a knee-cap of leather or muslin to 
 partially fix the joint, with compresses so arranged as to 
 make pressure upon the edge of the joint. 
 
 Dislocation of the Fibula. 
 
 Dislocations of the fibula may occur at either of its ex- 
 tremities, and the direction of the displacement may be 
 forward, backward, or upward, dislocation of the head or 
 upper extremity of the fibula being the most common, 
 although all are rare forms of displacement. 
 
 The reduction of dislocations of the head of the fibula 
 is effected by flexing the leg upon the thigh and making 
 direct pressure and extension. Dislocations of the lower 
 extremity of the fibula are reduced by manipulation and 
 pressure. The dressing of cases after reduction of dislo- 
 cations of the fibula consists in the application of a com- 
 press and moulded binder's-board splint, and the dressing 
 should be retained for three or four weeks. 
 
 Dislocations of the Ankle. 
 
 Dislocation of the foot upon the bones of the leg 
 results from the separation of the articular surface of the 
 
DISLOCATIONS OF THE TARSAL BONES. 
 
 419 
 
 astragalus from that of the tibia and fibula, and the dis- 
 placement may he forward, backward (Fig. 311), or lateral 
 (Fig. 312), the latter variety being often associated with 
 fractures of the malleoli. 
 
 Fig. 311. 
 
 Fig. 312. 
 
 Dislocation of foot backward. 
 (Bryant.) 
 
 Dislocation of foot inward. 
 (Bryant.) 
 
 The reduction of dislocations of the ankle is effected by 
 traction, combined with flexion and rotation of the ankle- 
 joint, the leg being first flexed upon the thigh to relax the 
 tendo Achillis, and in some cases the subcutaneous divi- 
 sion of this tendon is required before the reduction can be 
 satisfactorily accomplished. 
 
 The dressing of dislocations of the ankle after reduction 
 consists in the application of a fracture-box, or of paste- 
 board splints to fix the ankle, care being taken to see that 
 the foot is fixed at a right angle to the leg, and in the 
 application of evaporating lotions for a few days ; after 
 the swelling has subsided a plaster-of-Paris dressing 
 should be applied and retained for three or four weeks. 
 
 Dislocations of the Tarsal Bones. 
 
 The astragalus may be dislocated from the bones of the 
 leg and from the other tarsal bones, being thrust for ward, 
 
420 
 
 DISLOCATIONS. 
 
 Fig. 313. 
 
 backward, outward (Fig. 313), or inward. The reduction 
 of dislocations of the astragalus outward is effected by first 
 flexing the leg upon the thigh and making extension from 
 the foot and rotating it at the same time, direct pressure 
 being made upon the displaced bone; in some cases subcu- 
 taneous section of the tendo Achillis has assisted materially 
 in the reduction of the displaced bone. Backward dislo- 
 cation of the astragalus is usually irreducible ; the patient, 
 however, in many cases recovers with a useful foot. In 
 cases of irreducible dislocations of the astragalus, excision 
 of the astragalus may ultimately be required. 
 
 After the reduction of dislocations of the astragalus, 
 the foot and leg should be put at rest in a fracture-box, 
 or by means of moulded splints of pasteboard or felt ; 
 evaporating lotions should also be employed to the region 
 
 of the injury for a few days, 
 and when the swelling has 
 subsided, a plaster - of- Paris 
 dressing should be applied 
 and retained for three or four 
 weeks. 
 
 Dislocations of the calca- 
 neum and scaphoid upon the 
 astragalus, or of the calca- 
 neum upon the astragalus and 
 cuboid, or upon the astragalus 
 alone ; of the scaphoid and 
 cuboid upon the calcis and 
 astragalus ; or of the cuboid, 
 scaphoid, or cuneiform bones, 
 are occasionally met with. 
 
 Their reduction is effected 
 by traction and direct pres- 
 sure, and after this has been 
 accomplished the parts should 
 be put at rest by the appli- 
 _ . ,. ' . , . cation of a splint and com- 
 
 Dislocation of astragalus outward. * 
 
 (Hamilton.) presses. 
 
OLD DISLOCATIONS. 
 
 421 
 
 Dislocations of the Metatarsal Bones and 
 Phalanges of the Toes. 
 
 These dislocations usually result from crushing forces 
 which destroy the vitality of the soft parts so completely 
 that amputation is required. Their reduction in cases of 
 simple or uncomplicated dislocations is effected by trac- 
 tion, manipulation, and pressure. After reduction of the 
 displacement, the parts should be kept in position by the 
 application of splints and compresses. 
 
 Old Dislocations. 
 
 The reduction of old dislocations is attended with more 
 difficulty and danger than that of recent dislocations, due 
 to the permanent contraction and structural changes which 
 occur in the muscles, and to the abnormal adhesions 
 
 Fig. 314. 
 
 Reduction of old dislocation of the femur by pulleys. (Cooper.) 
 
 which form between the displaced bone and the parts 
 with which it is in contact. The reduction of old dis- 
 locations can usually be accomplished by the manipula- 
 tions appropriate for recent dislocations of the same va- 
 riety, but occasionally the use of more forcible extension is 
 required, which is made by bands and pulleys (Fig. 314), 
 
 19 
 
422 
 
 DISLOCATIONS. 
 
 or by vertical extension (Fig. 315). The first step in the 
 reduction of old dislocations consists in thoroughly break- 
 ing up the adhesions which have been formed between the 
 displaced bone and the surrounding tissues ; this has, in 
 some cases, resulted in the laceration of muscles, nerves, 
 and bloodvessels, and in the fracture of the displaced bones 
 
 Fig. 315. 
 
 Reduction of old dislocation of hip by vertical, extension. (Bigelow.) 
 
 or neighboring bones, so that the manipulations should be 
 made w T ith the least force that will accomplish the object 
 desired. After the reduction of old dislocations, difficulty 
 is sometimes experienced in maintaining the bone in its 
 proper place, due to the changes which have occurred in 
 the articular surfaces. 
 
CONGENITAL DISLOCATIONS. 423 
 
 Compound Dislocations. 
 
 These are always grave injuries, and amputation or 
 excision is often required. When, however, operative 
 measures are not required, the reduction is effected in the 
 same manner as in simple dislocations of corresponding 
 parts, the greatest care being taken to render the wound 
 aseptic, and to keep it in this condition by the application 
 of a full antiseptic dressing. 
 
 Complicated Dislocations. 
 
 In dislocations complicated by fracture near the seat of 
 displacement, the displaced bone should, if possible, be 
 first reduced, and this in many cases is a matter of much 
 difficulty, as the fracture prevents the surgeon from using 
 leverage otherwise present, in the reduction, and he has 
 often to depend entirely upon pressure and manipulation 
 to restore the displacement. 
 
 After reduction of the dislocation the fracture should be 
 reduced and dressed. 
 
 Dislocation complicated by rupture of the main artery 
 of the limb may require, after reduction of the displace- 
 ment, exposure and ligation of the vessel or amputation 
 of the limb. Rupture of an important nerve trunk com- 
 plicating a dislocation may call for subsequent exposure 
 and suturing of the divided nerve. 
 
 Spontaneous Pathological and Congenital 
 Dislocations. 
 
 In the treatment of these varieties of dislocations after 
 the reduction of the displacement by manipulation and 
 pressure, much difficulty is often experienced in maintain- 
 ing the reduction. To effect the latter object the use of 
 splints and bandages is employed, and also the use of 
 many ingenious forms of apparatus adapted to particular 
 dislocations. 
 
 Tenotomy or myotomy is often required to prevent 
 recurrence of the deformity, and continuous extension is 
 also of much value in the treatment of these displacements. 
 
PART V. 
 
 OPERATIONS 
 
 In view of the fact that at the present time in our 
 medical schools much more attention is paid to practical 
 surgery, that is, operative procedures upon the cadaver, 
 it has been thought advisable to introduce a very brief 
 description of a number of operations which can with 
 advantage be performed upon the cadaver. Too much 
 value cannot be attached to the importance of the student 
 rendering himself familiar with the use of instruments 
 and their manipulation in the various operative pro- 
 cedures, and also familiarizing himself with the appear- 
 ance of the anatomical parts exposed in operations. The 
 introduction of sutures, the application of ligatures, the 
 closing of wounds, the cutting and fitting of flaps in 
 plastic operations, are procedures, the practical value of 
 which, to the student, cannot be overestimated. 
 
 Ligation of Arteries, 
 
 In the application of a ligature to an artery in its con- 
 tinuity the surgeon should make his incision in the line 
 which corresponds to the general course of the vessel, and 
 he should be thoroughly familiar with the anatomy and 
 with the surgical landmarks of the part. A portion of 
 the vessel, when possible, should be selected for the appli- 
 cation of the ligature half an inch or an inch from any 
 
LIGATION OF ARTERIES. 
 
 425 
 
 large collateral branch. The position of the incision being 
 selected, the surgeon steadies the skin with two fingers and 
 makes an incision of the required length through it with 
 a scalpel; the superficial fascia is next picked up on a 
 director, any large superficial veins which come into view 
 being displaced and divided to an equal length with the 
 incision in the skin ; the deep fascia being exposed, it 
 should be nicked and divided upon a director ; the inter- 
 muscular space or the edge of the muscle or muscles 
 which are the guide to the vessel should next be sought 
 
 Fig. 316. 
 
 Fig. 317. 
 
 Opening sheath. Passing ligature aroand the 
 vessel. Tying the artery. (Bryant.) 
 
 Aneurism needle. 
 
 for, small vessels coming from the main vessel through 
 these spaces will often serve as valuable guides to the 
 position of the vessel. The surgeon next separates the 
 tissues with the director, handle of the knife, or the finger 
 until the sheath of the vessel is exposed ; this is recognized 
 by its communicated pulsation and by the absence of the 
 smooth shining surface and pinkish-white color which 
 
426 OPERATIONS. 
 
 the surface of the artery presents. The sheath of the 
 artery should be picked up with forceps and nicked with 
 the point of the knife applied flatwise ; the incision into 
 the sheath should be very limited, only large enough to 
 allow the aneurism needle to pass through it around the 
 vessel ; extensive dissections or separations of the sheath 
 from the vessel should be avoided, as the nutrition of the 
 artery at the point of ligature may thus be impaired and 
 sloughing and secondary hemorrhage may result. A dis- 
 tinct sheath is found only about the main arterial trunks, 
 which is replaced in the smaller arteries by a layer of 
 loose cellular tissue. The wall of the artery being exposed 
 an aneurism needle is passed around the vessel, threaded 
 with a catgut ligature, and withdrawn ; the needle may be 
 threaded before being passed, in which case the ligature 
 is grasped with forceps and drawn through while the 
 needle is withdrawn. The best material for ligatures is 
 carefully prepared chromicized catgut. The needle should 
 be passed away from important structures such as accom- 
 panying veins and nerves. 
 
 Before the ligature is tied the surgeon should satisfy 
 himself that the ligature when tied will control the circu- 
 lation in the vessel below its point of application, by 
 placing the tip of his finger upon the vessel and drawing 
 upon the ends of the ligature so as to occlude the vessel at 
 the point of application. Being satisfied as to this point, 
 the ligature is tied with a reef-knot, or a surgeon's knot 
 and reef-knot combined. 
 
 Some authorities recommend the application of two 
 ligatures a short distance apart in the ligation of vessels 
 in their continuity, and a division of the vessel between 
 them, so that both ends can retract into the cellular sheath. 
 
 The ends of the ligature are cut short in the wound, 
 which is irrigated and drained if necessary, and is closed 
 by the application of a few sutures, and an antiseptic 
 dressing is applied. 
 
LIGATION OF THE INNOMINATE ARTERY. 427 
 
 Ligation of Special Arteries. 
 
 Ligation of the Innominate Arteky. 
 
 The innominate artery lies immediately behind the 
 sterno-clavicular articulation, and is in relation in front 
 with the innominate veins and pneumogastric nerve, on 
 the inner side with the trachea, on the outer side and be- 
 hind with the pleura. 
 
 Incision. — A V-shaped incision, each branch of which 
 is two and a half or three inches in length, one of which 
 
 Fig. 318. 
 
 Line of incision for— A, innominate artery ; B, right subclavian artery ; C, left 
 subclavian artery ; Z>, vertebral or inferior thyroid artery ; E, axillary artery 
 below clavicle. (Stimson.) 
 
 lies over the anterior edge of the sterno-cleido-mastoid 
 muscle, and the other parallel to and a little above the 
 clavicle. (Fig. 318, A.) The incisions are carried down 
 to the superficial fascia and a flap is dissected up. If the 
 anterior jugular vein is met with, it should be displaced. 
 The sternal and clavicular attachments of the sterno- 
 cleido-mastoid are next divided upon a director half an 
 inch above the bone. The sterno-thyroid and sterno- 
 hyoid muscles and the middle cervical fascia are next ex- 
 
428 OPERATIONS. 
 
 posed, covered by the thyroid veins. The outer fibres of 
 the sternohyoid and sterno-thyroid muscles are next 
 divided, the thyroid vein being held aside, when upon 
 tearing through the fascia with a director the common 
 carotid artery is exposed and traced down to the innomi- 
 nate artery ; the in Dominate veins are pressed against the 
 sternum with the finger, and the artery is separated from 
 its sheath about half an inch below its bifurcation, and 
 the aneurism needle is passed around the vessel from the 
 outer side so as to avoid the vein, pneumogastric nerve, 
 and pleura. 
 
 Ligation of the Subclavian Artery. 
 
 This artery may be tied at three points ; in its first 
 portion, between the trachea and scaleni muscles ; in its 
 second portion, behind the scaleni muscles ; and in its third 
 portion, external to the scaleni muscles. 
 
 The left subclavian artery in its first portion is larger 
 and more vertical in its direction than the right subclavian, 
 and is situated more posteriorly ; from the difficulty in 
 exposing this portion, and from the possibility of injuring 
 the thoracic duct, the ligation of this artery in its first 
 portion has been seldom attempted. 
 
 Incision for the first portion of the subclavian artery is 
 the same as that for the innominate (Fig. 318,-4), and the 
 ligature is passed from the outer side, the pneumogastric 
 and phrenic nerves being pressed inward toward the 
 carotid artery. 
 
 The right and left subclavian arteries are also seldom 
 tied in their second portions — that is, behind the scaleni 
 muscles ; but are frequently tied in their third portions — 
 that is, external to the scaleni muscles. 
 
 Incision for the second portion of the subclavian artery 
 begins an inch external to the sternoclavicular articulation 
 half an inch above and parallel to the clavicle, and is three 
 or four inches in length. (Fig. 318, B or 01) The steps 
 of the operation are the same as for ligation of the third 
 portion, and when the scalenus anticus muscle has been 
 
LIGATION OF THE INNOMINATE ARTERY. 429 
 
 exposed it is divided upon a director; the phrenic nerve 
 which lies upon its anterior aspect is to be avoided. 
 
 Incision for the third portion of the subclavian artery is 
 the same as for the second portion. (Fig. 318, B or C.) 
 
 Fig. 319. 
 
 Ligation of subclavian and lingual arteries. (Bey ant.) 
 
 The skin and platysma being divided, the jugular vein is 
 exposed and drawn to one side or divided between the 
 ligatures ; the superficial fascia is next divided upon a 
 director ; the posterior belly of the omo-hyoid muscle is 
 next found and drawn upward and outward ; the outer 
 border of the scalenus anticus is next felt for and followed 
 down to the tubercle of the first rib — the artery lies 
 against this, between it and the lowest bundle of the 
 
 19* 
 
430 OPERATIONS. 
 
 brachial plexus. The artery is next denuded with the 
 director, and the needle is passed from below, care being 
 taken not to include the lowest bundle of the brachial 
 plexus in the ligature. (Fig. 819.) 
 
 Ligation of the Vertebral Artery. 
 
 Incision for the ligation of the vertebral artery is three 
 or three and a half inches in length, parallel with the 
 anterior edge of the sterno-cleido-mastoid muscle, ending 
 an inch above the clavicle. (Fig. 318, D.) The anterior 
 edge of the sterno-cleido-mastoid being exposed the middle 
 cervical fascia is divided and the carotid artery and jugu- 
 lar vein are exposed and drawn inward. The gap between 
 the longus colli muscle and the scalenus anticus muscles is 
 next felt for about an inch below the carotid tubercle; the 
 fascia covering it is next torn through and the muscles are 
 separated and the vertebral vein comes into view. When 
 this vein is held aside the vertebral artery is exposed, 
 and the ligature is then passed around it. 
 
 Ligation of the Inferior Thyroid Artery. 
 
 Incision for the inferior thyroid artery is the same as 
 that for the vertebral artery. (Fig. 318, D.) The anterior 
 edge of the sterno-cleido-mastoid muscle being exposed it 
 is drawn outward, the middle cervical fascia is next divided, 
 and the carotid artery and internal jugular vein are drawn 
 outward with a retractor. The head being flexed slightly, 
 the surgeon feels for the carotid tubercle, and then sepa- 
 rates the cellular tissue with a director, and the artery 
 should be found below the carotid tubercle. The needle 
 should be passed between the artery and vein. 
 
 Ligation of the Internal Mammary Artery. 
 
 Incision , a vertical one, two and a half inches in length, 
 commencing at the lower border of the clavicle, parallel 
 with and three lines external to the margin of the sternum. 
 
LIGATION OF THE COMMON CAROTID ARTERY. 431 
 
 Divide the skin and superficial fascia and expose the fibres 
 of the great pectoral muscle, the external intercostal apon- 
 eurosis and the muscular fibres of the internal intercostal 
 muscle. Raise the fasciculi of the latter muscle upon a 
 director and divide them, and the vessels will be exposed. 
 The internal mammary artery is not often tied below 
 the fourth intercostal space. 
 
 Ligation of the Common Carotid Artery. 
 
 The point of election for the ligation of the common 
 carotid artery is just above the omo-hyoid muscle, about 
 
 Fig. 320. 
 
 Line of incision for common carotid artery at point of election. (Stimson.) 
 
 three-quarters of an inch below the bifurcation of the 
 vessel, which takes places at a point on a line with the 
 upper border of the thyroid cartilage. 
 
 Incision for the common carotid artery is three inches 
 in length along the anterior border of the sternocleido- 
 mastoid muscle, the centre of which corresponds with the 
 crico-thyroid space. (Fig. 320.) 
 
 Divide the skin, platysma, cellular tissue and apo- 
 
432 
 
 OPERATIONS. 
 
 neurosis, avoiding the superficial veins, and expose the 
 anterior edge of the sterno-cleido-niastoid ; seek for the 
 interspace between this muscle and the sterno-hyoid and 
 sterno-thyroid muscles, draw the latter muscles inward 
 and the artery will be exposed with the jugular vein 
 external to it ; the descendens noni nerve lying upon its 
 sheath, which should be displaced outward. The sheath 
 is next picked up and opened and the artery is separated 
 
 Relation of the left common carotid artery above the omo-hyoid muscle. 
 
 (ESMARCH.) 
 
 from it with a director ; the artery lies internally, the in- 
 ternal jugular vein externally and somewhat more super- 
 ficial, and the pneumogastric nerve lies between the two 
 and is more deeply placed. The sympathetic nerve is 
 posterior to the vessel external to the sheath. The needle 
 is passed from without inward, care being taken to avoid 
 injury of the vein and nerve. (Fig. 321.) 
 
LIGATION OF THE INTERNAL CAROTID ARTERY. 433 
 
 Ligation of the External Carotid Artery. 
 
 Incision for the ligation of the external carotid artery 
 is over the inner edge of the sterno-cleido-mastoid muscle 
 from the angle of the jaw to a point corresponding to the 
 middle of the thyroid cartilage. (Fig. 322, B.) The skin, 
 platvsrua, and cellular tissue being divided, the external 
 jugular vein is drawn aside when encountered; the deep 
 fascia being opened, the facial and lingual veins will be 
 exposed, which should be drawn to one side; the artery is 
 next exposed covered by the hypoglossal nerve and the 
 stylo-hyoid and digastric muscles. The vessel should 
 next be isolated from the internal carotid artery and in- 
 ternal jugular vein, both of which lie along its outer side. 
 The needle should be passed from without inward. 
 
 Ligation of the Internal Carotid Artery. 
 
 Incision the same as for the external carotid artery (Fig. 
 322, B) ; the vessel is external to the external carotid 
 
 Fig. 322. 
 
 Line of incision for— A. Lingual artery. B. External and internal carotid arteries. 
 C. Occipital artery. D. Temporal artery. E. Facial artery. (Stimson.) 
 
434 OPERATIONS. 
 
 artery, and in passing the needle the point should be 
 directed away from the internal jugular vein — that is, 
 from without inward. 
 
 Ligation of the Superior Thyroid Artery. 
 
 Incision about three inches in length along the anterior 
 border of the sterno-cleido-mastoid muscle, starting a little 
 lower down than that for the external carotid artery. The 
 skin, superficial fascia, platysma, and deep fascia being 
 divided, the cellular tissue in the sulcus between the upper 
 portion of the larynx and the great vessels of the neck 
 should be broken up with the director and the vessel 
 exposed. The needle should be passed around the vessel 
 from above downward. 
 
 Ligation of the Lingual Artery. 
 
 Incision a, curved one two inches long, its concavity 
 directed upward from the anterior edge of the sterno- 
 
 FlG. 323. 
 
 Relations of the lingual artery. (Esmarch.) 
 
 cleido-mastoid muscle half an inch above the great horn 
 of the hyoid bone, to a point one inch within the median 
 
LIGATION OF TEE OCCIPITAL ARTERY. 435 
 
 line of the neck. (Fig. 322, A.) Divide the skin and 
 platysrna, displacing the superficial veins, and open the 
 deep fascia, when the submaxillary gland will be exposed; 
 this is displaced upward with the handle of the knife and 
 the tendon of the digastric muscle attached to the hyoid 
 bone, and the hypoglossal nerve will be exposed; next 
 divide the fibres of the hypoglossus muscle midway be- 
 tween the hypoglossal nerve and the hyoid bone, and the 
 lingual artery will be exposed. (Fig. 323.) 
 
 The needle should be passed around the vessel from 
 above downward in order to avoid the nerve. 
 
 Ligation of the Facial Artery. 
 
 The facial artery passes over the inferior maxilla just 
 in front of the anterior edge of the masseter muscle and 
 is accompanied by the facial vein, which lies nearer to the 
 muscle. 
 
 Incision either a horizontal one along the lower border 
 of the maxilla or a vertical one an inch in length. (Fig. 
 322, E.) The skin, subcutaneous tissue, and fascia being 
 divided, the artery is exposed and the needle should be 
 passed around the vessel away from the vein. 
 
 Ligation of the Occipital Artery. 
 
 Incision two inches in length, starting from a point half 
 an inch below and in front of the apex of the mastoid 
 process carried obliquely backward parallel to the border 
 of this process. (Fig. 322, (7.) Divide the skin and 
 fascia and expose the insertion of the sterno-cleido-mastoid 
 muscle, which is also divided, and the aponeurosis of the 
 splenius is exposed ; this is also opened and the digastric 
 groove is felt for, and when the belly of the digastric 
 muscle is exposed the artery is brought into view by 
 separating the cellular tissue in the anterior angle of the 
 wound with a director. (Fig. 324.) 
 
436 
 
 OPERATIONS. 
 
 Ligation of the. Temporal Artery. 
 
 Incision a transverse one, one inch in length, starting 
 from the tragus of the ear forward over the zygomatic 
 arch (Fig. 321, D), or a vertical one of the same length a 
 little in front of the tragus of the ear. 
 
 Divide the skin and expose the subcutaneous cellular 
 tissue, which in this region is very dense and fibrous. This 
 tissue should be broken up with a director and the artery 
 should be found in it about a quarter of an inch in front 
 of the ear. (Fig. 325.) The temporal vein accompanies 
 
 Fig. 324. 
 
 Fig. 325. 
 
 Ligation of the occipital artery. 
 (Skey.) 
 
 Ligation of the temporal artery. 
 (Skey.) 
 
 the artery and lies nearer to the ear, and in some cases the 
 auriculo-temporal nerve is in close relation to the artery. 
 The needle should be passed from behind forward. 
 
 Ligation of the Axillary Artery. 
 
 The axillary artery extends from the middle of the 
 clavicle to the insertion of the teres major into the 
 humerus; the axillary vein lies upon the inner side and in 
 front of the artery. The axillary artery is tied either in 
 
LIGATION OF THE AXILLARY ARTERY 437 
 
 its upper portion, just below the clavicle, or at its lower 
 portion in the axilla. 
 
 Ligation of the Axillary Artery Below the Clavicle. 
 
 Incision four inches in length from the summit of the 
 coracoid process inward a short distance below the clavicle 
 (Fig. 318, E) y or an incision three inches in length, com- 
 mencing at a point one-half an inch from the sterno- 
 clavicular articulation and carried obliquely downward 
 toward the axilla. 
 
 The skin and subcutaneous tissue having been divided 
 the deep fascia is exposed and opened, or the axillary 
 artery may be reached by following the intermuscular 
 space between the sternal and clavicular fibres of the pec- 
 toralis major which leads upward toward the clavicle and 
 to the pectoralis minor ; or the fibres of the pectoralis 
 major being exposed are cut through and the costo-coracoid 
 membrane is next torn through with a director, care being 
 taken to avoid injury of the cephalic vein at the outer 
 portion of the wound ; the pectoralis minor is now seen, 
 and after separating the cellular tissue with a director the 
 axillary vein is seen crossing from the upper edge of the 
 muscle to the clavicle ; the vein almost completely covers 
 the artery, which is exposed by drawing the vein inward. 
 The needle is passed around the artery from within 
 outward. 
 
 Ligation of the Axillary Artery in the Axilla. 
 
 Incision two and a half inches long, started at the upper 
 part of the axilla and carried down the arm at the edge of 
 the coraco-brachialis muscle. (Fig. 326, A.) The skin 
 only is divided in the first incision. The deep fascia is then 
 picked up and divided upon a director. As soon as the 
 fibres of the inner border of the coraco-brachialis muscle 
 are exposed and held aside by a retractor, the operator will 
 see the median nerve, the musculo-cutaneous nerve, and 
 the axillary artery. To the inner side of the artery are 
 
438 
 
 OPERATIONS. 
 
 the axillary vein, ulnar and internal cutaneous nerves. 
 The needle should be passed around the artery from the 
 vein toward the coraco-brachialis muscle. 
 
 Fig. 326. 
 
 %0**- 
 
 
 * % 
 
 A. Incision for axillary artery in axilla. B. Incision for brachial artery. 
 (Stimson.) 
 
 Fig. 327. 
 
 Relations of right axillary artery in axilla. (Esmarch.) 
 
 Ligation of the Brachial Artery. 
 
 Incision at the middle of the arm three inches long on a 
 line corresponding to the inner edge of the biceps muscle. 
 
LIGATION OF THE BRACHIAL ARTERY. 
 
 439 
 
 (Fig. 326, B.) The skin and cellular tissue having been 
 divided, care being taken not to injure the basilic vein, 
 which should be drawn posteriorly, the deep fascia is next 
 cut through and the fibres of the biceps muscle are ex- 
 posed (Fig. 328) ; this muscle should be drawn forward, 
 and the sheath of the vessels enclosing the artery, veins, 
 and median nerve exposed ; the sheath having been opened, 
 the median nerve is pressed aside and the artery is sepa- 
 
 Fig. 328. 
 
 Relations ot right brachial artery at middle of arm. (Esmarch.) 
 
 rated from its veins, and the needle is passed from the side 
 of the nerve around the vessel. 
 
 In ligating the brachial artery the occasional high 
 division of the vessel must be borne in mind. 
 
 Ligation of the Brachial Artery at Bend of the Elbow. 
 
 Incision two inches in length, along the inner border of 
 the tendon of the biceps muscle. Divide the skin, super- 
 ficial fascia, and the bicipital aponeurosis, under which 
 the artery will be exposed, resting upon the brachialis 
 anticus muscle. (Fig. 329.) The median nerve is to the 
 
440 OPERATIONS. 
 
 inner side and some distance from the artery. The needle 
 should be passed around the vessel, after isolating the 
 veins, from within outward. 
 
 Fig. 329 
 
 Tendinous aponeurosis 
 divided. 
 
 Ligation of the brachial artery at the bend of the elbow. (Bryant.) 
 
 Ligation of the Radial Artery. 
 
 The radial artery extends in a straight line from a point 
 half an inch below the centre of the fold of the elbow to 
 the inner side of the styloid process of the radius. 
 
 The radial artery may be tied at its upper, middle, or 
 lower third, or at the root of the thumb. 
 
 Ligation of the Radial Artery in the Upper Third of the 
 Forearm. 
 
 Incision for the radial artery at its upper third is two 
 and a half inches in length on a line drawn from the 
 middle of the bend of the elbow to the ulnar side of the 
 styloid process of the radius ; the incision should begin 
 one and a half inches below the bend of the elbow. (Fig. 
 330, A.) Divide the skin and superficial fascia, avoiding 
 the superficial veins. When the deep fascia is exposed, 
 find the edge of the supinator longus muscle and divide 
 the aponeurosis along its ulnar side, and expose the fibres 
 of the pronator radii teres muscle. The vessel lies in the 
 interspace between these muscles surrounded by adipose 
 
LIGATION OF THE RADIAL ARTERY, 
 
 441 
 
 tissue, and upon being exposed the veins should be iso- 
 lated and the needle passed from without inward. The 
 
 Fig. 330. 
 
 Fig. 331. 
 
 Relations of right radial artery in 
 the upper third of the forearm. 
 (Esmarch.) 
 
 Fig. 332. 
 
 Line of incision for— A. Radial artery 
 in upper third. B. Radial artery in 
 lower third. C. Ulnar artery in upper 
 third. D. Ulnar artery in lower third. Relations of right radial artery above 
 (Stimsox.) the wrist. (Esmarch.) 
 
 radial nerve lies so far external to the artery that it is not 
 often exposed in the operation. (Fig. 331.) 
 
 Ligation of the Radial Artery in the Middle Third of the 
 
 Forearm. 
 
 Incision two inches in length, following the same line 
 as that for the upper third of the artery. After dividing 
 
442 OPERATIONS. 
 
 the skin, superficial and deep fascia, the artery is found 
 in the interspace between the flexor carpi radialis on the 
 inner side and the supinator longus on the outer side ; the 
 radial nerve at this part of the arm is in close relation 
 with the vessel to the radial side, and the needle should 
 be passed around the artery from without inward. 
 
 Ligation of the Radial Artery in the Lower Third of the 
 
 Forearm. 
 
 Incision two inches in length following the same line 
 (Fig. 330, JS), ending one inch above the wrist. The skin, 
 superficial fascia, and deep fascia being divided, the artery 
 will be found between the tendon of the flexor carpi 
 radialis on the inner side and the tendon of the supinator 
 longus on the outer side. (Fig. 332.) The veins being 
 separated the needle may be passed in either direction. 
 
 Ligation of the Radial Artery at the Root of the Thumb. 
 
 The radial artery may also be tied at the root of the 
 thumb. 
 
 Incision one inch in length between the tendons of the 
 extensor ossis metacarpi pollicis and extensor primi inter- 
 nodii pollicis on the outer side, and the tendon of the ex- 
 tensor secundi internodii pollicis on the inner side. The 
 skin and superficial fascia being divided, and the radial 
 vein being displaced, the deep fascia is opened and the 
 artery is exposed at the bottom of the wound ; the needle 
 may be passed in either direction. 
 
 Ligation of the Ulnar Artery. 
 
 The ulnar artery is tied at the junction of the upper 
 and middle third of the forearm and at the lower third. 
 
 Ligation of the Ulnar Artery at the Junction of the Upper 
 and Middle Thirds of the Forearm. 
 
 Incision three inches in length, starting four inches below 
 the internal condyle of the humerus, on a line passing from 
 
LIGATION OF THE ULNAR ARTERY. 
 
 443 
 
 the internal condyle of the humerus to the outer border of 
 the pisiform bone. (Fig. 330, C and D.) Divide the skin 
 and superficial fascia, and when the deep fascia has been 
 exposed the interspace between the flexor carpi ulnaris and 
 the flexor sublimis digitorum appears, enter this interspace 
 
 Fig. 333. 
 
 Relations of the right ulnar artery at upper third of the forearm. (Esmakch ) 
 
 and raise the flexor sublimis digitorum and work trans- 
 versely across the arm. The artery will be found rest- 
 ing upon the deep flexor, with the ulnar nerve to the ulnar 
 side. The needle should be passed from the nerve around 
 the artery. (Fig. 333.) 
 
 Ligation of the Ulnar Artery in the Lower Third of the 
 Forearm. 
 
 Lneision two inches in length a little to the radial side 
 of the tendon of the flexor carpi ulnaris, which is at- 
 tached to the pisiform bone, ending an inch above the 
 wrist. (Fig. 330, D.) Divide the skin and superficial 
 fascia and open the deep fascia, and the artery will be ex- 
 posed, with its accompanying veins, between the tendons 
 of the flexori carpi ulnaris and flexor sublimis digitorum, 
 the ulnar nerve being to the ulnar side of the vessel. 
 
444 OPERATIONS. 
 
 The needle should be passed from within outward to 
 avoid the nerve. (Fig. 334.) 
 
 Relations of right ulnar artery above the wrist. (Esmarch.) 
 
 Ligation of the Interosseous Artery. 
 
 Incision similar to that employed in the ligation of the 
 ulnar artery in its upper third. 
 
 Ligation of the Abdominal Aorta. 
 
 Incision in the linea alba from a point three inches 
 above the umbilicus to a point three inches below it. The 
 superficial structures being divided, the peritoneum is 
 opened upon a director, and the intestines are pressed aside 
 and the aorta is exposed covered by peritoneum, with the 
 filaments of the sympathetic nerve resting upon it, and 
 the vena cava to the right side. Tear through the peri- 
 toneum and pass the needle from left to right around the 
 vessel. After tying the ligature the ends should be cut 
 short, and the external wound should be closed as in the 
 ordinary coeliotomy wound. 
 
 The vessel may also be exposed by an incision along the 
 anterior border of the quadratus lumborum muscle, from 
 the last rib to the crest of the ilium. The skin, lumbar 
 muscles, and fascia transversalis being divided, the wound 
 is held open with blunt hooks, so that the retro- peritoneal 
 space is exposed and the aorta brought into view. The 
 
LIGATION OF THE COMMON ILIAC ARTERY. 445 
 
 vessel being separated from the vena cava and nerves, the 
 needle is passed around it and the ligature applied. 
 
 Ligation of the Common Iliac Artery. 
 
 The aorta divides into the two common iliac arteries on 
 the left side of the fourth lumbar vertebra, and these 
 arteries are usually about two inches in length, and 
 bifurcate opposite the sacro-iliac synchondrosis to form 
 the internal and external iliac arteries ; the length of the 
 common iliac artery, however, may vary considerably, 
 being three or four inches in length in some cases. 
 
 Fig. 335. 
 
 Line of incision for— A, common iliac artery. B, external iliac artery. 
 C, femoral artery in Scarpa's triangle. (Stimson.) 
 
 Incision for ligation of the common iliac artery is four 
 to six inches in length, beginning one-half inch above the 
 middle of Poupart's ligament, and is carried outward, 
 curving upward after passing the anterior superior spine 
 of the ilium. (Fig. 335, A.) 
 
 Divide the skin, superficial fascia and aponeurosis of 
 the external oblique muscle, and then divide the fibres of 
 the internal oblique and transversalis muscles upon a 
 director and expose the transversalis fascia. This is 
 opened at the lower part of the wound, and the finger is 
 
 20 
 
446 
 
 OPERATIONS. 
 
 introduced and the peritoneum is pressed back ; the open- 
 ing in the transversalis fascia is next enlarged, and the 
 peritoneum is carefully drawn inward and upward with 
 the fingers toward the inner edge of the wound. The 
 operator next feels for the external iliac artery, and passes 
 the finger along this until the common iliac artery is 
 beached. The loose cellular tissue in which it is imbedded 
 is next separated, and the needle is passed from within 
 outward, to avoid the common iliac vein (Fig. 336), which 
 
 Fig. 336. 
 
 Ligation of the common iliac artery. (Liston.) 
 
 on the left side lies on the inner side of the artery, and 
 on the right side lies behind the artery. The ureter 
 generally remains attached to the peritoneum; if not, it is 
 seen crossing the bifurcation of the common iliac with the 
 genito-crural nerve, and care should be taken to avoid 
 injury of these structures if present. 
 
 The common iliac artery may also be exposed and tied 
 by an incision made over the artery through the peritoneal 
 cavity ; the vessel being tied, the ends of the ligature are 
 
LIGATION OF THE EXTERNAL ILIAC ARTERY. 447 
 
 cut short, and the external wound is closed in the same 
 manner as that resulting from the exposure of the ab- 
 dominal aorta by incision through the peritoneum. 
 
 Ligation of the Internal Iliac Artery. 
 
 Incision in the same line as for the common iliac artery, 
 but it need not be quite so long. (Fig. 335, A.) The peri- 
 toneum being exposed, it is pushed upward and inward, 
 and the internal iliac artery is exposed. The vessel is care- 
 fully isolated from the vein, which lies behind and on the 
 inner side, and the needle is passed from within outward. 
 
 Ligation of the External Iliac Artery. 
 
 Incision three or four inches in length, half an inch 
 above the middle of Poupart's ligament, made at first par- 
 
 Relations of the right external iliac artery. (Esmarch.) 
 
 allel to it and then curved upward. (Fig. 335, B.) The 
 tissues of the abdominal wall being divided and the peri- 
 
448 
 
 OPERATIONS. 
 
 toneum exposed, it is pushed upward and inward in the 
 same manner as for exposure of the common iliac artery. 
 The artery lies at the inner border of the psoas muscle, 
 the vein on its inner side, and the anterior crural nerve 
 covered by the iliac fascia on the outer side; the genito- 
 craral nerve passes obliquely across the artery. (Fig. 337.) 
 The needle should be passed from within outward. 
 
 Ligation of the Gluteal, Artery. 
 
 Incision three or four inches in length, from the posterior 
 superior spinous process of the ilium to a point midway 
 between the tuber ischii and the great trochanter. (Fig. 
 338, A.) After division of the skin and fascia, the fibres 
 
 Fig. 338. 
 
 Line for — A, gluteal artery. B, sciatic and internal pudic artery. (Stimson.) 
 
 of the gluteus maximus muscle are separated and held 
 apart, and the deep fascia is divided, and the artery should 
 then be sought for above the pyriformis muscle at the 
 upper border of the great sacro-sciatic notch. It is accom- 
 
LIGATION OF THE FEMORAL ARTERY. 
 
 449 
 
 panied by large veins, injury to which should be avoided 
 in exposing the artery and passing the needle. 
 
 Ligation of the Sciatic and Internal Pudic 
 Arteries. 
 
 Incision three or four inches in length, a little lower 
 than that employed for exposure of the gluteal artery. 
 (Fig. 338, B.) Divide the skin, superficial fascia and 
 fibres of the gluteus maximus muscle and deep fascia, and 
 search for the vessels as they leave the great sciatic notch 
 at the lower edge of the pyriformis muscle. The internal 
 pudic artery enters the pelvis through the lesser sciatic 
 notch, lying on the inner side of the sciatic artery during 
 its passage over the spine of the ischium. The vessels are 
 isolated and the needle is passed so as to avoid injury of 
 the veins. 
 
 Ligation of the Femoral Artery. 
 
 The femoral artery may be ligated just below Poupart's 
 ligament, at the apex of Scarpa's triangle, at the middle of 
 the thigh, or in Hunter's canal. 
 
 Fig. 339. 
 
 Relations of the right femoral artery below Poupart's ligament. (Esmarch.) 
 
450 OPERATIONS. 
 
 Ligation of the Femoral Artery below Poupart's Ligament: 
 
 Incision beginning midway between the anterior superior 
 spinous process of the ilium and the symphysis pubis, 
 one-fourth of an inch above Poupart's ligament, and ex- 
 tending two inches downward. Divide the skin and super- 
 ficial fascia and the deep fascia so as to expose the sheath 
 of the vessels; open this one-half an inch below Poupart's 
 ligament and isolate the femoral artery from the femoral 
 vein which lies to the inner side; the anterior crural nerve 
 lies to the outer side. Pass the needle from within out- 
 ward. (Fig. 339.) 
 
 Ligation of the Femoral Artery at the Apex of Scarpa's 
 Triangle. 
 
 Incision three inches long, the centre of which should be 
 a little above the point where the sartorius muscle crosses 
 
 Fig. 340. 
 
 m 
 
 Lines of incision for the femoral artery. (Stimson.) 
 
 a line drawn from the middle of Poupart's ligament to the 
 inner condyle of the femur. (Fig. 340.) Divide the skin, 
 superficial fascia and deep fascia, avoiding the internal 
 saphenous vein, and expose the edge of the sartorius 
 muscle, which may be recognized by the direction of its 
 
LIGATION OF THE FEMORAL ARTERY. 
 
 451 
 
 fibres. This muscle is drawn outward and the sheath of 
 the vessels is exposed and opened ; the vein lies on the 
 inner side and somewhat behind the artery and the long 
 saphenous nerve is on the outer side. (Fig. 341.) Pass 
 the needle from within outw r ard. 
 
 Ligation of the Femoral Artery in the Middle of the 
 Thigh. 
 
 Incision in the line above mentioned, its centre being a 
 little above the middle of the thigh. Divide the skin, 
 superficial and deep fascia and expose the sartorius muscle, 
 which is drawn outward after the leg has been flexed ; 
 
 Fig 341. 
 
 Fig. 342. 
 
 Relations of right femoral 
 artery at the apex of Scarpa's 
 triangle. (Esmarch.) 
 
 Relations of the right femoral 
 artery in the middle of the thigh. 
 (Esmarch.) 
 
 the sheath of the vessel is exposed and opened ; the long 
 saphenous nerve lies upon the artery and the femoral vein 
 lies behind the artery ; the saphenous vein lies more super- 
 ficially and internal to the vessel. Pass the needle from 
 within outward. (Fig. 342.) 
 
452 
 
 OPERATIONS. 
 
 Ligation of the Femoral Artery in Hunter's Canal. 
 
 Incision three inches in length along the tendon of the 
 adductor magnus, the centre of which is at the junction of 
 the lower and middle thirds of the thigh. (Fig. 340.) 
 Divide the skin, superficial fascia and deep fascia, care 
 being taken not to injure the internal saphenous vein, 
 which should be displaced, and expose thesartorius muscle, 
 which should be displaced downward, and expose the 
 aponeurosis which forms the anterior wall of the vascular 
 canal ; this should be opened upon a director, and the 
 artery is uncovered and should be separated from the vein, 
 which lies upon the outer side. The needle is passed from 
 without inward. 
 
 Ligation of the Popliteal Artery. 
 
 Fig. 343. 
 
 aO Relations of the right popliteal artery. (Esmarch. 
 
LIGATION OF THE ANTERIOR TIBIAL ARTERY. 453 
 
 Incision three or four inches in length, along the exter- 
 nal border of the semi-membranosus muscle. Divide the 
 skin and superficial fascia, taking care not to injure the 
 saphenous vein, and open the deep fascia. The edges of 
 the wound being held apart the adipose tissue is broken 
 
 Fig. 344. 
 
 Ligation of popliteal artery. (Smith.) 
 
 up with a director, and the internal popliteal nerve will 
 be first exposed, and next the vein — both external to the 
 artery. (Fig. 343.) The artery is isolated and the needle 
 passed from without inward. (344.) 
 
 Ligation of the Anterior Tibial Artery. 
 
 The anterior tibial artery may be tied in the upper, 
 middle, and lower thirds of the leg ; the general direction 
 of the artery corresponds with a line drawn from the 
 middle of the space between the head of the fibula and the 
 tubercle of the tibia to the middle of the anterior inter- 
 malleolar space. 
 
 Ligation of the Anterior Tibial Artery in the Upper Third 
 of the Leg. 
 
 Incision two and a half to three inches in length, one 
 and one-fourth inches external to the spine of the tibia. 
 Divide the skin and superficial fascia, and when the deep 
 
 20* 
 
454 
 
 OPERATIONS. 
 
 Fig. 345. 
 
 fascia is exposed open it on a line corresponding to the 
 inter-muscular space between the tibialis anticus and the 
 extensor longus digitorum mus- 
 cles. Separate the muscles and 
 work down in this interspace 
 until the artery is found with a 
 vein on either side of it, and the 
 anterior tibial nerve externally. 
 (Fig. 345.) The needle should 
 be passed from without inward, 
 after isolating the veins. 
 
 Ligation of the Anterior Tibial 
 Artery at its Middle Third. 
 
 Incision three inches in length 
 in the same line as that for the 
 upper portion of the vessel. After 
 dividing the skin, superficial and 
 deep fascia, the interspace between 
 the tibialis anticus and the exten- 
 sor longus digitorum muscles is 
 opened and a third muscle comes 
 into view, the extensor proprius 
 pollicis. The artery lies between 
 the extensor proprius pollicis and 
 the tibialis anticus muscles; and the anterior tibial nerve 
 is to the outer side. The veins should be isolated and the 
 needle should be passed from without inward. 
 
 Ligation of the anterior tib- 
 ial artery at its upper third. 
 (Stimson.) 
 
 Ligation of the Anterior Tibial Artery in its Lower Third. 
 
 Incision two inches in length, beginning three inches 
 above the ankle-joint on the line of the artery. Divide 
 the skin, superficial and deep fascia, and seek for the 
 tendon of the extensor proprius pollicis muscle, the second 
 tendon from the tibia. The artery is found in the inter- 
 space between this tendon and the tendon of the extensor 
 longus digitorum muscle, the nerve being to the outer side. 
 
LIGATION OF THE DORSALIS PEDIS ARTERY. 455 
 
 The veins are isolated from the artery, and the needle is 
 passed from without inward. 
 
 Ligation of the Dorsalis Pedis Artery. 
 
 Incision one inch in length on a line drawn from the 
 middle of the anterior inter-malleolar space to a point 
 midway between the extremities of the first two metatarsal 
 bones or along the outer border of the tendon of the ex- 
 tensor proprius pollicis. Divide the skin, superficial and 
 
 Fig. 346. 
 
 Extensor 
 
 brevis digitorum 
 
 muscle. 
 
 Ligation of the dorsalis pedis artery. (Bryant.) 
 
 deep fascia, and the artery will be found lying next to 
 the inner tendon of the short extensor muscle of the toes. 
 (Fig. 346.) The nerve is to the outer side. After separating 
 the veins the needle is passed from without inward. 
 
456 
 
 OPERATIONS. 
 
 Ligation of the Posterior Tibial Artery. 
 
 The course of the posterior tibial artery is indicated 
 
 by a line drawn from the middle of the popliteal space to 
 
 a point midway between the tendo 
 
 fig. 347. Achillis and the internal malleolus 
 
 of the tibia. 
 
 The posterior tibial artery may 
 be ligated in its upper, middle, and 
 lower thirds. 
 
 Ligation of the Posterior Tibial 
 Artery at its Upper Third. 
 
 Incision three inches and a half 
 in length, one-half inch from the 
 inner edge of the tibia, beginning 
 two inches from the upper edge of 
 the bone. (Fig. 347.) Divide 
 the skin and superficial fascia, 
 avoiding large superficial veins ; 
 next open the deep fascia and de- 
 tach the origin of the soleus muscle 
 from the tibia, and on raising it its 
 under surface will present a white 
 shining sheath of tendinous mate- 
 rial, beneath which will be seen a 
 layer of fascia covering the tibialis 
 posticus muscle. If search is made 
 toward the middle of the leg, the 
 artery will be found covered by the inter muscular fascia, 
 the nerve being to the outer side. The needle is passed 
 from without inward after the veins have been separated 
 from the artery. (Fig. 348.) 
 
 Ligation of the Posterior Tibial Artery at its Middle Third. 
 
 Incision two and a half inches in length, parallel with 
 the inner edge of the tibia and half an inch from its 
 
 Lines of incision for the 
 posterior tibial artery. 
 (Stimson.) 
 
LIGATION OF POSTERIOR TIBIAL ARTERY. 457 
 
 border. Divide the skin, superficial and deep fascia, and 
 the inner edge of the soleus will be exposed ; press this 
 outward and the artery with its veins will be exposed, also 
 
 Fig. 348. 
 
 Relations of the right posterior tibial artery in its upper third. (Esmarch.) 
 
 the posterior tibial nerve to the outer side. Pass the needle 
 from without inward after separating the veins. 
 
 Ligation of the Posterior Tibial Artery Behind the Inner 
 Malleolus. 
 
 Incision a curved one two inches in length, midway 
 between the tendo Achillis and the internal malleolus. 
 (Fig. 349.) Divide the skin and superficial fascia; then 
 lift the deep fascia upon a director and opn it freely, 
 when the artery will be exposed with the tendons of 
 the tibialis posticus and flexor longus digitorum mus- 
 cles on the inner side, and the posterior tibial nerve and 
 the tendon of the flexor longus pollicis muscle on the 
 
458 
 
 OPERATIONS. 
 
 Fig. 349. 
 
 Ligation of the posterior tibial artery behind the inner malleolus. (Bryant.) 
 
 outer side. (Fig. 349.) After separating the veins 
 from the artery the needle should be passed from without 
 inward. 
 
PART VI 
 
 AMPUTATIONS. 
 
 The term amputation is now generally applied to the 
 removal of a limb, and this may be removed through the 
 bones, when the operation is spoken of as an amputation 
 in the continuity of the limb ; or it may be removed 
 through its joints, and is then known as an amputation in 
 the contiguity or a disarticulation. 
 
 Methods of Amputating. 
 
 Fig. 350. 
 
 Amputation by circular method. (Druitt.) 
 
 Amputations may be performed by the circular flap, 
 oval, and elliptical methods; the modified circular opera- 
 
460 
 
 AMPUTATIONS. 
 
 Fig. 351. 
 
 tion, and Teale's method by rectangular flaps, are also em- 
 ployed. 
 
 Circular Method. 
 
 In performing an amputation by this method the inci- 
 sion of the skin is made at a distance below the point 
 where the bone is to be divided. An assistant grasps the 
 limb and draws the skin evenly and firmly toward the 
 root of the part and the surgeon passes the heel of the 
 
 knife well into the tissues and 
 makes a circular sweep around 
 the limb and completes the di- 
 vision of the skin and cellular 
 tissue with one motion of the 
 knife. (Fig. 350.) 
 
 In some cases a cutaneous 
 sleeve consisting of the skin 
 and cellular tissue is dissected 
 up and turned back, and some- 
 times it may be necessary to 
 make a slit on one side of the 
 flap to allow it to be turned up. 
 The second incision in an am- 
 putation by the circular method 
 consists, after retraction of the 
 skin, in making a circular cut through all of the tissues 
 down to the bone. (Fig. 351.) 
 
 The third step in an amputation by the circular method 
 consists, after retracting the skin and muscles and holding 
 them back by a retractor, in the division of the bone with 
 a saw. 
 
 Flap Method. 
 
 This method of amputating is susceptible of many 
 variations. There may be one or two flaps of equal or 
 unequal length ; the flaps may be cut antero-posteriorly, 
 laterally, or obliquely. (Fig. 352.) They may be made 
 by transfixing the limb and cutting outward, or they may 
 be cut from without inward, or they may be made to in- 
 
 Division of muscles in circular 
 amputation. (Smith.) 
 
METHODS OF AMPUTATING. 
 
 46 L 
 
 elude the whole thickness of the tissues down to the bone, 
 or merely the skin and superficial fascia, the deeper struc- 
 tures being divided by a circular incision. The flaps may 
 
 Fig. 352. 
 
 Double-flap amputation ; antero-posterior and lateral flaps. (S. Smith.) 
 
 have a curved outline or may be rectangular in shape. In 
 amputating by the antero-posterior flap operation the sur- 
 
 FlG. 353. 
 
 Amputation by antero-posterior flaps. (Bryant.) 
 
 geon grasps the limb and enters the point of a long knife 
 into the tissues at the side nearest himself, and pushing it 
 
462 AMPUTATIONS. 
 
 across and around the bone or bones brings its point out 
 through the skin at a point diametrically opposite its point 
 of entrance. He then shapes the flap by cutting down- 
 ward with a rapid sawing motion and then cuts obliquely 
 forward until all the tissues are divided. The flap being 
 turned up, he re-enters his knife at the same point and 
 passes it on the other side of the bone or bones and cuts 
 the second flap in the same manner. (Fig. 353.) A re- 
 tractor is next applied and the bone is divided with a saw. 
 
 The Oval Method. 
 
 The oval amputation is really a circular one in which 
 the cuff of skin has been slit at one side and the angles 
 rounded off. This is the form of amputation frequently 
 performed at the metacarpo-phalangeal and metatarso- 
 phalangeal joints, and is one of the methods of amputation 
 at the shoulder-joint. 
 
 Elliptical Method. 
 
 This is a form of the oval method of amputation which 
 is employed in amputations at the knee- and elbow-joints, 
 
 Fig. 354. 
 
 Modified circular amputation. (Skey.) 
 
METHODS OF AMPUTATING. 
 
 463 
 
 the incision forming an ellipse coming below the joint on 
 the front or outside of the limb, the resulting flap being 
 folded upon itself. 
 
 Modified Circular Method. 
 
 In this method of amputation two oval skin flaps, 
 antero-posterior or lateral, are turned up, and the muscles 
 are next divided by a circular sweep of the knife down to 
 the bone. (Fig. 354.) 
 
 Teale's Method by Rectangular Flaps. 
 
 In this method of amputation, two flaps are made of 
 unequal length ; the incisions are so planned that the 
 shorter flap contains the main vessel or vessels. The 
 
 Fig. 355. 
 
 Teale's method of amputation. (Bryant.) 
 
 flaps are cut of equal width and the length of the long 
 flap should be one-half of the circumference of the limb at 
 the point where the bone is to be divided ; the length of 
 the short flap should be one eighth of the circumference of 
 the limb. The flaps are cut from without inward, and 
 embrace all of the tissues of the limb down to the bone. 
 After the flaps have been dissected up, the bone is divided 
 
464 AMPUTATIONS. 
 
 with a saw, and the long flap is folded over and sutured 
 to the short flap (Fig. 355). The disadvantage of this 
 method of amputation is that in muscular limbs it requires 
 the bone to be divided at a higher point than would 
 otherwise be necessary. 
 
 Periosteal Flaps. 
 
 In any of the methods of amputation previously de- 
 scribed the periosteum may be dissected up in two flaps 
 attached to the muscles, or pushed up as a sleeve by means 
 of a director or periosteotome before the bone is sawed. 
 This procedure is most easily accomplished in young sub- 
 jects. When these flaps are made and they are brought 
 together, the periosteum covers the cut surface of the bone, 
 to which it soon forms adhesions. 
 
 Instruments Required for Amputations. 
 
 The instruments required for amputations are knives 
 of various shapes and sizes, saws, dissecting forceps, bone 
 forceps, artery forceps, tenacula, haemostatic forceps, scis- 
 sors, periosteotome, tourniquets, Esmarch's bandage and 
 strap, retractors, ligatures, sutures, and suture needles. 
 
 Amputating Knives. 
 
 The knives required for amputations vary according to 
 the method of amputation and the part to be amputated. 
 
 Fig. 356. 
 
 Scalpel. 
 
 In certain amputations a scalpel (Fig. 356) or straight 
 bistoury may be used (Fig. 357), while in other cases the 
 employment of amputating knives of various sizes will be 
 found more satisfactory. For amputations of the thigh a 
 
INSTRUMENTS REQUIRED FOR AMPUTATION. 465 
 
 knife with a blade of eight or nine inches is generally 
 employed, and for smaller limbs a knife with a blade of 
 six or seven inches in length ; double-edged catlins are 
 
 Fig. 357. 
 
 Straight bistoury. 
 
 employed in amputations of the leg and forearm to divide 
 the interosseous tissues before applying the saw. The 
 amputating knives now employed are constructed with 
 
 Fig. 358. 
 
 Amputating knife and catlin. 
 
 solid metal handles so that they can be rendered thoroughly 
 aseptic by immersion in boiling water before being used. 
 (Fig. 358.) 
 
 Amputating Saws. 
 
 Several kinds of amputating saws are in general use ; 
 one with a blade ten inches long by two and a half inches 
 
 Fig. 359. 
 
 Amputating;saw. 
 
 wide, with a heavy back to give it additional firmness, is 
 a very good variety of saw (Fig. 359). For amputations 
 
466 
 
 AMPUTATIONS. 
 
 about the foot or hand a narrow saw with a movable back 
 will be found very convenient. (Fig. 360.) A bow saw 
 
 Fig. 360. 
 
 Small amputating saw. 
 
 with a metallic handle and a reversible blade is a very 
 useful variety of saw, as it can be used either in amputa- 
 
 FlG. 361. 
 
 §R1I 
 
 Amputating saw with reversible blade. 
 
 tions or in excisions, and, being constructed entirely of 
 metal, it can be easily rendered aseptic. (Fig. 361.) 
 
 Bone-forceps, or Cutting Pliers. 
 
 These instruments are used in smoothing off any rough 
 edges of bone left after the use of the saw, or for the 
 
 Fig. 362. 
 
 Bone-forceps, or cutting pliers. 
 
 division of the small bones in amputations of the fingers 
 and toes. The forceps should be from ten to twelve 
 
INSTRUMENTS REQUIRED FOR AMPUTATION 467 
 
 inches in length, with blades from one to one and a half 
 inches in length. (Fig. 362.) 
 
 Periosteotome. 
 
 The periosteotome, or raspatory, is employed for dis- 
 secting up a flap of periosteum, which, after sawing the 
 
 Fig. 363. 
 
 Periosteotome. 
 
 bone, is drawn down over the sawed end of the bone. 
 
 (Fig. 363.) 
 
 Artery Forceps and Tenaeula. 
 
 These instruments are used for taking up the vessels, 
 and one of the best forms of artery forceps is that known as 
 the double-spring artery forceps. (Figs 208 and 209.) 
 Tenaeula are also employed for the same purpose. Haemo- 
 static forceps will also be found most useful in cases of 
 amputation, for the rapid control of hemorrhage from 
 small vessels after the tourniquet has been removed, the 
 vessels beiug secured by ligatures before the haemostatic 
 forceps are removed. 
 
 Retractors. 
 
 These consist of pieces of muslin six or eight inches in 
 width, one end of which is split into two or three tails ; 
 the former variety of retractor is employed where one 
 bone is divided, as in amputations of the arm and thigh, 
 and the latter in cases where two bones are divided, as in 
 amputations of the forearm and leg. (Fig. 364.) 
 
468 
 
 AMPUTATIONS. 
 Fig. 364. 
 
 Retractor applied. (Esmaech.) 
 
 Ligatures. 
 
 The best material to employ for the ligature of vessels 
 is juniper or chromicized catgut or sterilized silk, the 
 preparation of which has been described. 
 
 Sutures. 
 
 Fig. 365. 
 
 Fig. 366. 
 
 Deep or buried sutures of muscles. 
 (Esmarch.) 
 
 Sutures of the skin. 
 (Esmarch.) 
 
DETAILS OF AN AMPUTATION. 469 
 
 The materials employed for sutures in cases of amputa- 
 tion may be silkworm-gut, catgut, silk, or silver wire ; 
 deep or buried sutures of catgut in bringing together the 
 edges of the periosteal flaps, muscles, and fascia, are often 
 employed with advantage in amputations (Fig. 365), the 
 skin flaps being brought together with interrupted or 
 continuous sutures of silk, catgut, silkworm-gut, or silver 
 wire. (Fig. 366.) 
 
 Tourniquets. 
 
 For the control of hemorrhage during the amputation 
 the Esniarch's apparatus (Fig. 206) or Petit's tourniquet 
 (Fig. 199) is employed ; or the employment of both at the 
 same time will often be found most satisfactory. The 
 Esmarch bandage and tube being applied, after the removal 
 of the bandage the tourniquet of Petit is loosely applied 
 at a higher point, and after the main vessels have been 
 secured the elastic strap is removed, and the tourniquet is 
 screwed down and controls the bleeding until the smaller 
 vessels have been secured by ligatures. 
 
 Details of an Amputation. 
 
 The following are the steps of an amputation of the 
 lower part of the thigh : 
 
 The skin is first thoroughly cleansed by rubbing it 
 with turpentine, soap and water. It is then washed with 
 an antiseptic solution either of carbolic acid 1 : 40 or 
 bichloride of mercury 1 : 2000. Provision is next made 
 to prevent the loss of blood during the operation by the 
 application of Esmarch's bandage and tube ; the bandage 
 being removed a tourniquet is placed over the femoral 
 artery in Scarpa's triangle and loosely secured. The limb 
 is again washed with bichloride solution. The instruments 
 having been previously thoroughly sterilized, a rubber 
 cloth covered with towels wrung out in a bichloride solu- 
 tion is placed under the limb. The variety of amputation 
 having been decided upon, the flaps are cut and the muscles 
 
 21 
 
470 
 
 AMPUTATIONS. 
 
 are divided down to the bone ; the periosteum being dis- 
 sected up, a two-tailed retractor is applied, and the tissues 
 are held back by an assistant while the surgeon divides 
 the bone with the saw. When the bone has been divided 
 the retractor is removed, and the surface of the wound is 
 irrigated with a 1 : 2000 bichloride solution. The femoral 
 artery and vein are next found and secured with ligatures, 
 and any branches which can be found are also secured. 
 The elastic strap is removed after screwing down the 
 tourniquet, and by letting up the pressure on this smaller 
 
 Fig. 367. 
 
 Stump showing application of sutures and drainage-tubes. (Smith.) 
 
 vessels which bleed are picked up with artery forceps or 
 haemostatic forceps and secured. After all bleeding has 
 been controlled the tourniquet is removed, and the wound 
 is again thoroughly irrigated with a 1 : 2000 bichloride 
 solution. If there is much oozing from the smaller vessels, 
 this solution should be as hot as the hands of the operator 
 can comfortably stand, which will act promptly in con- 
 trolling this variety of bleeding. The periosteal flaps, if 
 they have been made, are brought together by two or three 
 catgut sutures, and a drainage-tube is next introduced or 
 two short tubes are introduced at either extremity of the 
 
RE-DRESSIXG OF AMPUTATIONS. 47 1 
 
 wound and secured by sutures or safety-pins ; the muscles 
 should next be brought together by a few deep or buried 
 sutures of catgut, and the skin flaps should then be 
 brought into apposition by a number of interrupted 
 sutures. The inner surface of the stump is next irrigated 
 by a stream of bichloride solution introduced through the 
 drainage-tube, and the surface of the stump is washed 
 with the same solution ; a piece of protective is next 
 placed over the line of the wound and over this is placed 
 a moist carbolized, bichloride, or iodoform gauze dressing, 
 and over this a number of layers of dry gauze ; this is 
 next covered by rubber tissue and a number of layers of 
 bichloride cotton, or, if the dry method of dressing is pre- 
 ferred, the rubber tissue is omitted and a number of layers 
 of bichloride cotton are laid over the gauze dressing, and 
 the whole dressing is held in place by a recurrent bandage 
 of the stump. 
 
 If the aseptic method is employed, no antiseptic solu- 
 tions are brought in contact with the wound, sterilized 
 water only being used if it is necessary to flush the wound, 
 and after bringing the flaps together a sterilized gauze 
 dressing is applied. 
 
 Re-dressing of Amputations. 
 
 The first dressing of an amputation, if strict antiseptic 
 precautions have been observed at the time of operation, 
 need not, as a rule, be made for a week or ten days, except 
 in cases where the oozing is so profuse as to soak the dress- 
 ings, or where consecutive hemorrhage has occurred, or 
 the patient's condition shows that the wound is not running 
 an aseptic course. The re-dressing of a stump can be ac- 
 complished without pain to the patient if the surgeon and 
 his assistants are careful in their manipulations. 
 
 The dressings to be applied, the solutions for irrigation, 
 and the instruments required, should be prepared and at 
 hand before the stump is exposed. The surgeon and his 
 assistants should wash their hands carefully, and then dip 
 them in a 1 : 2000 bichloride solution. The bandage re- 
 
472 AMPUTATIONS. 
 
 taining the dressings to the stump should be divided with 
 bandage scissors without lifting the stump from the pillow 
 upon which it rests. After the bandage has been divided 
 and turned aside, the gauze dressing is next unfolded and 
 turned down ; an assistant now slips his hands under the 
 stump and gently raises it from the dressings, and at the 
 same time a rubber cloth covered with towels which have 
 been wrung out in a 1 : 2000 bichloride solution is slipped 
 under the stump and the soiled dressings are removed. 
 The protective covering the incision is next removed and 
 the surface of the stump is irrigated with a 1 : 2000 bichlo- 
 ride solution ; the drainage-tubes are next examined and 
 the cavity of the stump irrigated with the bichloride solu- 
 tion through the tubes by means of a syringe or an irri- 
 gating apparatus, or the irrigation may be omitted. 
 
 If the wound is aseptic and there seems to be no further 
 indication for the use of the drainage-tubes, they may be 
 removed and the track of the tube should be washed out 
 with the antiseptic solution by the syringe or irrigator. 
 The sutures are next examined, and if the wound is firmly 
 healed alternate sutures may be removed ; if catgut or 
 silkworm-gut sutures have been used, they need not be 
 disturbed at this dressing, and their removal may be post- 
 poned until a subsequent dressing. 
 
 The wound should next be covered with a piece of pro- 
 tective, and a gauze dressing should be applied consist- 
 ing of a number of layers, and over this several layers 
 of bichloride cotton, and the dressings should be held in 
 place by a recurrent bandage of the stump, In holding 
 the stump the assistant should hold it firmly to prevent 
 muscular spasm, and after the dressings have been secured 
 it should be placed upon a clean pillow prepared for its 
 reception. The same procedures are adopted at subsequent 
 dressings, and if the wound has run an aseptic course, two 
 or three dressings, at most, will be required. 
 
AMPU1AT10NS OF THE HAND. 473 
 
 Special Amputations. 
 Amputations of the Hand. 
 
 Amputations of the Fingers. 
 
 The fingers may be amputated in the continuity of the 
 phalanges or in their contiguity, and, as a rule, as it is 
 important to save as much as possible of the finger, the 
 former method is generally to be employed instead of dis- 
 articulation at a higher point. The incision should be so 
 planned that the cicatrix does not occupy the palmar sur- 
 face ; the larger flap should, therefore, be taken from the 
 palmar aspect of the finger. In amputating the phalanges 
 of the fingers in their continuity the circular method (Fig. 
 
 Fig. 368. 
 
 Amputation of a finger by the long palmar flap. (Erich sen.) 
 
 371, B) or a short dorsal flap and a long palmar flap may 
 be employed. In disarticulating a phalanx it is best to 
 enter the joint with a narrow knife from the dorsal side, 
 and after having carried it through the joint, to cut a long 
 palmar flap, keeping close to the bone. (Fig. 368.) In 
 
474 
 
 AMPUTATIONS. 
 
 locating the position of the phalangeal joints, it is well to 
 remember that the prominence of the knuckle when the 
 finger is flexed is formed entirely of the head of the proxi- 
 
 Fig. 370. 
 
 Fig. 369. 
 
 Phalanges flexed. 
 
 Guides to articulations of the finger. 
 (Smith.) 
 
 imal, and not of the base of the distal phalanx (Fig. 369), 
 and also that the folds on the palmar surface of the finger 
 do not correspond exactly to the joints. (Fig. 370.) 
 
 Amputation of the Finger through the Metacarpo- 
 phalangeal Articulation. 
 
 In this variety of amputation an incision is made from 
 a point of the dorsal surface of the metacarpal bone a 
 quarter of an inch above the articulation, which is carried 
 through the interdigital web and back upon the palmar 
 surface to a point a quarter of an inch above the flexor 
 fold (Fig. 371, C). A similar incision beginning and 
 ending at the same points is made upon the opposite side 
 of the finger. The flaps are dissected back, and the lateral 
 ligaments, tendons, and remainder of the capsule are 
 
AMPUTATIONS OF THE HAND. 
 
 475 
 
 divided. The finger may also be amputated at the meta- 
 carpophalangeal joint by making an incision on one side 
 and dissecting the flap back to the joint, then dividing the 
 lateral ligament, opening the joint and carrying the knife 
 across this, dividing the tendons and lateral ligament on 
 the other side and cutting a flap from within outward. 
 
 Fig. 371. 
 
 A. Disarticulation of phalanx ; palmar flap. B. Amputation in continuity 
 by a circular flap. C. Metacarpophalangeal disarticulation. D. Amputation 
 of metacarpal bone in continuity. E. Disarticulation of little finger. F. Dis- 
 articulation of fifth metacarpal bone. G. Amputation at the wrist, circular. 
 H. Amputation at the wrist. (Stimson.) 
 
 Removal of the head of the metacarpal bone if desired 
 may be accomplished by the use of cutting pliers (Fig. 372) ; 
 but, as a rule, this procedure is not to be recommended, 
 for, although the deformity is diminished, the strength of 
 the hand is also diminished. 
 
476 AMPTJTA TIONS. 
 
 In amputating the little and index fingers a full lateral 
 flap may be cut on the free side and an incision is next 
 carried across the palmar surface to the angle of the web 
 and thence back to the joint, which is opened and the dis- 
 articulation effected. (Fig. 371, E.) 
 
 Fig. 372. 
 
 Removal of the head of a metacarpal bone. (Skey.) 
 
 In amputations of the finger at the phalangeal joints or 
 at the metacarpo-phalangeal joints two vessels usually re- 
 quire ligaturing, and after these are secured a catgut drain 
 or a small drainage-tube is introduced and the flaps are 
 brought together by a few interrupted sutures. 
 
 Amputations of the Metacarpal Bones. 
 
 In amputating the metacarpal bones it is advisable to 
 leave the carpal ends of the bones to avoid opening the 
 wrist-joint, except in the case of the first and fifth meta- 
 
AMPUTATIONS OF THE HAND. 
 
 477 
 
 Fig. 373. 
 
 carpal bones, which do not communicate with the others 
 and with the synovial sacs. 
 
 The incisions for the removal of the metacarpal bones 
 are the same as for the removal of a finger at the meta- 
 carpophalangeal joint, the incision being prolonged back- 
 ward as far as necessary over the dorsal surface of the 
 bone. (Fig. 371, D.) After the metacarpal bone has 
 been bared for a sufficient distance, it is cut through with 
 bone-pliers or disarticulated, and the distal end is raised 
 from its bed and carefully separated from the soft parts, 
 care being taken to avoid injury of the 
 structures of the palm of the hand. 
 
 In amputating the fifth metacarpal 
 bone the incision should be made along 
 the inner border of the hand and carried 
 down to the bone between the skin and 
 the abductor minimi digiti muscle. (Fig. 
 373.) The lower end of the incision 
 passes over the knuckle to the web of the 
 finger, and backward under the palmar 
 surface to join the first incision. 
 
 Amputation of the entire thumb with 
 its metacarpal bone is effected by making 
 an oval flap from the palmar surface ; in 
 the case of the left thumb the joint may 
 be opened by an oblique incision on the 
 dorsal surface of the hand, beginning a 
 little in front of the joint and being car- 
 ried down to the web between the thumb 
 and forefinger; the palmar flap is then 
 made by thrusting the knife upward to its point of en- 
 trance and cutting downward and outward. In amputat- 
 ing the right thumb with its metacarpal bone it is better 
 to make the palmar flap first by transfixion, the dorsal 
 flap being made subsequently. 
 
 Amputation of the hand at the carpo-metacarpal joint is 
 occasionally performed, or between the rows of carpal 
 bones; but is not as a rule to be recommended, as the 
 carpal bones are apt subsequently to become diseased and 
 
 21* 
 
 Incision for re- 
 moval of the fifth 
 metacarpal bone. 
 (Smith.) 
 
478 AMPUTATIONS. 
 
 require removal; it is therefore better to amputate at the 
 radio-carpal joint. 
 
 Amputations at the Wrist. 
 
 Circular Method. 
 
 The skin of the forearm near the wrist being retracted 
 by an assistant, a circular incision of the skin and cellular 
 tissue is made half an inch below the point of the styloid 
 process of the radius. (Fig. 371, G.) The skin and 
 cellular tissue are next dissected back as far as the joint, 
 which is opened and the disarticulation is completed. 
 
 Antero-posterior Flap Method. 
 
 This method is also employed in amputations at the 
 wrist-joint ; an incision curved downward is made on the 
 
 Amputation at the wrist. (Erichsen.) 
 
 back of the hand from one styloid process to the other ; 
 the hand being flexed the tendons are divided and the 
 joint opened, and the palmar flap, which should extend as 
 
AMPUTATIONS OF THE FOREARM. 479 
 
 far as the base of the metacarpal bones, is cut from within 
 outward. (Fig. 374.) Amputation at the wrist is some- 
 times performed by cutting a single flap from the palm, 
 the joint being opened by a transverse incision on the back 
 of the hand from one styloid process to the other. 
 
 Lateral Flap Method. 
 
 This method (Fig. 371, H) is also sometimes employed 
 in amputation at the wrist, and may be employed with 
 advantage in cases of laceration of the hand, in which the 
 injury to the tissues prevents the formation of the flaps 
 used in the other methods of amputation. 
 
 Amputations of the Forearm. 
 
 The forearm may be amputated by the circular or flap 
 methods, or by making rectangular flaps (Teale's method). 
 
 Circular Method. 
 
 At the lower portion of the forearm the circular method 
 of amputation is to be preferred. A circular incision of 
 the skin and cellular tissue is made and a cuff is dissected 
 up, the muscles and interosseous membrane being cut 
 through ; a three-tailed retractor is next applied and the 
 bones are divided with a saw. 
 
 Mixed Method. 
 
 Amputation of the forearm by the mixed method, which 
 consists in first dissecting up two antero-posterior oval 
 flaps of skin and cellular tissue and then dividing the 
 muscles by a circular incision, is also a satisfactory opera- 
 tion. (Fig. 375.) 
 
 In amputation at the upper portion of the forearm, 
 antero-posterior or lateral flaps, cut from without inward 
 or by transfixion, or rectangular flaps may be made with 
 advantage. 
 
480 AMPUTATIONS. 
 
 Fig. 375. 
 
 Amputation of the forearm by the mixed method. (Bryant.) 
 
 The principal vessels requiring the application of liga- 
 tures in amputations of the forearm are the radial, ulnar, 
 and interosseous arteries. 
 
 Amputations at the Elbow. 
 
 The methods of amputation employed at the elbow are 
 the anterior flap, lateral flap, and circular. 
 
 Anterior Flap Method. 
 
 A flap three inches in length with its base parallel to 
 and half an inch below the condyles of the humerus, is 
 cut either by transfixion or from without inward. The 
 joint is next opened and the lateral ligaments divided. 
 The olecranon is then exposed and the attachment of the 
 triceps separated and a posterior flap is cut from without 
 inward, or from within outward, a little below the line of 
 the condyles. (Fig. 376, A.) 
 
 Lateral Flap Method. 
 
 In amputation at the elbow-joint lateral flaps may be 
 employed, cut either from without inward or by trans- 
 fixion. (Fig. 376, B.) An external flap three inches in 
 length is made on the outer side of the arm, starting from 
 a point a finger's breadth below the bend of the elbow, by 
 transfixion or by cutting from without inward ; a shorter 
 internal flap is next cut in the same manner, and the joint 
 is opened and the disarticulation is effected. (Fig. 377.) 
 
AMPUTATIONS OF THE ARM. 
 
 481 
 
 Circular Method. 
 
 An incision dividing the skin and cellular tissue is 
 made around the limb three inches below the line of the 
 
 Fig. 376. 
 
 Fig. 377. 
 
 Amputation at the elbow- 
 joint. A. Anterior flap 
 method. B. External flap 
 method. C. Circular method. 
 
 (Stimson.) 
 
 Lateral flap method of amputation at the elbow- 
 joint. (Smith.) 
 
 Fig. 878. 
 
 Circular amputation at the elbow. 
 (Smith.) 
 
 condyles of the humerus (Fig. 376, 0), the skin is dis- 
 sected up and a circular incision made through the mus- 
 cles, the joint is opened and the disarticulation is effected. 
 (Fig. 378.) 
 
 Amputations of the Arm. 
 
 The arm may be removed at any point below the attach- 
 ment of the muscles at the axilla, by either the circular, 
 flap, oval, or modified circular methods. 
 
482 AMPUTATIONS. 
 
 Circular Method. 
 
 This operation is usually employed in removing the arm 
 in its lower third : a circular incision of the skin and 
 muscles is first made, and when the cuff has been dissected 
 
 Fig. 379. 
 
 Circular amputation of the arm. 
 
 up a circular division of the muscles is made, and after 
 applying the retractor the bone is sawed through. (Fig. 
 379.) 
 
 Flap Method. 
 
 From the central position of the bone in the arm, the 
 flap method in amputating the arm is preferred by many 
 operators. The arm being grasped by the hand the point 
 of a medium-sized amputating knife is thrust through the 
 arm so as to pass over the humerus and make its exit at a 
 corresponding point in the skin on the opposite side ; a 
 flap of sufficient length is cut from within outward. The 
 knife is next passed behind the bone and a posterior flap 
 is cut in the same manner (Fig. 380) ; the bone is next 
 cleared of muscular tissue, the flaps are retracted and it is 
 divided with a saw. 
 
 Lateral flaps may be made in this amputation in the 
 
AMPUTATIONS OF THE ABM. 
 
 Fig. 380. 
 
 483 
 
 Amputation of the arm by flap operation. (Bryant.) 
 
 place of the anteroposterior flaps, and they are cut from 
 within outward in the same manner. 
 
 Oval, or Modified Oval Method. 
 
 This method of amputating the arm is also employed 
 with advantage. An oval flap of skin and cellular tissue 
 
 Fig. 381. 
 
 Esmarch's strap applied in high amputation of the arm. (Smith.) 
 
 is made and dissected up, and the muscular tissue is 
 divided by a circular incision. Or two oval flaps of skin 
 
484 
 
 AMPUTATIONS. 
 
 and cellular tissue are cut and dissected up, and the mus- 
 cles are next divided by a circular sweep of the knife. 
 
 In all amputations of the arm it is well to remember the 
 possibility of a high division of the brachial artery, and to 
 see that the abnormal vessel is properly secured, if present. 
 
 In high amputations of the arm there is sometimes not 
 room enough to apply Esmarch's strap or a tourniquet to 
 the arm itself to control the hemorrhage during the opera- 
 tion, and in such cases the strap may be passed from the 
 axilla around the outer end of the clavicle, as is done to 
 control the bleeding during amputation at the shoulder- 
 joint. (Fig. 381.) 
 
 Amputations at the Shoulder- joint. 
 
 Several methods of operation are employed in ampu- 
 tating at the shoulder-joint, such as the oval method, or 
 
 Fig. 382. 
 
 Amputation at the shoulder-joint. A. Oval, or Larrey's method. 
 B. Double-flap, or Lisfranc's method. (Stimson.) 
 
 Larrey's method, flap method, Lisfranc's, or Dupuytren's 
 method, and Spence's method. (Fig. 382.) The control 
 
AMPUTATIONS AT THE SHOULDER-JOINT. 485 
 
 of the bleeding from the axillary artery during the opera- 
 tion is a matter of the first importance, and it may be 
 arrested by pressure made upon the subclavian artery, as 
 it crosses the first rib, with the thumb, or the padded 
 handle of a large key, or by the fingers of an assistant 
 grasping the axillary flap and compressing the vessel after 
 the head of the bone has been disarticulated, or by the use 
 of an elastic strap applied around the axilla and shoulder. 
 (Fig. 381.) Wyeth's pins may also be employed with an 
 elastic tube or strap to control bleeding during amputa- 
 tion at the shoulder-joint. The anterior pin is passed 
 through the anterior fold or the axilla, and is brought out 
 in front of the acromion, the posterior pin is passed through 
 the posterior fold of the axilla and is brought behind the 
 acromion, the rubber strap or tube is then wrapped around 
 the shoulder behind the pins and controls the hemorrhage 
 during the operation. 
 
 Oval, or Larrey's Method. 
 
 In this method of amputation the point of the knife is 
 entered just below the acromion process and a deep in- 
 cision three inches in length is made down to the head of 
 the bone along the axis of the arm ; from the middle of this 
 incision two others are made obliquely downward to the 
 points where the anterior and posterior folds of the axilla 
 end in the tissues of the arm ; the latter incision should 
 be only deep enough to divide the skin and superficial 
 fascia. The flaps are then dissected up until the head of 
 the bone is well exposed, and, after opening the capsule 
 and dividing the muscles, inserted into the neck and 
 tuberosities of the humerus, which division may be 
 facilitated by rotating the head of the bone outward and 
 inward, the disarticulation is effected by adducting the 
 elbow; the knife is next passed downward behind the 
 bone and made to cut outward in the line of the cutaneous 
 incisions — an assistant controlling the artery before it is 
 divided by grasping the axillary tissues behind the knife 
 with his fingers. 
 
486 
 
 AMPUTATIONS. 
 
 Fig. 383. 
 
 Amputation at the shoulder-joint by Larrey's method. 
 
 Flap, or Dupuytren's Method. 
 
 In this method of amputation at the shoulder-joint the 
 flaps may be cut either by transfixion or from without 
 inward ; the large flap embraces the greater part of the 
 deltoid muscle, and the smaller or short flap is cut from 
 the inside of the arm after the head of the bone has been 
 disarticulated. When cut by transfixion, the point of the 
 knife should be entered an inch in front of the acromion 
 process and pushed across the outer aspect of the head of 
 the humerus, and should be brought out at the posterior 
 fold of the axilla ; the knife is made to cut downward 
 until a large deltoid flap is formed. This flap is turned 
 up, and the head of the bone is disarticulated ; the knife 
 being placed behind it, a short flap is formed, keeping 
 close to the bone, so that the vessel is divided with the 
 last cut of the knife. (Fig. 384.) An assistant should 
 
AMPUTATIONS AT THE SHOULDER- JOINT. 487 
 
 ccmtrol the vessel by grasping the axillary tissues with his 
 fingers behind the knife. 
 
 Fig. 384. 
 
 Fig. 385. 
 
 Amputation at the shoulder-joint. Dupuytren's method. (Bryant.) 
 
 Double Flap, or Lisfranc's Method. 
 
 In this method of amputation at the shoulder-joint, the 
 point of the knife is entered at the outer side of the cora- 
 coid process, and is carried across 
 the outer aspect of the head of the 
 humerus and brought out a little 
 below the posterior border of the 
 acromion process, and a long flap 
 is cut downward. This flap is 
 turned up and the attachments 
 of the head of the bone are 
 divided and it is disarticulated. 
 The knife is again entered behind 
 the bone, and a long posterior 
 flap is cut from within outward. 
 (Fig. 382, B.) 
 
 Spence's Method. 
 In this method of amputation 
 
 . , i i -i-i • ' j. • • • Amputation at the shoulder- 
 
 at the shoulder-joint an incision ]oint P Spence > smethod . (Stim . 
 is made down to the head of the S0N .) 
 
488 AMPUTATIONS. 
 
 humerus immediately in front of the coracoid process, 
 and is continued downward through the clavicular fibres 
 of the deltoid and the pectoralis major muscles until the 
 attachment of the latter to the humerus is reached. (Fig. 
 385.) The incision is now carried backward to the poste- 
 rior fold of the axilla. A second incision, including only 
 the skin and cellular tissue, is next made from the ante- 
 rior portion of the first incision across the inside of the 
 arm to meet the incision on the outer part. The outer flap 
 thus formed is turned up and the head of the bone is dis- 
 articulated. The operation is completed by dividing the 
 remaining tissues on the axillary aspect. 
 
 Many other methods of removing the arm at the 
 shoulder-joint have been devised and employed, including 
 the circular method. 
 
 Amputation above the Shoulder- joint. 
 
 Fig. 386. 
 
 . ft 
 
 Amputation of arm, scapula, and clavicle (dotted line representing posterior 
 incision). (Treves.) 
 
 This form of amputation consists in the removal of the 
 arm with a part or the whole of the scapula and sometimes 
 a portion of the clavicle. 
 
AMPUTATIONS OF THE FOOT. 
 
 489 
 
 As this form of amputation is required in cases in which 
 the laceration of the parts has passed beyond the shoulder- 
 joint, or in cases of growths involving the tissues beyond 
 the joint, no definite rule can be laid down for the in- 
 cisions ; the only rule being as far as possible to make the 
 incisions in such a manner that the least possible amount 
 of skin is sacrificed, so that a sufficient covering for the 
 wound can be obtained. 
 
 Amputations of the Foot. 
 Amputations of the Toes. 
 
 Fig. 388. 
 
 Fig. 387. 
 
 Relations of web and metatarso- 
 phalangeal joints of toes. (Stim- 
 son.) 
 
 Incisions for amputation of toes and 
 metatarsal bones. (Stimson.) 
 
490 AMPUTATIONS. 
 
 The phalanges of the toes may be removed in the same 
 manner as those of the fingers. It is better to amputate 
 at the metatarsophalangeal articulations than to attempt to 
 remove them at the joints in front of this articulation, 
 except in the case of the great toe, as the preservation of a 
 portion of a toe is rather a discomfort than an advantage, 
 except in the instance mentioned. All incisions should 
 be made so that the resulting cicatrix does not occupy the 
 plantar surface, and it is well to remember that the web 
 of the toes is considerably below the position of the meta- 
 tarso-phalangeal joint. (Fig. 387.) 
 
 The toes are usually removed by an incision on the 
 dorsal surface a little above the joint, which is carried 
 down the bone for about an inch and then diverges into 
 the web, and is carried under the toe and back on the 
 other side to the point of divergence. (Fig. 387.) 
 
 Amputation of Two Adjoining Toes. 
 
 The dorsal incision should be made in the inter- 
 metatarsal space just above the level of the joint (Fig. 
 388, B) and carried down to the beginning of the web ; 
 then over the toe to the beginning of the adjoining web, 
 then under the plantar surface of both toes in the line of 
 the digito-plantar fold, through the web and back to the 
 point of divergence. 
 
 Amputation of the Great Toe. 
 
 This may be accomplished by means of the racket-shaped 
 incision employed in amputation of the other toes or by 
 means of a lateral flap. In the latter case the knife is 
 made to enter the joint by cutting through the commissure, 
 and the operation is completed by carrying the knife 
 through the joint and along the outer side of the bone, 
 forming a flap of the required size. (Fig. 389.) 
 
 In this amputation a short dorsal flap and long plantar 
 flap may be employed, or a long internal flap may be 
 used. 
 
AMPUTATIONS OF THE METATARSAL BONES. 491 
 
 Amputation of All the Toes. 
 
 To amputate all the toes, make a dorsal incision from 
 the head of the fifth to the head of the first metatarsal 
 bone ; the incision should be a curved one passing just in 
 front of the joints. (Fig. 390.) Dissect up the flap and 
 
 Fig. 390. 
 
 Amputation of the great toe. 
 (Smith.) 
 
 Incision for amputation of all the 
 toes. (Smith.) 
 
 open the joints, dividing the lateral ligaments, and pass 
 the knife behind the phalanges and cut a flap from the 
 plantar surface. 
 
 Amputations of the Metatarsal Boxes. 
 
 It is better in these amputations to leave the tarsal head 
 of the metatarsal bone in place and divide the bone, or, in 
 other words, to do an amputation in continuity to prevent 
 opening up the tarsal articulations. 
 
 Amputation of the Metatarsal Bone of the Great Toe. 
 
 The incision begins upon the dorsal surface of the meta- 
 tarsal bone, a little below the point at which the bone is 
 
492 
 
 AMPUTATIONS. 
 
 to be divided, and is carried down below the metatarso- 
 phalangeal joint, then diverges and passes under the toe 
 and comes back again to the point of divergence. (Fig. 
 388, C.) The bone is exposed and cut through with cut- 
 ting forceps, and is then lifted up and dissected loose from 
 the tissues. (Fig. 391.) 
 
 Fig. 391. 
 
 Amputation oi the great toe and first metatarsal bone. (Smith ) 
 
 Amputation of the Fifth Metatarsal Bone. 
 
 The incision for the removal of the fifth metatarsal bone 
 is made over the bone a little below the metatarso-tarsal 
 articulation, and is carried down and curved around the 
 toe (Fig. 388, D), and after the bone is exposed by dis- 
 secting back the flaps, it is divided, or the joint is opened 
 and it is dissected out. 
 
 Amputation Through the Metatarsal Bones. 
 
 In performing this amputation an incision is made 
 across the dorsum of the foot, and a short dorsal flap is 
 dissected up ; the metatarsal bones are next divided with 
 a saw and a long plantar flap is cut from within outward 
 by entering the knife behind the ends of the bones. 
 
AMPUTATION OF THE METATARSAL BONES. 493 
 
 Tarso-metatarsal Amputations. 
 
 In all amputations of the foot involving the tarsus the 
 surgeon should be thoroughly familiar with the anatomy 
 of the foot and the surgical landmarks of the different 
 articulations. I shall refer to those laid down by Mr. 
 Bryant, which are as follows : 
 
 Fig. 392. 
 
 Fig. 393. 
 
 Surgical guides to the foot as expressed 
 by anatomy. (Bryant.) 
 
 Incision for — A. Lisfranc's am- 
 putation. B. Chopart's ampu- 
 tation. (Stimson.) 
 
 " On the inner side of the foot, not far from the inner 
 malleolus, the tubercle of the scaphoid (Fig. 392, A) is to 
 be felt as a marked prominence ; about one-half an inch 
 in front of this will be found the articulation with the 
 
 22 
 
494 AMPUTATIONS. 
 
 cuneiform bone (if), and one inch in front of this the joint 
 which the surgeon will have to open in Lisfranc's or Hey's 
 operation ((7) ; just above the tubercle of the scaphoid will 
 be found the articulation with the astragalus, the line of 
 Choparfs amputation (i)). On the outer side of the foot, 
 one inch below the external malleolus, a sharply defined 
 projection will always be felt, which is the peroneal tuber- 
 cle (E) ; one-half an inch in front of this will be found the 
 joint which separates the os calcis from the cuboid (F), 
 this joint forming the outer circle to Chopart's amputa- 
 tion. Half an inch in front again, or one inch from the 
 tubercle, the prominence of the fifth metatarsal bone is 
 always to be felt (H), the line above this prominence 
 indicating the articulation with the cuboid bone, which 
 forms the outer boundary of the incision for Hey's or 
 Lisfranc's amputations." 
 
 Tarso-metatarsal Amputation (Lisfranc's). 
 
 The incision for this amputation is a curved one carried 
 across the dorsum of the foot from the base of the fifth to 
 the base of the first metatarsal bone. (Fig. 393, A.) The 
 incision should involve the skin only, its centre lying half 
 an inch or more below the centre of the line of the articu- 
 lations, and it should begin and end at the sides of the 
 foot at their junction with the sole. A plantar flap should 
 be marked out by a curved incision crossing the sole of 
 the foot near the origin of the toes, starting and ending at 
 the same points as the dorsal incision. 
 
 The dorsal flap is next dissected back to the line of the 
 articulations ; the tendons, muscular fibres, and fascia being 
 divided, the joints between the tarsal and metatarsal bones 
 are opened with a stout, narrow-bladed knife. (Fig. 394.) 
 Difficulty is sometimes experienced in opening the joint 
 between the head of the second metatarsal bone and the 
 second cuneiform bone, which occupies a position higher on 
 the foot than the other articulations. The disarticulation 
 may also be facilitated by forcibly depressing the anterior 
 portion of the foot. After all the joints have been opened, 
 
AMPUTATIONS OF THE METATARSAL BONES. 495 
 Fig. 394. 
 f 
 
 Amputation at tarsometatarsal joint (Lisfranc's). 
 
 the knife is passed behind the ends of the metatarsal bones, 
 and a plantar flap is cut from within outward, following 
 the line of the incision previously marked out. The 
 plantar flap may be cut from without inward if preferred. 
 
 Tarso-metatarsal Amputation (Hey's). 
 
 The line of incision and the steps of this operation are 
 similar to those in Lisfranc's amputation, with the excep- 
 tion that Hey sawed off the projecting portion of the 
 internal cuneiform bone after disarticulating the meta- 
 tarsal bones. This modification, although it improves the 
 appearance of the stump, possesses no advantages over the 
 previous procedure. 
 
 Medio-tarsal, or Ckopart's Amputation. 
 
 In this amputation the disarticulation is through the 
 joints formed by the astragalus and calcaneum behind and 
 the scaphoid and cuboid in front. An incision is made 
 from the tubercle of the scaphoid across the dorsum of 
 the foot an inch in front of the head of the astragalus to 
 
496 
 
 AMPUTATIONS. 
 
 the lower and outer border of the cuboid. (Fig. 395, A.) 
 The plantar flap is next marked out by an incision begin- 
 
 FlG. 395. 
 
 Line of incision for— A. Chopart's amputation. B. Syme's amputation. 
 D. Section of bone in Syme's amputation. C. Subastragaloid amputation. 
 
 (Stimson.) 
 
 ning and ending at the same points as the first incision 
 and crossing the sole of the foot four or five finger- 
 
 FlG. 396. 
 
 Chopart's amputation. (Bryant.) 
 
 breadths nearer the toes. The dorsal flap is next dissected 
 up, and after the tendons and fascia have been divided 
 
AMPUTATIONS AT THE ANKLE-JOINT 
 
 497 
 
 the joint is opened and a plantar flap is cut from within 
 outward, following the line of the previously marked out 
 plantar incision. (Fig. 396.) 
 
 Subastragaloid Amputation. 
 
 In this amputation all the bones of the foot are removed 
 except the astragalus. An incision is made beginning an 
 inch below the tip of the external malleolus, which is car- 
 ried forward to the base of the fifth metatarsal bone; it is 
 then carried over the dorsum of the foot to the calcaneo- 
 cuboid articulation. (Fig. 395, (7.) The joints between 
 the scaphoid and astragalus and between the astragalus 
 and calcis are opened, and the latter bone is carefully dis- 
 sected out ; the ligaments are divided and the astragalus 
 only is allowed to remain in place. 
 
 Amputations at the Ankle-joint. 
 Syme's Amputation at the Ankle-joint. 
 
 Fig. 397. 
 
 Syme's amputation at the ankle-joint. (Skey.) 
 
498 
 
 AMPUTATIONS. 
 
 In this amputation, the foot being at a right angle to 
 the leg, an incision is made from the centre of one mal- 
 leolus directly across the sole of the foot to the centre of 
 the opposite malleolus. (Fig. 395, B.) The tissues of the 
 heel are next carefully dissected from the bone by keeping 
 the knife close to the osseous surface until the tuberosity 
 of the os calcis is fairly turned. The two extremities of 
 the first incision are then joined by a transverse one across 
 the instep, and, the joint being opened, the lateral liga- 
 ments are divided to complete the disarticulation. (Fig. 
 397.) The knife is next used to clear the malleoli, and 
 they are next removed by the saw in the line indicated. 
 (Fig. 395, D.) 
 
 Pirogoff's Amputation at the Ankle-joint. 
 
 In this amputation the posterior portion of the os calcis 
 is retained. The incision is carried from the tip of the 
 
 Fig. 398. 
 
 Pirogoff's amputation. A. Cutaneous incision. B. Line of section of bones. 
 
 (Stimson.) 
 
 inner malleolus, over the instep, half an inch in front of 
 the anterior edge of the tibia, to a point half an inch in 
 
AMPUTATIONS AT THE ANKLE-JOINT 499 
 
 Fig. 
 
 Application of saw to os calcis in Pirogoff's amputation. (Erichsen.) 
 
 front of the tip of the outer mal- FlG - 400 
 
 leolus; a second incision, crossing 
 
 the sole of the foot and carried 
 
 down to the bone, is next made. 
 
 (Fig 398, A.) The plantar flap 
 
 is dissected back for a quarter of 
 
 an inch, the joint is opened by 
 
 dividing the lateral ligaments, and 
 
 the astragalus is disarticulated, and 
 
 the malleoli are exposed. A narrow 
 
 saw is next applied to the upper 
 
 and posterior part of the calcaneum 
 
 behind the astragalus, and it is 
 
 divided obliquely downward in the 
 
 line of the plantar incision. (Fig. 
 
 399.) The malleoli and a thin slice 
 
 of the tibia are next removed with 
 
 the saw as in Syme's amputation. 
 
 (Fig. 395, D.) Some surgeons do 
 
 not remove the malleoli, but press the sawed surface of 
 
 the os calcis between them when it is possible to do so. 
 
 Union between calcaneum 
 and tibia in Pirogoff's ampu- 
 tation. (Hewson ) 
 
5U0 AMPUTATIONS. 
 
 The position of the os calcis in relation to the tibia after 
 union has occurred is shown in Fig. 400. 
 
 Roux's Amputation at the Ankle-joint 
 
 In this method of amputation an incision is made at the 
 outer edge of the tendo-Achillis, a little above its inser- 
 tion, which is carried forward under the outer malleolus, 
 and across the instep half an inch in front of the anterior 
 edge of the tibia, and back to a point just in front of the 
 inner malleolus ; the incision is carried from this point 
 downward and partly across the sole of the foot, and then 
 back to the point of origin of the original incision. (Fig. 
 401.) The flaps are dissected up for a short distance, the 
 ankle-joint is then opened, the disarticulation is effected, 
 and the internal flap is carefully dissected from the bones, 
 
 Fig. 401. 
 
 Incision in Roux's amputation. 
 
 Other methods of amputation of the foot are sometimes 
 employed ; such, for instance, as that advocated by Hancock, 
 who has combined Pirogoff's amputation with the sub- 
 astragaloid method, bringing the sawed surface of the os 
 calcis in contact with a transverse section of the astragalus. 
 
 Hancock has advocated the propriety of amputating in 
 
AMPUTATIONS OF THE LEG. 501 
 
 the foot without regard to the position of the tarsal joints, 
 cutting the flaps of sufficient length and dividing the bones 
 with a saw. 
 
 Tripier has also modified the subastragaloid amputation 
 by leaving the upper part of the calcaneum, which he saws 
 through on a level with the sustentaculum tali, and at right 
 angles to the axis of the leg ; the external incisions are 
 made as in Chopart's amputation. 
 
 In the method advocated by Mikulicz the astragalus and 
 calcaneum are removed, the ends of the tibia and fibula 
 are sawed off, and the sawed surface of the scaphoid and 
 cuboid are approximated to these, the stump resulting re- 
 sembling the foot of pes equinus. 
 
 Amputations of the Leg. 
 
 The leg may be amputated at its lower, middle, or upper 
 third, the rule being to save as much of the limb as pos- 
 sible, but as regards the application of prothetic apparatus, 
 I think the stumps resulting from amputations in the 
 middle and upper thirds will be found more satisfactory. 
 It is well also in sawing the bones to divide the fibula at 
 a slightly higher point than the tibia. 
 
 Amputation of the Lower Third of the Leg. 
 
 At this position the leg may be amputated by the cir- 
 cular, modified circular, or elliptical method. 
 
 Circular Method. 
 
 A circular incision is made through the skin and con- 
 nective tissue just above the malleoli, and the cuff is dis- 
 sected up for a sufficient distance, and a circular incision 
 of the tendons and muscles is next made, and the tissues 
 being retracted the bones are divided with a saw. 
 
 22* 
 
502 
 
 AMPUTATIONS. 
 
 Modified Circular Method. 
 
 In this method of amputation of the leg a circular in- 
 cision of the skin and connective tissue and two short 
 
 Fig. 402. 
 
 Fig. 403. 
 
 Fig. 402.— Amputation of the leg. A. Modified circular method. B. Rectangu- 
 lar flap, a Antero-posterior flap. The dotted lines indicate the levels at which 
 the bones are to be sawn through. (Stimson.) 
 
 Fig. 403.— Amputation of the leg. A. Long anterior flap. B. Supra-malleolar 
 long posterior flap. 0. At upper third. (Stimson.) 
 
AMPUTATIONS OF THE LEG. 
 
 503 
 
 lateral incisions are made. The flaps are then dissected up 
 to the end of the incisions, and a circular division of the 
 muscles is next made. (Fig. 402, A.) Or oval skin flaps 
 
 Fig. 404. 
 
 Oval skin flaps with circular division of the muscles. 
 
 are made and dissected up, and the tissues are next divided 
 down to the bone by a circular incision and the bones are 
 divided with a saw 7 . (Fig. 404.) 
 
 Elliptical Method. 
 
 In this method of amputation the incision is in the form 
 of an ellipse ; its lower end crosses the heel below the inser- 
 tion of the tendo Achillis and the upper end of the inci- 
 sion is about an inch above the anterior articular edge of 
 the tibia. (Fig. 403, B.) 
 
 Long Anterior Flap Method. 
 
 An anterior flap equal in length to the diameter of the 
 leg at its base is marked out by a curved incision through 
 the skin beginning at the posterior edge of the tibia on 
 the inner side, a little below the point at which the bones 
 are to be divided, and is carried over the leg to a point 
 directly opposite over the fibula. (Fig. 403, A.) The 
 anterior muscles are divided transversely half an inch 
 above the lower end of the flap and are dissected from the 
 bone to the base of the flap. 
 
 The posterior flap is then made by entering the knife 
 behind the bones at the point of the original incision and 
 cutting directly outward. 
 
504 AMPUTATIONS. 
 
 Long Anterior Rectangular Flap Method. (Teale.) 
 
 In this method of amputation of the leg an incision 
 equal in length to half of the circumference of the leg is 
 made from the point at which the bones are to be divided 
 on one side of the leg, and is carried across the limb and 
 back upon the opposite side to a point opposite the point 
 of starting. The flap thus marked out is dissected up to 
 its base and a posterior flap of one-fourth the length is next 
 cut by a transverse incision down to the bones, and is dis- 
 sected back to the line of the origin of the first incision. 
 (Fig. 402, B.) The long flap is next doubled back and 
 its edges secured to the posterior flap, or the long flap may 
 be cut from the posterior surface of the leg and the short 
 flap from the anterior surface. 
 
 Antero-posterior Flap Method. 
 
 A long anterior flap including half of the circumference 
 of the limb may be cut from without inward, composed of 
 skin, connective tissue, and muscles, and a short posterior 
 flap cut from within outward may also be employed. This 
 method is often employed in amputations in the upper 
 portion of the leg. (Fig. 402, O.) 
 
 Lateral Flap Method. 
 
 In the lower and middle thirds of the leg the method 
 of amputation by means of lateral skin flaps may be em- 
 ployed with advantage. In this method an incision is 
 made over the spine of the tibia, and an oval flap em- 
 bracing one-half of the circumference of the leg, composed 
 of the skin and connective tissue, is dissected up ; starting 
 from the same point a similar flap is formed on the opposite 
 side of the leg and dissected up ; the muscles at the upper 
 extremity of the flaps are next divided by a circular incision 
 and the bones are divided with a saw. 
 
AMPUTATIONS AT THE KNEE-JOINT 505 
 
 External Flap Method. (Sedillot.) 
 
 In this method of amputation of the leg the point of the 
 knife is entered a finger's breadth external to the spine of 
 the tibia and carried outward, grazing the fibula, and is 
 brought out as far as possible to the inner side ; a flap 
 three or four inches in length is then cut from within out- 
 ward ; the extremities of the incision are next united by 
 an incision across the inner side of the limb involving the 
 skin only ; any remaining muscular tissue is next divided 
 and the bones are sawed. The long external flap is then 
 brought over the ends of the bones and fastened to the 
 edges of the incision on the inner side of the limb. Prof. 
 Ashhurst modifies this operation by cutting the long ex- 
 ternal flap from without inward, and makes also a short 
 internal flap in the same manner. By either method the 
 resulting stump is a good one, with the ends of the bones 
 covered by the tissues of the external flap. 
 
 Amputations at the Knee-joint. 
 
 Amputations at the knee-joint may be done either by 
 the circular or elliptical incision or by means of flaps, and 
 may consist in simple disarticulations or sections through 
 the condyles of the femur. 
 
 Elliptical or Oval Method. 
 
 In this operation an incision crossing the spine of the 
 tibia five finger-breadths below the lower extremity of the 
 patella, is carried around the back of the leg three finger- 
 breadths higher than in front ; the tissues on the front of 
 the leg are dissected up until the tendon of the patella is 
 exposed ; the leg is then flexed, and the ligament of the 
 patella is divided ; the capsular ligament and the lateral 
 and crucial ligaments are next severed, care being taken 
 not to injure the popliteal vessels with the point of the 
 knife. The tibia is next drawn forward and the knife is 
 
506 
 
 AMPUTATIONS. 
 
 Fig. 405. 
 
 passed behind its posterior border, and the remaining soft 
 parts are divided from within outward. 
 
 Anterior Flap Method. 
 
 In this method of amputation a long cutaneous flap is 
 formed ; the incision beginning half an inch below the 
 
 articulation is carried five inches 
 below the patella ; crossing the 
 anterior surface of the leg it is 
 carried back to the condyle of the 
 femur on the opposite side. This 
 flap is dissected up and the liga- 
 ment of the patella is divided, 
 and the disarticulation is effected. 
 A short posterior flap, uniting the 
 anterior incision one inch below 
 its extremities, is next cut by 
 transfixion or from without in- 
 ward. (Fig. 405, A.) The pa- 
 tella is not removed. 
 
 Amputation through the Condyles 
 of the Femur. 
 
 In this amputation, which is 
 known as Garden's amputation, 
 an anterior flap, whose lower ex- 
 tremity is three finger- breadths 
 below the patella, is cut and the 
 disarticulation is effected, and the 
 posterior soft parts are divided. 
 The patella is removed, and the 
 condyles next sawed through just 
 above the edge of the articular 
 cartilage. (Fig. 405, B.) 
 
 Lateral Flap Method. 
 
 In this operation an incision 
 is made just below the patella, 
 
 Amputations at the knee-joint 
 and lower third of the thigh. A. 
 Long anterior flap. B. Ampu- 
 tation through condyles. C. 
 Modified flap at lower third of 
 thigh. (Stimson.) 
 
AMPUTATIONS OF THE THIGH. 
 
 507 
 
 which is carried down the spine of the tibia for three 
 inches, and is then carried backward to the middle of the 
 leg to a point opposite the beginning of the incision ; a 
 
 Fig. 406. 
 
 Amputation at the knee-joint by lateral flaps. (Smith.) 
 
 similar flap is cut on the opposite side of the leg, and the 
 flaps are dissected up to the line of the articulation. When 
 this point is reached the joint is opened and the disarticu- 
 lation is effected. The patella is not removed. (Fig. 406.) 
 
 GrrittVs Amputation at the Knee-joint 
 
 In this operation a long rectangular anterior flap is 
 first cut and dissected up, and after the disarticulation 
 has been effected the skin covering the posterior surface 
 of the knee is cut from within outward. The condyles 
 of the femur are next removed by a saw above the edge 
 of the articular cartilage, and the articular surface of the 
 patella is removed by the saw or cutting forceps. The 
 patella is next brought down, so that its sawed surface is 
 in contact with the sawn surface of the condyles, and the 
 flaps are brought together. (Fig. 407, A) 
 
 Amputations of the Thigh. 
 Modified Flap Method. 
 
 Two semilunar flaps of skin and connective tissue, the 
 upper extremities of which are several inches above the 
 
508 
 
 AMPUTATIONS. 
 
 condyles of the femur, are cut and dissected up, and the 
 muscles are next divided by a circular incision, and the 
 bone is cut through with the saw. (Fig. 405, (7.) 
 
 Long Anterior Flap Method. 
 
 In this operation an incision is made on the anterior 
 aspect of the thigh, marking out a flap whose length is 
 
 Fig. 407. 
 
 A. Gritti's amputation at the knee. A'. Lines of division of the bones. 2?. 
 Amputation of the thigh, long anterior flap. B'. Division of the bone. C. Am- 
 putation at the lower third of the thigh. (7. Division of the bone. D. Dis- 
 articulation at the hip-joint. 
 
AMPUTATIONS OF THE THIGH. 509 
 
 equal to one-third, and whose width at its base is equal to 
 two-thirds, of the circumference of the limb. The anterior 
 muscles are next divided obliquely upward and backward, 
 so that the flap shall not be too thick, and the posterior 
 muscles are cut transversely and the bone is divided with 
 a saw. (Fig. 407, B.) 
 
 Amputation in the lower third of the thigh may also be 
 effected by employing a long anterior and short posterior 
 flap. The anterior flap is cut, its lower extremity extend- 
 ing down to the lower edge of the patella, and after dis- 
 secting up the skin and cellular tissue to the upper 
 extremity of the patella, the muscles are cut obliquely up 
 to the point at which the bone is to be divided. A short 
 posterior flap is next cut, and the soft parts being retracted, 
 the bone is sawed through. (Fig. 407, C.) 
 
 Amputation of the Thigh by Transfixion. 
 
 In amputations of the thigh the flaps may also be cut 
 by transfixion, either lateral or a ntero-posterior flaps being 
 employed. (Fig. 408.) 
 
 Fig. 408. 
 
 Amputation of thigh by flaps cut by transfixion. 
 
510 
 
 AMPUTATIONS. 
 
 Amputation of the Thigh through the Trochanters. 
 
 When, for any reason, it is inadvisable to amputate at 
 the hip-joint, an amputation may be made through the 
 trochanters, a long anterior and short posterior flap being 
 employed with a circular division of the muscles. 
 
 Amputations at the Hip-joint. 
 
 In amputations at the hip-joint it is important that 
 provision be made for the control of hemorrhage during 
 the operation, and this is accomplished by the use of an 
 abdominal tourniquet (Fig. 409), or by the use of Davy's 
 lever making compression upon the common iliac artery 
 from the rectum, or by compression of the femoral artery 
 
 Fig. 409. 
 
 Abdominal tourniquet. 
 
 by the fingers of an assistant, or by the preliminary liga- 
 tion of the femoral artery just below Poupart's ligament. 
 Esmarch's elastic strap may also be employed for the con- 
 
AMPUTATIONS AT THE HIP-JOINT. 51 1 
 
 trol of bleeding during amputation at the hip-joint, the 
 strap being applied in such a manner that it occupies the 
 position of the turns of a spica bandage of the groin. 
 (Fig. 410.) 
 
 Dieffenbach and Wyeth, to avoid hemorrhage, make 
 first a circular amputation in the continuity of the thigh, 
 and after controlling the hemorrhage disarticulate the 
 head of the femur and remove it ; Jordan and Senn dis- 
 
 Fig. 410. 
 
 Esmarch's elastic strap applied to control hemorrhage during 
 amputation at the hip-joint. 
 
 articulate the head of the bone first through an external 
 incision and control the bleeding before the amputation is 
 completed by passing an elastic tourniquet around the soft 
 parts above the point where they are to be divided. 
 
 The methods of amputation at the hip-joint are the 
 oval, antero-posterior flap, and lateral flap, and modified 
 circular methods. 
 
 Oval Method. 
 
 This is performed by entering the point of a strong 
 knife into the tissues below the anterior superior spinous 
 
512 
 
 AMPUTATIONS. 
 
 process of the ilium and making two oblique incisions, 
 one forward and downward and the other backward, both 
 incisions meeting on a transverse line on the inner side 
 of the thigh. The muscles are next divided on a little 
 higher line, and when the joint is exposed disarticulation 
 is effected from the outer side and any remaining tissue is 
 divided. 
 
 Antero-posterior Flap Method. 
 
 In this method the point of a long amputating knife is 
 thrust into the tissues about two finger-breadths below the 
 anterior superior spinous process of the ilium, and is pushed 
 through the tissues grazing the hip-joint, and is brought 
 out on the opposite side of the thigh close to the junc- 
 tion of the scrotum. The knife is next carried downward 
 
 Fig. 411. 
 
 Amputation at the hip-joint by antero-posterior 
 
 (Holmes.) 
 
 close to the bone and an anterior flap of sufficient length 
 is cut from within outward. This flap is held up by an 
 
AMPUTATIONS AT THE HIP-JOIXT. 51 3 
 
 assistant and the head of the bone is disarticulated, and 
 the knife being passed behind the bone, a posterior flap of 
 equal length is cut from within outward. (Fig. 411.) 
 
 Guthrie? s method of amputation at the hip-joint consists 
 in cutting the flaps from without inward, a smaller knife 
 being used for this purpose and the posterior flap being 
 cut first. 
 
 Modified Circular Method. 
 
 In this operation short anteroposterior flaps of skin 
 and connective tissue are cut and dissected up, and the 
 muscles are divided by a circular incision on the level of 
 the joint, and the disarticulation of the head of the femur 
 is next effected. 
 
 Lateral Flap Method. 
 
 In this operation two flaps are cut from the inner and 
 outer side of the thigh by transfixing, or by cutting from 
 
 Fig. 412. 
 
 Amputation at the hip-joint "by external and internal flaps. (Bryant.) 
 
 without inward and exposing the joint, which is opened 
 and the disarticulation of the head of the femur is effected 
 as in the previous methods. (Fig. 412.) 
 
 Wyeth's Method of Amputating at the Hip-joint. 
 
 In amputating at the hip-joint by this method the hip 
 to be operated upon is brought well over the edge of the 
 
514 AMPUTATIONS. 
 
 table and an Esmarch bandage is applied to the limb, and 
 two stout steel mattress needles twelve or fourteen inches 
 in length are required ; the point of one of these needles 
 is passed through the skin one and a half inches below 
 and slightly to the inner side of the anterior superior spine 
 of the ilium and carried through the tissues about half- 
 way between the great trochanter and the spine of the 
 ilium external to the neck of the femur, and its point is 
 made to emerge just behind the trochanter; the second 
 needle is made to enter the skin an inch below the crotch, 
 internal to the saphenous opening, and its point is made 
 to emerge about an inch and a half in front of the tuber 
 
 Fig. 413. 
 
 Pins inserted and tube applied. 
 
 ischii. The points of the needles are next protected with 
 corks, and a long piece of rubber tubing or an Esmarch 
 elastic strap is wound tightly five or six times about the 
 limb above the fixation needles. (Fig. 413.) The Esmarch 
 bandage should then be removed and a circular incision 
 of the skin and cellular tissue should be made five inches 
 below the constricting band; this cellulo-cutaneous cuff* 
 should next be reflected to the level of the trochanter 
 minor : a circular division of all the muscles should next 
 
AMPUTATIONS AT THE HIP-JOINT. 
 
 515 
 
 be made at this point and the bone divided with a saw 
 The large vessels should next be secured, and after this has 
 been done the rubber tube should be removed and any 
 vessels which bleed should be tied ; all remaining attach- 
 ments of the femur and the capsule should be opened and 
 the head of the bone disarticulated. A drain should be 
 
 Fig. 414. 
 
 Limb amputated and bone sawn. (Wyeth.) 
 
 next introduced and the edges of the flaps brought together 
 vertically. 
 
PART VII. 
 
 EXCISIONS OR RESECTIONS. 
 
 Excision of a joint implies the partial or complete re- 
 moval of the articular surface of the bones making up the 
 joint. The term resection is sometimes used as synony- 
 mous with excision, but is usually employed to indicate 
 the removal of a portion or the whole of the shaft of one 
 of the long bones. Excisions or resections of joints and 
 bones may be required on account of injury, disease, or 
 anchylosis of a joint in faulty position. In the operation 
 of excision of the joint the incision should be free enough 
 to permit of an inspection of the diseased portions of the 
 joint, and it is preferable to remove the diseased articular 
 surface of the bone with a saw ; small areas of diseased bone 
 may be removed with the curette or gouge forceps. In per- 
 forming excisions of joints in young subjects care should 
 be taken to see that the epiphyseal cartilage is not en- 
 croached upon, for if this is removed the subsequent 
 growth of the limb is interfered with. The result desired 
 in cases of excision of joints, in addition to the removal 
 of the diseased tissue, varies somewhat with the joint in- 
 volved; for instance, in a knee-joint anchylosis is desired ; 
 in the shoulder, hip, elbow, and wrist, we wish to obtain a 
 movable false joint ; when the latter condition is desired 
 after excision, care should be exercised not to divide mus- 
 cles or tendons, and as far as possible not to interfere with 
 their attachments. When anchylosis is desired the divi- 
 sion of muscles or tendons is not a serious consideration ; 
 
EXCISIONS OB RESECTIONS, 
 
 517 
 
 anv injury to the principal arteries, veins, and nerves 
 should always be avoided. 
 
 Butcher's saw. 
 
 The instruments required for the excision of joints are a 
 stout scalpel (Fig. 415), probe-pointed knife, an excision 
 
 Fig. 417. 
 
 Narrow-bladed saw. 
 Fig. 418. 
 
 Chain saw. 
 
 saw with reversible blade (Fig. 416), narrow-bladed saw 
 (Fig. 417), or chain saw (Fig. 418), strong lion-jawed for- 
 
518 
 
 EXCISIONS OB RESECTIONS. 
 
 Fig. 419. 
 
 Lion-jawed forceps. 
 Fig. 420. 
 
 Retractor. 
 Fig. 421. 
 
 Elevator. 
 Fig. 422. 
 
 Bone-cutting pliers. 
 Fig. 423. 
 
 Knife-bladed forceps. 
 Fig. 424. 
 
 Periosteotome. 
 
EXCISION OF THE SHOULDER- JOINT. 51 9 
 
 ceps (Fig. 419), retractors (420), an elevator (421), heavy 
 bone-cutting pliers (Fig. 422), knife-bladed forceps (Fig. 
 423), and a periosteotome (Fig. 424). 
 
 Excision of the Shoulder- joint. 
 
 In excising the shoulder-joint the arm is adducted and 
 rotated inward, and a straight incision is made extending 
 
 Fig. 4'25. 
 
 Excision of shoulder-joint : A. Regular incision. B. Supplementary. 
 
 from the beak of the coracoid process down the arm in the 
 line of the bicipital groove ; this incision may be supple- 
 mented by a short, transverse incision from the upper edge 
 of the first incision to the acromion process. As the in- 
 cision is deepened the fibres of the deltoid muscle are 
 divided in this line, and the capsule of the joint is exposed 
 and divided along the outer edge of the tendon of the long 
 head of the biceps muscle ; this tendon is held to one side 
 and the capsule of the joint is freely opened, and the 
 muscles inserted into the tuberosities of the humerus are 
 divided with a probe-pointed knife and freed with an ele- 
 vator ; the head of the bone can then be removed by saw- 
 ing across the surgical neck of the bone with a narrow 
 metacarpal saw or chain-saw, and the sawn surface of the 
 humerus should then be rounded off with bone pliers. If 
 
520 EXCISIONS OB RESECTIONS. 
 
 upon examination the glenoid cavity is found to be dis- 
 eased, this with the neck of the scapula may be removed 
 with gouge forceps or a small saw. The bone is then 
 reduced and the wound is drained and closed. 
 
 Eesection of the Humerus. 
 
 The whole or a portion of the humerus may require re- 
 section for injury or disease. The incision should be made 
 upon the outer side of the bone and carried down in the 
 muscular interspaces on a line with the shaft, care being 
 taken to avoid injury of the musculo-spiral nerve, which, 
 as it passes around the posterior surface of the humerus 
 lies close to the bone between the humeral heads of the 
 triceps muscle at a point corresponding to the deltoid in- 
 sertion anteriorly — L e., about the centre of the shaft of 
 the humerus. This nerve should be isolated and held 
 aside and the bone should be exposed. After separating 
 the periosteum as completely as possible, if the shaft of 
 the bone is diseased, it should be removed by dividing it 
 in the middle with a saw or forceps, and removing each 
 fragment as far as the upper and lower epiphysis, or the 
 upper or lower portion only may require removal. In 
 resecting the humerus for an ununited fracture the inci- 
 sion is made upon the outer surface of the arm over the 
 seat of fracture, and when the latter has been exposed the 
 fragments are separated, and the end of each fragment is 
 removed with a saw to obtain a fresh bone surface. The 
 freshened ends of the bone are then drilled and united by 
 heavy silver-wire sutures, silver plates, or screws. 
 
 Excision of the Elbow- joint. 
 
 In excising the elbow-joint the forearm is slightly 
 flexed, and a longitudinal incision is begun about two 
 inches above the olecranon process and a little to its inner 
 side, and carried about three or four inches down in the 
 line of the ulna; the tissues are then divided down to 
 bone, and the ulnar nerve is dissected from its groove be- 
 
RESECTION OF RADIUS AND ULNA. 
 
 52 L 
 
 Fig. 426. 
 
 \ 
 
 hind the inner condyle of the humerus and held aside by 
 a retractor, the tendon of the triceps is divided and its 
 attachment to the fascia and periosteum 
 over the olecranon process is separated 
 with an elevator or periosteotome and 
 turned downward; the joint is next 
 opened and the lateral ligaments are 
 divided as the forearm is flexed upon 
 the arm. The upper part of the ulna 
 and the head of the radius are freed 
 with a probe-pointed knife and are re- 
 moved with a narrow-bladed saw, care 
 being taken in making the section of 
 the radius to divide its neck so that the 
 attachment of the biceps muscle is not 
 interfered with. The condyles of the 
 humerus are next freed and removed 
 with a saw. In freeing the bones at 
 the anterior portion of the joint great 
 care should be used to avoid injury of 
 the brachial artery and vein and the 
 median nerve. After the joint has 
 been excised the bones are reduced and the wound is 
 drained and closed. 
 
 / 
 
 Incision for excision of 
 the elbow-joint. 
 
 Resection of the Radius and Ulna. 
 
 The radius or ulna may be resected either entirely or 
 partially by making an incision over the bone to be re- 
 moved upon the back of the forearm ; the bone being ex- 
 posed, the periosteum is separated with an elevator and 
 the bone is divided with a saw, and each fragment is lifted 
 and separated from its muscular attachments up to the 
 point where it is desired to remove it. If the articular 
 surface of the bone is to be removed, the disarticulation 
 should be made carefully with a strong scalpel or a probe- 
 pointed knife, care being taken to avoid injury of the 
 vessels and nerves lying upon its palmar surface. 
 
522 
 
 EXCISIONS OR RESECTIONS. 
 
 Fig. 427 
 
 Resection of the lower end of the radius. 
 
 Excision of the Wrist. 
 
 The wrist is covered on its posterior and lateral aspect 
 with skin, fascia, and tendons ; the relative position of the 
 
 Fig. 428. 
 
 Articulations of the wrist-joint. (Lister.) 
 
 bones entering into the articulation can be seen in the 
 accompanying figure. (Fig. 428.) The wrist-joint may 
 
EXCISIOX OF THE WRIST. 
 
 523 
 
 be excised by making a dorsal incision which begins at the 
 middle of the ulnar border of the second metacarpal bone, 
 and is carried upward about four inches, crossing the ulnar 
 edge of the tendon of the extensor carpi- radialis-brevior, 
 and splitting the dorsal ligaments of the wrist between 
 the tendons of the extensor secondi-internodii and the ex- 
 tensor of the forefinger. The incision should be carried 
 down to the bone, and the soft parts and tendons should 
 be dissected loose with an elevator. By flexing the hand the 
 
 Fig. 429. 
 
 MB : (\ 
 
 Incision for excision of wrist-joint. 
 
 first row of the carpus is made to present in the wound, and 
 the scaphoid is separated from the trapezium and removed ; 
 the semilunar and cuneiform should next be removed ; the 
 trapezium and pisiform should be left if possible. In re- 
 moving the second row of carpal bones the knife should 
 be passed between the trapezium and trapezoid and then 
 into the carpo-metacarpal joint, and cutting the ligaments 
 of the dorsal side of the ends of the metacarpal bones the 
 trapezoid, os magnum, and unciform can then be removed. 
 The lateral ligaments are next carefully divided, and 
 
524 
 
 EXCISIONS OR RESECTIONS 
 
 the articular ends of the radius and ulna removed with a 
 saw, the euds of the metacarpal bones should next be re- 
 moved with a saw or cutting pliers. 
 
 Resection of the Metacarpal Bones. 
 
 The metacarpal bones may be resected by making a 
 longitudinal incision on the back of the hand over the 
 bone to be removed. The incision should extend from 
 one articular end to the other, and the extensor tendon 
 when exposed should be held to one side by retractors ; 
 the periosteum should next be separated as far as possible, 
 
 Fig 430. 
 
 Resection of metacarpal bone. 
 
 and when the bone has been fully exposed it may be re- 
 moved by dividing it in the middle with bone-cutting 
 pliers, and then disarticulating each fragment ; or the 
 articular ends may be freed and the bone removed in one 
 piece. (Fig. 430.) 
 
 ExcrsiON of Metacarpophalangeal Joints or 
 Inter-phalangeal Joints. 
 
 In excising a metacarpophalangeal joint the joint is 
 exposed by a longitudinal incision over the dorsal surface 
 
RESECTION OF THE CLAVICLE. 525 
 
 of the knuckle; the extensor tendon being exposed and 
 held to one side, the lateral ligaments are divided. The 
 articular ends of the bones are tben exposed and removed 
 with a metacarpal saw or with bone- cutting pliers. (Fig. 
 
 Fig. 431. 
 
 Excision of the metacarpophalangeal joint. 
 
 431.) In excising the inter-phalangeal joints the incision 
 is usually made upon the side of the joint, and when the 
 articular surfaces of the bone have been exposed they are 
 removed with a small saw or cutting-pliers. 
 
 Resection of the Clavicle. 
 
 The clavicle is resected by making an incision over the 
 bone from one articulation to the other, which is carried 
 directly down to the bone ; the periosteum is then sepa- 
 rated and the shaft of the bone may be divided at the 
 middle and each fragment raised and disarticulated, or 
 the bone may be disarticulated at one extremity, then 
 raised up and freed from its adherent tissues and disar- 
 ticulated at the other extremity. In disarticulating the 
 sternal articulation of the clavicle (Fig. 432) a probe- 
 pointed knife should be used, and great care should be 
 exercised to avoid injury of the important vessels and 
 nerves which lie in close proximity to it. 
 
 23* 
 
526 EXCISIONS OB RESECTIONS. 
 
 Fig. 432. 
 
 Resection of the sternal end of the clavicle. 
 
 Resection of the Ribs. 
 
 In excising a rib the incision should correspond in length 
 and direction with the portion of bone to be removed, and 
 may be crossed at each end by a short transverse incision. 
 The tissues overlying the rib are then dissected loose, the 
 periosteum is separated as far as possible, and the rib is 
 divided by cutting-pliers at two points, and the piece is 
 grasped with forceps and the attachments to the under 
 surface of the rib are separated with an elevator. Care 
 should be taken to avoid opening the pleural cavity. 
 
 Estlander's Operation. 
 
 This operation is employed in cases of empyema, and 
 consists in resecting the portions of several adjoining ribs 
 to allow the chest wall to sink inward and unite with the 
 pleura. The incision is made along the intercostal space 
 occupied by the fistula and the adjoining ribs as far as it 
 may be necessary. To resect them a flap is then made 
 and dissected up, and portions of several ribs are divided 
 with bone- cutting pliers and removed with forceps. If 
 the costal pleura is very thick, to expose the cavity so as 
 
EXCISION OF THE SCAPULA. 
 
 527 
 
 to permit of free drainage and allow the chest wall to sink 
 in it may be cut away over a part of the area from which 
 the ribs have been resected; one to four inches of three to 
 six adjoining ribs may be removed. 
 
 Resection of Sternum. 
 
 Resection of the sternum is performed by making a 
 longitudinal incision over the portion of the bone to be 
 removed ; the periosteum is separated, and the diseased 
 portion of the sternum is then carefully freed with an ele- 
 vator and removed. 
 
 Excision of the Scapula. 
 
 To excise this bone an incision should be made along 
 the whole length of the spine of the scapula, and from its 
 
 Fig. 433. 
 
 Incision for excision of scapula. 
 
 posterior extremity ; two other incisions should be made, 
 one running about an inch or two above, and the other 
 
528 EXCISIONS OB RESECTIONS. 
 
 passing down the posterior border of the bone to its inferior 
 angle (Fig. 433) ; the flaps thus made are loosened by sepa- 
 rating the muscles attached to the outer surface of the bone. 
 The attachments of the deltoid and trapezius to the acro- 
 mion and spine of the scapula are separated, the lower 
 angle is freed by detaching the teres major and serratus 
 magnus. The bone is then raised, and the subscapularis 
 muscle is detached from below upward. The neck of the 
 scapula should be divided with a chain-saw or cutting 
 forceps; the acromion is next separated from the clavicle 
 and the scapula turned upward, the joint being opened 
 from below. The coracoid process should be separated 
 from its muscular and ligamentous attachments, or may 
 be divided with a saw and left in place. In clearing the 
 supraspinous fossa care should be taken not to injure the 
 suprascapular nerve in the suprascapular notch ; it should 
 be raised with the periosteum and its fibrous sheath. 
 
 Excision of the Hip. 
 
 In excising the hip-joint an incision is made from a 
 point about three inches below the crest of the ilium, and 
 about the same distance behind the anterior superior spine of 
 the ilium, which should be carried downward over the great 
 trochanter in the line of the femur for about five or six 
 inches (Fig. 434) ; the soft parts are dissected from the 
 great trochanter and upper part of the sheath of the femur, 
 and the capsule of the joint is opened. An assistant should 
 next rotate the thigh inward and outward, and with a 
 blunt-pointed knife the muscles attached to the trochanters 
 are shaved off close to the bone; the neck of the femur is 
 next freed by the use of a knife and elevator ; the thigh 
 is adducted and pushed upward, and the head and neck of 
 the bone are made to project from the wound. A transverse 
 section of the bone is then made with a saw just below the 
 great trochanter. In some cases it is difficult to remove the 
 head of the bone, which may be ankylosed firmly to the 
 acetabulum ; here the bone may first be divided with a 
 chain-saw passed around the femur just below the great 
 
ANTERIOR EXCISION OF THE HIP. 
 
 529 
 
 trochanter, or may be divided with a chisel, the head and 
 neck of the bone afterward being removed with gouge or 
 bone-cutting pliers. After the head and neck of the bone 
 
 Fig. 434. 
 
 Incisions for excision of hip-joint. 
 
 have been removed the acetabulum is examined, and if it 
 is found to be diseased the diseased tissues should be 
 removed with a curette, gouge, and forceps. 
 
 Anterior Excision of the Hip. 
 
 In this method of excising the hip-joint an incision is 
 made upon the front of the thigh over the joint, beginning 
 half an inch below r the anterior superior spine of the 
 ilium, and is carried three or four inches downward and 
 a little inward; as the incision is deepened the tensor 
 vagina femoris and the glutei muscles are exposed, and 
 
530 
 
 EXCISIONS OB RESECTIONS. 
 
 should be drawn to the outer side, and the sartorius and 
 rectus muscles are held to the inner side, and the neck of 
 the femur is exposed ; the neck of the bone is then divided 
 with a metacarpal saw or Adams's saw, and the diseased 
 portion of the bone is next grasped with strong seques- 
 trum forceps, and by the use of these and an elevator the 
 head of the bone is removed ; the acetabulum is then ex- 
 amined, and, if diseased, the diseased tissue is removed 
 with gouge or curette. 
 
 Excision of the Knee-joint. 
 
 Fig. 435. 
 
 The knee-joint is excised by making an incision which 
 begins at the inner side of the limb behind the inner con- 
 dyle of the femur, and is carried 
 over the front of the knee just below 
 the patella to a corresponding point 
 upon the external condyle of the 
 femur (Fig. 435); the flap thus 
 formed is dissected up to a point 
 corresponding with the upper edge 
 of the patella, the ligamentum pa- 
 tella is then cut through, the leg is 
 slightly flexed, and the joint is 
 opened ; the lateral ligaments are 
 then divided, and by flexing the leg 
 upon the thigh the joint is freely ex- 
 posed. The semilunar cartilages are 
 next removed, and the condyles of the 
 femur are freed ; a narrow-bladed 
 saw is placed under the condyles and 
 a transverse section of the condyles 
 is removed; the head of the tibia is 
 next cleared, and a transverse sec- 
 tion of this bone is also removed with a saw. The patella 
 may be removed before excising the ends of the bone, or, 
 if ankylosed to the condyles, may be removed with the 
 section of bone which removes a portion of the condyles. 
 After sufficient bone has been removed, if localized areas 
 
 Incisions for excision of 
 the knee-joint. 
 
RESECTION OF THE TIBIA OR FIBULA. 531 
 
 of carious bone present themselves upon the sawn surface 
 of the bones, they may be removed with a gouge or gouge 
 forceps. In excising the knee-joint in young persons care 
 should be taken to remove only so much bone as may 
 be done without encroaching upon the lines of the epiphy- 
 seal cartilages, as removal of the epiphyseal cartilage would 
 interfere with the subsequent growth of the bones. 
 
 Arthrectomy of the Knee-joint. 
 
 This operation is employed as a substitute for the oper- 
 ation of excision in disease of the knee-joint, and is 
 performed by exposing the joint by an incision similar to 
 that employed in excision ; the ligamentum patella is 
 divided and the patella is reflected with the skin flap. 
 When the joint has been freely exposed the diseased artic- 
 ular cartilages, semilunar cartilages, crucial ligaments, and 
 synovial pouches are removed by the use of the knife or 
 scissors and the curette ; if the surface of the bone is found 
 to be carious, it is removed by the curette or gouge. After 
 the joint has been thoroughly cleared of diseased tissue, it 
 is irrigated, and the divided ligamentum patella is sutured 
 with several strands of chromicized catgut or silk, and the 
 wound is drained and closed. 
 
 Excision of the Patella. 
 
 The patella may be excised by making a longitudinal or 
 crucial incision ; the periosteum is carefully separated from 
 the bone, and the latter is grasped with strong bone forceps 
 and dissected free from its attachments upon the under sur- 
 face. The knee-joint is generally opened in removing the 
 patella, unless the removal of the bone be undertaken for 
 necrosis or caries when it is possible to accomplish its 
 complete removal without opening the knee-joint. 
 
 Eesectiox of the Tibia or Fibula. 
 
 In resecting the tibia or fibula the bones may be exposed 
 by a longitudinal incision over the bone to be removed, 
 
532 
 
 EXCISIONS OR RESECTIONS. 
 
 and after the shaft of the bone has been exposed and 
 the periosteum separated as completely as possible, the 
 shaft of the bone may be divided at its middle and each 
 
 Fig. 436. 
 
 Resection of lower end of fibula. 
 
 fragment grasped with forceps and dissected up, and re- 
 moved at its epiphyseal junction. (Fig. 436.) 
 
 Excision of the Ankle-joint. 
 
 In excising the ankle-joint an incision is made at a point 
 two inches above the external malleolus, and carried down- 
 ward over the fibula to the tip of the external malleolus; it 
 is then curved slightly upward toward the dorsum of the 
 foot (Fig. 437), care being taken that the incision does not 
 extend so far forward as to endanger the extensor tendons 
 or the dorsal artery. The bone is exposed in this incision 
 and the periosteum is separated and turned aside; the 
 peroneal tendons are next exposed and held to one side by 
 
EXCISION OF THE OS CALCIS. 
 
 533 
 
 Fig. 437. 
 
 retractors ; the external malleolus is next divided with 
 bone-cutting pliers and removed, and the astragalus is 
 exposed. The upper articulating 
 surface of the astragalus is next 
 removed with bone forceps or a 
 saw, or the whole bone may be re- 
 moved. The foot is next inverted 
 and the end of the tibia is cleared 
 with a probe-pointed knife, care 
 being taken not to injure the pos- 
 terior tibial artery, nerve, or vein, 
 and when the articular surface has 
 been freedit is removed with a saw 
 or bone-cutting pliers. The articu- 
 lar end of the tibia may be exposed 
 by making an additional incision 
 upon the inner side of the ankle 
 over the internal malleolus if de- 
 sired. 
 
 Excision of the Astragalus. 
 
 Incision for excision of 
 ankle-joint. 
 
 In excising the astragalus a semi- 
 lunar incision is made upon the 
 outside of the ankle-joint, very 
 similar to that employed in excising the ankle ; the exter- 
 nal lateral ligaments are divided with a probe-pointed 
 knife, and the astragalus is exposed by forcibly inverting 
 the foot ; the bone is then seized with strong forceps, and 
 its ligamentous attachments are divided with a probe- 
 pointed knife, and it is removed. 
 
 Excision of the Os Calcis. 
 
 An incision is made on the level of the upper part of the 
 bone, beginning at the inner border of the tendo Achilles, 
 dividing this tendon and passing around the back and outer 
 surface of the foot to the base of the fifth metatarsal bone; 
 a short incision is then made at the anterior end of the first 
 
534 EXCISIONS OB RESECTIONS. 
 
 incision and carried down to the sole of the foot, the bone 
 is exposed and held by forceps ; the flap thus formed, 
 which includes the peronei tendons, is then separated from 
 the bone, and the cuboid ligaments are cut and also the 
 interosseous ligament between the os calcis and the astrag- 
 alus, and the bone is removed with forceps. 
 
 Resection of Metataesal Bones. 
 
 Any of the metatarsal bones may be resected by an 
 incision on the dorsum of the foot over the bone to be re- 
 moved ; the bone is exposed, the extensor tendons being 
 held aside by retractors ; the bone is disarticulated at 
 
 Fig. 438. 
 
 Incision for the resection of the metatarsal bone of the great toe. 
 
 either end or is cut in its middle and each fragment dis- 
 sected up and removed at its articulation. The metatarsal 
 bone of the great toe is exposed by making a curved incision 
 over that bone on the inner side of the foot. (Fig. 438.) 
 
 Excision of the Coccyx. 
 
 In excising the coccyx the finger is passed into the 
 rectum and the position of the bone is determined; a 
 longitudinal incision through the skin and fibrous tissues 
 covering the coccyx is made from a point about a quarter 
 of an inch above its upper limit, and is carried down to a 
 little below its lower extremity. This incision may be sup- 
 plemented with a transverse incision. The sacro coccygeal 
 articulation is then opened ; an elevator is next introduced 
 into the articulation and the bone is raised up and grasped 
 with forceps. It should then be freed from its lateral 
 
EXCISION OF THE SUPERIOR MAXILLA. 
 
 535 
 
 attachments and those upon its anterior surface with a 
 knife and elevator. 
 
 Excision of the Superior Maxilla. 
 
 In excising the superior maxilla the incision is begun 
 half an inch below the inner canthus of the eye, and is 
 carried downward along the line of junction of the nose 
 and face and along the course which limits the alse nasi, 
 and longitudinally to the septum, and then down through 
 the free border of the lip ; it is also advisable to carry the 
 
 Fig. 439. 
 
 Incision for excision of upper superior maxilla. 
 
 incision along the lower edge of the orbit upward over the 
 malar bone (Fig. 439) ; the flap being dissected away from 
 the surface of the bone, a small, narrow metacarpal saw is 
 then applied to the floor of the nostril until a deep groove 
 is made ; the soft and hard palate is next divided from 
 within the mouth with a strong knife; one or two incisor 
 teeth should be removed, and one blade of a pair of strong 
 bone-cutting pliers is introduced into the floor of the nose 
 in the line of the saw incision, the other is introduced into 
 the mouth in the line of the division of the structures of 
 the palate, and the bone is divided. The malar bone is 
 
536 
 
 EXCISIONS OR RESECTIONS. 
 
 next divided with a saw or forceps, and, finally, the blades 
 of a strong pair of bone-cutting forceps are introduced, one 
 into the nostril and the other at the edge of the orbit, the 
 important structures of the orbit being held upward with 
 a retractor, and the inner angle of the orbit is cut across ; 
 the superior maxillary bone is then grasped with strong, 
 lion-jawed forceps, and can be twisted out, any band of 
 tissues which holds it being divided with the knife or 
 scissors. 
 
 Excision of the Inferior Maxilla. 
 
 Partial or complete excision of the lower jaw may be 
 practised. 
 
 Excision of the Ramus and Half of the Body 
 of the Lower Jaw. 
 
 The incision should be made from a point just below the 
 free border of the lip over the symphysis, and carried 
 
 Fig. 440. 
 
 Incision for excision of the lower jaw. 
 
 down to the lower border of the jaw, from this point it is 
 carried along the ramus to the lobe of the ear (Fig. 440); 
 
EXCISION OF THE LOWER JAW. 537 
 
 the flap is then dissected up, separating the masseter muscle 
 from the bone as far as possible without opening the cavity 
 of the mouth ; an incisor tooth is next drawn, and the bone 
 is sawn through near the symphysis ; the jaw is then 
 seized with forceps and drawn downward and forward, and 
 denuded upon its inner surface. The insertion of the 
 temporal muscle into the coronoid process is divided, and 
 the condyle of the jaw is disarticulated from the glenoid 
 cavity, and the remaining soft parts are carefully detached 
 with a knife or elevator. The facial artery and the inferior 
 dental nerve and artery are necessarily divided in removing 
 this portion of the jaw. 
 
 Partial Excision of the Lower Jaw or Alveolus. 
 
 The removal of a portion of the alveolar process of the 
 jaw may often be accomplished through the mouth without 
 the aid of a cutaneous incision. The condyle of the jaw 
 may be excised by making an incision close in front of the 
 temporal artery and carrying it forward along the zygoma 
 for an inch and a half; the tissues being divided and the 
 bone exposed, a second incision involving only the skin 
 is then carried from the center of the first directly down- 
 ward for about an inch ; the soft parts are next carefully 
 separated with a knife and elevator from the margin of 
 the zygoma and outer surface of the joint, and drawn 
 downward with a retractor, to prevent injury of the parotid 
 gland, nerves, and vessels. The neck of the condyle is 
 then cleared by working around it in front and behind 
 with a director, keeping close to the bone to avoid injury 
 of the internal maxillary artery. A chain-saw is then 
 passed around the neck of the bone, which is divided, and 
 the condyle is seized with forceps and removed with an 
 elevator or gouge. 
 
538 TREPHINING. 
 
 Trephining the Skull. 
 
 This is an operation in which a circular disk of bone 
 of the skull is removed by a circular saw or trephine to 
 expose the membranes and the brain. If a wound is 
 already present in the scalp, exposing the skull, as in the 
 case of compound fracture of the skull, it is exposed and 
 bared, so that the crown of the trephine can be placed 
 fairly on the bone ; if no wound exists a U-shaped flap is 
 made, including all the structures down to the bone. The 
 base of the flap should be so situated as to contain a sufficient 
 blood-supply, and the flap should be so planned as to favor 
 drainage from the wound. When the bone has been exposed 
 
 Fig. 441. 
 
 Trephine. 
 
 the trephine is placed with the centre pin projecting about 
 one-sixteenth of an inch, and the instrument is turned from 
 right to left until a groove is made in the bone ; the tre- 
 phine is then removed, and the centre pin is raised so that 
 as the teeth of the trephine approach the inner table of the 
 skull the point of the centre pin will not injure the mem- 
 branes or brain. The instrument is then reapplied and 
 worked cautiously as the groove in the bone is deepened. 
 When the diploe is reached there is usually some bleeding 
 from the wound, and as the trephine approaches the inner 
 table of the skull it should be manipulated with great care, 
 and when the resistance is felt to diminish at any one part 
 of the bone the trephine is made to cut at other points of 
 
TREPHINING THE SKULL. 
 
 539 
 
 the bone where the resistance is still apparent. When the 
 disk is completely cut through it can be lifted out in the 
 crown of the trephine, or can be removed with forceps or 
 an elevator. If the wound has to be enlarged to obtain 
 greater exposure of the membranes or brain, it can be done 
 very satisfactorily with a form of rongeur forceps. 
 
 Fig. 442. 
 
 1. Trephine opening for mastoid antrum. 2. For abscess from otitis media. 3. 
 To expose cerebellum. 4-5. For middle meningeal hemorrhage. A. Lateral 
 sinus. B. and C. Limit of up and down variation. (Stimson.) 
 
 When the trephine is applied to expose hemorrhage from 
 the middle meningeal artery, or hemorrhage from the 
 lateral sinus, or abscess from middle-ear disease, or to open 
 the mastoid antrum, the positions for the application of 
 the trephine are indicated in Fig. 442. 
 
540 OPERATIONS UPON NERVES. 
 
 Trephining the Antrum of Highmore. 
 
 The antrum may be opened by extracting the first or 
 second molar tooth and deepening its socket with a small 
 gouge or bone drill. 
 
 The antrum may also be opened through the mouth to 
 avoid a scar upon the face, by the use of a small trephine 
 or bone gouge; the gingivo-labial fold is divided up to a 
 point just below the infra-orbital foramen, the trephine is 
 placed here and a disk of bone removed, opening the antrum. 
 
 Frontal Sinus. 
 
 This sinus may be opened by a trephine or bone gouge. 
 An incision is made from the centre of the supra-orbital 
 ridge to the median line above the root of the nose. The 
 tissues are divided down to the periosteum ; this is incised 
 and turned aside, and the trephine or gouge is placed at the 
 centre of the incision near the inner edge of the supra- 
 orbital ridge and a disk of bone is removed, exposing the 
 frontal sinus. 
 
 Operations upon Nerves. 
 
 Neurotomy. 
 
 Neurotomy is an operation in which the nerve trunk is 
 exposed and a section made through the nerve. As in the 
 case of ligation of vessels, it is most important that the 
 operator should have an accurate knowledge of the ana- 
 tomical relations of the nerves and the surrounding struc- 
 tures. The nerve is exposed by an incision similar to that 
 for the exposure of an artery for the application of a 
 ligature. 
 
 Neurectasy. 
 
 In the operation of neurectasy, or stretching of nerves, 
 the nerve is exposed and isolated and is lifted upon a blunt 
 
NERVE-GRAFTING. 541 
 
 hook, or, in the case of the larger nerves, is hooked out of 
 the wound by the finger, and is thoroughly stretched and 
 replaced. 
 
 Neurectomy. 
 
 In this operation the nerve is exposed and a portion of 
 the nerve is excised. 
 
 Suture of Nerves or Neurorrhaphy. 
 
 In bringing into apposition the ends of divided nerves 
 primary or secondary sutures may be employed. The 
 material employed for sutures should be fine silk or fine 
 chromicized catgut. 
 
 In using primary sutures the suture in the case of the 
 smaller nerves should be passed through the sheath and 
 substance of the nerve, and in the larger nerves two sets 
 of sutures can be used, one passing through the substance 
 of the nerve, the other being passed through the sheath. 
 
 Nerve-grafting. 
 
 In employing secondary sutures to unite the divided ends 
 of nerves when there has been a loss of substance in the 
 nerve, or there has been so much retraction of the nerve 
 that it is impossible to bring the ends together, nerve- 
 
 Fig. 443. 
 
 Nerve-grafting. (Willakd. 
 
 grafting may be made use of; the ends of the nerve being 
 freshened, a section of a fresh nerve from an amputated 
 limb or animal is sutured to the ends of the divided nerve 
 to fill up the gap, as seen in Fig. 443. 
 
 Another method of lengthening the ends of the divided 
 nerve, known as neuroplasty, may be employed where the 
 
 24 
 
542 
 
 OPERATIONS ON NERVES. 
 
 ends cannot be brought into apposition by the ordinary 
 method ; in this method flaps are made for the nerve in 
 
 Fig. 444. 
 
 Neuroplasty. (Willard.) 
 
 the same way as in the lengthening of shortened tendons, 
 and the ends of the flaps are sutured together, as seen in 
 Fig. 444. 
 
 The following incisions are given to expose the nerves 
 for some of these various operations : 
 
 Supra-orbital Nerve. 
 
 This nerve is exposed at the supra-orbital notch at the 
 junction of the middle and inner thirds of the supra-orbital 
 
 A and B. Incision for resection of supra-orbital nerve. C. Incision for resection 
 of the superior maxillary nerve. 
 
 arch. An incision is made one and a half inches in length, 
 parallel to the eyebrow (Fig. 445), and is carried down to 
 
LINGUAL NERVE. 543 
 
 the bone ; the nerve is recognized and grasped with for- 
 ceps, and resected or stretched as may be desired. 
 
 Superior Maxillary Nerve. 
 
 A vertical incision is made along the inner side of the 
 nose from the bony ridge of the nasal process of the supe- 
 rior maxillary bone to the ala of the nose; a second 
 incision is begun at the upper part of this incision and 
 carried outward along the lower margin of the orbit be- 
 yond its centre ; the lower flap is dissected up, and the 
 nerve is exposed. The upper flap is next lifted up with 
 the lower eyelid and eyeball, exposing the floor of the 
 orbit, and the infra-orbital canal can be recognized run- 
 ning backward and inward ; the canal is opened with a 
 knife or chisel, and the nerve is separated from the artery 
 and cut off as far back as may be necessary. The nerve 
 may also be reached by exposing the anterior wall of the 
 antrum, and trephining this and the posterior wall, and, 
 when found, may be cut off close to the exit of the main 
 trunk from the round foramen in the sphenoid bone. 
 
 Inferior Dental Nerve. 
 
 To expose this nerve an incision is made along the lower 
 jaw, from a point just behind the angle, and carried for- 
 ward to a point just in front of the edge of the masseter 
 muscle; the periosteum and masseter muscle are then 
 separated from the bone with an elevator, and the inferior 
 dental canal may be opened with a small trephine or 
 chisel ; the exposed nerve is then raised upon a hook and 
 resected. 
 
 Lingual Xerve. 
 
 The lingual nerve can be felt just behind the attach- 
 ment of the pterygo-maxillary ligament on the inner side 
 of the lower jaw, close to the bone, below the last molar 
 tooth ; the tongue should be drawn to one side and the 
 mucous membrane divided for an inch, parallel to the 
 
544 
 
 OPERATIONS ON NERVES. 
 
 alveolar process, beginning at the last molar tooth ; the 
 nerve is then found in the submucous tissue. 
 
 Facial Nerve. 
 
 This nerve may be exposed at the posterior border of 
 the ramus of the jaw by an incision extending from just 
 in front of the tragus of the ear to the angle of the jaw. 
 The parotid fascia is divided and the cervico-facial branch 
 may be exposed first, and can be followed back to its 
 junction with the temporo-facial branch. 
 
 Brachial Plexus. 
 
 The brachial plexus consists of the four lower cervical 
 nerves and the greater part of the first dorsal ; it lies be- 
 
 FlG. 446. 
 
 Resection of brachial plexus. 
 
 tween the anterior and middle scaleni muscles and crosses 
 the floor of the subclavian triangle at the base of the neck. 
 To expose the brachial plexus the neck and head are ex- 
 
THE ULNA AND RADIAL NERVES. 545 
 
 tended and the face is turned toward the opposite side ; an 
 incision is made half an inch above the clavicle, between 
 the sterno-cleido-roastoid and trapezius muscles, and is 
 carried forward for about three inches parallel to the an- 
 terior border of the trapezius. The skin and platysma are 
 divided, and the external jugular vein is either cut and 
 ligatured or held to one side ; the deep cervical fascia is 
 next opened in the line of the external incision, and the 
 outer border of the anterior scalenes muscle is felt for; 
 the brachial plexus is found just outside the latter, and is 
 exposed by careful dissection. (Fig. 446.) 
 
 Spinal Accessory Nerve. 
 
 To expose the spinal accessory nerve an incision about 
 three inches in length is made downward from the tip of 
 the mastoid process along the anterior border of the sterno- 
 mastoid muscle ; the cervical fascia should be divided and 
 the muscles strongly retracted to put the nerve on the 
 stretch. The nerve should be found external to the jugu- 
 lar vein, about an inch and a half below the tip of the 
 mastoid process on the fascia covering the rectus capitis 
 anticus major. 
 
 The Median Nerve. 
 
 The median nerve may be exposed at the bend of the 
 elbow or just above the wrist. To expose the median 
 nerve at the bend of the elbow an incision is made about 
 an inch and a half in length upon the inner edge of the 
 biceps tendon ; the bicipital fascia is divided and the 
 nerve is exposed at the inner side of the brachial artery. 
 The median nerve may also be exposed above the w r rist by 
 an incision two inches in length along the inner border of 
 the tendon of the palmaris longus muscle. 
 
 The Ulnar and Radial Nerves. 
 
 These nerves may be exposed by an incision similar to 
 that employed for ligation of the ulnar or radial artery. 
 
546 OPERATIONS ON NERVES. 
 
 MUSCULO-SPIRAL NERVE. 
 
 The musculo-spiral nerve is exposed by an incision in 
 the outer side of the arm above the elbow, from the upper 
 part of the supinator groove ; the fascia being divided, 
 the nerve is sought for at the bottom of this groove. 
 
 The Great Sciatic Nerve. 
 
 To expose the great sciatic nerve an incision three or 
 four inches in length is made vertically downward from 
 the gluteal fold at a point midway between the tuberosity 
 of the ischium and the great trochanter; the skin and fascia 
 being divided, the lower border of the gluteus maximus 
 and the hamstring muscles are exposed ; the nerve rests 
 on the external rotators of the thigh just in front of the 
 outer side of the hamstring muscles. 
 
 Internal Popliteal Nerve. 
 
 This nerve is exposed by an incision two inches in 
 length in the middle of the popliteal space. The nerve is 
 slightly external to the vein and artery, and is more super- 
 ficially placed. 
 
 External Popliteal Nerve. 
 
 This nerve is exposed by an incision two inches in 
 length, parallel and close to the inner side of the biceps 
 tendon, and lies close behind and to the inner side of the 
 biceps. 
 
 Anterior Crural Nerve. 
 
 This nerve is exposed by an incision about two inches 
 in length, extending from Poupart's ligament downward, 
 and about an inch to the outer side of the femoral artery. 
 
TENOTOMY OF SPECIAL TENDONS. 547 
 
 Operations upon Tendons. 
 Tenotomy. 
 
 This is an operation which consists in the division of a 
 tendon, and it may be done subcutaneously or by an open 
 operation. The former method of tenotomy is to be pre- 
 ferred in most cases, but in certain tendons which lie in 
 close proximity to important vessels and nerves it is 
 
 Fig. 447. 
 
 Sharp-pointed tenotome. 
 
 safer to employ the open operation. In dividing ten- 
 dons the parts should be placed in such a position as to 
 put the tendon upon the stretch. The instruments re- 
 quired are a sharp and blunt-pointed tenotome. (Fig. 
 447.) The sharp-pointed tenotome is used to make a 
 puncture down to the edge of the tendon, beiug entered 
 flatwise ; it is then withdrawn and a blunt-pointed teno- 
 tome (Fig. 448) is introduced through the puncture, passed 
 
 Fig. 448. 
 
 Blunt-pointed tenotome. 
 
 under the tendon, and turned so that the tendon rests 
 upon its cutting edge ; by a gentle rocking motion the 
 tendon is then divided, and the tenotome should be with- 
 drawn. 
 
 Tenotomy of Special Tendons. 
 
 Tendo Achillis. 
 
 The tenotome should be entered at the inner border of 
 the tendon about an inch above its attachment to the cal- 
 
548 
 
 TENOTOMY. 
 
 caneum (Fig 449) ; the heel should be depressed as much as 
 possible so as to make the tendon prominent, and the knife 
 
 Fig. 449. 
 
 Tenotomy of tendo A chillis. 
 
 should be entered. The posterior tibial artery, nerve, and 
 vein lie to the inner side, and are not likely to be injured 
 if the tendon is divided from this point. 
 
 Posterior Tibial Tendon. 
 
 This tendon may be divided above the malleolus. The 
 muscle is made tense by inverting the foot, and the teno- 
 tome is entered at the inner side of the tendon and passed 
 behind it. The posterior tibial tendon may also be divided 
 upon the side of the foot ; for this operation the foot is 
 inverted and the tenotome is passed from above down- 
 ward and passed under the upper border of the tendon at 
 a point half an inch below and in front of the tip of the 
 internal malleolus. 
 
 Anterior Tibial Tendon. 
 
 This tendon is divided upon the dorsal surface of the 
 foot just below the annular ligament of the ankle midway 
 between the two malleoli. 
 
 Peroneal Tendons. 
 
 The peroneal tendons may be divided about an inch 
 above the external malleolus, the tenotome being passed 
 
EXTENSOR PBOPEIUS POLLICIS. 549 
 
 from before backward between the fibula and the tendons, 
 or the tendons may be divided at a point midway between 
 the end of the malleolus and the tubercle of the cuboid. 
 
 Hamstring Tendons. 
 
 The inner hamstring consists of the tendons of the semi- 
 tendinous, semi-membranosis, gracilis and sartorius. The 
 external hamstring consists of the tendon of the biceps. 
 To divide either of these tendons the knife is entered at 
 the inner side of the tendon. In dividing the external 
 hamstring care should be taken to keep close to the tendon 
 of the biceps, as the external popliteal nerve lies close to 
 its inner border. 
 
 Adductor Longus. 
 
 To divide this tendon abduct the thigh and make the 
 muscle prominent near its insertion ; then pass the teno- 
 tome from without downward and inward. 
 
 Flexor Longus Pollicis. 
 
 This tendon may be divided on the first phalanx or near 
 the inner edge of the foot, where it may be made promi- 
 nent by strong extension of the great toe, the tenotome 
 being passed close to the border of the tendon. 
 
 Extensor Longus Digitorum. 
 
 These tendons are divided upon the dorsal surface of 
 the metatarsal bones, where they are quite prominent. 
 They may also be divided near the ankle. 
 
 Extensor Proprius Pollicis. 
 
 This tendon may be divided in the same incision used 
 for division of the long flexor of the toes, the point of the 
 knife being carried inward. 
 
 24* 
 
550 OPERATIONS ON TENDONS. 
 
 Sterno-cleido-mastoid. 
 
 In tenotomy of this muscle the sternal and clavicular 
 attachments are divided about an inch above the sternum 
 and clavicle. A puncture is made to the outer side of the 
 muscle with a sharp tenotome, and when the tendinous ex- 
 pansion of the muscle is reached it is withdrawn, and a 
 
 Fig. 450. 
 
 Tenotomy of sterno-mastoid. 
 
 blunt tenotome is substituted for it and the structure is 
 divided. The sternal attachment is divided through a 
 separate puncture in the same way. The external jugular 
 vein is to be avoided at the outer border of the muscle. 
 
 Suture of Tendons. 
 
 In bringing together the divided ends of tendons pri- 
 mary or secondary sutures are employed ; primary sutures 
 are those introduced immediately after the injury, and 
 secondary sutures are those introduced after retraction of 
 the ends has occurred and the wound has healed. 
 
SUTURE OF TENDONS, 
 
 551 
 
 Primary Suture of Tendons. 
 
 The material employed for sutures may be silk, silk- 
 worm-gut, catgut, or kangaroo-tendon, and one or more 
 sutures may be employed, being passed through the sub- 
 stance of the ends of the tendon and secured by tying ; the 
 divided sheath of the tendon, if possible, should be 
 brought together by fine silk sutures. (Fig. 451.) Very 
 
 Fig. 451. 
 
 Sutures passed through the substance of the ends of divided tendon. 
 
 marked retraction of the ends of the tendon is apt to occur, 
 and a considerable dissection is often required to bring them 
 into view. 
 
 Fig. 452. 
 
 Tendon-suture which does not easily tear out. (Stimson.) 
 
 When there is difficulty in bringing the ends of the 
 tendon together, and the sutures are apt to cut out, the 
 form of suture shown in Fig. 452 may be employed. 
 
 Secondary Sutures of Tendon. 
 
 In applying secondary sutures to tendons the principal 
 difficulty is often encountered in bringing the ends of the 
 
552 
 
 OPERATIONS ON TENDONS. 
 
 tendon in contact, and in holding them successfully in this 
 position. The ends of the tendon have first to be freshened, 
 and this may be done by cutting them obliquely, and 
 introducing a suture as shown in Fig. 453. This method 
 
 Fig. 453. 
 
 Oblique section of ends of tendon to increase surface of contact. (Stimson.) 
 
 of section presents a larger raw surface of the tendon for 
 union. When so large a gap exists between the ends of 
 the tendon that they cannot be brought into apposition, a 
 plastic operation may be performed upon their ends, which 
 
 Fig. 454. 
 
 Lengthening of retracted tendon by flaps. (Stimson.) 
 
 often overcomes the difficulty. This consists in making 
 a section half way through the tendons at some distance 
 from their ends, and splitting them toward their divided 
 extremities, and then turning out these flaps and securing 
 their ends by means of sutures. (Fig. 454.) 
 
TRACHEOTOMY. 553 
 
 Tracheotomy. 
 
 This operation consists in dividing the tissues over the 
 trachea in the median line of the neck, and after the trachea 
 has been exposed it is opened by dividing two or three of 
 the tracheal rings. 
 
 The operation of tracheotomy may be required to relieve 
 the dyspnoea dependent upon membranous or diphtheritic 
 laryngitis, growths in the larynx or trachea, growths ex- 
 ternal to these organs causing pressure upon them, oedema 
 of the mucous membrane of the larynx or trachea from 
 inflammation from burns or scalds, or from the inhalation 
 of irritating gases or the swallowing of corrosive liquids. 
 The operation may also be required for the removal of 
 foreign bodies from the larynx, trachea, or from the 
 bronchi, as well as for the relief of the dyspnoea due to 
 their presence, and it is also required in cases of fracture 
 or laceration of the larynx or trachea, and occasionally in 
 cases of spasm of the glottis, and in cases of glossitis, to 
 overcome the mechanical obstruction which prevents the 
 entrance of air into the air-passages. 
 
 The ease with which the operation is performed varies 
 much in different cases ; it is, as a rule, a much simpler 
 operation in adults than in children. In the latter sub- 
 jects the shortness of the neck, the relatively greater size 
 of the thyroid gland, and the possible presence of the 
 thymus body, the great vascularity of the parts, and the 
 abundance of adipose tissue, render the trachea difficult to 
 expose and open. 
 
 Under certain circumstances the operation may be per- 
 formed with very few instruments ; but if the surgeon has 
 the choice he will find it convenient to have at hand two 
 small scalpels, one short grooved director, a tenaculum, 
 two aneurism needles which may be used as retractors, one 
 pair of artery forceps, haemostatic forceps, two pairs of dis- 
 secting forceps, a pair of scissors, a sharp-pointed tenotome, 
 a pair of tracheal forceps, a tracheal dilator, tracheotomy 
 tubes, tapes, ligatures, sponges, a flexible catheter, and 
 feathers. The director should be short ; the ordinary 
 
554 TRACHEOTOMY. 
 
 grooved director is too long to use with satisfaction in 
 operating upon the short necks of children ; so that I 
 have had made a shorter and somewhat broader one, which 
 has a bevelled extremity, which allows it to be passed with 
 ease between the different layers of the tissue. (Fig. 455.) 
 
 Fig. 455. 
 
 Author's tracheotomy director. 
 
 Hcemostatie forceps are also of great use in controlling 
 hemorrhage during the operation in case of the division 
 of vessels which bleed freely, when the operator from the 
 urgency of the case does not think it justifiable to ligature 
 them at the time of their division. They may also be 
 employed und^r similar circumstances to clamp the isthmus 
 of the thyroid gland on either side of the trachea when it 
 becomes necessary to divide it to expose the trachea. 
 
 A sharp-pointed tenotome is the instrument I prefer to 
 employ in opening the trachea, as its sharp point enables 
 it to be easily thrust into the trachea, and its short cutting 
 surface and the narrowness of the blade obscure as little 
 as possible the line of incision, and thus enable the opera- 
 tor to see exactly where he is cutting. 
 
 Tracheal dilators of various kinds are employed, but 
 the most satisfactory tracheal dilator which I have employed 
 is that of Golding-Bird (Fig. 456), which is a self-retain- 
 ing instrument ; the blades are slipped through the tracheal 
 incision and are then expanded by turning the screw to 
 which they are attached. 
 
 Trousseau's tracheal dilator, the blades of which are 
 introduced through the incision in the trachea and are 
 expanded by bringing together the handles, is also a satis- 
 factory instrument (Fig. 457), but is not so useful as the 
 tracheal dilator previously mentioned, as it has to be 
 retained in position by the hand. Tracheal dilators may 
 
TRACHEOTOMY. 
 
 555 
 
 be improvised from bent hairpins or pieces of wire, which 
 will often serve a useful purpose where ordinary dilators 
 cannot be obtained. 
 
 Fig. 456. 
 
 Fig. 457. 
 
 Golding-Bird's tracheal dilator. 
 
 Trousseau's tracheal dilator. 
 
 It is also well to have at hand a number of pliable 
 feathers to be used in cleaning the trachea or larynx of 
 mucus or membrane after it has been opened, and by their 
 use this object can be accomplished with little risk of 
 injury to the mucous membrane. 
 
 Tracheal forceps, which are constructed with a double 
 spring and curved blades are also useful in removing mem- 
 brane or foreign bodies from the larynx above the wound 
 or from the trachea below the tracheal incision. (Fig. 458.) 
 
 Fig. 458. 
 
 Tracheal forceps. 
 
 Tracheotomy-tubes of various shapes are made of silver, 
 aluminum, hard and soft rubber, but the tube which I 
 think is the most satisfactory for general use is a silver 
 quarter-circle tube with a movable collar (Fig. 459), and 
 provided with a fenestrated guide. (Fig. 460). A good 
 tracheotomy-tube is one which inflicts the least possible 
 
556 
 
 TRACHEOTOMY. 
 
 injury upon the mucous membrane of the trachea, and to 
 insure this object the part of the tube within the trachea 
 
 Fig. 459. 
 
 Fig. 460. 
 
 Silver tracheotomy-tube. 
 
 Silver tracheotomy-tube with 
 fenestrated guide. 
 
 should lie exactly in its axis, and its free extremity should 
 be capable of as little movement as possible. The trache- 
 otomy-tube is held in position after being introduced by 
 means of tapes attached to the shield of the tube and tied 
 around the neck. 
 
 Position of Patient for Tracheotomy. 
 
 The best position in which to place the patient for this 
 operation is that which brings the neck into the greatest 
 prominence, and this can best be obtained by laying the 
 patient upon his back upon a firm table and placing under 
 the shoulders a round cushion ; or an empty wine-bottle, 
 or a roller-pin wrapped in towels will answer the same 
 purpose. If an anaesthetic is not used, the arms should 
 be held by an assistant, which is better than securing them 
 by a binder fastened around the chest, which restricts 
 respiratory movements. 
 
OPERATION OF TRACHEOTOMY. 557 
 
 Use of an Ancesthetic in Tracheotomy. 
 
 As a rule, I think it is better not to administer an anaes- 
 thetic in performing this operation, as little pain is expe- 
 rienced, in cases in which the dyspnoea is well marked, 
 after the incision in the skin has been made, and I have 
 seen the dyspnoea which was well marked before the use 
 of the anaesthetic suddenly become so alarming that the 
 trachea had to be opened before it was thoroughly exposed, 
 which is a procedure always attended with risk. So strong 
 is my conviction that the risks of the operation are much 
 increased by the employment of an anaesthetic that in later 
 years I have abandoned its use. 
 
 Operation of Tracheotomy. 
 
 The trachea may be opened above the isthmus of the 
 thyroid gland or below it, and these operations constitute 
 respectively the high and low operations. 
 
 The high operation is generally selected, because at this 
 point the trachea is more superficial and is more easily 
 exposed, whereas in the low operation the trachea is more 
 difficult to expose by reason of its relatively greater depth, 
 the large size and number of the veins, and its proximity 
 to the large arterial trunks. 
 
 The patient being placed in position, and the best posi- 
 tion is secured by placing a firm pad under the shoulders 
 (Fig. 461), or the head may be dropped over the edge of 
 the table, the object being to secure a free exposure of the 
 neck and to render the trachea as superficial as possi- 
 ble. The operator stands at the head of the patient ; this 
 position I prefer, as it is easier from this point to keep the 
 incisions exactly in the median line of the neck. The 
 operator next makes himself familiar with the landmarks 
 of the neck ; locating the position of the cricoid cartilage, 
 he makes an incision through the skin in the median line 
 of the neck from one and a half to two inches in length, 
 the position of the cricoid cartilage being the middle point. 
 
558 TRACHEOTOMY. 
 
 There is no disadvantage in making a longer incision if a 
 freer exposure of the parts is required. Having divided 
 the skin, the operator will often see a large vein lying in 
 the superficial fascia — the superficial anterior jugular ; 
 this should be displaced, and the fascia divided upon the 
 director. 
 
 Fig. 461. 
 
 
 r* 
 
 m&m 
 
 V 
 
 
 1m' 
 
 
 
 -Cisjy 
 
 
 ■:\ : .^y ■■]:::::■ --f. : ! 
 
 
 
 HUB 
 
 
 
 
 ■';;,. :■':;.;::■■:■,; 
 
 1 WtK^ 
 
 ■%: 
 
 Position of patient for tracheotomy. 
 
 The surgeon should keep his incisions strictly in the 
 median line of the neck, for this is the line of safety ; and 
 he should be careful, as the wound increases in depth, not 
 to make the incisions too short, so that it becomes funnel- 
 shaped. 
 
 When the deep fascia is exposed it should be picked up 
 and divided upon the director, and any large veins in the 
 line of the wound should be carefully displaced, or, if 
 this is impossible, they should be ligated on each side and 
 then divided between the ligatures. 
 
 The operator now looks for the intermuscular space 
 between the sterno-hyoid and the sterno-thyroid muscles, 
 which can generally be found without difficulty, and the 
 muscles are now separated in this line with the handle of 
 the knife or with the director, and the isthmus of the thy- 
 roid gland will be exposed. The muscles should now be 
 held aside by retractors placed on either side. A caution 
 
OPERATION OF TRACHEOTOMY. 559 
 
 here as to the use of retractors may not be out of place : 
 the operator should place them himself and allow the 
 assistants to hold them. I once almost lost a case in 
 which I had the trachea exposed, and while I turned aside 
 to pick up a knife with which to open it, my assistant, in 
 replacing a retractor which had slipped, included the 
 movable trachea in the grasp of the retractor, pulling it 
 to one side and completely shutting off respiration ; when 
 I attempted to find the trachea to open it I could only feel 
 the anterior surface of the vertebrae at the bottom of the 
 wound, and it was only when I appreciated what had 
 occurred, and lifted the retractor, allowing the trachea to 
 spring back iuto its normal position, that I was able to 
 open it. Mr. Durham and Mr. Marsh mention somewhat 
 similar cases in which the trachea and vessels were held 
 aside with retractors by assistants until the surgeon had 
 exposed the cervical vertebrae. 
 
 The operator should carefully explore the wound with 
 the finger, to locate exactly the position of the trachea, 
 and to ascertain, if possible, the presence of any anomalous 
 arteries. 
 
 The isthmus of the thyroid gland having been exposed, 
 generally a position over the first three tracheal rings, 
 the gland is usually surrounded by a plexus of veins 
 which should be displaced with the director, or, if this 
 is impossible, they should be ligated on each side and 
 divided between the ligatures. The thyroid isthmus is 
 next displaced upward or downward, according as the 
 surgeon desires to open the trachea below or above this 
 body. This is often done without difficulty, especially its 
 upward displacement ; but when there is difficulty in dis- 
 placing it downward, a procedure recommended by Bose 
 may be employed, which consists in making a transverse 
 incision across the cricoid cartilage to divide the layer of 
 fascia by which the isthmus is bound down ; a director is 
 then passed into this incision, and the isthmus is gently 
 depressed without difficulty. 
 
 Having displaced the isthmus of the thyroid gland 
 upward or downward, the trachea, yellowish-white in 
 
560 
 
 TRACHEOTOMY. 
 
 appearance, covered by the tracheal fascia, should be ex- 
 posed ; this fascia should next be thoroughly broken up 
 with the director or handle of the knife so as to bare the 
 trachea, and in doing this the operator can feel it crepitate 
 under the finger from the suction of air drawn in with 
 inspiration. Having arrived at this stage of the opera- 
 tion the operator should examine the wound to see that 
 it is free from hemorrhage, and he should also replace the 
 retractors so as to expose as large a portion as possible of 
 the trachea, for, be the case ever so urgent, he now feels 
 
 Fig. 462. 
 
 Opening the trachea. (Liston.) 
 
 assured that he can open the trachea in a moment if the 
 breathing should cease. The trachea is now fixed with a 
 tenaculum, introduced into it a little to one side of the 
 median line ; an incision is made into it with a narrow 
 knife from below upward, from one-half to three-fourths 
 of an inch in length (Fig. 462), care being taken to see 
 that this incision is in the median line, for if the trachea 
 be opened by a lateral incision the wound does not heal 
 so promptly and the tracheotomy-tube does not fit well, 
 and its lower extremity may cause injury to the mucous 
 membrane of the trachea. If the wound be a deep one, 
 
OPERATION OF TRACHEOTOMY. 561 
 
 after fixing the trachea with the tenaculum the operator 
 may lift it slightly from its bed, thereby bringing it more 
 prominently into view and making it more superficial in 
 the wound, thus facilitating its opening. As soon as the 
 incision is made into the trachea there is a gush of air 
 from the wound in the trachea, mixed with blood or mem- 
 brane ; this should be wiped away with a sponge and a 
 tracheal dilator should next be introduced and the trachea 
 should be cleared of membrane, if it is present in the re- 
 gion of the wound, with a feather or with forceps. The 
 tracheotomy-tube is next introduced and is secured in 
 position by tapes tied around the neck. 
 
 If respiration has ceased, artificial respiration should be 
 resorted to or the use of a tube attached to a bellows, or 
 Fell's apparatus, and these efforts should be continued for 
 at least fifteen minutes, for I have seen resuscitation take 
 place in patients who were apparently dead by a persistent 
 employment of artificial respiration. 
 
 The care of the tracheotomy-tube is a matter of some 
 importance after its introduction ; the inner tube should 
 be removed at short intervals, washed and replaced, and 
 if the operation has been done for an inflammatory condi- 
 tion of the larynx or trachea a moistened feather should 
 occasionally be passed through the tube into the trachea 
 to withdraw any mncus or membrane which is present. 
 In cases of croup after tracheotomy the use of a spray of 
 steam or of a spray composed of 
 
 Carbonate of sodium 5j to 5ijss. 
 
 Glycerin fgij. 
 
 Water f'5vi. 
 
 applied by means of a steam atomizer, the spray being 
 directed over the opening of the tube, will be found most 
 satisfactory in softening the discharges and thus facilitat- 
 ing their expulsion through the tube. 
 
 The tracheotomy-tube is usually allowed to remain in 
 the trachea from five to ten days ; its permanent removal 
 is indicated as soon as the patient is able to breathe through 
 the larynx with the wound in the trachea closed ; its use 
 
562 LARYNGOTOMY. 
 
 may be required for a longer time, but as soon as the in- 
 dication for its presence has disappeared the sooner it is 
 removed the better, for its presence sometimes sets up a 
 troublesome tracheitis. After its removal the wound 
 rapidly diminishes in size, the healing taking place by 
 granulation and contraction. Difficulty is occasionally 
 met with in the permanent removal of tracheotomy-tubes; 
 for the causes and treatment of this complication the reader 
 is referred to special works upon tracheotomy. 
 
 Where the operation for tracheotomy is done for the 
 removal of foreign bodies from the air-passages, the steps 
 of the operation are the same, but after the removal of 
 the foreign body the treatment of the wound is somewhat 
 different. If the foreign body has remained in the trachea 
 only for a short time, the wound in the soft parts may be 
 closed by means of sutures or may be allowed to remain 
 open, being covered by a piece of moistened gauze, and 
 the use of the steam spray is here also beneficial for a few 
 days. If, however, the body has remained in the larynx, 
 trachea, or one of the bronchi for some time, and has set 
 up a certain amount of inflammatory trouble, it is better 
 to introduce a tracheotomy-tube and allow it to remain 
 for a few days. If it is found impossible to locate or re- 
 move the foreign body at the time of operation, a trache- 
 otomy-tube should be introduced and allowed to remain 
 until the foreign body is expelled through the tube or 
 removed subsequently by means of forceps. 
 
 Laryngectomy. 
 
 In this operation an opening is made into the air-passages 
 through the erico-thyroid membrane. It is a simple opera- 
 tion, and one which is practically free from risk, and can 
 therefore be performed much more rapidly and safely in 
 urgent cases than tracheotomy. 
 
 In this operation the same objection exists to the use of 
 an anaesthetic as in tracheotomy, and therefore it should be 
 dispensed with. The patient being placed in the recum- 
 
LARYNGO-TRACHEOTOMY. 563 
 
 bent posture, with the shoulders slightly elevated and the 
 head thrown back to make the neck as prominent as pos- 
 sible, the surgeon feels for the prominence of the thyroid 
 cartilage , and steadying the larynx between the finger and 
 thumb of the left hand, he makes an incision in the median 
 line over the centre of the thyroid cartilage and extending 
 downward for an inch or an inch and a half. The skin 
 and superficial fascia being divided, the fascia between the 
 sterno-hyoid muscles and the areolar tissue is exposed and 
 divided, and the crico-thyroid membrane is exposed. The 
 knife is then passed transversely through the membrane 
 into the larynx, care being taken that both that membrane 
 and the mucous membrane which covers its inner surface 
 are divided at the same time. As soon as the knife enters 
 the cavity of the larynx blood and mucus will be forcibly 
 expelled. 
 
 The wound should be carefully enlarged and a tube 
 introduced, which differs from the ordinary traclieotomy- 
 tube in being slightly flattened ; this is secured in position 
 by tapes tied around the neck as in the case of the ordi- 
 nary tracheal tube. The only bleeding which is likely to 
 occur is from the crico-thyroid arteries or veins, and if 
 these cannot be avoided, and are divided in the operation, 
 they should be temporarily secured by haemostatic forceps 
 or ligatured, and if the case is not extremely urgent, all 
 bleeding should be arrested before the crico-thyroid mem- 
 brane is incised. 
 
 The after-treatment of cases of laryngotomy is similar 
 to that of cases of tracheotomy ; the same attention is 
 required in the care of the tube and in the general man- 
 agement of the patient. 
 
 Laryngo-tracheotomy. 
 
 This operation consists in making an incision into the 
 air-passages by dividing one or two of the upper rings of 
 the trachea, the crico-tracheal membrane, the cricoid 
 cartilage, and the crico-thyroid membrane. This opera- 
 
564 
 
 INTUBATION OF THE LARYNX, 
 
 tion is employed in cases where, from the age of the 
 patient, the crico-thyroid space is too small to admit of a 
 sufficient opening, or in those in which, for any reason, 
 the surgeon does not deem it advisable to attempt to open 
 the trachea lower down. The incision in the skin and 
 superficial fascia of the neck is made in the same manner 
 as in the operation of laryngotomy, but is carried a little 
 further downward. It may be necessary to displace the 
 isthmus of the thyroid gland downward to expose the 
 upper portion of the trachea, and when the trachea is 
 exposed the incision should be made through this and the 
 cricoid cartilage from below upward. 
 
 This operation is more often performed in the high 
 operation of tracheotomy than is generally supposed. A 
 tracheotomy tube is introduced through the wound and 
 secured by tapes tied around the neck, and the care of the 
 tube should be similar to that in cases of tracheotomy. 
 
 Intubation of the Larynx. 
 
 This procedure, at the present time, is widely employed 
 as a substitute for tracheotomy in the treatment of the 
 
 Fig. 463. 
 
 Mouth-gag. 
 
INTUBATION OF THE LARYNX. 
 
 565 
 
 dyspnoea due to inflammatory affections of the larynx or 
 trachea, or stenosis of the larynx; it consists in the intro- 
 duction of a metallic tube into the larynx, which is allowed 
 to remain in place for a few days. The operation has been 
 recently reintroduced to the profession by Dr. O'Dwyer, of 
 New York, who has devised a set of ingenious instruments 
 for the purpose of laryngeal intubation. 
 
 Fig. 464. 
 
 Intubation-tube and introductory 
 
 The instruments required are a mouth-gag (Fig. 463), 
 with which the jaws are separated and held open ; an in- 
 strument for the introduction of the tube, which is fastened 
 to the obturator which fills the cavity of the tube (Fig. 
 
 Fig. 465. 
 
 Intubation-tube extractor. 
 
 464), and an instrument for extracting the tube after it 
 has been placed in the larynx. (Fig. 465.) The tubes 
 are of metal and have a collar which rests upon the 
 false cords and bulge slightly toward their middle and 
 again taper toward their lower extremity ; at the collar 
 of the tube there is a perforation through which a strand 
 of silk is passed which is made into a loop ; this is used 
 
 25 
 
566 
 
 INTUBATION OF THE LARYNX. 
 
 Fig. 466. 
 
 to allow the operator to remove the tube if on its introduc- 
 tion it is found to have passed into the oesophagus irjstead 
 of the larynx, and also is used to remove 
 the tube if it becomes occluded with mem- 
 brane while in the larynx. The intuba- 
 tion set now in common use is provided 
 with a scale of six tubes ranging in size 
 from such as are suited for a child of one 
 year or less up to the age of twelve or 
 fourteen years. (Fig. 466.) 
 
 In performing the operation of intu- 
 bation of the larynx the child is placed 
 upon the lap of the nurse or assistant, 
 wrapped in a blanket, and the arms are 
 secured by the nurse holding the elbows 
 so as not to interfere with the respiratory 
 movements. 
 
 The patient's head is next secured by 
 an assistant, and the position of the head, 
 neck, and body should be as if he were 
 hung from the top of the head, and this 
 position should be firmly maintained dur- 
 ing the insertion of the tube. The mouth-gag is next in- 
 serted upon the left side and the blades dilated so as to open 
 the jaws widely, and as the gag is self-retaining this position 
 is easily maintained. The jaws being thus held open, the 
 operator, sitting on a chair facing the patient (Fig. 467), next 
 introduces the index-finger of the left hand, protected by a 
 strip of adhesive plaster, into the mouth and passes it over 
 the tongue until he feels the epiglottis ; the introducing- 
 instrument to which the tube is attached is held in the right 
 hand, and this is now introduced into the mouth, first seeing 
 that the silken loop is free, and it is swept over the tongue 
 and passed down until it touches the epiglottis; this is 
 hooked up by the index-finger of the left hand and the tube 
 is passed into the larynx; the index-finger of the left hand 
 is then transferred to the edge of the tube, and by drawing 
 upon the trigger of the instrument with the index-finger 
 of the right hand the obturator is detached and the instru- 
 
 Scale of intubation- 
 tubes. 
 
INTUBATION OF THE LARYNX. 
 
 567 
 
 ment is withdrawn, and before removing the finger it is 
 well to place it upon the head of the tube and to sink it 
 well into the larynx. As soon as the obturator is removed 
 there is usually a violent expiratory effort which is accom- 
 panied by a gush of mucus, muco-purulent matter, or mem- 
 brane from the tube, and after this escapes the breathing 
 
 Fig. 467. 
 
 *4 
 
 Intubation of the larynx. 
 
 is usually satisfactorily established. If the operator has 
 passed the tube into the oesophagus and has detached it 
 from the introducing-instrument, no improvement in the 
 respiration takes place ; it should then be withdrawn by 
 the silk loop and attached to the obturator and another 
 attempt should be made to introduce it into the larynx. 
 
 The mistake which inexperienced operators make in 
 attempting to introduce the tube is in not hugging the 
 
568 INTUBATION OF THE LARYNX. 
 
 posterior surface of the tongue closely, so that they pass 
 the tube over the epiglottis into the oesophagus. 
 
 The silken loop may be brought out at one side of the 
 mouth and fastened around the ear or fastened to the side 
 of the face by strips of adhesive plaster for a few hours, 
 so that by drawing upon it the nurse or attendant is able 
 to withdraw the tube instantly if it should become ob- 
 structed with membrane ; or, if it is coughed up, by this 
 means it may be withdrawn from the oesophagus if it has 
 not been expelled from the mouth. Some operators keep 
 the loop attached to the tube during the time it is retained 
 in the larynx. I prefer to remove it after the tube is se- 
 curely placed in the larynx, and remove the tube by means 
 of the extracting-instrument when required. The tube is 
 removed at the end of the second or third day, and if the 
 child is able to breathe comfortably for an hour or two it 
 is not reintroduced ; if, however, the dyspnoea returns it 
 is reintroduced and allowed to remain one or two days 
 longer ; several attempts may have to be made before the 
 tube is permanently removed, but it is usually dispensed 
 with from the third to the eighth day. 
 
 The most serious complication which is apt to occur 
 during the introduction of the intubation-tube is the de- 
 tachment and pushing of a mass of membrane in front of 
 the tube into the trachea ; if this is too large to be expelled 
 through the tube, the breathing is suddenly arrested. The 
 tube should be removed at once, and if the mass of membrane 
 does not escape upon the expiratory efforts of the patient 
 the trachea should be rapidly opened as the only means 
 of re-establishing the respiratory function. So much do 
 I dread this accident, which has occurred in a few cases, 
 that I never introduce the intubation-tube without having 
 at hand the necessary instruments to do a tracheotomy if 
 it should be suddenly required, and if possible obtain the 
 consent of the parents or friends to perform tracheotomy 
 if it should be indicated. 
 
 One of the greatest troubles after intubation of the 
 larynx is the satisfactory feeding of the patient ; liquids 
 as a rule are not swallowed well, a portion of them escaping 
 
INTUBATION 01 THE LARYNX. 
 
 569 
 
 into the tube, causing coughing and difficulty in breathing. 
 The diet I usually order is of semi-solids, such as corn- 
 starch, soft-boiled eggs, and mush ; and if these are not 
 
 FIG. 468. 
 
 Feeding a case of intubation of the larynx. 
 
 well swallowed, it may be necessary to resort to nutritious 
 enemata or the use of a stomach-tube to introduce food. 
 Some patients swallow liquids and semi-solids quite well 
 if the head is dropped a little lower than the body during 
 the act of deglutition. (Fig. 468.) 
 
570 OPERATIONS. 
 
 Operations upon the Kidney. 
 
 Nephrotomy. 
 
 In this operation an incision is made into the kidney. 
 The incision for exposure of the kidney is four inches in 
 length, and should be made from a point two and a half 
 inches from the spine, half an inch below the last rib and 
 parallel with it. The latissimus dorsi, external and internal 
 oblique, and transversalis muscles are divided, and the 
 lumbar fascia is opened, exposing the perinephric fat ; the 
 kidney is then reached by displacing this. 
 
 Lumbar Nephrectomy. 
 
 The incision is the same as for nephrectomy, but the 
 wound can be enlarged by another incision at right-angles 
 to the first, if more space is required. After the kidney 
 is exposed its capsule is incised, and the finger is passed 
 around the organ to separate it freely from the capsule. 
 When the ureter is recognized it is brought into view, liga- 
 tured, and cut off. The pedicle containing the vessels is 
 next tied, and it is then divided in advance of the ligature 
 with scissors, and the kidney is removed. 
 
 Abdominal Nephrectomy. 
 
 To reach the kidney by abdominal incision an incision 
 four inches long is made at the outer border of the rectus 
 muscle; the abdomen is opened and the viscera turned 
 aside ; the kidney is exposed and the capsule is opened ; 
 the ureter is ligated and the vessels are tied and the organ 
 is removed. 
 
 Nephrorrhaphy. 
 
 Nephrorrhaphy is an operation in which the kidney is 
 exposed through the same incision as that for nephrotomy, 
 with the object of suturing a movable kidney fast in its 
 
INGUINAL COLOTOMY, OB COLOSTOMY. 
 
 571 
 
 normal position in the back ; when the kidney has been 
 reached a number of sutures are introduced into the cap- 
 sule of the kidney, and secured to the fibrous and muscular 
 tissue of the incision. 
 
 Operations upon the Colon. 
 
 Lumbar Colotomy, or Colostomy. 
 
 In performing lumbar colotomy on the left side, the 
 patient should be placed upon the right side, and a pillow 
 should be placed under the loin to make the left side more 
 prominent. An incision four inches in length is made 
 midway between the last rib and the crest of the ilium, 
 the centre of the incision corresponding to the point mid- 
 way between the anterior superior and posterior superior 
 processes of the ileum ; the tissues are divided to the full 
 
 Fig. 469. 
 
 Incision in lumbar colotomy — dotted line shows situation of the colon. 
 
 extent of the wound, until the lumbar fascia and edge of 
 the quadratus lumborum muscle have been reached ; the 
 former being cut through and the fascia divided, the bowel 
 is exposed, when it is brought to the surface and fastened 
 by sutures and opened. 
 
572 OPERATIONS. 
 
 Inguinal Colotomy, or Colostomy. 
 
 In the operation of inguinal colotomy an incision two 
 or three inches in length is made on the left side parallel 
 to and one inch above Poupart ? s ligament, with its centre 
 on the level of the anterior superior spine of the ileum, or 
 a little lower, or as practised by Ball, the colon may be ex- 
 posed by an incision two and a half inches in length, fol- 
 lowing the line of the linea semilunaris, stopping just short 
 of Pou part's ligament, the tissues are divided layer by layer, 
 and the peritoneum is opened ; the skin and parietal peri- 
 toneum may be united by a few sutures, and the gut is 
 then brought out at the wound and fastened to its margins 
 by fine sutures and is next opened. 
 
 Kemoval of the Appendix Vermiformis. 
 
 To expose the appendix an incision three to four inches 
 in length at the outer border of the right rectus muscle is 
 made, with its centre on a line drawn between the umbilicus 
 and the anterior superior spine of the ileum ; the tissues 
 are divided layer by layer and the peritoneum is picked 
 up and opened ; the anterior longitudinal band is recog- 
 nized and traced down to its origin at the appendix. 
 When the appendix is found the meso-appendix is liga- 
 tured and the appendix is removed. In removing the 
 appendix a circular incision may be made around it near 
 its base, and the cuff* may be turned back ; the body of 
 the appendix is then ligated, and the turned-back cuff is 
 then brought forward and united by fine silk or catgut 
 sutures. 
 
 Left Lateral Lithotomy. 
 
 In performing this operation the patient is placed upon 
 his back, the hands and feet are secured together, the 
 bladder is injected with a few ounces of boric solution ; 
 a grooved staff is introduced into the bladder, and the 
 operator first passes one finger into the rectum to locate 
 
SUPRAPUBIC LITHOTOMY. 
 
 573 
 
 the position of the staff as regards the prostate ; an inci- 
 sion is then made a little to the left of the raphe of the 
 perineum, a quarter to half an inch in front of the anus, 
 
 Fig. 470. 
 
 Deep incision in lateral lithotomy. (Fergusson.) 
 
 and is carried downward by careful strokes of the knife 
 until the staff is reached, about half an inch in front of 
 the prostate. When the point of the knife enters the 
 groove in the staff it is pushed backward, keeping it well 
 in the groove until the prostate is incised and a gush of 
 fluid escapes along the knife ; the index-finger is then in- 
 troduced and the stone-located ; stone forceps are next 
 introduced and the stone is removed. (Fig. 470.) 
 
 Suprapubic Lithotomy. 
 
 The operation of opening the bladder above the pubes 
 may be performed for the removal of stone from the blad- 
 der, or for the extirpation of growths, or for drainage of 
 the bladder. The hair on the pubes should be shaved off 
 and the bladder should be injected with a few ounces of 
 fluid and a rubber band tied around the penis ; a small 
 
 25* 
 
574 
 
 OPERATIONS. 
 
 rubber bag is then introduced into the rectum empty and 
 filled with air or water. An incision two or three inches 
 in length is made in the median line of the abdomen just 
 above the symphysis pubis, and is deepened gradually 
 until the fascia is reached ; this is divided and exposes the 
 prevesical fat ; when this is displaced the wall of the blad- 
 der is exposed to view. A tenaculum is next introduced 
 into the highest part of the vesical wall to fix it, and a 
 knife is then thrust through the wall of the bladder and 
 the incision is carried downward about an inch. After 
 the bladder is opened forceps are introduced and the cal- 
 culus is removed. If the bladder-walls are healthy, the 
 wound may be sutured with stitches, which do not pass 
 through the mucous coat. The external wound is then 
 sutured and the bladder is drained by a soft catheter passed 
 by the urethra. If the bladder-walls are much diseased, 
 the wound is left open, and drainage is effected by a 
 rubber tube passed through the suprapubic wound in the 
 bladder. 
 
 Circumcision. 
 
 Circumcision is performed by drawing the prepuce for- 
 ward and then enclosing it in a pair of clamp-forceps 
 
 Fig. 471. 
 
 Circumcision. 
 
CHOLECYSTOTOMY. 575 
 
 placed obliquely just in front of the glans. (Fig. 471.) 
 The prepuce is next divided with a straight bistoury, the 
 forceps are removed, and the skin and mucous membrane 
 retract. The mucous membrane, if adherent, is dissected 
 loose from the glans, and, if redundant, is trimmed off with 
 scissors to make it correspond to the line of skin incision, 
 and the cut edge of the mucous membrane is next fastened 
 to the cut edge of the skin by a few sutures of silk or cat- 
 
 gut. 
 
 Kemoval of the Testicle. 
 
 In removing the testicle a longitudinal incision is made 
 over the upper part of the gland and cord and the en- 
 velopes of the testicle and cord are divided ; the cord is 
 then exposed and is ligatured, or the different elements of 
 the cord may be separated and tied independently ; the 
 gland is then removed and the cord divided in advance 
 of the ligature. 
 
 Operation for Varicocele. 
 
 In operating for varicocele the dilated veins of the sper- 
 matic cord may be ligatured by a subcutaneous ligature 
 passed around the cord, care being taken to see that the 
 vas deferens is not included. Or the veins of the cord are 
 exposed by an incision at the upper part of the scrotum 
 over the cord almost an inch and a half in length. The 
 veins are exposed and the larger portion of them are iso- 
 lated, and two ligatures are passed around the mass of 
 veins about an inch or an inch and a half apart and firmly 
 tied. The portion of the cord between the ligatures is 
 excised and the divided ends of the veins are brought in 
 contact by tying together the ends of the ligatures upon 
 the proximal and distal ends of the veins ; the wound is 
 drained and closed with sutures. 
 
 Cholecystotomy. 
 
 An incision three or four inches in length is made verti- 
 cally downward from the lower border of the liver oppo- 
 
576 OPERATIONS. 
 
 site the tip of the lower border of the tenth rib ; the tissues 
 are divided and the peritoneum is opened. The gall- 
 bladder is then exposed, opened and sutured to the edges 
 of the wound. If the gall-duct is to be explored, this is 
 done with the finger from without or by a probe. After 
 the gall-bladder has been opened and the stone removed, 
 it may be closed by sutures, or it may be left open, its 
 edges being sutured to the external wound. 
 
 External GEsophagotomy. 
 
 A sound is passed through the mouth into the oesophagus 
 until its point comes in contact with the stricture of the 
 oesophagus or the foreign body which requires removal. 
 An incision is then made from a point one inch above the 
 sternum to the line of the upper border of the thyroid 
 cartilage on the inner side of the sterno-cleido mastoid 
 muscle ; the anterior jugular vein is displaced, the fascia is 
 divided, the omo-hyoid muscle is drawn aside, the sterno- 
 mastoid muscle and the vessels are drawn to the outer side 
 with blunt hooks, then by dissecting down with the finger 
 the oesophagus is exposed ; the sound which has been 
 passed into the oesophagus can easily be felt, and the 
 oesophagus is incised upon the point of this sound. If a 
 permanent opening is desired, the edges of the oesophagus 
 are sutured to the skin. 
 
 Gastrostomy. 
 
 An incision one and a half to two inches is made 
 parallel to and a finger's breadth from the border of the 
 left costal cartilage, ending opposite the border of the tenth 
 rib ; the tissues are divided layer by layer until the peri- 
 toneum is reached (Fig. 472). The latter membrane 
 should be pinched up and opened ; the stomach is recog- 
 nized and brought out of the wound ; the parietal perito- 
 neum is stitched to the skin around the wound, and a 
 fold of the unopened stomach is brought out of the wound 
 
OSTEOTOMY. 
 
 577 
 
 and transfixed by pins. The opening of the stomach is 
 delayed for some days if possible, to allow of the forma- 
 
 Fig. 472. 
 
 Anatomical relations of stomach. (Stimson.) 
 
 tion of adhesions between its surface and the parietal 
 peritoneum. 
 
 Osteotomy. 
 
 This operation consists in dividing the bones with a saw 
 or osteotome, and is employed to correct deformities of the 
 bones. 
 
 Fig. 473. 
 
 >*s^g. 
 
 Adams' saw. 
 
 The instruments employed are a saw with short cutting 
 surface, Adams's saw (Fig. 473), or osteotomes (Fig. 474) ; 
 
 Fig. 474. 
 
 ggpSEigBBSa ggg 
 
 Macewen's osteotome. 
 
 3X9 
 
 a heavy mallet is used to drive the osteotome through the 
 bone. Osteotomy is employed to correct deformities of the 
 
578 
 
 OPERATIONS. 
 
 femur following coxalgia, and here the femur is divided 
 either at the neck, Adams's operation, or just below the 
 trochanters, Gant's operation. 
 
 Osteotomy of the Femur below the Trochanters. 
 
 A puncture is made with a bistoury oil the outer side of 
 the femur just below the great trochanter, and is carried 
 down to the bone ; the blade of the saw is then introduced 
 and the femur is divided by the saw from before backward. 
 The femur may also be divided in this position with an 
 osteotome. 
 
 Osteotomy for Knock-knee. 
 
 The operation employed to correct this deformity is a 
 transverse section of the femur above the condyles. (Fig. 
 475.) In the operation of supra-condyloid osteotomy the 
 
 Fig. 475. 
 
 A. Epiphyseal line. C. Line of bone section in supra-condyloid osteotomy. 
 
 knee is flexed and supported on a sand-bag. A longi- 
 tudinal incision one inch in length is made half an inch 
 
OSTEOTOMY. 579 
 
 anterior to the tendon of the abductor magnus and a 
 finger's breadth above the internal condyle ; the knife is 
 carried down to the bone, and before it is withdrawn an 
 osteotome is introduced and its edge turned so as to divide 
 the bone transversely. The section of the bone is accom- 
 plished by the use of the osteotome and mallet. After the 
 bone has been divided the deformity is corrected, the 
 wound is closed, and the limb is put up in a plaster-of- 
 Paris dressing in the corrected position. 
 
 Osteotomy for Bowlegs. 
 
 To correct this deformity the tibia and fibula are divided 
 at the point of greatest bowing with an osteotome. The 
 fibula is divided first at the point of greatest bowing by 
 an osteotome entered through a puncture over the fibula, 
 and next the tibia is divided in the same manner. The 
 bones being divided, the deformity is corrected and the 
 limb is put up in a plaster-of- Paris dressing in the cor- 
 rected position. Osteotomy may also be employed to 
 correct deformities in other positions, or for the deformity 
 resulting from fractures united in faulty position. 
 
INDEX. 
 
 4 BDOMINAL aorta, ligation of, 
 i\ 444 
 
 nephrectomy, 570 
 
 tourniquet, 510 
 Abscess, acute, 304 
 
 chronic, 305 
 
 diffused, 306 
 
 treatment of, 304 
 
 tuberculous, 305 
 Absorbent cotton, 160 
 A.-C.-E. mixture, 240 
 Acid, boric, 130 
 
 carbolic, 126 
 Actual cautery, 186 
 Acupressure in arterial hemor- 
 rhage, 294 
 
 method of, 294 et seq. 
 Acupuncture, 183 
 
 needles, 183 
 Acute abscess, 304 
 Adductor longus tendon, tenotomy 
 
 of, 549 
 Adhesive plaster, 164 
 Aluminum aceticum, 128 
 Ambulant method of treatment in 
 
 fractures of the leg 380 
 American bandage of foot, 88 
 Amputating knives, 464 
 
 saws, 465 
 Amputation or amputations, 459 
 
 at ankle-joint, 497 
 Hancock's, 500 
 PirogofFs, 498 
 Koux's, 500 
 Syme's, 497 
 
 of arm, 481 
 
 circular, 460 
 
 details of, 469 
 
 at the elbow, 480 
 
 Amputation, elliptical, 462 
 of fingers, 473 
 flaps in, 460 
 of the foot, 489 
 
 Chorpart's, 495 
 
 Hey's, 495 
 
 Lisfranc's, 494 
 
 Tripier's, 501 
 of forearm, 479 
 of hand, 473 
 
 carpo-metacarpal, 477 
 hemorrhage in, control of, 469 
 of hip-joint, 510 
 
 Guthrie's, 512 
 
 Wyeth's,513 
 pins in, 513 
 instruments for, 464 
 at knee-joint, 505 
 
 Carden's, 506 
 
 Gritti's, 507 
 of leg, 501 
 
 of metacarpal bones, 476 
 of metatarsal bones, 491 
 modified circular, 463 
 oval, 462 
 
 periosteal flaps in, 464 
 redressing of, 471 
 retractors for, 467 
 above shoulder-joint, 488 
 at shoulder-joint, 484 
 
 Dupuytren's, 486 
 
 Larrey's, 485 
 
 Lisfranc's, 487 
 
 Spence's, 487 
 
 Wyeth's pins in, 485 
 subastragaloid, 497 
 tarso-metatarsal, 493 
 Teale's, 463 
 of thigh, 507 
 
582 
 
 INDEX. 
 
 Amputation of toes, 489 
 tourniquets in, 469 
 at wrist, 478 
 Anaesthesia from chloride of ethyl, 
 229 
 from cocaine, 230 
 from cold, 229 
 infiltration, 231 
 local, 229 
 
 from rapid respiration, 230 
 Anaesthetics, 229 
 
 in tracheotomy, 557 
 Aneurism needle, 293 
 Ankle, dislocations of, 418 
 Ankle-joint, amputation at, 497 
 Hancock's, 500 
 PirogofFs, 498 
 Boux's, 500 
 Syme's, 497 
 excision of, 532 
 Anomalous dislocations of femur, 
 
 415 
 Anterior crural nerve, excision of, 
 546 
 tibial artery, ligation of, 453 
 tendon, tenotomy of, 548 
 Antisepsis, 119 
 Antiseptic bandages, 143 
 
 dressing, improvised, 143 
 method, 123 
 operation, 150 
 poultice, 173 
 Antrum of High more, trephining 
 
 of, 540 
 Aorta, abdominal, ligation of, 444 
 Appendix vermiformis, removal of, 
 
 572 
 Aquae ammonia as rubefacient, 
 180 
 as a vesicant, 182 
 Aristol, 131 
 Arm, amputation of, 481 
 
 and chest bandage, 73 
 Arteriotomy, 195 
 Arterial transfusion, 199 
 
 hemorrhage, 281 See Hemor- 
 rhage 
 Arteries, ligation of, 424 
 
 wounded, treatment of, 299 
 Arteriversion in arterial hemor- 
 rhage, 292 
 
 Artery, anterior tibial, ligation of, 
 453 
 axillary, ligation of, 436 
 brachial, ligation of, 438 
 common carotid, ligation of, 
 431 
 iliac, ligation of, 445 
 dorsalis pedis, ligation of, 455 
 external carotid, ligation of, 
 433 
 iliac, ligation of, 447 
 facial, ligation of, 435 
 femoral, ligation of, 449 
 gluteal, ligation of, 448 
 inferior thyroid, ligation of, 
 
 430 . 
 innominate, ligation of, 427 
 
 internal carotid, ligation of 
 
 433 
 
 iliac, ligation of, 447 
 
 mammary, ligation of, 430 
 
 pudic, ligation of, 449 
 
 interosseous, ligation of, 444 
 
 lingual, ligation of, 434 
 
 occipital, ligation of, 435 
 
 popliteal, ligation of, 452 
 
 posterior tibial, ligation of, 456 
 
 radial, ligation of, 440 
 
 sciatic, ligation of, 449 
 
 subclavian, ligation of, 428 
 
 superior thyroid, ligation of, 
 
 434 
 
 temporal, ligation of, 436 
 
 ulnar, ligation of, 442 
 
 vertebral, ligation of, 430 
 
 Arthrectomy of knee-joint, 531 
 
 Artificial respiration, 201 
 
 direct method of, 203 
 
 Hall's method, 207 
 
 Laborde's method, 207 
 
 Sylvester's method, 205 
 
 Asepsis, 119 
 
 Aseptic dressings, improvised, 143 
 
 method, 123 
 
 operation, 153 
 
 Aspiration, 208 
 
 Aspirator, 209 
 
 Astragalus, dislocation of, 420 
 
 excision of, 533 
 
 fracture of, 385 
 
 Axillary artery, ligation of, 436 
 
INDEX. 
 
 583 
 
 BACILLUS pyogenes, 121 
 fcetidus, 121 
 Bandage or bandages, 13 et seq 
 antiseptic. 143 
 arm and chest, 73 
 Barton's, 41 
 
 modified, 43 
 of breast, suspensory and com- 
 pressor, 78 
 circular, 19 
 compound 24 
 crossed, of both eyes, 53 
 
 of eye, 52 
 demi-gauntlet, 60 
 Desault's, 69 
 dimensions of, 17 
 figure-of eight, 23 
 
 of chest, 76 
 
 of elbow, 63 
 
 of knee, 85 
 
 of leg, 91 
 
 of neck and axilla, 67 
 of finger, spiral, 57 
 flannel, 98 
 of foot, American, 88 
 
 French 89 
 in fractures, 330 
 gauntlet, 58 
 Gibson's. 44 
 glue and zinc, 116 
 gum and chalk, 114 
 handkerchief, 29 
 hardening, 100 
 bust and neck, 51 
 Liebreich's. 96 
 lithotomy, 95 
 many-tailed, 28 
 occipitofacial, 54 
 
 -frontal, 56 
 oblique, 20 
 
 of head, 55 
 
 of jaw, 41 
 paraffin, 115 
 plaster-of-Paris, 101 
 
 application of, 102 
 
 preparation of, 102 
 
 removal of, 112 
 
 trapping of, 110 
 recurrent, 24 
 
 of head, 47 
 
 of stump, 94 
 
 Bandage, reversing of, 18 
 rubber, 98 
 scissors, 19 
 
 silicate of potassium, 115 
 silicate of sodium, 115 
 of Scultetus, 97 
 spica, 22 
 
 of foot, 87 
 
 of groin, double, 83 
 
 single, 80, 8L 
 of shoulder, ascending, 64 
 
 descending, 66 
 of thumb, 61 
 spiral, 20 
 
 of chest, 75 
 reversed, 21 
 
 of lower extremity, 90 
 of penis, 93 
 of upper extremity, 62 
 starched, 114 
 transverse recurrent, of head, 
 
 49 
 V-, of head, 50 
 varieties of, 19 
 Yelpeau's, 68 
 Bandaging, 13 
 
 general rules for, 17 
 Barton's bandage, 41 
 modified, 43 
 handkerchief, 40 
 Bavarian dressing, 108 
 Bedsores, 314 
 Beta-naphtol. 128 
 Bichloride cotton, 144 
 of mercury, 125 
 gauze, 140 
 Binders' board splints, 117, 328 
 Bisaxillary cravat, 34 
 Bladder, hemorrhage from, treat- 
 ment of, 303 
 irrigation of, 253 
 Bloodletting, 188 
 Blood, transfusion of, 195 
 direct, 196 
 indirect, 197 
 Bone chips, preparation of, 220 
 forceps, 466 
 grafting, 219 
 Bouisson's suture, 269 
 Borated gauze, 142 
 Boric acid, 130 
 
584 
 
 INDEX. 
 
 Boro-salicylic lotion, 130 
 Bougies, 247 
 Bougie, oesophageal, 212 
 Bowlegs, osteotomy for, 579 
 Brachial artery, ligation of, 438 
 
 plexus, excision of, 544 
 Bran bags, 329 
 Bread poultice, 172 
 Breast, strapping of, 167 
 Breasts, bandage of, 80 
 
 suspensory bandage of, 78 
 Bromide of ethyl, 241 
 Bruises, 311 
 Brush-burn, 312 
 Buried suture, 260 
 Burns, 312 
 Butcher's saw, 517 
 Buttock, spica bandage of, 84 
 Button suture, 264 
 
 pALCANEUM, dislocation of, 
 \J 420 
 
 fracture of, 384 
 Cantharidal collodion, 181 
 Cantharidis, ceratum, 181 
 Capillary hemorrhage, treatment 
 
 of, 298 
 Capsicum as rubefacient, 180 
 Carbolic acid, 126 
 Carbolized gauze, 141 
 Carbuncle, strapping of, 170 
 Carden's amputation at knee-joint, 
 
 506 
 Carpal bones, fracture of, 363 
 Carpus, dislocation of, 409 
 
 of bones of, 410 
 Cartilages, semilunar, dislocation 
 
 of, 418 
 Catgut, 134 
 
 sterilization of, 135 
 Catheters, 245 
 
 female, introduction of, 251 
 
 flexible, 245 
 
 introduction of, 249 
 
 metallic, 245 
 
 prostatic, 246 
 
 securing of, in bladder, 251 
 Cautery, actual, 186 
 
 irons, 186 
 
 Paquelin's, 187 
 
 Cauterization in arterial hemor- 
 rhage, 291 
 Ceratum cantharidis, 181 
 Chain saw, 517 
 Charcoal poultice, 172 
 Chemical sterilization in wounds, 
 
 146 
 Chest, Estlander's operation upon, 
 526 
 
 figure-of-eight bandage of, 76 
 
 spiral bandage of, 75 
 
 strapping of, 167 
 
 T-bandage of, 25 
 Chin, four-tailed bandage of, 28 
 Chloride of ethyl, 229 
 
 of zinc, 1*28 
 Chloroform, 238 
 
 administration of, 238 
 
 as rubefacient, 179 
 
 as a vesicant, 182 
 Cholecystotomy, 575 
 Chopart's amputation of foot, 495 
 Chronic abscess, 305 
 Circular bandage, 19 
 
 amputation, 460 
 Circumcision, 574 
 Clavicle, dislocation of, 399 
 
 fracture of, 343 
 
 resection of, 525 
 Clinical thermometer, 226 
 Closed fracture, 319 
 Cocaine, 230 
 
 local anaesthesia from, 230 
 Coccyx, dislocation of, 396 
 
 excision of, 534 
 
 fracture of, 340 
 Cold, anaesthesia for, 229 
 
 in arterial hemorrhage, 289 
 
 compresses, 177 
 
 water dressings, 177 
 Colles' fracture, 361 
 Collodion, cantharidal, 181 
 Colon, operations on, 571 
 Colostomy, inguinal, 572 
 
 lumbar, 571 
 Colotomy, inguinal, 572 
 
 lumbar, 571 
 Comminuted fracture, 319 
 Common carotid artery, ligation of, 
 431 
 
 iliac artery, ligation of, 445 
 
INDEX. 
 
 585 
 
 Complete dislocation, 393 
 
 fracture, 318 
 Complicated dislocation, 393, 423 
 
 fracture, 320 
 Compound bandages, 24 
 
 dislocation, 393, 423 
 
 fracture, 319 
 
 dressing of, 387 
 Compresses, 162 
 
 cold, 177 
 
 hot, 173 
 
 in fractures, 330 
 Condyles of femur, fracture of, 374 
 Congenital dislocations, 423 
 Constriction of arteries in arterial 
 
 hemorrhage, 292 
 Continued suture, 261 
 Contused wounds, 309 
 Contusions, 311 
 Coronoid process of ulna, fracture 
 
 of, 358 
 Costal cartilages, fracture of, 339 
 Cotton, 160 
 
 absorbent, 160 
 
 bichloride, 144 
 Counter-irritation, 178 
 Creolin, 129 
 
 Crossed bandage of eyes, 52 
 Cupping, 189 
 
 dry, 190 
 
 glass, 190 
 
 wet, 191 
 Cyanide of mercury and zinc, 131 
 
 gauze. 141 
 Cystoscope, 222 
 Czerny suture, 270 
 
 DEFOEMITY in fracture, 322 
 Demi-gauntlet bandage, 60 
 Desault's bandage, 69 
 Diffused abscess, 306 
 Digital compression in hemor- 
 rhage, 281 
 Direct method of artificial respira- 
 tion, 203 
 transfusion of blood, 196 
 Disinfection of the hands, 147 
 Dislocation or dislocations, 393 
 of the ankle, 418 
 of astragalus, 420 
 
 Dislocation of bones of carpus, 410 
 of calcaneum, 420 
 of carpus, 409 
 of clavicle, 399 
 of coccyx, 396 
 complicated, 393, 423 
 complete, 393 
 compound, 393, 423 
 congenital, 423 
 of elbow, 405 
 of femur, 412 
 
 anomalous, 415 
 
 dorsal,412 
 
 ischiatic, 412 
 
 pubic, 415 
 
 thyroid, 413 
 of fibula, 418 
 of fingers, 410 
 of head of humerus, 401 
 
 of radius, 407 
 of hip, 412 
 
 of humerus, Kocher's method 
 in, 403 
 
 reduction of, 402 
 
 subclavicular, 402 
 
 subglenoid, 401 
 
 subcoracoid, 401 
 
 subspinous, 402 
 of inferior angle of scapula, 400 
 of jaw, 396 
 of knee, 417 
 
 of metacarpal bones, 410 
 of metatarsal bones, 421 
 old, 394, 421 
 partial, 393 
 of patella, 416 
 pathological, 423 
 of pelvis, 398 
 of phalanges of toes, 421 
 of proximal phalanx of 
 
 thumb, 411 
 recent, 394 
 reduction of, 394 
 of ribs, 398 
 of scapula, 400 
 of semilunar cartilages, 418 
 of shoulder, 401 
 simple, 393 
 spontaneous, 423 
 of sternum, 398 
 of tarsal bones, 419 
 
586 
 
 INDEX. 
 
 Dislocation of upper end of ulna, 
 408 
 of vertebrae, 396 
 of wrist, 409 
 Dorsal dislocation of femur, 412 
 Dorsalis pedis artery, ligation of, 
 
 455 
 Dorso-axillary cravat, 35 
 
 -bisaxillary cravat, compound, 
 
 . 36 
 Dressing, antiseptic, improvised, 
 
 143 
 
 aseptic, improvised, 143 
 
 cold water, 177 
 
 gauze, 1 39 
 
 moss, 142 
 
 sawdust, 142 
 
 sterilized, 145 
 Drainage-tubes, 136 
 Dry cupping, 190 
 
 sterilized dressings, 145 
 Dupuytren's amputation at the 
 shoulder, 486 
 
 splint, 384 
 
 ELASTIC ligature, 279 
 Elbow, amputation at, 480 
 dislocations of, 405 
 figure-of-eight bandage of, 
 
 63 
 -joint, excision of, 520 
 Electrolysis, 220 
 Elliptical amputation, 462 
 Enemata, 228 
 
 nutritious, 228 
 Epiphyseal fracture, 322 
 
 of radius, 363 
 Epistaxis, treatment of, 300 
 Erichsen's ligature, 278 
 Esmarch's bandage and tube, 287 
 Estlander's operation of chest, 
 
 526 
 Ether, 233 
 
 administration of, 234 
 first insensibility from, 235 
 inhaler, 234 
 vomiting after, 237 
 Ethyl bromide, 241 
 
 chloride, 227 
 Excision or excisions, 516 
 
 Excision of ankle-joint, 532 
 
 of astragalus, 533 
 
 of coccyx, 534 
 
 of elbow-joint, 520 
 
 of hip-joint, 528 
 anterior, 529 
 
 of inferior maxilla, 536 
 
 instruments for, 517, 518 
 
 of inter-pbalangeal joints, 524 
 
 of knee-joint, 530 
 
 metacarpophalangeal joints, 
 524 
 
 of os calcis, 533 
 
 of patella, 531 
 
 of scapula, 527 
 
 of shoulder-joint, 519 
 
 of superior maxilla, 535 
 
 of wrist, 522 
 Exploring-needle, 216 
 
 -trocar, 217 
 Extensor longus digitorum, tenot- 
 omy of, 549 
 
 proprius pollicis, tenotomy of, 
 549 
 External carotid artery, ligation 
 of, 433 
 
 iliac artery, ligation of, 447 
 External popliteal nerve, excision 
 
 of, 546 
 Eye, crossed bandage of, 52 
 
 crossed bandage of both, 53 
 Facial artery, ligation of, 435 
 
 nerve, excision of, 544 
 
 FABADIZATION, 222 
 Fascia, strains of, 317 
 Felt splints, 328 
 
 Femoral artery, ligation of, 449 
 Femur, dislocation of, 412 
 
 anomalous, 415 
 
 dorsal, 412 
 
 ischiatic 412 
 
 pubic, 415 
 
 thyroid, 413 
 
 upper extremity of, 366 
 fracture of, 366 
 
 condyles of, 374 
 
 green-stick, 373 
 
 incomplete, 373 
 
 neck of, 366 
 
INDEX 
 
 587 
 
 Femur, fracture of lower end of, 374 
 shaft of, 370 
 
 in children, 372 
 osteotomy of, 578 
 Fomentations, hot, 173 
 Fibula, dislocations of, 418 
 fracture of, 382 
 
 of lower end of, 383 
 Pott's fracture of, 383 
 resection of, 531 
 Figure-of-eight bandage, 23 
 of chest, 76 
 of elbow, 63 
 of knee, 85 
 of leg, 91 
 
 of neck and axilla, 67 
 Fingers, amputation of, 473 
 dislocation of, 410 
 phalanges, fractures of, 365 
 spiral bandage of, 57 
 Fixed dressings, 100 
 Flap amputations, 460 
 Flannel bandage, 98 
 Flat knot, 257 
 Flaxseed poultice, 171 
 Flexible catheter, 245 
 Flexor longus digitorum, tenotomy 
 of, 549 
 pollicis, tenotomy of, 549 
 Foot, American bandage of, 88 
 amputation of, 489 
 Chopart's, 495 
 Hey's, 495 
 Lisfranc's, 494 
 Tripier's, 501 
 French bandage of, 89 
 spica bandage of, 87 
 Forearm, amputation of, 479 
 dislocation of, at elbow, 405 
 fracture of both bones of, 358 
 Forced respiration, 207 
 Forceps, haemostatic, in hemor- 
 rhage, 286 
 Fracture or fractures, 318 
 of astragalus, 385 
 bandages in, 330 
 -bed, 327 
 
 of bones of forearm, 358 
 of leg, 377 
 -box, 329 
 of calcaneum, 384 
 
 Fracture of carpal bones, 363 
 of clavicle, 343 
 closed, 319 
 of coccyx, 340 
 Oolles', 361 
 comminuted, 319 
 complete, 318 
 complicated, 320 
 compound, 319 
 
 dressing of, 387 
 compresses in, 330 
 coronoid process of ulna, 358 
 of costal cartilages, 339 
 deformity in, 322 
 direction of, 321 
 epiphyseal, 322 
 evaporating lotions in, 330 
 examination of, 323 
 of the femur, 366 
 of the fibula, 382 
 green-stick, 318 
 
 of bones of forearm, 358 
 of head and neck of radius, 358 
 of the humerus, 350 
 of hyoid bone, 337 
 impacted, 320 
 incomplete, 318 
 of larynx, 337 
 of the leg, ambulant method 
 
 in, 380 
 longitudinal 321 
 of lower end of femur, 374 
 of fibula, 383 
 
 maxilla, 334 
 
 end of radius, 360 
 of malar bone, 333 
 of metacarpal bones, 364 
 of metatarsal bones, 386 
 multiple, 319 
 of nasal bones, 331 
 of neck of femur, 366 
 oblique, 321 
 of olecranon process of ulna, 
 
 356 
 open, 319 
 
 dressing of, 387 
 partial, 318 
 of patella, 375 
 of pelvis, 340 
 of phalanges of fingers, 365 
 
 of toes, 386 
 
588 
 
 INDEX. 
 
 Fracture, plaster-of-Paris splints in, 
 329 
 
 provisional dressing of, 324 
 
 of radius, epiphyseal, 363 
 
 repair of, 322 
 
 of ribs, 338 
 
 of sacrum, 340 
 
 of scapula, 349 
 
 setting of, 326 
 
 of shaft of femur, 370 
 
 in children, 372 
 
 simple, 319 
 
 of skull, 342 
 
 splints for, 327 
 
 of sternum, 339 
 
 of tarsal bones, 384 
 
 of tibia and fibula, 377 
 
 of trachea, 337 
 
 of upper extremity of femur, 
 ~366 
 maxilla, 333 
 
 varieties of, 318 
 
 of vertebrae, 341 
 
 of zygoma, 333 
 Franklinization, 222 
 French bandage of foot, 89 
 Frontal sinus, trephining of, 540 
 
 GALVANO-CAUTERY, 221 
 Gastrostomy, 576 
 sutures in, 273 
 Gauze, bichloride of mercury, 140 
 borated, 142 
 carbolized, 141 
 cyanide of mercury and zinc, 
 
 141 
 dressings, 139 
 
 preparation of, 139 
 iodoform, 140 
 pads, 133 
 pledgets, 133 
 pyoktanin, 142 
 salicylated, 142 
 Gauntlet bandage, 58 
 Gely's suture, 268 
 Gibson's bandage, 44 
 Glover's suture, 261 
 Glue and zinc bandage, 116 
 Gluteal artery, ligation of, 448 
 Gluteo-femoral triangle, 38 
 
 Gluteo-inguinal cravat, 38 
 Glycerin enema, 228 
 Granny knot, 258 
 Green-stick fracture, 318 
 
 of bones of forearm, 358 
 
 of femur, 373 
 Gritti's amputation at knee-joint, 
 
 507 
 Groin, spica bandage of, double, 83 
 
 single, 80, 81 
 Gum and chalk bandage, 114 
 Gunshot-wounds, 311 
 Guthrie's amputation at hip-joint, 
 
 512 
 Gutta-percha splints, 328 
 
 HALL'S method of artificial res- 
 piration, 207 
 Halstead's quilt suture, 268 
 Hamstring tendons, tenotomy of, 
 
 549 
 Hancock's amputation at ankle- 
 joint, 500 
 Hand, amputation of, 473 
 
 carpo-metacarpal, 477 
 disinfection of, 147 
 Handkerchief bandages, 29 
 
 Barton's, 40 
 Harelip suture, 262 
 Haemostatic forceps, 286 
 Hatter's felt splints, 118 
 Head and neck bandage, 51 
 four-tailed bandage of, 28 
 oblique bandage of, 55 
 of radius, dislocation of, 407 
 recurrent bandage of, 47 
 transverse recurrent bandage 
 
 of, 49 
 V-bandage of, 50 
 Heat as a sterilizer, 124 
 Hemorrhage in amputations, con- 
 trol of, 469 
 arterial, 281 
 
 acupressure in, 294 
 arteriversion in, 292 
 cauterization in, 291 
 cold in, 289 
 control of, permanent, 288 
 
 temporary, 281 
 compresses in, 282 
 
INDEX. 
 
 589 
 
 Hemorrhage, arterial, constriction 
 of arteries in, 292 
 digital compression in, 281 
 Esmarch's tube in, 284 
 haemostatic forceps in, 286 
 hot water in, 289 
 ligation in, 293 
 position in, 289 
 pressure in, 290 
 Spanish windlass in, 283 
 styptics in, 289 
 torsion in, 291 
 tourniquets in, 282 
 from bladder, treatment of, 303 
 capillary, treatment of, 298 
 from middle meningeal artery, 
 
 trephining for, 539 
 from the rectum, treatment of, 
 
 303 
 secondary, treatment of, 298 
 treatment of, 280 
 from the urethra, treatment of, 
 
 302 
 venous, treatment of, 297 
 Hernia, femoral, truss for, 243 
 inguinal, truss for, 242 
 irreducible, truss for, 245 
 umbilical, truss for, 244 
 Hey's amputation of foot, 495 
 Hip, dislocations of, 412 
 
 -joint, amputation at, 510 
 Guthrie's, 510 
 Wyeth's, 513 
 excision of, 528 
 anterior, 529 
 Hoey's clamp, 285 
 Hot compresses, 173 
 fomentations, 173 
 water in arterial hemorrhage, 
 289 
 as a rubefacient, 178 
 Humerus, dislocation of head of, 
 401 
 fracture of, 350 
 resection of, 520 
 subclavicular dislocation of, 
 
 402 
 subcoracoid dislocation of, 401 
 subglenoid dislocation of, 401 
 subspinous dislocation of, 402 
 Hydrogen peroxide, 129 
 
 Hyoid bone, dislocationof, 397 
 
 fracture of, 337 
 Hypodermic injections, 214 
 
 TCE-BAG, 177 
 1 Immediate irrigation, 174 
 Impacted fracture, 320 
 Improvised antiseptic dressings, 1 43 
 
 aseptic dressings, 143 
 Incised wounds, 307 
 Incomplete fracture, 318 
 
 of femur, 373 
 India-rubber suture, 263 
 Indirect transfusion of blood, 1 97 
 Inferior dental nerve, excision of, 
 543 
 
 thyroid artery, ligation of, 430 
 Infiltration anaesthesia, 231 
 Inguinal colostomy, 572 
 
 colotomy, 572 
 Injections, hypodermic, 204 
 
 urethral, 253 
 Innominate artery, ligation of, 427 
 Instruments, sterilization of, 148 
 Internal carotid artery, ligation of, 
 
 . . 433 
 
 iliac artery, ligation of, 447 
 
 mammary artery, ligation of. 
 
 430 
 popliteal nerve, excision of, 
 
 546 
 pubic artery, ligation of, 449 
 Interosseous artery, ligation of, 
 
 444 
 Inter-pharyngeal joints, excision 
 
 of, 524 
 Interrupted plaster-of-Paris dress- 
 ing, 104 
 suture, 259 
 Intestinal anastomosis, sutures in, 
 
 271 
 Intravenous injection of milk, 200 
 
 of saline solution, 199 
 Intubation of larynx, 564 
 instruments for, 565 
 operation of, 566 
 Iodoform, 127 
 
 collodion, 127 
 emulsion, 127 
 gauze, 140 
 
 26 
 
590 
 
 INDEX. 
 
 Iodol, 131 
 Irrigation, 174 
 
 immediate, 174 
 
 mediate, 176 
 Ischiatic dislocation of femur, 412 
 Isinglass plaster, 165 
 Issues, 183 
 
 JACKET, plaster-of-Paris, 105 
 Jaw, dislocation of, 396 
 
 lower, excision of, 536 
 fracture of ? 334 
 oblique bandage of, 46 
 upper, excision of, 535 
 fracture of, 333 
 Jobert's suture, 270 
 Joints, strapping of, 170 
 Junk bags, 329 
 Jury-mast with plaster-of-Paris 
 
 jacket, 108 
 Jute, 161 
 
 KIDNEY, operations on, 570 
 Knee, dislocation of, 417 
 figure-of-eight bandage of, 
 : 85, 86 
 
 -joint, amputation at, 505 
 Carden's, 506 
 Gritti's, 507 
 arthrectomy of, 531 
 excision of, 530 
 Knives, amputating, 464 
 Knock-knee, osteotomy for, 578 
 Kreolin, 129 
 
 T ABOKDE'S method of artificial 
 Jj respiration, 207 
 Lacerated wounds, 308 
 Larrey's amputation at the shoul- 
 der-joint, 485 
 Laryngo- tracheotomy, 563 
 Laryngotomy, 562 
 Larynx, fracture of, 337 
 
 intubation of, 564 
 Leather splints, 116, 328 
 Leeching, 191 
 Leeches, 191 
 Leg, amputation of, 501 
 
 Leg, figure-of-eight bandage of, 91 
 
 fractures of, 377 
 Lembert's suture, 267 
 Liebreich's bandage, 96 
 Ligation of abdominal aorta, 444 
 of anterior tibial artery, 453 
 of arteries, 424 
 of axillary artery, 431 
 of brachial artery, 438 
 of common carotid artery, 431 
 
 iliac artery, 445 
 of dorsalis pedis artery, 455 
 of external carotid artery, 433 
 
 iliac artery, 447 
 of the facial artery, 435 
 of femoral artery, 449 
 of gluteal artery, 448 
 of inferior thyroid artery, 430 
 of innominate artery, 427 
 of internal carotid artery, 433 
 
 iliac artery, 447 
 
 mammary artery, 430 
 
 pudic artery, 449 
 of interosseous artery, 444 
 of lingual artery, 434 
 of occipital artery, 435 
 of popliteal artery, 452 
 of posterior tibial artery, 456 
 of radial artery, 440 
 of sciatic artery, 449 
 of subclavian artery, 428 
 of superior thyroid artery, 434 
 of temporal artery, 436 
 of ulnar artery, 442 
 of vertebral artery, 430 
 in arterial hemorrhage, 293 
 Ligature, elastic, 279 
 securing of, 257 
 in vascular growths, 274 
 
 double, 275 
 
 Erichsen's, 278 
 
 quadruple, 276 
 
 single, 275 
 
 subcutaneous, 277 
 Lingual artery, ligation of, 434 
 
 nerve, excision of, 543 
 Lint, 158 
 Lisfranc's amputation of foot, 494 
 
 at the shoulder-joint, 487 
 Lister's aorta-compressor, 285 
 Lithotomy bandage, 95 
 
INDEX. 
 
 591 
 
 Lithotomy, lateral, 572 
 Local anaesthesia, 229 
 Longitudinal fracture, 321 
 Lower jaw, fracture of, 334 
 Lumbar colostomy, 571 
 colotomy, 571 
 nephrectomy, 570 
 
 MACKINTOSH, 138 
 Malar bone, fracture of, 333 
 Many-tailed bandage, 28 
 Massage, 224 
 
 Maxilla, inferior, excision of, 536 
 lower, fracture of, 334 
 superior, excision of, 535 
 upper, fracture of, 333 
 Mechanical leech, 192 
 Mediate irrigation, 176 
 Median nerve, excision of, 545 
 Mento vertico-oceipital cravat, 32 
 Mercury, bichloride, 125 
 Metacarpal bones, amputation of, 
 476 
 dislocation of, 410 
 fracture of, 364 
 resection of, 524 
 Metacarpophalangeal joints, ex- 
 cision of, 524 
 Metallic cathether, 245 
 Metatarsal bones, amputation of, 
 491 
 dislocation of, 421 
 fracture of, 386 
 resection of, 534 
 Milk, intravenous injection of, 200 
 Minor surgery, 119 
 Modified circular amputation, 463 
 Moist dressings in wounds, 146 
 method of dressing wounds, 154 
 sterilized dressings, 145 
 Moss- dressing, 142 
 Moulded plaster-of-Paris splints, 
 
 110 
 Mouth-to-mouth inflation, 202 
 Moxa, 184 
 
 Multiple fracture, 319 
 Muscle -grafting, 220 
 Muscles, strains of, 317 
 Musculo-spiral nerve, excision of, 
 546 
 
 Muslin, oiled, 161 
 Mustard foot-bath, 179 
 
 papers, 180 
 
 plaster, 179 
 
 as rubefacient, 179 
 
 NASAL bones, fracture of, 331 
 Neck and axilla, figure-of- 
 eight bandage of, 67 
 Needles, acupuncture, 183 
 aneurism, 293 
 exploring-, 216 
 -holder, 256 
 mounted, 256 
 surgical, 255 
 Nephrectomy, abdominal, 570 
 
 lumbar, 570 
 Nephrorrhaphy, 570 
 Nephrotomy, 570 
 
 Nerve, anterior crural, excision of, 
 546 
 external popliteal, excision of, 
 
 546 
 facial, excision of, 544 
 -grafting, 220, 541 _ _ 
 inferior dental, excision of, 543 
 internal popliteal, excision of, 
 
 546 
 lingual, excision of, 543 
 median, excision of, 545 
 musculo-spiral, excision of, 
 
 546 ^ 
 operations upon, 540 
 radial, excision of, 545 
 sciatic, excision of, 546 
 spinal accessor excision of, 
 
 545 
 -stretching, 540 
 superior maxillary, excision of, 
 
 543 
 supra-orbital, excision of, 542 
 suture of, 541 
 ulnar, excision of, 545 
 Neurectasy, 540 
 
 of special nerves. See under 
 each nerve. 
 Neurotomy, 540, 541 
 Neuroplasty, 541 
 Neurorrhaphy, 541 
 Nitrate of silver as rubefacient, 180 
 
592 
 
 INDEX. 
 
 Nitrous oxide gas, 232 
 Normal salt-solution, 199 
 Nose, T-bandage of, 27 
 Nutritious enemata, 228 
 
 AAKUM, 159 
 \J poultice, 173 
 Oblique bandage, 20 
 of head, 55 
 of jaw, 46 
 
 fracture, 321 
 Occipital artery, ligation of, 435 
 Occipto-facial bandage, 54 
 
 -frontal bandage, 56 
 triangle, 32 
 (Esophageal bougie, 212 
 (Esophagotomy, external, 576 
 Oiled muslin, 161 
 
 silk, 161 
 Old dislocation, 394, 421 
 Olecranon process of ulna, fracture 
 
 of, 356 
 Open fracture, 319 
 
 dressing of, 387 
 Operation or operations, 424 
 
 antiseptic, 150 
 
 aseptic, 153 
 
 preparation of patient for, 149 
 of surgeon for, 148 
 Os calcis, excision of, 533 
 Osteotomy, 577 
 
 for bowlegs, 579 
 
 of femur, 578 
 
 for knock-knee, 578 
 Oval amputation, 462 
 
 PANELECTEOSCOPE, 224 
 Paper splints, 329 
 Paquelin's cautery as rubefacient, 
 180 
 thermo-cautery, 187 
 Paraffin bandage, 115 
 
 paper, 161 
 Parchment paper, 139, 162 
 Partial dislocation, 393 
 
 fracture, 318 
 Passive motion, 225 
 Pasteboard splints, 117 
 Patella, dislocations of, 416 
 
 Patella, excision of, 531 
 
 fracture of, 375 
 Pathological dislocations, 423 
 Pelvis, dislocation of, 498 
 
 fracture of, 340 
 Penis, spiral reversed bandage of, 
 
 93 
 Periosteal flaps in amputation, 464 
 Periosteotome, 467 
 Permanganate of potassium, 130 
 Peroneal tendons, tenotomy of, 548 
 Peroxide of hydrogen, 129 
 Petit' s tourniquet, 283 
 Phalanges of fingers, dislocation of, 
 410 
 fractures of, 365 
 of toes, dislocation of, 421 
 fractures of, 386 
 PirogofF's amputation at ankle- 
 joint, 498 
 Plate suture, 265 
 Plaster or plasters, 164 
 adhesive, 164 
 isinglass, 165 
 mustard, 179 
 -of-Paris bandage, 101 
 
 application of, 102 
 preparation of, 102 
 removal of, 112 
 dressing, interrupted, 104 
 
 uses of, 113 
 jacket, application of, 105 
 
 with jury-mast, 108 
 removal of, from hands, 
 
 111 
 splints in fracture, 329 
 moulded, 110 
 resin, 164 
 
 rubber adhesive, 164 
 soap, 165 
 swan's-down, 164 
 poisoned wounds, 310 
 Popliteal artery, ligation of, 452 
 Porous felt splints, 118 
 Position in arterial hemorrhage, 
 
 289 
 Posterior tibial artery, ligation of, 
 456 
 tendon, tenotomy of, 548 
 Potassium, permanganate, 130 
 Pott's fracture of fibula, 383 
 
INDEX. 
 
 593 
 
 Poultices, 170 
 
 antiseptic, 173 
 
 bread, 172 
 
 charcoal, 172 
 
 flaxseed, 171 
 
 oakum, 173 
 
 starch, 172 
 Powder-burns, 311 
 Pressure in arterial hemorrhage, 
 
 290 
 Prostatic catheter, 246 
 Protective, 138 
 
 Provisional dressing of fracture, 324 
 Pubic dislocation of femur, 415 
 Puncturation, 189 
 Punctured wounds, 310 
 Pyoktanin, 130 
 
 gauze, 142 
 
 QUADRUPLE ligature, 276 
 Quilled suture, 264 
 Quilt suture, 263 
 
 RADIAL artery, ligation of, 440 
 nerve, excision of, 545 
 Radius, dislocation of head of, 407 
 fracture of head and neck of, 
 358 
 of lower end of, 360 
 resection of, 521 
 Rapid respiration, anaesthesia from, 
 
 230 
 Raw-hide splints, 116 
 Recent dislocations, 394 
 Rectal bougie, 227 
 
 tube, 227 
 Rectum, hemorrhage from, treat- 
 ment of, 303 
 Recurrent bandage, 24 
 of head, 47 
 of stump, 94 
 Reduction of dislocations, 394 
 Reef knot, 257 
 Resections, 516 
 
 of clavicle, 525 
 of fibula, 531 
 of humerus, 520 
 instruments for, 517, 518 
 of metacarpal bones, 524 
 
 Resections of metatarsal bones, 534 
 
 of radius, 521 
 
 of ribs, 526 
 
 of sternum, 527 
 
 of tibia, 531 
 
 of ulna, 521 
 Respiration, artificial, 201 
 
 forced, 207 
 
 rapid, anaesthesia from, 230 
 Resin plaster, 164 
 Retractors, 163 
 Ribs, dislocation of, 398 
 
 fracture of, 338 
 
 resection of, 526 
 Roller bandage, 14 
 double, 16 
 single, 16 
 Roux's amputation at ankle-joint, 
 
 500 
 Rubber adhesive plaster, 164 
 
 bandage, 98 
 
 dam, 139 
 
 tissue, 139, 161 
 Rubefacients, 178 
 
 SACRUM, fracture of, 340 
 Salicylated gauze, 142 
 Saline solution, intravenous injec- 
 tion of, 199 
 Salt-solution, normal, 199 
 Sand-bags, 329^ 
 Saws, amputating, 465 
 
 Butcher's, 517 
 Sawdust dressing, 142 
 Scalds, 312 
 Scapula, dislocation of, 400 
 
 dislocation of inferior angle of, 
 
 400 
 excision of, 527 
 fracture of, 349 
 Scarification, 188 
 Sciatic artery, ligation of, 449 
 
 nerve, excision of, 546 
 Scultetus, bandage of, 97 
 Secondary hemorrhage, treatment 
 of, 298 
 sutures, 255 
 Semilunar cartilages, dislocation of, 
 418 
 
 sepsis 
 
 119 
 
 26* 
 
594 
 
 INDEX. 
 
 Septic wounds, dressing of, 157 
 Serum, injections of, 215 
 Seton, 184 
 
 needle, 185 
 Shotted suture, 265 
 Shoulder, dislocation of, 401 
 
 -joint, amputation above, 488 
 at, 484 
 
 Dupuytren's, 486 
 Larre>'s, 485 
 Lisfranc's, 487 
 Spence's, 487 
 excision of, 519 
 spica bandage of, ascending, 64 
 descending, 66 
 Signorini's tourniquet, 285 
 Silicate of potassium bandage, 115 
 
 of sodium bandage, 115 
 Silk, oiled, 161 
 
 sterilization of, 134 
 Silkworm-gut, 134 
 Simple dislocation, 393 
 
 fracture, 319 
 Sinapisms, 179 
 Sinus, 307 
 Skin-grafting, 217 
 
 Thiersch's method, 218 
 Skull, fracture of, 342 
 trephining of, 538 
 Slings, 28 
 Soap plaster, 165 
 Sounds, 249 
 Spanish windlass, 283 
 Spence's amputation at shoulder- 
 joint, 487 
 Spica bandage, 22 
 
 of buttock, 84 
 
 of foot, 87 
 
 of groin, double, 83 
 
 of groin, single, 80, 81 
 
 of shoulder, ascending, 64 
 
 descending, 66 
 of thumb, 61 
 Spinal accessory nerve, excision of, 
 
 545 
 Spiral bandage, 20 
 of chest, 75 
 of finger, 57 
 reversed bandage, 21 
 
 of lower extremity, 90 
 of penis, 93 
 
 Spiral reversed bandage of upper 
 
 extremity, 62 
 Spirits of turpentine, 178 
 Splints, 327 
 
 binder's board, 117, 328 
 
 Dupuytren's, 384 
 
 felt, 328 
 
 gutta-percha, 328 
 
 hatter's felt, 118 
 
 leather, 116, 328 
 
 paper, 329 
 
 pasteboard, 117 
 
 porous felt, 118 
 
 raw-hide, 116 
 Sponges, sterilization of, .1 32 
 Spontaneous dislocations, 423 
 Sprains, 315 
 
 fracture, 317 
 Staffordshire knot, 259 
 Staphylococcus pyogenes albus, 
 121 
 
 aureus, 121 
 
 citreus, 121 
 Starched bandage, 114 
 Starch poultice, 172 
 Sterilization of catgut, 135 
 
 by heat, 124 
 
 of instruments, 148 
 
 of silk, 134 
 
 of sponges, 132 
 Sterilized dressings, dry, 145 
 
 moist, 145 
 Sterno-cleido-mastoid, tenotomy of, 
 
 550 
 Sternum, dislocation of, 398 
 
 fracture of, 339 
 
 resection of, 527 
 Stomach pump, 211 
 
 tube, 210 
 Strains of muscles and fascia, 317 
 Strapping, 165 
 
 breast, 167 
 
 of carbuncle, 170 
 
 chest, 167 
 
 of joints, 170 
 
 testicle, 166 
 
 of ulcers, 168 
 Streptococcus pyogenes, 121 
 Stump, recurrent bandage of, 94 
 Styptics in arterial hemorrhage, 
 289 
 
INDEX. 
 
 595 
 
 Subastragaloid amputation, 497 
 Subclavian artery, ligation of, 428 
 Subclavicular dislocation of hu- 
 merus, 402 
 Subcoracoid dislocation of humerus, 
 
 401 
 Subcutaneous ligature, 277 
 Subcuticular suture, 262 
 Subglenoid dislocation of humerus, 
 
 401 
 Subspinous dislocation of humerus, 
 
 402 
 Sulpho-carbolate of zinc, 128 
 Superior maxillary nerve, excision 
 of, 543 
 
 thyroid artery, ligation of, 434 
 Supra-orbital nerve, excision of, 
 542 
 
 pubic lithotomy, 573 
 Surface thermometer, 226 
 Surgeon's knot, 258 
 
 preparation for operation, 148 
 Surgery, minor, 119 
 Surgical cleanliness, 122 
 
 needles, 255 
 Suspensory bandage of breast, 37 
 
 and compressor bandage of 
 breast, 78 
 Sutures, 254 
 
 of approximation, 255 
 
 Bouisson's, 269 
 
 buried, 260 
 
 button, 264 
 
 of coaptation, 255 
 
 continued, 261 
 
 Czerny, 270 
 
 in gastrostomv, 273 
 
 Gely's, 268 
 
 Glover's, 261 
 
 Halstead's, 268 
 
 harelip, 262 
 
 India-rubber, 263 
 
 interrupted, 259 
 
 in intestinal anastomosis, 271 
 
 Jobert's, 270 
 
 of nerves, 541 
 
 plate, 265 
 
 quilled, 264 
 
 quilt, 263 
 
 of relaxation, 255 
 
 removal of, 266 
 
 Sutures, subcuticular, 262 
 
 secondary, 255 
 
 securing of, 257 
 
 shotted, 265 
 
 of tendons, 550 
 
 tongue and groove, 265 
 
 twisted, 262 
 
 varieties of, 259 
 Sylvester's method of artificial res- 
 piration, 205 
 Sy rue's amputation at ankle-joint, 
 497 
 
 TAMPOX, 162 
 Tarsal bones, dislocation of, 
 419 
 fracture of, 384 
 Tarso-metatarsal amputations, 493 
 T-bandages, 24 
 of chest, 25 
 double, 26 
 of nose, 27 
 single, 24 
 Teale's amputation, 463 
 Temporal artery, ligation of, 436 
 Tenaculum, 293 
 
 Tendo Achillis, tenotomy of, 547 
 Tendons, lengthening of, 552 
 operations upon, 547 
 suture of, 550 
 
 secondary, 551 
 Tenotomes, 547 
 Tenotomy, 547 
 
 of adductor longus, 549 
 
 of anterior tibial tendon, 548 
 
 of extensor proprius pollicis, 
 
 549 
 of flexor longus digitorum, 
 
 549 
 of flexor longus pollicis, 549 
 of hamstring tendons, 549 
 of peroneal tendons, 548 
 of posterior tibial tendon, 548 
 of sterno-cleido-mastoid, 550 
 of tendo Achillis, 547 
 Tent, 162 
 Testicle, removal of, 575 
 
 strapping of, 166 
 Thiersch's method of skin-grafting, 
 218 
 
596 
 
 INDEX. 
 
 Thigh, amputation of, 507 
 Thumb, dislocation of proximal 
 phalanx of, 411 
 
 spica bandage of, 61 
 Thyroid dislocation of femur, 
 
 413 
 Tibia, fracture of, 377 
 
 resection of, 531 
 Toes, amputation of, 489 
 
 fracture of phalanges of, 386 
 Tongue and groove suture, 265 
 Torsion in arterial hemorrhage, 
 
 291 
 Tourniquets, 283, 285 
 
 abdominal, 510 
 
 in amputation, 469 
 
 Petit's^ 283 
 
 Signorini's, 285 
 Trachea, fracture of, 337 
 Tracheal dilators, 554 
 
 forceps, 555 
 Tracheotomy, 553 
 
 after-treatment of, 561 
 
 anaesthetics in, 557 
 
 for foreign bodies, 562 
 
 operation of, 557 
 
 position of patient for, 556 
 
 tube, 556 
 Transfusion of blood, 195 
 
 arterial, 199 
 
 of blood, direct, 196 
 indirect, 197 
 Transverse fracture, 321 
 
 recurrent bandage of head, 49 
 Trapping plaster-of- Paris bandage, 
 
 110 
 Trephining the antrum of High 
 more, 540 
 
 of frontal sinus, 540 
 
 for hemorrhage from middle 
 meningeal artery, 539 
 m the skull, 538 
 Tripier's amputation of foot, 501 
 Trusses, 241 
 
 for femoral hernia, 243 
 
 for inguinal hernia, 242 
 
 for irreducible hernia, 245 
 
 for umbilical hernia, 244 
 Tuberculous abscess, 305 
 Turpentine stupes, 178 
 Twisted suture, 262 
 
 ULCEKS, strapping of, 168 
 Ulna, dislocation of upper end 
 of, 408 
 fracture of coronoid pro- 
 cess of, 358 
 of olecranon process 
 of, 356 
 resection of, 521 
 Ulnar artery, ligation of, 442 
 
 nerve, excision of, 545 
 Upper extremity, spiral reversed 
 bandage of, 62 
 jaw, fracture of, 333 
 Urethra, hemorrhage from, treat- 
 ment of, 302 
 Urethral injections, 253 
 Urethroscope, 223 
 
 yACCINATION, 212 
 
 V Varicocele, operation for, 575 
 Vascular growths, ligatures in ; 274 
 V-bandage of head, 50 
 Velpeau's bandage, 68 
 Venesection, 193 
 Venous hemorrhage, treatment of, 
 
 297 
 Vertebrae, dislocations of, 395 
 
 fracture of, 341 
 Vertebral artery, ligation of, 430 
 Vesicants, 181 
 Vomiting after ether, 237 
 
 WAXED paper, 161 
 Wet cupping, 191 
 Wood-wool, 161 
 Wounded arteries, treatment of, 
 
 299 
 Wounds, asepsis in, method of se- 
 curing, 145 
 chemical sterilization in, 146 
 contused, 309 
 dressing of, 307 
 dry dressings in, 145 
 gunshot, 311 
 incised, 307 
 lacerated, 308 
 
 moist dressings in, 146, 154 
 poisoned, 310 
 punctured, 310 
 
INDEX. 
 
 597 
 
 Wounds, reapplication of dressings 
 
 in. 154 
 Wrist, amputation at, 478 
 dislocations of, 409 
 excision of, 522 
 Wveth's amputation at hip-joint, 
 513 
 
 Wyeth's pins in amputation at hip- 
 joint, 513 
 at shoulder-joint, 485 
 
 ZIXC chloride, 128 
 sulpho-carbolate, 1^8 
 Zygoma, fracture of, 333 
 
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 LEHMANN (C. G.), A MANUAL OF CHEMICAL PHYSIOLOGY. 
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 LOOMIS (ALFRED L.) AND THOMPSON (W. GILMAN). 
 
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 LUCAS (CLEMENT). DISEASES OF THE URETHRA. Preparing, 
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 LUDLOW (J. L.). A MANUAL OF EXAMINATIONS UPON 
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 LUFF (ARTHUR P.). MANUAL OF CHEMISTRY, for the use of 
 
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 LYMAN (HENRY M.). THE PRACTICE OF MEDICINE. In one 
 
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 LYONS (ROBERT D.). A TREATISE ON FEVER. In one octavo 
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 MANUALS. See Student's Quiz Series, p. 14, Student's Series of Manu- 
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 MAY(C. H.). MANUAL OF THE DISEASES OF WOMEN. For 
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 MILLER (JAMES). PRINCIPLES OF SURGERY. Fourth Ameri- 
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Lea Beothers & Co.'s Publications. 11 
 
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 MITCHELL (JOHN K.). .REMOTE CONSEQUENCES OF IN- 
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 MORRIS (HENRY). SURGICAL DISEASES OF THE KIDNEY. 
 
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 NATIONAL DISPENSATORY. See Stille, Maisch & Caspari, p. 14. 
 
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 Cloth, $2. 
 
 NORRIS (WM. F.) AND OLIVER (CHAS. A.). TEXT-BOOK OF 
 
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 PEPPER'S SYSTEM OF MEDICINE. See p. 2. 
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 SURGICAL PATHOLOGY. In one 12mo. volume of 511 pages, 
 
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12 Lea Beothers & Co.'s Publications. 
 
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 THE SYSTEMATIC TREATMENT OF NERVE PROSTRA- 
 
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 PYE-SMITH (PHILIP H.). DISEASES OF THE SKIN. In one 
 
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Lea Brothers & Co.'s Publications. 13 
 
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Lea Brothers & Co.'s Publications. 15 
 
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 YEAR-BOOKS OF TREATMENT FOR 1891, 1892 and 1893, similar 
 to above. Each, cloth, $1.50. 
 
 YEAR-BOOKS OF TREATMENT FOR 1886 and 1887. Similar to 
 above. 12mo., 320-341 pages. Limp cloth, $1.25. 
 
 YEO (I. BURNEY). FOOD IN HEATH AND DISEASE. In one 
 
 '\r\ 12mo. vol. of 590 pp. Cloth, $2. See Series of Clinical Manuals, p. 13. 
 ■ A MANUAL OF MEDICAL TREATMENT, OR CLINICAL 
 
 9 
 
 THERAPEUTICS. Two volumes containing 1275 pages. Cloth, $5.50. 
 YOUNG (JAMES K.). ORTHOPEDIC SURGERY. In one 8vo. 
 Xt T$u& e A£ ^f P a & es > witn 286 illustrations. Cloth, $4 ; leather, $5. 
 

 
 
 
 
 
 
 
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