iw'-v;-'.; 5' I Qass Book COPYRIGHT DEPOSIT MINOR SUEGEKY; HINTS EVERY-DAY DUTIES OF THE SURGEON. Co HENRY H. SMITH, M.D., Lecturer on the Practice of Surgery.; Fellow of the College of Physicians ; Member of the Philadelphia Medical Society, etc. SECOND EDITION, WITH NUMEROUS ADDITIONS. XUustrateli bv 227 iBnflrabinfls. k PHILADELPHIA: ED. BARRINGTON & GEO. D. HASWELL. 1846. Entered, according to Act of Congress, in the year one tiiousand eight hundred and forty-six, by BARRINGTON & HASWELL, in the clerk's office of the District Court for the Eastern District of Pennsylvania. i PREFACE TO THE SECOND EDITION. In the publication of the first edition of this volume, unforeseen circumstances so limited its size and cha- racter, as to cause a considerable modification of the plan originally proposed : thus rendering it evidently incomplete, in the portion mainly connected with the title selected. Notwithstanding this, the work has gained for itself some little share of public favor, and drawn attention to a practical class of duties in which Professional Instruction was certainly deficient in this country, although Europe had long shown a different estimate of its importance. On the completion, there- fore, of the former edition, the author determined so to arrange the present one as to remedy these defects; and he has now, in addition to a careful revision and modification of the former text, added upwards of one hundred pages of new matter. The liberality of the publishers has also enabled him to increase very ma- terially the illustrations. These, it is hoped, will in- crease the usefulness of the volume, without adding much to its original cost. The execution of the cuts w^as confided to Mr. Spittall, and has been faithfully executed by him. Pretendingto offer nothing but " Hints on theEvery- Day Duties of the Surgeon," the consideration of many of the subjects referred to has necessarily been brief; and what might, perhaps, be looked on as oversights, become therefore part of the proposed structure. Aware, that in a subject of daily utility, little could be claimed as original, his wish has been rather to present what he knew from experience to be useful, than to suggest new methods or offer a collection of 4 PREFACE. plans, plausible enough in theory, yet utterly defec- tive in practice. Nevertheless, he has not been inattentive to the onward progress of Surgery, even in these minor matters, and wherever new suggestions have seemed to be of value has embodied them in the text. In doing this, and throughout the work, he is consequently largely indebted to the practical men of both Europe and the United States ; and as it has not been an easy matter to define at the moment the source of information which, from its value, he had rendered matter of every-day practice, he has sub- joined a list of the authors whom he has mainly con- sulted, and to whom he would refer those who may wish to learn more in detail of the hints here given. From this reference, the younger reader will be enabled to trace the latest points from which the subject has been enriched : whilst the more advanced will readily recognise its Hippocratic origin beneath the more superficial stratum of the modern schools. HENRY H. SMITH. No. 117 S. Ninth Street, Oct. 1st, 1846. LIST OF AUTHORS. The following list embraces some of the more important works consulted in connection with the present subject : — Amesbury, on Fractures. J. Rhea Barton, North American Journal, &.c. BoYER, Maladies Chirurgicales. BouRGERY, Minor Surgery, by Kissam. Bond, North American Medical Journal. Baynton, on Ulcers. Sir Astley Cooper, on Dislocations and Fractures. Samuel Cooper, Dictionary. Coster, Manual of Operative Surgery, by Fife. Cutler, on Bandages. R. Coates, Journal Medical Sciences. Dorsey, Elements of Surgery. Dessault's Surgery, by Caldwell. Druit, Modern Surgery, by Flint. Dupuytren, Legons Orales. Fergusson, Surgery, by Norris. Gerdy, Bandages et Pansements. Gibson, Institutes and Practice of Surgery. Goddard, on the Teeth. Jamain, Petite Chirurgie. Liston, Elements of Surgery, by Gross. Mayor, Bandages et Appareils. Malgaigne, Medecine Operative. Pancoast, Operative Surgery. Pott, Chirurgical Works. Sedillot, Medecine Operatoire. N. R. Smith, Baltimore Medical and Surgical Journal. Thillaye, Traite des Bandages. Velpeau, Medecine Operatoire. CONTENTS. Preface to Second Edition PAGE 3 PART I. OF DRESSINGS AND BANDAGES. Introduction . . . . 17 CHAPTER I. ON THE PREPARATION AND APPLICATION OF DRESSINGS. Dressings, Preparation and Application of . 19 Apparatus for 19 Instruments of , 19 Pieces of 22 Lint , 22 Charpie 23 Cotton • • , 26 Tow 27 Compresses . 27 Square 27 Triangular , 28 Cribriform . 28 Perforated Compress , 30 Graduated . 30 Pyramidal , 31 Malteese Cross 28 Retractors , 29 Adhesive Strips 31 Baynton's use of . 33 applied in Epididy mitis , 36 Isinglass Plaster . , 37 Court Plaster 38 Poultices , 38 Plasters 40 Irrigation , 41 Rules for Dressing . • 45 CHAPTER II. OF THE PREPARATION AND APPLICATION OF THE BANDAGE. Bandaging .... , • 48 Roller, Simple , , 48 Manufacture of , , 49 Single-headed • • , 49 Double-headed . . . 50 CONTENTS. Bandage, rolling of . Application of Circular Oblique Spiral Uniting Dividing Compressing Expelling . Retaining Reverses of . Spiral . of Chest Abdomen Penis . Finger all the Fingers, or Gauntlet Demi-Gauntlet Upper Extremity- Lower Extremity French Spiral CHAPTER III. OF THE CROSSED, OR FIGURE OF 8 BANDAGES Crossed of one Eye both Eyes Angle of the Jaw the Jaw- Barton's for the Jaw Posterior 8 of the Chest Anterior 8 . Of one Breast both Breasts Spica of Groin . both Groins Shoulder Thumb Instep Figure of 8 of the Elbow Wrist Figure of 8 of both Thighs Knee Ankle Figure of 8 of Neck and Axilla Ribbail's CHAPTER IV. OF KNOTTED BANDAGES. Knotted Bandage of Head 89 CONTENTS. CHAPTER V. OF RECURRENT BANDAGES. Recurrent Bandage of Head two Globes . Amputations CHAPTER VI. 91 92 93 OF THE COMPOSITION AND APPLICATION OF THE COMPOUND BANDAGE, OR THE BANDAGE PROPER. T Bandage i . . . • . 95 of Head . . . 96 Ear . 97 Nose .... 98 Chest . 99 Abdomen 99 Triangular T of Groin . 100 Double T of Buttock 101 of Hand . 102 Perforated of Hand 102 CHAPTER Vn. OP THE INVAGINATED, OR SLIT AND TAIL BANDAGES. Invaginated Bandages . . . . 104 for Wounds of Lips . , . 104 of Body . . . . . 105 for Longitudinal Wounds of the Extremities 106 for Transverse Wounds of the Extremities 107 for Wry Neck . . . 107 Jbrg's Apparatus . . . . .108 Uniting, of Transverse Wounds of Neck . , 110 CHAPTER VHI. OF SLINGS. Slings or Bandage of Galen Four-tailed of Head of Neck ..... of Chin of Face ... Mask ..... of Breast . CHAPTER IX. OF SUSPENSORIES, SHEATHS, AND LACED BANDAGES Purses or Suspensories ofNose of Scrotum . . > Sheaths . . . ... Ill 111 112 113 113 114 114 115 117 117 118 119 10 CONTENTS, Laced or Buckled Bandages Gaiter Stocking for the Knee PART II. 119 119 120 120 CHAPTER I. MAYOR'S HANDKERCHIEF SYSTEM. General Considerations CHAPTER II. OF THE HANDKERCHIEFS AS APPLIED TO THE HEAD, Handkerchiefs for Head Square Cap of Head . Fronto-Occipital Triangle Occipito-Frontal Bi-Temporal Triangle Occulo-Occipital Triangle Fronto-Occipito-Labialis . Facial Triangle Verlico-Mental Cravat Occipito-Auricular Sternal Handkerchief Fronto-Dorsal Parieto-Axillaris CHAPTER HI. OF THE HANDKERCHIEFS AS APPLIED TO THE TRUNK Cervical Cravat ..... Simple Bis-Axillary Cravat . Compound Bis-Axillary Cravat . Simple Bis-Axillo-Scapulary Cravat . Compound Bis-Axillo-Scapulary Cravat Dorso-Bis-Axillaris . Triangular Cap of Breast Sub-Femoral Handkerchief . Inter-Femoral Handkerchief Single Spica Handkerchief . Double Spica Handkerchief Suspensory or Handkerchief to Scrotum CHAPTER IV. OP THE HANDKERCHIEFS OF THE UPPER EXTREMITIES. Cervico-Brachial Sling ..... Ante-Brachial Trough .... Triangular Cap of Shoulder .... Triangular Cap of Amputations . . . 121 128 128 128 129 130 130 130 131 131 131 132 133 138 135 135 135 136 137 137 138 139 140 140 140 141 142 142 144 144 CONTENTS. 11 Carpo-Olecranien Handkerchief Flexor of Wrist Carpo-Dorsal Triangle . 145 145 146 CHAPTER V. OF THE HANDKERCHIEFS OF THE LOWER EXTREMITIES. Metatarso-Malleolar Cravat . , 147 Triangular Cap of Heel . . . 147 Tarso-Pelvien Cravat . , 148 Compound Metatarso-Rotular Cravat . 148 Tarso-Patella Cravat . 150 Triangular Cap of Foot . , . 150 Tibio.Cervical Sling . 150 Tibial Cravat , . 152 Barton's Handkerchief 153 Mayor's Hyponarthecia , . 153 Anle-Brachial Hyponarthecia 158 Hyponarthecia of Lower Extremities . , . 160 Mayor's Clinical Frame 176 PART III. CHAPTER I. APPARATUS FOR FRACTURES. General Considerations . 186 CHAPTER II. FRACTURES OF BONES OF THE HEAD AND TRUNK Fractures of Skull .... . 1917 Nose 191 Lower Jaw . 191 Gibson's Bandage for 192 Vertebrae .... . 193 Sternum .... 193 Ribs . . . • . 194 Pelvis ..... 194 Clavicle .... 1D4 Dessault's Apparatus for . 194 Boyer's „ 198 Mayor's ,, 199 Fox's 200 Scapula .... 202 Velpeau's Bandage for - . 203 12 CONTENTS. CHAPTER III. OF FRACTURES OF THE UPPER EXTREMITY. Fractures, Neck of Humerus Boyer's Bandage for for Fracture of Shaft of Humerus Pennsylvania Hospital Plan of the Condyles Physick's Apparatus for Carved Splint . Fore-arm Lower End of Radius Barton's Bandage for Metacarpal Bones . . Phalanges . , Olecranon Astley Cooper's Apparatus for JDessault's „ Pennsylvania Hospital „ Boyer's „ Mayor's „ Gerdy's „ of Coronoid Process CHAPTER IV. OF FRACTURES OF THE LOWER EXTREMITY General Considerations .... Elevator for Treatment of CHAPTER V. OF FRACTURES OF THE FEMUR. Fractures, of Femur Bell's Inclined Plane Dupuytren's Inclined Plane Coates's Extending Band Physick's Gaiter Coates's Perineal Band . Junct-Bags . Splint Cloth Scultet's Bandage Eighteen-Tailed Bandage Splints, Dessault's . Physick's Boyer's Hartshorne's Amesbury's Gibson's Hagedorn Gibson's Simple Inclined Plane N. R. Smith's Splints , CONTENTS. 13 CHAPTER VI. OF FRACTURES OF THE PATELLA. Fractures, of Patella . . . . .243 Dessault's Apparatus for . . 243 Dorsey's „ ... 244 Mayor's „ . . 245 Gerdy's „ ... 245 CHAPTER Vn. OF FRACTURES OF THE LEG. Fractures, of Leg ..... 246 Hospital Fracture-Box . . . 246 Barton's Bran Dressing . . 248 Amesbury's Apparatus for . . 249 Dupuytren's Apparatus for Fracture of the Lower Extremity of the Fibula . 253 Boyer's Apparatus for Fracture of the Os Calcis ... 254 CHAPTER Vni. OF THE IMMOVABLE APPARATUS. General Account of . . . . • 256 PART IV. CHAPTER I. OF THE APPARATUS FOR IHE TREATMENT OF DIS- LOCATIONS. General Considerations . . . . 263 CHAPTER II. DISLOCATIONS OF THE HEAD AND TRUNK. Dislocations, of Head and Trunk . . . 265 Lower Jaw .... 265 Oblique Processes of Verlebree . 266 Ribs . . . . .266 Clavicle .... 267 CHAPTER m. DISLOCATIONS OF THE UPPER EXTREMITY. Dislocations, of Upper Extremity . . . 269 Head of Humerus . . . 269 Fore-arm . * . .271 Head of Radius . . . 272 14 CONTENTS. Dislocations, RedQction of . . . Rule for Diagnosis of Injuries to Elbow of Bones of Fore-arm on Wrist of all Bones of Wrist ofMagnum . , . of Metacarpal Bones . of Phalanges Clove Hitch 273 273 274 274 274 275 275 276 CHAPTER IV. ON DISLOCATIONS OF THE LOWER EXTREMITY. Dislocations of Hip-Joint . 278 Fahnestock's Mode of Reducing . 279 Reduction by PuUies . 279 Dislocation on Pubis . 281 into Sciatic Notch • . 281 Foramen Thyroideum 282 of Patella . . 282 Head of Tibia. 283 Fibula . 283 Bones of Tarsus 283 Metatarsal Bones . 284 Phalanges 284 PART V. OF THE MINOR SURGICAL OPERATIONS. Definition of . . 285 CHAPTER I. OF BLOOD-LETTING Phlebotomy .... 285 Venesection .... . 286 Anatomy of Veins of Arm . 286 Lancets .... . 289 Spring Lancet 289 Thumb Lancet .... . 290 Operation with Spring Lancet 291 Thumb Lancet . . 292 Bleeding in Hand 293 External Jugular Vein . 293 at the Ankle 294 Arteriotomy . 297 Local Blood-letting . 298 Leeching . 299 Arrest of Hemorrhage from 301 Preservation of Leeches . . 302 Cupping . , . • 303 CONTENTS. 15 CHAPTER II. OP CUTANEOUS IRRITATION. General Considerations of . . . . 305 Blisters ...... 305 Granville's Lotions for . . 307 Issues . . . • 307 Issue Peas ..... . 308 Formation of Issue by Potash, Acids, &c. . 309 Setons ...*.. . 310 Moxa . . . . . . 312 CHAPTER III. OF PUNCTURES. General Considerations of . . . : 315 Acupuncturation 315 Electro-Puncture . . . . . 317 Vaccination 317 Preservation of Vaccine 319 Perforation of Lobe of Ear .... 320 Puncture of Membrana Tympani . 323 Paracentesis Abdominis . . . • 322 Puncture of Hydrocele . . • . . 324 Ranula ...... 325 Salivary Concretions . . • . . 326 Puncture of Abscesses .... 326 Diagnosis of Abscesses .... . 327 CHAPTER IV. OPERATIONS FOR ARRESTING HEMORRHAGE. General Consideration of . 329 Pressure . . . . . 329 Spanish Windlass ..... 331 Tourniquet of Petit . . . . . 332 Ligature . . , • . 334 Surgeon's Knot . . , 335 Sailor's Knot . . . 335 Torsion . . . . . . , 336 Plugging of Nostrils . . , 337 Arrest of Hemorrhage from Rectum 339 Hemorrhage from Bladder .... 340 CHAPTER V. OFWOUNDS. General Consideration of ... . 341 Sutures . . . • . , 341 Interrupted Suture 341 Continued Suture ..... 343 16 CONTENTS. Twisted or Hare-lip 344 Quilled . . . . . . 345 Dry 345 CHAPTER VI. CATHETERISM. General Consideration of . . . . 347 Catheterism of Urethra . . . .347 Stomach .... 351 Eustachian Tube . • • 353 CHAPTER Vn. OF INJECTIONS. General Use of . . . • . 355 Injection of Lachrymal Ducts . . . . 355 Lungs ..... 356 into Urethra ..... 357 Vagina ..... 358 Rectum ; . . . . 358 CHAPTER VIIL OF EXTRACTION OF FOREIGN BODIES, &C. General Consideration of . . . . 360 Extraction of Teeth . . . • .360 Cilise 363 Foreign Bodies from Eye-Ball . . 364 Matter from Eye-lids . 365 Bodies from Nostrils . . 365 Ear . . 365 Throat . . 366 Dr. Bond's Forceps for 367 Trachea Matter from Wounds Bodies from Rectum Urethra Corns . . Bunnions Toe Nail Ulcer . Dr. Meig's Plan of Treating Various Operations Insertion of Glass Eye Excision of Pterygium . Uvula Tonsils 368 368 369 369 369 371 371 372 373 373 374 375 376 Conclusion . . . . . . 377 MINOR SURGERY. PART I INTRODUCTION. The daily duties required of the surgeon, call for such varied qualifications, both in his natural tem- perament and that acquired by education, that com- paratively few of the great mass of medical men, are fitted for their performance, or have any inclination to undertake them. All practitioners are, however, often compelled by circumstances to resort to means that are as purely operative, as those necessitating the extensive use of the knife, and Surgery has, there- fore, since a very early period, been divided into Minor and Major Surgery, or parts purely operative or otherwise ; the various works written on the subject, having thus divided their matter, in order to treat it the more systematically. But as these terms are purely conventional, there has been much difference of opinion, as to what constituted the boundaries of each, and some writers have in consequence, so min- gled the two, as to render it difficult to know where to draw the line. In the strictest acceptation of the term, Minor Surgery means that portion of Surgery, proper, which treats of the minor operations, such as Bleeding, Leeching, Extraction of Teeth, &c. This, however, is too limited a definition to meet the necessities of 2 18 INTRODUCTION. most practitioners, and in the present work, we shall, therefore, embrace a wider field, and include under the head of Minor Surgery, all such duties, as every medical man is liable to, provided they do not re- quire the extensive division of our tissues, or, in other words, constitute a capital operation. In the systematic consideration of our subject, five divisions, naturally present themselves : — 1st. Dres- sings and Bandaging, — 2d. Provisional Dressings,— 3d. Apparatus for Fractures, — 4th. Apparatus for Dislocations ; and 5lh Minor Operations. APPLICATION OF DRESSINGS. 19 CHAPTER I. ON THE PREPARATION AND APPLICATION OF DRESSINGS. Although very varied information and skill, are necessary to the immediate treatment of surgical in- juries, and especially those requiring the performance of operations, yet will the successlikely to follow them, depend in a great degree, upon the attention subsequent- ly given to the case. The art of Dressingbecomes, there- fore, a subject of equal, if not greater importance, than that of operating, and should be properly regarded as a matter of vital consequence, as without it all other means would often prove unavailing. The object of all dress- ings, being the relief of injured parts, their application must, of course, depend upon circumstances, but gene- rally, they are intendedto preserve such parts in proper coaptation ; to unite them, or prevent too hasty union ; to shelter them from the action of the atmosphere or of external injuries ; to absorb discharges ; prevent des- sication of surface ; and lastly, though equally im- portant, to ensure cleanliness. Dressings may, there- fore, be defined as those portions of different sub- stances, which are applied with such intentions, di- rectly to operated or injured surfaces. The different articles employed and the means by which they are appHed, are known under the general head of Apparatus of Dressing ; and consists of two parts, one containing the Instruments for Dressings the other the Pieces of Dressing to be employed. The Instruments for Dressing, are such as are generally found in the assemblage furnished by the cutlers, and known under the name of the Pocket Case. This contains Dressing or Ring Forceps ; Simple Forceps ; Scissors, both straight and curved ; Probes ; Directors ; Spatulee ; Bistouries ; Abscess- 20 PREPARATION AND Lancets ; Porte Caustic ; Tenacula ; Straight and Curved Needles ; Ligatures ; and often such others, as the taste of the cutler or his interests may lead him to select. Under the same head should also be included, Razors, Basins, Sponges, Buckets, and all that is requisite for the preparing of a part for the application of the dressing, or the removal of ihe previous one. The DressingForceps, are employed for removing the different pieces of dressing ; not only in order to protect the fingers of the Surgeon from discharges that are often very irritating, but also on account of their seizing them with less risk of injuring surround- ing parts, especially by pressure. In cases of fistulae or sinuses, they are also often necessary, in order to cleanse the bottom of the sinus, or remove deep- seated portions of dressing, or other foreign matter. The Simple or Dissecting Forceps, may be fre- quently substituted for the Dressing Forceps, especially where minute portions of dressing — as ligatures, &c., are to be removed. They are, however, more frequently used for seizing such portions of integument, &c., as may require to be cut off by the knife or scissors. The Straight Scissors, are employed in dressing, for the ordinary purposes of scissors — but those which are curved, either on the side or front, are mainly employed in the removal of such dressings as adhere closely to the body; as adhesive strips, bandages, &c., especially where it is desirable to remove them without deranging the position of the part. Scissors are also occasionally used for excision of portions of integuments, as in hare-lip ; but they do not answer as well as the scalpel for such operations, because they are apt to bruise the edges of the part divided, and thus interfere with its subsequent adhesion. Probes, should always be made of silver, or some equally flexible metal, in order that they may be readily bent, to suit the position of the part to be APPLICATION OF DRESSINGS. 21 examined. They are employed either for the exami- nation of parts deeply seated within the integuments, or for the introduction of different portions of dress- ings into fistulse, &c. The Director, is a broad probe with a groove in it, which is generally used to direct the point of a scalpel or bistoury, in the division of deep-seated parts, especially where important organs are in the neighbourhood of the incision. Sometimes it has a flat end for a handle, and sometimes a ring or some slight expansion, to keep it from turning in the fingers of the operator. The Spatula, may be used either in spreading cerates, in the preparation of dressings, &c., or for removing such portions of similar substances as re- main adherent to the skin. Bistouries and Scalpels, are required for various operations involving the division of the different tis- sues of the body. Their use, therefore, is generally described in the works on Operative Surgery. Abscess Lancets resemble the ordinary thumb- lancets, except that they are larger. The manner of using them will be again referred to. The Porte-Caustic is employed, as its name designates. It usually carries in it the Nitrate of Silver, or lunar caustic, and not the caustic potash. As a general rule it should be made of silver, as this metal is not acted upon by the caustic ; whereas bone and similar substances, of which it is sometimes formed, are soon destroyed. When it is desirable in arming it, to give the caustic a fine point, so as to enable us to touch only small spots, as in the treatment of ul- cerated cornea, chancre, &c., it will be best accomplish- ed by rubbing it down with a piece of wet rag, so as to wear it away, rather than by scraping ; as the brittleness of the nitrate of silver, renders it difficult to bring it to a point, merely by the use of the knife. Straight and Curved Needles — Tenacula 22 PREPARATION AND and Ligatures, will be treated of under another head, and the other instruments of dressing are so simple, as only to require the mere mention of them, in order to guard against their omission in the Apparatus of Dressing. The Pieces of Dressing, are Lint ; Charpie ; Cot- ton ; Tow ; Spread Cerate, or other ointment ; Com- presses ; Malteese Cross ; Shields for Amputations ; Adhesive Strips ; Setons ; Poultices ; Plasters ; and means of Irrigation. Lint, is a soft, delicate tissue or mass, prepared in two ways ; — in one of which the transverse threads of soft old linen, are drawn out by a machine, leaving the longitudinal ones covered by a sort of tomentum Fig. 1. or cotton-like mass ; the other, in which the cotton- like surface is produced by scraping with a sharp knife, a similar piece of cloth, previously fastened to some firm substance. The first is known as the Patent Lint, and may be obtained of any druggist. APPLICATION OF DRESSINGS. 23 as it is now generally manufactured. The second, is the Domestic Lint, and may be made at a moment's notice when the first is not convenient. They are both employed as primary dressings, either spread with ointments, or alone. Charpie, is a substance much employed by the French surgeons, and now gaining a more general application in the United States. It is made by collecting the threads torn from pieces of linen, four or five inches square, such as is used for patent lint. The process, however, goes a step farther than that for making lint, and tears the threads entirely apart, in- stead ofpreserving the cloth. The cloth should be new and clean ; especially as Gerdy has proved, that when made from new linen, it absorbs better than when old. It is usually divided into two kinds, according to the length and fineness of the thread composingit; that which is long and coarse beingemployed to keep open sinuses, fistulae, and as an outer dressing; while the softer, finer kind may be placed in immediate contact with the part, especially where the surface requires stimulation. Various names are given to Charpie, according to the way in which its fibres are arranged, previously to its application. Thus there is the Pledget, Roll, Tent, Mesh, Bullet, Tampon, and Pellet; each of which have their peculiar advantages. The Pledget, is a mass of charpie i-v^. 2. formed by a collection of ravellings, the threads of which are laid parallel to each other, with the ends folded underneath. This being flattened between the palms of the hands, may be made of an oval, spheroidal, or square shape, according to the part on which it is to be applied. As thus formed, it is usually spread with cerate, and neatly adapted to the parts it is to cover ; care being taken not to make it 24 PREPARATION AND Fig. 3. SO thick as to overload and heat it, nor yet so thin as to become quickly saturated with the pus. Where charpie cannot be obtained, the patent lint, cotton, or tow, similarly arranged, may be substituted. The Roll, is a smaller mass of charpie, formed by rolling its fibres longitudinally between the hands, so as to make an ob- long mass, which is then tied firmly in the middle, so that when the ends are brought in contact laterally, it may form a sort of cone. It serves for absorbing pus in deep wounds, where there is a tendency in the edges to close, before the bottom has filled up. It is also useful in arresting hemor- rhages from deep-seated vessels ; pressure being made by forcing the central part upon the vessel by a probe, while the loose tissue made by the ends, assists in the formation of the clot. A director or probe is necessary, in order to carry it into deep wounds or upon a vessel. The Tent, is a conical or cylindrical mass of charpie, formed like the roll, except that instead of applyingastringtoits middle, it is there simply dou- bled on itself and its loose ends twisted by the fingers, so as to give it a spiral form and make the apex of a cone, the base of w^hich is the part where the fibres are doubled on themselves. This, is also employed to dilate fistulous canals, or openings which are too small to allow of the free escape of pus, and where only moderate dilatation is required. But where parts are rigid, the Sponge Tent, or that made by slicing gentian, carrot, or some other por- ous root into the shape of a cone, or plug, answers better. The Sponge Tent, is the one most generally em- ployed, and answers better than the others in most cases. It is prepared by saturating common sponge Fig. 4. APPLICATION OF DRESSINGS. 25 Fig. 5. with melted bees-wax ; allowing it to cool and harden ; and then slicing it into small pieces, of such a size as will nearly fill the orifice to be di- lated. The heat of the part melts the wax ; the sponge fills with the fluids of the tissues, and gradually dilates them to the size required ; after which a new morsel must be introduced. The Mesh, consists of the threads of charpie, placed parallel with each other andbent on themselves, and is of great use in the treatment of deep fistula, espe- cially fistula in ano. When thus used, it should be anointed with cerate, and introduced into the cavity on the point of a probe until it touches the bottom. It acts by preventing the edges from healing, and causing the cavity to fill from below, upwards. Bullets, are little balls, made by rolling charpie between the hands until it acquires this form. They are extremely porous, absorbent, and useful in filling up puru- lent cavities ; where they pre- vent the matter from bur- rowing. When a number of Bullets _ are placed together at the bottom of any cavity, either with a view of distending it, or of arresting hemorrhage, they take the name of Tampon. They are often thus used in gonorrhoeal inflammations of the vagina ; in fluor albus ; and to arrest uterine hemorrhage. For the latter purpose, especially if the hemorrhage follows an operation, or a laceration of the neck of the womb, they may be made of the Boletus Igniarius, or puff-ball. The Pellet, is a large bullet surrounded by a piece 26 PREPARATION AND of soft rag, the edges of which are brought together and tied firmly. It is occasionally em- ^^S"- '^' ployed in the treatment of hernia, espe- cially the umbilical hernia of children, where, when bound down by adhesive strips, or a bandage, it answers very well the purpose of a truss. It is also useful in the compression of large vessels ; as in wounds of the axillary artery, in the reduction of dislocations into the axilla, and in hemorrhage from parts in the neighbourhood of the rectum, being there confined under a T bandage. In the hemorrhage which sometimes follows the ex- traction of a tooth, a very useful pellet may be formed of a bottle cork, cut into a cone and forced into the socket with a little lint, by closing the jaws. For the convenience of those who may desire to obtain charpie in this country, I would state that Mrs. F. B. Jones, S. W. corner of Juniper and Walnut Streets, Phila.,makesit of an excellen,t quality, at $1.25 per pound ; very little more than the cost of patent lint. Cotton and Tow, are substances which are too well known to require a description. Both are of comparatively limited utility as dressings, their places being usually supplied by charpie. Before, however, the application of either to surgical purposes, they should be well picked or carded, to free them from foreign matter. The chief use of cotton, is as a dress- ing to superficial burns, where it is useful by pro- tecting them from the air, absorbing the discharges, and thus forming a sort of scab under which tney readily heal. When intended to be thus used, it is, however, especially necessary to see that it is free even from specks^ as the fly is exceedingly apt to lay its egg in it, where, being vivified by the heat of the body, it generates maggots, to the great annoyance of the patient and the astonishment of all around him ; who, under the belief that he is eaten by worms, usually regard it as a fatal sign. APPLICATION OF DRESSINGS. 27 Tow, is employed chiefly as an outer dressing, to stumps which are discharging freely, in order to protect the bed. Care is requisite in forming the Pledget of Tow for this purpose, that it be not too thick and heating, as union, is often thus prevented. Compresses, are pieces of linen of various sizes, used to make pressure, confine dressings, prevent external injuries, and equalise the surface of limbs, in order better to adapt them to the use of the bandage, and the compression of the soft parts. They may be made of any soft substance, as flannel, muslin, calico, &c., and with one or two exceptions, are to be applied over other dressings. When intended to be placed directly on a wound, they should always be made of soft linen, or lint. Compressess have received various names, according to the way in which they are folded, or the indications to be fulfilled ; thus we have the Square, Ob- long, Triangular, and Cribriform Com- press, the Malteese Cross, the Half Malteese Cross, the Single and Double Split Compress, as well as the Perforated, Graduated, and Pyramidal Compresses. The Square Compress, is that in which the substance used has the same dimensions in its two principal diame- ters. If it is twice as long as it is broad, and will form a square when doubled in its length, it constitutes the Oblong Compress, or Band, and is useful in surrounding the trunk, or limbs. If it is a square piece of linen folded so as to unite two of its angles, it forms the Triangular Compre.ss. This is exceedingly useful in confining dressings to stumps, especially when it is desirable to remove the dressing frequently 28 PREPARATION AND t > \ k » « « < • ,««»»* f f t » « V « « « c * « HI •«>*«*» I « •«»»«»« »♦♦»««» I » « 4 « « > 1 » « « t « ^ i « ( t f 4 f » ♦ « ♦ » » » without deranging the limb, as in the use of poultices, &c. To apply one for this purpose, cut it of such a size as will surround the limb, place the stump in the centre of the side a 6; then turn up the apex c, and afterwards the points aandZ>; confining them by pins. The Cribriform Compress, is a square piece of linen in which a number of holes are cut. It is formed by folding linen four or six times on ^^^' ^0- itself, so as to form several ob- long squares, one within the other; then nick the sides in several points with the scissors, soastoremovesmallpieces; and on opening it out, we shall have the form desired. When spread with cerate, it is to be applied directly to a suppurating sur- face, and the pus, passing out through the holes, will allow the compress to remain directly in contact with the surface, and thus pre- vent the wound from being constantly bathed in mat- ter, which sometimes is unhealthy. It will also assist in the removal of other dressings, by preventing them from sticking to the part. The Malteese Cross, so named from its shape, is made from a square piece of linen, by folding it into an oblong square ; doubling this in its length to form a smaller square ; joining two of the angles to form a triangle, as in the figure ;(Fig. ll)andfoldingthis equila- terally, to form a smaller triangle ; then mark a line on its hypotheneuse half an inch from its apex, and slit the sides down to this line, as in that which is dot- ted in the figure. On opening it out, we have a very regu- lar cross, with a space in the centre, (Fig. 12), intended to cover the front of the stump, whilst the arxgles go APPLICATION OF DRESSINGS. 29 Fig. 12, jP/g, 13. around it. This cross is of great use, as a primary or secondary dressing in amputations, as by means of the slits, it folds over and fits the part, very ac- curately. The Half Malteese Cross (Fig. 13) is formed by slitting the two angles of the loose side of an oblong square, to within an inch or two of their centre, as seen in the figure, and in some cases serves a better pur- pose than the full cross ; as in dressing stumps at the shoulder, or after am- putation at the hip-joint, &c. If the linen is doubled and cut in this form, it will, when opened out, form the cross (Fig. 12) as readily, as the one in the plan there stated. The Retractor of Two Tails, (Fig. 14) is an oblong piece of muslin split as represented in the figure, and intended to be used as a shield to the soft parts, in amputations of the arm or thigh. In applying it, draw the tails downwards on each side of the bone, and the upper part or body of the retractor, upwards over the stump, so as to force back the muscles and protect them from the action of the saw. The diamond shaped opening at the end of the split, is intended to adapt it more accurately to the bone it- self. Fig. 14. The Retractor of Three Tails, (Fig. 15) is made 30 PREPARATION AND like the preceding, only it is split into three tails in- Fig. 15. 0^ stead of two. It is employed in the same manner, in amputations of the forearm and leg ; the third or middle tail, being pushed through the inter- osseous space, so as to protect more thoroughly both the bones of the part. The Perforated Compress, (Fig. 16) is the name given to a piece of muslin folded several times on itself, so as to make a thick mass, in the centre of which an opening is cut. It is used in order to relieve points from pressure, especially where they have a tendency to slough, as on the internal condyle in fractures of the arm ; on the trochanter of the femur, or on the heel, in fractures of the lower extremity. The sore point, being placed in the centre of the opening, is saved from the weight, whilst the pressure is borne by the parts on its circumference. Frequently it is made out of a small pad or pillow, cut and formed like Fig. 16. Whenever used, attention should be paid to the parts of the limb, pressed on by the cir- cumference of the opening. Graduated Compresses, are named from their construction, and are of several kinds ; the substance of each being folded differ- ently, according to the object in view. The Common Graduated Compress, is made by fold- ing a piece of muslin several times on itself, so that each fold may not entirely cover the one that has preceded it. It may be graduated at one end, as in the cut, or Fig. 16. Fig.V r. APPLICATION OF DRESSINGS. 31 Fi!r. 18. from end to end as would be the case if Fig. 17 had another folded end at its left extremity. The Pyramidal Compress, is one that is most accurately form- ed, by placing on one another squarepieces of muslin, gradually decreasing in size, so as to form a pyramid (Fig. I8j. It may also be made by folding a piece of 2^ inch bandage on itself, so as to form a compress graduated from end to end, and then placing a piece of cork, or cotton, or other body in the centre of the last turns (Fig. 19.) Thus formed, it is very ^^S"- ^^' useful in making pressure upon certain points ; as in cases of hemorrhage from the deep-seated vessels of the leg, or arm. Adhesive Strips, are pieces of linen spread with some adhesive plaster, (usually Diachylon,) and in- tended to promote the union of divided parts. As this plaster is kept very generally by the druggists, the for- mula for its composition, would here be out of place. When the strips are wanted, they may be prepared from the sheet on which it is usually spread, by sliding the scissors according to the line of the thread of the cloth, and slitting it into pieces about three-quarters of an inch in width, (Fig. 20) and of a length suffi- cient to enable it to extend at least three inches be- yond each side of the wound which is to be united. Before applying them, it is generally necessary to soften the plaster by heat ; and the most convenient method of so doing, is to fill a bottle with boiling water and wrap the strip around it ; the outside of the strip being next the surface of the bottle. In its application, the strip should be first placed on that 32 PREPARATION AND portion of the wounded surface which is most de- pending, in order to draw it up to the other, and not from above downwards ; the intervals between the strips being such as to allow of the free escape of matter. In order to remove them readily, wash the part with warm water, or apply a warm poultice to it a few hours before the dressing is to be changed. After this, the surgeon lays hold of one of the extre- mities of each piece in succession, and gently raising its end, reflects it upon the wound. This extremity being detached to within half an inch of the edge, he detaches the other to about the same distance, and holding them together, lifts them perpendicularly from the parts, taking care at the same time to apply APPLICATION OF DRESSINGS. 33 the thumb and index finger of the left hand upon the sides of the wound, to prevent injury being clone to the cicatrix. (Fig. 21.) Fig. 21. As adhesive strips sometimes irritate and inflame the skin, owirg to their tearing out the small hairs or down, which cover it, or to the plaster being badly made, their application is frequently followed by Erysipelas. In this case, their place may be very well supplied by the slit and tail, or uniting bandage hereafter mentioned, or by Cooper's Isinglass Plaster. Adhesive strips are also much used as a dressing to ulcers ; for compression in cases of Epididymitis or Hernia Huraoralis, &c., &c. As the treatment of ulcers by means of these adhe- sive strips has gained much celebrity, a detailed ac- count of Baynton's plan is here given. *' The parts," says Mr. Baynton, " should be first cleared of the hair sometimes found on them in con- siderable quantities, by means of a razor, that none of the discharges by being retained may become acrid and inflame the skin, and that the dressings may be removed with ease at each time of their re- newal, which in some cases where the discharges are very profuse, and the ulcers irritable, may perhaps be necessary, twice, in twenty-four hours. Several 3 34 PREPARATION AND strips of adhesive plaster, about two inches in breadth, and of a length that will, after being passed round the limb, leave an end of about four or five inches, are to be applied to the sound part of the limb, the mid- dle of the strap being opposite to the inferior portion of the ulcer, so that the lower edge of the plaster may be placed about an inch below the lower edge of the sore, and the ends drawn over the ulcer with as much gradual extension, as the patient can well bear. Other slips are to be secured in the same way, each above, and in contact with the other until the whole surface of the sore and the limb are completely covered, at least one inch below, and two or three above the diseased part. '' The whole of the leg, should then be equally de- fended with pieces of soft calico, three or four times doubled, and a bandage of the same, about three inches in breadth, and four or five yards in length, or rather, as much as will be sufficient to support the limb from the toes to the knee, should be applied as smoothly as possible, and with as much firmness as can be borne by the patient. '' If the parts be much inflamed, or the discharges very profuse, they should be well moistened and kept cool with cold spring water, poured on them as often as the heat may indicate to be necessary, or perhaps, at least once in every hour. The patient may like- wise take what exercise he pleases, and it will be always found that an alleviation of his pain, and the promotion of his cure, will follow as its consequence, though under other modes of treating the disease, it aggravates the pain, and prevents the cure. The first application will sometimes occasion pain, which, however, soon subsides, and is felt less sensibly at every succeeding dressing. The force with which the ends are drawn over the limb, must then be gradually increased until the parts are restored to their natural state, especially if the limb be in that enlarged APPLICATION OF DRESSINGS- 35 and incompressible state which has been denominated the scorbutic. Fig. 22. *' If the patient be of a spare habit, it may be necessary to guard against excoriation by defending the tendo-Achilles with a small shred of soft leather, previously to the application of the adhesive slips. "^ This plan, although published by Mr. Baynton in 1797, has yet many opponents among the English surgeons, who deny entirely its utility, or insist that it can be replaced by better and less trouble- some means, such as bandages, &c. But the expe- riments of Velpeau, Roux, and many others of the French surgeons, have established very conclu- sively, that it requires only about half the time to cure an ulcer under Baynton's plan, than it did under the old system of ointments, &c. Velpeau has also enlarged considerably the use of adhesive strips, on the principle of Baynton, as a means of making pres- sure, in the treatment of other surgical diseases besides ulcers, such as chronic enlargements of the joints ; in wounds in which it is difficult or improper to heal by the contact of the edges, on account of deformed cicatrises ; in the treatment of burns ; in ganglia, or other tumors about joints ; in scrofulous ulcers of the neck, especially when presenting thickened edges or those which are undermined ; and in different ulcers of the mammary region where otherwise cicatrisation would be extremely slow. '* In Burns," says he, "the adhesive strips act marvellously well. In those of the first degree, one application of the strips, sus- 36 PREPARATION AND tained slightly by a compressing bandage, and which may all be removed from the fourth to the eighth day, is sufficient to effect a cure. If it is a burn of the second degree, that is, one with blisters, and not much phlegmonous inflammation, I remove the cuti- cle, cleanse the exuded matter, apply the strips and obtain a cure at the end of the second dressing, sometimes at the first, and nearly alw^ays at the third; so that if it isnot cured by the fourth, it will be better to change the treatment. If there is much engorge- ment, with a tendency to erysipelas, I commence by an emollient poultice, or a few leeches, and then apply the strips. If the burn is of the third degree, that is to say, with change of structure, or conversion of the true skin to an eschar, the same treatment is pursued, and the cure is not less certain ; only it exacts here, ten or twenty days. When the burn is yet deeper and comprises the whole thickness of the derm, as the strips cannot do away with the neces- sary loss of substance in the separation of the eschar, it is useless to apply them before it has separated, that is, after the formation of the ulcer." It must, however, be recollected that Velpeau changes the strips every three or four days, and not every twenty-four or forty-eight hours, as proposed by Baynton. Nothing answers so well for a compressive bandage of the testi- cle in cases of Epididymitis, or chronic enlargement of the testicle, especially after free leeching, as a firm compression of the part by strips of adhesive plaster, as practised by Ricord and Fricke. In order to apply them in this case, the swelled testicle should be forced to the bottom of the scrotum, Fi^. 23. APPLICATION OF DRESSINGS. 37 by surrounding the cord with the thumb and fingers of one hand so as to form a ring,while with the other, or with the hand of an assistant, the strips are so applied as to surround the part entirely as seen in Fig. 23. These strips should be of the width of the thumb, and applied over one another from below upwards, till the testis and a part of the cord are compressed between them. Previous to their appli- cation, the parts should be cleansed and well shaved; and the strips should be renewed, as often as they become slack from the abatement of the swelling in the testicle. It may perhaps be useful to the young surgeon to say, that the use of adhesive strips to suppurating sur- faces often produces a marked blackness of the skin. This is nothing but a chemical change, produced in the plaster by the action of the discharges, and not the forerunner of gangrene, as many have at first sup- posed. Considerable objection has been raised within the last few years, to the use of adhesive strips, as a means for uniting wounds, on the ground that it proved irritating, and gave rise to erythema and erysipelas. As a substitute for it, the Isinglass 'plas- ter has been verj generally recommended, as possess- ing equal adhesiv^e powers, and having the advan- tage, on account of its transparency, of enabling the surgeon to see the state of the wound through the plaster. '' It is composed," according to Mr. Liston, "of a solution of isinglass i^ spirit, and may be spread for use, as occasion requires, on slips of oiled silk ; on silk glazed on one side only, and on the unglazed side. It is cut into strips of the desired breadth, and the adhesive matter dissol^^ed immediately before it is employed, by the application of a hot, moist spo;ige." This plaster has been recommended to some extent in the United States, but our own expe- 38 PREPARATION AND rience is against it, the warmth of the part, and the discharges, having invariably softened the material, as much as the sponge did previous to its application ; in consequence of which it invariably lost its hold. Court Plaster, sometimes called gummed silk, is occasionally used in slight wounds and excoriations, although mainly, in domestic practice. The English court plaster, that is generally deemed the best, is made by placing one part of choice isinglass, cut into little pieces, in an earthenware vessel upon a sand bath, and digesting it in four parts of water. When this is dissolved, it is strained through a fine linen cloth ; eight parts of alcohol are added ; it is evaporated to one-half, again strained, and the tepid liquid is then spread upon black silk with a camel's hair pencil. Four or five layers are thus put on, care being taken to see that the former is perfectly dry. Between the last two coats of the Icthyocolla, a little Tinct. of Benzoin or Bals. Peru is added to give it an agree- able flavour. Thus prepared, the plaster is allowed to dry for twenty-four hours. When used, a piece is moistened, by placing the gummed side on the tongue and immediately applying it."* Poultices or Cataplasms, are different kinds of pulp or pastes, intended to cover injured surfaces, and made of various substances, according as the object is to have an emollient, an astringent, or a stimulating one. The Emollient Poultice, may be made of any mild, unirritating substance, as bread and milk ; bread and water ; bran and water ; corn-meal and water ; and ground flaxseed, or flaxseed meal. The latter forms decidedly the best poultice, not only as regards its properties, but also its economy. It is prepared by simply pouring hot water on the meal, * BOURGERT. An analogous preparation will be fouud in the U.S. Dispensatory. APPLICATION OF DRESSINGS. 39 Fig. 24. ^^ ^^i W-'i'-' '' - ,,>^^l fe^;^ ■ ,3^ S:S*?i^-VV'' < ■'j ^ '""i j^h! H M^ and stirring it till it acquires such a consistence as will prevent its running from its softness, or its dry- ing and breaking off from the reverse. In order to spread it, a portion of the paste is dropped on a suit- able piece of muslin, and levelled of an even thick- ness, say about one-fourth or half an inch ; the free ends of the muslin being folded over, so as to form a sort of frame or border, and thus prevent the adhe- sion of the edges (Fig. 24). If the meal is not fresh, it will be necessary to rub a little sweet oil or lard over the surface of the poultice, or to cover it with a piece of fine gauze previously softened in warm water, to re- move its starch. This will pre- vent the adhesion of the poul- tice (Fig. 25). Every poultice should be renewed at least twice in twenty-four hours, or more frequently if it becomes hard and dry. Care must also be taken that the meal has not fer- mented, or the oil, if used, be- come rancid, as it will then irritate, instead of soothing the part. The bread and milk, or bread and water poultice, is made by breaking the crumb of bread into either of these liquids till they have the proper con- sistence, when they may be spread and used like the first one. The Astringent Poultice, is formed of the above, by adding some astringent article. Frequently it consists of bread and lead-water, or of a curd made by throwing alum into boiling milk and straining off the whey, or rubbing it up with the white of ^g^^. Fig. 25. 40 PREPARATION AND These poultices should always be covered with gauze, being chiefly used in the treatment of affections of the eye. The oak bark, pomegranate, persimmon, nut- galls, bistort, tormentilla, &c., are also sometimes employed, beaten into a pulp, or mixed w^ith other and more adhesive or farinaceous substances. They may be used in any proportions. The Stimulating Poultice, is formed of various substances, as boiled carrot, grated down to a pulp ; raw potato, grated and applied cold ; grated onions, grated horse-radish, cloves of garlic, or black pepper ; corn-meal and some fermenting liquor, as yeast or porter ; or flowers of mustard. The Fermenting Poultice, or that made of corn- meal and porter, should always be spread on or covered with oiled silk, to prevent its evaporation and too rapid drying; and it should, likewise, be covered by the gauze to prevent its adhesion. It is of great use in cases of sloughing ; mortification ; hospital gan- grene, &c. The Mustard Poultice, is prepared by mixing flowers of mustard with water, to the consistence of that which is commonly employed for the table, and then spreading it very thinly on muslin, allowing it to remain on the part only till it reddens it — be it five, or fifteen minutes. The vinegar with which it is sometimes mixed, so far from increasing its powers of stimulation, materially weakens them. Narcotic Poultices, or those containing opiates, as poppyheads, or powdered opium, &c., will sometimes prove very serviceable, and may be made by the addi- tionofany ofthesesubstancestotheEmollientPoultice. To confine a poultice to a part, some of the ban- dages hereafter mentioned may be employed, at the option of the surgeon. Plasters, are made of various substances, and are occasionally employed to soften indolent tumours, procure their resolution, or hasten their suppuration. APPLICATION OF DRESSINGS. 41 Fig. 26. Fig. 27. in their preparation, the surgeon has no part, as this properly belongs to the apothecary. He may, how- ever, be required to directthe shape of them, in order to ensure their more accurate application. In general, nothing is necessary but to slit the angles which pro- ject when the plaster is applied to the surface ; but in the plaster for the female mammae, a peculiar shape is required, which may be best obtained thus : — Fold a piece of paper on itself, so as to form a perfect square of the size required ; fold this so as to make an oblong square ; double it and fold its angles so as to make a smaller square ; fold this into a triangle, and round off its upper angles as in the dotted line (Fig. 26). Then cut off semicircularly, as much of the point as will make an opening large enough to admit the nipple, or more if desired ; and slit the sides, at the circumfer- ence, for one inch, towards the centre. This when open- ed out will give the figure required (as in Fig. 27), and will enable any one to spread a plaster of a proper shape. IRRIGATIONS, Or dressings by imbibition, is the term applied to cer- tain dressings which are intended to keep the parts con- stantly cool and moist, by the use of cold fluids, and thus diminish an excess of inflammatory action. In simple erysipelas of some extent; in phlegmonous erysipelas; in compound fractures ; in sprains ; dislocations, and other injuries to joints ; and in cases of sloughing from excessive action after amputations, they aflbrd us a most excellent means of combating the inflam- 42 PREPARATION AND matory action. In order, however, that they may be properly applied, considerable care and attention is requisite on the part of the attendant ; for if the stream of the liquid is not kept up steadily, there will be a constant change in the temperature of the part, and a reaction from cold to hot, which will do harm by exciting an increased circulation in the part ; or there may be too great a degree of cold ; or the pa- tient become wet with the dressing and suffer from cold in some internal organ. As illustrative of the marked advantages of Irrigation, in the treatment of numerous injuries, we would here cite the following cases, reported by Mr. Gilchrist, of Aberdeen, in the British and Foreign Medical Review, for July, 1846. " 1st. A man received an injury by the machinery in a large paper-mill, which laid open the wrist-joint. The hand was half separated from the fore-arm ; the tendons were torn, and the inferior end of the radius which is naturally related to the carpus, was exposed ; the arm and hand were placed straight upon a pillow, the w^ound was cleaned, and two stitches taken ; a pledget of cloth soaked in cold water was applied, and a bandage rolled, not too tightly, round the hand, wrist, and forearm ; a large basin of cold water was placed conveniently by the bed-side, and directions left to apply freshly soaked cloths over the bandage, every two or three minutes, to prevent any heat or inflammation ensuing. No inflammation took place ; the modelling process was uninterrupted, without suppuration, and an excellent cicatrix formed in little more than a fortnight. "2d. A girl had the whole of the soft parts on the palm or surface of the four fingers, as it were scraped off, by the machinery in a flax-mill ; the tendons were torn, and the phalanges exposed at different places. Each finger was dressed as follows every day : being first bathed in cold water, a piece of soft cloth was placed round the finger, and a narrow roller to keep APPLICATION OF DRESSINGS. 43 it applied ; when the fingers were all thus dressed, a larger cloth soaked in cold water was wrapped round them together, and changed as frequently as the slightest tendency to become heated reappeared. The modelling process advanced steadily without suppu- ration, and cicatrisation was completed in about four weeks. The fingers gradually acquired flexibility. '^ 3d. A little boy had scrofulous disease of the bones of the ankle-joint, on account of which I am- putated, by the flap operation, below the knee. Two stitches were used for two days ; a strip or two of plaster and cloths wrung out of cold water, were the sole applications. The wound was whole, in a week. Other amputations have been similarly treated, with equal success. " 4th. A girl received a sharp instrument into the ball of the eye, at the Woodside works. The cornea and sclerotic coat were ruptured ; the iris was lace- rated, and prolapsus followed. Rest in bed ; con- tinued persevering use of cloths wrung out of cold water, and simple laxative medicine constituted the treatment. The treatment was effectual in prevent- ing inflammation, which was clearly the only indica- tion in the case. The termination was as favourable as could be, under the circumstances." These cases are strong arguments in favour of this simple and ancient remedy, and might be supported by numerous others under our own observation, did it seem necessary. The simplest form in which irrigation can be pro- perly arranged, is that shown in the cut. (Figure 28, ABC). The part to which it is to be applied, is first laid upon a piece of oil cloth or coach-curtain, to prevent the wetting of the bed and clothes ol the patient. This should be bent on the outer side, so as to form a little gutter to carry off the water, after it has gone on the limb, into the vessel placed below. Then a 44 PREPARATION AND vessel filled either with cold water, cold lead-water, or other cold lotion, is placed near the bed at such a height as will be most convenient, and from it strips of patent lint twisted together ; or, what is better, a piece of cotton-wick, as A and B, made to extend to another piece of lint which covers the part affected, and absorbs the liquid brought over. The wick, previous to its application, should be so wet as to absorb readily the fluid in the basin, or, in other words, form a Syphon. Another mode of irrigation, which is rather neater, is by means of a tube with a cock, arranged as in the Fig. 28. rmri. cut at C, and which may be made at a moment's notice, by any tin-plater, or extemporaneously of a piece of cane-angle and some quills. APPLICATION OF DRESSINGS. 45 In either case, if the patient complains of the cold, it is easy, by means of the cock^ or by plugs of wood introduced into the quills, to regulate the amount of fluid which shall pass over. This is the only advan- tage which the latter apparatus possesses over the syphon, while the simplicity of the syphon, and the facility with which it may be made and applied, re- commend it strongly to our favour. Should it be desirable to foment the part, it is only necessary to change the liquids, though generally, the application of warmth can be more readily made by wringing flannels out of hot water, and changing them as they become cool. RULES FOR DRESSING. It will now be seen, that as the different articles employed in Dressings are very varied, and the cases to which they are applicable equally so, it is a diffi- cult matter to give special directions, as to their employment under one general head. Nevertheless there are certain rules founded on common usage, and such as experience has tested, that will be found advantageous to the young dresser, by anticipating difficulties that he would otherwise be unprepared for. Thus, the choice of the position of both surgeon and patient ; the selection of assistants ; the order in which the different articles are to be employed, &c., may readily be reduced to general laws ; whilst the modifications required for particular cases, can be treated of under a more special head. Before pro- ceeding then to any dressing, it is important that every step of it should be anticipated in order that nothing may be wanting. Proper assistants should also be ready, and each of them made fully to under- stand the duties that they will have to perform. 46 PREPARATION AND Especially is this necessary in the treatment of cases in private practice, where the surgeon is often obliged to take his assistants from among the friends of the patient ; these, from their desire to aid the patient, are generally very ready and willing to perform what- ever may be asked of them, yet when actually en- gaged, become faint, sick, hurried, or otherwise un- fitted for duty, in consequence of some peculiarity of system, or from want of habit. Even medical men, will thus occasionally be thrown out of service, as very many are sickened by a bloody operation, or disgusted by a simple dressing, accompanied only by the smell of unhealthy pus, &c. Every surgeon must have frequently experienced this even in very simple cases, and will readily admit that the selection 'of assistants often becomes a matter of the first im- portance. The observance of the following rules, in regard to dressing, will therefore be found to assist materially in all our operations. 1st. Make, or see made, all that is requisite for the new dressing before removing the old one. 2d. Have a sufficient number of capable aids, to whom special duties shall be assigned before com- mencing the dressing, as this prevents confusion ; thus, in dressing a stump, or wound, there should be one to support the limb ; another to furnish hot water, and change it as required ; heat the adhesive strips, hand cerate, &c., &c., by which means the surgeon can give his attention wholly to his own duty. 3d. Arrange the bed, as a general rule, after the dressings are changed ; or, if in a case of fracture, before the patient is placed on it. 4th. Let the position of the patient be such as will be as easy for him as possible, so as to cause him no unnecessary fatigue, and let the surgeon place him- self on. the outside of the limb, and with his face to APPLICATION OF DRESSINGS. 47 the patient, as this will give him more freedom in his movements, and prevent any accidental jars. 5th. Be especially careful to guard against all hasty and inconsiderate movements on the part of the assistants or of the surgeon, in order to prevent unne- cessary pain to the patient. 6th. In all operations, let each assistant under- stand, before you begin, that he is to confine himself solely to his own duties ; thus, one may hand instru- ments to the operator; another sponge away blood ; a third see to ligatures, &c., &c., so that when a tena- culum or other instrument is wanted, there may not be half-a-dozen hands snatching for it, to the great risk of all parties. 48 PREPARATION AND CHAPTER II. OF THE PREPARATION AND APPLICATION OF THE BANDAGE. By Bandaging, is generally understood the confine- ment, in their proper situation, of dressings and other surgical apparatus, or the retaining in their natural position of parts of the body which have been pre- viously displaced, by means of pieces of muslin or other substance, or by mechanical contrivances. The term Bandage, in its strict signification, is only appli- cable to a collection of bands, or to those pieces of stuff which are fastened to one another and employed as a whole ; though general usage now justifies its application to the single Band or Roller. This, is a strip of flannel, linen, muslin, calico, cloth, gum- elastic, or other substance ; and of different lengths and widths according to the object to be attained in its application. As most generally found, it consists of a strip, of muslin, eight or ten yards long ; one-half, two, two and a half, three, or four inches in width ; free from hems or darns ; soft, pliable, and unglazed, to prevent its slipping. As thus made, bandages are divided into two kinds : — Simple, or those formed by the application of the roller only ; and Compound, or those resulting from the complex arrangement of the pieces composing them, as in the double T, sling, &c. OF THE SIMPLE BANDAGE, OR THE ROLLER. The simple roller is prepared from a piece of mus- lin of the requisite length and width, by tearing it APPLICATION OF THE BANDAGE. 49 from the piece, and then winding it into a cylindrical form, either by the machine, or by the hand, so as to form one or two heads, and constitute what is called the Single or Double-headed Roller. The machine for rolling them, one of Dr. Barton's earliest contri- butions to Surgery, is seen in Figure 29, and Fig. 29. consists of a base A, and of two uprights, B B, in which runs a spin- dle, G, to receive the bandage ; a broader upright, C, to support a moveable frame, F, which, by its pressure, tends to tighten the bandage, D D, as it is rolled, and of a screw, E, to fasten the machine to a table. Various other ma- chines are used by different surgeons, so modified as to suit peculiar views ; but the principle of all, is that here shown. In rolling the bandage onanyof these, one extremity should be attached to the spindleby wrapping it around it, and the rest, wound up by turning the handle with onehand,whilethe other, directsthe course of the band and ensures its being wound evenly. Then tear off all the loose threads from the end of the cylinder, before it is used, as they will not unravel too much if the cylinder is tightly rolled, but will be much in the way of its application ; but if the threads are torn from the strip before it is formed into the cylinder, a large portion of it will be wasted in ravellings. Thus formed, the Single-headed Roller consists of a cylinder with two extremities; of an initial or free end ; of a terminal one, or that found in the centre of the cylinder ; of two surfaces, an external and Fig. 30. 50 PREPARATION AND an internal, and of a body, or portion between the two ends. The Double-headed Roller, has the same parts as the single one, except the initial end, which is wanting, both ends being here wrapped into cylinders. This roller, there- fore, always commences in its application with the body, or portion between the two heads. The necessity which exists for the re-application of the same roller, both from economy and convenience, sometimes compels us to prepare it without the aid of the machine, because, unless a roller is formed into a cylinder, it will be found impossible to apply it pro- perly. In order, therefore, to do this with the greatest ease, fold the terminal end of the roller five or six times on itself, so as to form a sort of axis or mass ; and roll this a few times on the thigh, to give it size. Then place its two extremities between the thumb and forefinger of the left hand, while the body is allowed to run over the forefinger of the right, and press it firmly by the thumb of the hand used, so as to make a considerable degree of traction, and tighten the cylinder. Having arranged this, give a rotatory motion to the band, by causing the cylinder to revolve upon its axis by means of the fingers and thumb of the left hand, whilst, at the same time, the right re- volves partially around the cylinder itself, which, by this compound movement, is soon formed as required. In the cut, the action is shown reversed. After a very little practice, it will be found an easy matter thus to roll a bandage with either hand, almost as quickly and tightly as can be done on the machine, although at first, it will seem to be very awkward. When the roller is intended for the body, it should APPLICATION OF THE BANDAGE 51 be twelve yards long and about four inches wide ; when for the head, five yards long by two inches wide ; when for the extremities, eight yards in length, Fi^- 32. and two, two and a-half, or three inches in width, according to the size of the limb, the thigh requiring one a little wider than that for the leg. In order to apply the single-headed roller, which is the one most generally employed, it should be held between the thumb and fingers of the right hand, and the cylinder pressed by the fingers against the palm, to prevent its slipping out of the hand as it unrols, which it is apt to do, if held so that its internal surface should be the part first applied to the body. Or, it may beheld by placing the thumb and first and second fingers of the right hand on the two extremities of the cylinder. In either case, the external surface of the initial end, should be the portion first applied to the part, and should be retained there by the fingers of the left hand until one or two turns are made round it, so as to fix it firmly ; after which we may proceed up the limb. 52 PREPARATION AND Bandages have been divided into several kinds ; 1st. from the direction which they take in covering the part ; and 2d. the object to be attained by their application ; thus, we have the Circular ; the Oblique ; the Spiral ; the Figure of 8 ; the Spica ; the Recurrent ; and we have also the Uniting, Dividing, Compressing, Expulsive, Retaining, &c., whether made by the Simple or Compound Ban- dages. The Circular, is that formed by horizontal turns of the roller, each of which overlaps, or very nearly overlaps, the one which preceded it. In the Oblique, the turns gradually ascend the limb, or pass obliquely to its axis. The Spiral, mounts still more ; — the Spica, forms a figure like the leaves of corn ; and in the Recur- rent, the folds run back to the point whence they started. The Uniting Bandage, named from its action, is that which is used to bring together the edges of wounds ; it should be adapted to their direction according as they take a longitudinal or transverse course, and will be again referred to under the Treat- ment of Wounds. The Dividing Bandage, is that which is used to prevent the formation of cicatrices in the treatment of burns, and of wounds, attended with great loss of substance. The Compressing Bandage, is used for exerting compression in cedematous swellings, callous ulcers, varices, aneurisms, &c. The Expelling Bandage, is employed in the treat- ment of deep-seated abscesses, fistulae, contused wounds, &c. It consists of a roller applied over compresses, upon the region wherein the matter to be expelled is placed, and acts by preventing these fluids from travelling along the interstices of the muscles, APPLICATION OF THE BANDAGE. 53 and detacliing the skin from the subjacent parts, thus forming sinuses. Retaining Bandages, are those which serve to con- fine dressings and displaced parts in their proper situa- tion, as those for fractures and dislocations. A bandage which does not give the most perfect support to the parts, maintain them in the position necessary to ensure the fulfilment of the indication proposed, and exert on the member an equable com- pression, is useless, or worse than useless, as it may produce such a state of things as will eventuate in the loss of the limb, or even of life. When, therefore, it is applied too tightly, or when the compression is not uniform, very serious consequences may arise, such as oedematous swellings, or even mortification : their proper application is, therefore, a matter ot great importance. In no department of surgery, will the reputation of the young practitioner be more seriously involved, than in that referring to the application of the ban- dage, and we accordingly find that in nearly every period, its importance has been strongly insisted on. Dr. Hennen, one of the most practical and distin- guished men of his time, says " too much attention can scarcely be paid to this portion of the surgeon's duty ; our young surgeons may study, philosophise, and reason well, but neither books nor reflection, nor arguments, will teach the application of a bandage without repeated practice." Practice alone can give that manual dexterity so necessary for its proper em- ployment ; and unless a bandage is properly applied, it had better be omitted ; for if too loose, it will not fulfil its indication ; and if too tight, may produce gan- grene. The practitioner's reputation is also liable to considerabie injury, not only from the result of the case, but also from the judgment of those around him, if he should be ignorant of this important duty. 54 PREPARATION AND The majority of persons are ever attentive to the manipulations of any workman, and can soon judge, and judge correctly, whether or not he is acquainted with his business ; consequently they do not hesitate to exercise their criticism to its fullest extent, in the case of the surgeon ; and when their opinion of his ignorance, is confirmed by the patient's suffering, they are ever ready to disseminate it widely. On the contrary, when a bandage lays smooth and regu- larly on the limb, when the patient is relieved from previous torture, and the case assumes the neat ap- pearance, that always follows the visit of an expe- rienced dresser, the confidence of all parties is raised, and the subsequent visit is looked forward to, with confident anticipations of relief. Those who, from want of practice, cannot produce the neat appearance of a well applied bandage, and thus escape the remarks so often made in regard to it by those around the patient, are frequently in- duced, in order to effect it, to resort to the wetting of the roller, as it then adapts itself much more readily to the part. But this should never be done except in the treatment of Dislocations, unless we would wish to expose a patient to the risks of mortifica- tion ; for it is impossible for any one to calculate exactly, how much a wet roller will shrink in drying, and consequently how great a degree of pressure it will make on a part, after w^e have left it. A handage may be of the proper degree of tightness, and the patient make no complaints, and yet in three or four hours, be suffering such agonies, as must be seen or felt, to be properly appreciated. The ques- tion, then, may very properly be asked, as to how much traction should be made, in order to apply a roller properly. This will, to a certain extent, de- pend on the object with which it is applied, as a bandage which is merely intended to confine a dress- APPLICATION OF THE BANDAGE. 55 ing, need not be as tight as one that is used to compress the muscles ; but, as a general rule, a dry bandage is not too tight, if the patient feels easy under it, two or three hours after its application ; until then practice has taught the degree to which a roller should be drawn, the fact should be recollected that one which is too tight must do serious injury, while all that can result from one that is too loose, will be the non-ful- filment of the indications for its application. The young surgeon had, therefore, better err in the latter case, as daily evidence shows that the tendency of all young dressers is to use too much traction on a bandage, and not too little. But it should be born in mind, that as the proper application can be readily gained, any defect arising from it should very justly be charged on the surgeon. In the consideration of the special application of the roller, w^e shall take up : 1st, its application, ac- cording to the course which it may take ; and 2d, that resulting from the object to be attained in its ap- plication, commencing with the head, and proceeding regularly to the toes. The Circular Bandage, is one, as has been said, in which each turn over- laps that which has pre- ceded it, so that the whole looks like a sin- gle turn, and runs di- rectly round the part. All the circular bandages are very simple, and con- sist of, one for the Fore- head, in which the turns encompass the vault of the cranium ; one for the Eyes, as to retain dressings after the operation for cata- ract ; one for the Neck, as in the dressing of blisters, setons, &c. ; one for the Arm, as in the compression 56 PREPARATION AND Fig. 34. of the veins previous to bleeding ; and a few of a like nature for other parts of the body, as may be readily understood. In the confinement of the terminal end of the cir- cular, or any other bandage, two means are em- ployed, — 1st. the use of pins; 2d. of little bands tied in bow-knots. If pins are used, they should be placed either in the direction of the length, or breadth of the band. If in its length, the head should always be turned from the free end of the roller, (Fig. 34) otherwise the tendency of the roller to become loose, by constant drawing against the head, will, at last withdraw the pin entirely. On the other hand, if it is applied transversely, the head should always present to the upper extremity of the limb, in order to pre- vents its sticking in the fingers of the surgeon when his hand is passed Fig. 35. Fig. 36. down the part either to smooth the turns of the roller, or to seek for the end in its re- moval. (Fig. 36.) A reference to Fig. 35 will show how the pin may be drawn out by the unwinding of the roller itself. Some persons prefer fastening the end of a roller by means of a piece of tape, or by slitting it for a short distance into two strips and tying the pieces in a bow-knot; (Fig. 37) but this is never as neat or firm as the pin, except in bandaging fingers, toes, &c., where it is rather more convenient. The Oblique Bandage, diflfers from the circular, in its turns being less at right angles to the axis of APPLICATION OF THE BANDAGE. 57 the limb, in consequence of which it is enabled to cover in a greater ex- tent of surface, each Fig. 37. turn passing a little beyond the one pre- viously made, and fol- Ml'' J'' MW\ >^^ lowing a course which leaves a considerable space between them. It is chiefly employed to retain dressings, although occasionally useful, especially when conjoined with other bandages in cases, which will be treated of hereafter. Fig. 38. The Spiral, is the bandage most frequently em- ployed in the treatment of affections of the extremi- ties, as well as in those cf the trunk. Its turns ascend less rapidly, are closer together^ and cover in the part much more firmly than the last, thus making a certain amount of pressure, in addition to the retention of a dressing. Each turn covers in at least one-third of the one below it, and as most of the parts to which it is applied are conical in their shape, especially the extre- mities, it follows that, in the ascent from the lower to the upper part of them, we must pass from the apex of the cone to its base, and that consequently one edge of the roller will press on the part, while the other will project beyond it, thus forming what are designated 58 PREPARATION AND as Gaps, as a, 6, c(Fig. 39). To obviate this, and cause the bandage to apply itself more perpendicularly to Fis'. 39. the whole surface of the part, in other words equalise the pressure, the roller must be half folded on itself, or a doubling made, which is called a Reverse. As the bandage by this action acquires an increased thickness, a greater degree of pressure will be made on these points than at any other, and it is therefore desirable, in order to obviate the welts, and other bad effects occasionally resulting from them, that the reverse should be as short and as smooth as possible. To make it, is therefore a matter of much import- ance, and constitutes the first difficult step in ban- daging, because its mechanism is not sufficiently attended to. The following rules, which long usage has confirmed, will render the matter perfectly simple, and if observed, make it very difficult to prevent its proper formation : — Hold the roller, as before di- rected, in the position in which it is generally applied, that is, either by its body or its two extre- mities, the hand being in a state of supination ; apply the initial extremity to the limb, and continue the simple spiral turns, until we approach the enlarged portion of the limb ; then, apply the fingers of the other hand, firmly to that portion of the bandage which is already in contact with the limb, not to / APPLICATION OF THE BANDAGE. 59 assist in forming the reverse, or to fold it down, but simply to prevent its slipping or becoming relaxed while the reverse is being made. This being fixed, see that no more of the band is unrolled than will enable us to separate the hand a short distance, say four or six inches from the limb ; then keeping all slack between the fingers which fix the body of the roller, and the part which is in the cylinder, turn the hand holding the cylinder from supination into de- Fig. 40. cided pronation, by a simple motion of Ihe wrist alone, without moving the fingers from the cylinder, (Fig. 40) — taking care to make no traction, nor to sink the cylinder below the level of the limb till the fold or reverse is made, when we may again proceed up the limb, recollecting that each turn ascends spirally, and only covers in about one-third of that which preceded it, so as to keep each edge and each reverse parallel to its fellow. These reverses being indispensable wherever there is an increase in the size of the part, as from the extra development of certain muscles, it is of the greatest importance that the proper way of making them should be acquired, as no spiral bandage can well 60 SPIRAL BANDAGES. proceed six inches on an extremity without requiring a reverse. Although generally regarded as the most difficult point in the application of the roller, it is not so in reality, and a little attention to the rules, especially while the reverse is being formed, that no traction be made, nor the cylinder sunk below the limb, or widely separated from it, will enable any one after a little practice to make them with great ease and neatness. To add to the latter, they should, as far as possible, be kept in a perpendicular line, as seen in the cut of the spiral of the lower extremity. This will always result from keeping the edges of each turn parallel. We repeat that the difficulties experienced in making reverses, and the terrible, twisted, and corded things, sometimes made for re- verses, are always the result of traction in the ban- dage, while the reverse is making. The special applications of the Spiral Bandage are as follows : — first. THE SPIRAL OF THE CHEST. This requires a single-headed roller, ten or twelve yards long, and three or J^i^.^i' four inches wide, and that the patient should be sitting up, in or- der that the hand of the surgeon may pass readily behind his back. In applying it, place the initial ex- tremity on the ante- rior part of one axilla, say the left ; and con- duct the roller up- wards across the front of the chest ; pass over the right clavicle, and over the back to the point SPIRAL BANDAGES. 61 of departure, another and similar turn being effected so as to make one or two oblique turns of the neck and that axilla, whence it started. Then carry it across the front of the chest to the right axilla, to form an oblique of this axilla, and the left clavicle ; after which, carry it firmly around the chest in spiral turns from above downwards, drawing each turn with firmness, so as to compress the ribs, and oblige the patient to breathe by the diaphragm and abdominal muscles. Use. — In fractures of the ribs or of the sternum, care being taken to apply compresses to their ante- rior and posterior extremities, if the fragments pro- ject inwards ; but if outwards, only upon the parts themselves. It is sometimes useful to add to this the T bandage for the body, as seen hereafter, in order to prevent the roller from slipping, if the patient, from mania a potu or other causes, should be very restless; but generally, the oblique turns of the neck and axilla serve this purpose. THE SPIRAL OF THE ABDOMEN, Is composed of the same bandage as the above. But in its application, commence at the lower part of the chest, and carry the roller spirally round the abdo- men from above downwards, adding to it a single T, or make one or two oblique turns around the thighs, to prevent its slipping upwards. Use. — To compress the abdomen, as in certain cases of tympanitis, or after the operation for tapping in ascites ; but its place may be well supplied by a double T of the abdomen, where firm pressure is not required. THE SPIRAL OF THE PENIS, Requires a bandage of eighteen or twenty -four inches in length, half an inch wide, and slit into two pieces 62 SPIRAL BANDAGES. Then coramence at the Fig. 42. at its terminal extremity, glans penis, and form an ordinary spiral which shall terminate at the root of the penis, and be confined there by tying the two ends (Fig. 42.) Use. — This is chiefly employed to retain dress- ings to the penis, in cases of chancres and other sores external to the prepuce. It has also been used in the treatment of gonor- rhoea, in order to compress the urethra, a catheter being left in it ; but it is very apt to produce erections, which do harm, and quickly derange the bandage. The sheath of the penis spoken of hereafter, answers better in many instances, and especially in gonorrhoea. THE SPIRAL OF THE UPPER EXTREMITY, Requires a roller, eight yards long, two or two and a half inches wide, and compresses, if it is to be used to make pressure on particular parts, and act as a Com- pressing Bandage. In its application, having covered in the fingers, if necessary, by the gauntlet, as shown hereafter, commence with one or two circular turns around the wrist, in order to fix the end of the ban- dage ; then pass obliquely over the back and palm of the hand, to reach the extremities of the fingers, and ascend by three spiral turns w^ithout reversing, until we reach the phalangeo-metacarpal joint of the thumb ; cover this and the wTist-joint by a figure of 8, such as is described hereafter, and ascend the limb by simple spiral and reversed turns, till we reach the elbow. Cover this also by a figure of 8, if the arm is to be flexed ; if not, by simple spiral turns without SPIRAL BANDAGES. 63 reverses, and continue the spiral and reverse turns to the shoulder, placing compresses, &c., where they may be required (Fig. 43.) Fig. 43, This bandage is daily used to cover in, sup- port, and compress the arm, as in varicose veins, aneurismal tumours, treatment of fractures, &c., and is with the exception of the turns for the elbow, per- fectly easy, and attention to the figure of 8 bandages will soon overcome this difficulty. Its effects, when well applied, are excellent ; but it may become very fatiguing and painful if drawn tight, and if too tight, may produce gangrenous ulcer, &c. In 1837, it was found necessary in the Pennsylvania Hospital to amputate the forearm of a man who had only a simple fracture of the lower extremity of the radius, but whose arm was gangrenous from the mal- application of this bandage, by a country surgeon. I would recommend those who are desirous of avoiding such consequences in this or other bandages, to have them applied to their own persons, and they will soon learn the proper degree of tightness, especially if allowance be made for subsequent swelling. 64 SPIRAL BANDAGES. THE SPIRAL OF THE FINGER, Is composed of a roller, known as a finger bandage, which is only one inch wide, and of the requisite length, say one yard, split into two ribbons, at its ter- minal extremity. The spiral turns of this little bandage are em- ployed by every one to retain dressings to the finger in cases of wounds, but without a turn round the wrist, as it is very apt to become deranged. Fix, therefore, the initial extremity round the wrist by a circular turn, and cross the back of the hand, in order to descend either finger to its extremity by very oblique turns. Then commencing at its extremity, make an ordinary spiral with reverses, and terminate the bandage either by a knot on the fingers, as seen in Fig. 37, or with a few circular turns round the wrist. THE SPIRAL OF ALL THE FINGERS, OR GAUNTLET, Requires a band, eight yards long and of the preced- ing width, rolled into a cylinder. Then com- mence, as before, by one or two circulars around the wrist ; pass obliquely over the back of the hand, and descend by oblique turns to the nail of the forefinger, after which as- cend by spiral and re- versed turns, to its base ; pass to the middle finger; descend by oblique turns to its nail ; ascend by spi- rals to its base, and so on, till all the fingers are cov- ered in, terminating at the base of the little finger. Then pass in front or on the back of the hand, to finish by circulars around the wrist. Fig. 44. turn SPIRAL BANDAGES. 65 in the cut is represented as much too wide; those on the fingers and hand are more correct. Use. — We may resort to this bandage when more than one finger is injured, and there is reason to fear their uniting if they are permitted to come in contact, as in cases of burns. To this, should be added the demi-gauntlet, double T of the hands, or perforated T, as hereafter shown, if there is a necessity for re- taining dressings at the metacarpal extremities of the fingers, or the inter-digital spaces. THE DEMI-GAUNTLET, Is formed of the same pieces as the preceding, and applied by making a few circular turns around thewrist, and then passing across the back or palm of the hand, as the case may be, by oblique turns which will pass from the root of each finger, or its interdigital space, to make a circular turn round the wrist (Fig. 45.) This very light ban- dage is chiefly useful in retaining dressings to the front or back of the hand. Its place may, however, be supplied by the perforated T, or the double T of the hands. Fi^-. 45. As the Spiral of the Thigh, of the Leg, of the Foot, and of the Toes, are all similarly applied, they may be readily included in 6 SPIRAL BANDAGES. THE SPIRAL OF THE LOWER EXTREMITY. This requires two single-headed rollers, each eightyards longandtwo and a-haif inches wide, and thatthe patient be seated with the extremity of his heel on the very point of the surgeon's knee, or else lieing down, with the leg supported by assistants. The surgeon being either at the foot, or on the outside of the limb, and either sitting or standing, commences by making one or two circular turns, from without in- wards, immediately above the malleoli, in order to fix the end of the roller ; he then descends, if in the right foot, from the external malleolus obliquely across the instep and under the sole to the extremity of the little toe ; from this he makes two or three oblique turns upwards, so as to cover in the foot as far as the instep, and then covers in the heel by turns of the figure of 8, one extremity of the eight embracing the heel and ankle, the other the instep. After this he ascends the limb by spiral reversed turns, made with either hand, until he reaches the knee ; this joint being covered in by a figure of 8, he then proceeds with the second roller, to make spiral reversed turns on the thigh, till the whole limb is covered. Use. — This bandage, if well applied, fulfils every indication required of a bandage in fractures, ulcers, varicose veins, or oedema, and will usually keep its place for two or three days without being re- newed, if the patient remains in bed. The main difficulty to its application, consists in the co- vering in of the heel. This is not absolutely ne- cessary, as in many cases the close adhesion of the integuments to the parts below, prevents any great amount of swelling ; but where a considerable de- gree of compression is to be made on the leg, as in the treatment of varices, fistulse, &c., it is a better plan to cover it. To do this, proceed from the inside of the instep, say of the right foot, over the point of the heel ; come up over the outside of the instep ; down on its SPIRAL BANDAGES. 67 Fig. 46. Fig. 47. inside ; under the sole of the heel, folding in the loose edge of the previous turn ; then around back of the heel to the inter- nal malleolus ; over the front of the ankle ; under the sole of the instep ; round the back ofthe heel; over the external malle- olus ; in front of the an- kle ; under the instep to the outside of the foot, and then up over the front of the ankle to the internal malleolus ; round the back of the leg to its outside, and then up the limb. The turns on the heel and foot when completed, are seen in Figure 46. The advantages of the circular turns round the ankle in commencing this ban- dage, are, that it gives greater firm- ness by preventing the initial end from becoming loose. The French surgeons, however, usually begin it at the toes, and do not cover in the heel, and their course may be pursued by those who may pre- fer it, by observing the rules for the application of THE FRENCH SPIRAL. This is formed by a roller, two and a-half inches wide, and seven yards long, which is used as fol- lows. Place the initial extremity of the roller on the outside of the instep, say of the right foot, and pass obliquely across to the ball of the big toe ; under the sole to the extremity of the 68 SPIRAL BANDAGES. little toe ; and then make as many spiral reversed turns as will carry us to the front of the ankle, or the front of the astragalus. Pass from this around the malleoli, and ascend the limb by spiral reverses, as in the former bandage. The reverses of this and the former bandage being the same, are shown in Fig. 47, the main difference in the two being in the turns covering the heel, and in the point of commence- ment. This bandage is used for the same purposes as the ordinary spiral just described, but especially for the application of the Dextrine or Starch Bandage, as it leaves the toes and heel open to inspection, which is all important, and will be again referred to in the treatment of fractures. Where it is necessary to make pressure on the instep, heel, or ankle, the Spica of the foot should be added to this, (see Fig. 62). THE CROSSED, OR FIGURE 8 BANDAGES. 69 CHAPTER III. OF THE CROSSED, OR FIGURE OF 8 BANDAGES. These compose some ofthe best and neatest applica- tions of the roller, and are so named from their shape. They are exceedingly useful in covering in joints and other points requiring a firm and solid compression, and may be made either with the single or double- headed roller, though, as the compression resulting from the turns of the latter is sometimes very painful and requires watching, it is seldom employed in this portion of the United States. THE CROSSED OF ONE EYE, Is made of a single-headed roller, two inches wide and five yards long. If the hair is long, cover in the head with a night- cap previous to the application of the bandage, as this will prevent the turns of the roller from slipping ; then make two or three circular turns, round the fore- head and occiput, passing from right to left if for the left eye, and the reverse, if for the right. On reaching the nape Fl^.is. of the neck in the third turn, carry the roller under the ear of the affected side, and then ob- liquely up over the jaw and the injured eye, inclining it well to the internal canthus, so as to cover the root of the nose, but not so as to affect the sound eye. Pass hence, across to the temple of the sound side ; descend to the nape ofthe neck, and make thus two or three oblique turns, termi- nating by circular ones around the forehead. 70 THE CROSSED, OR Use. — This answers tolerably well to retain dress- ings to the eye, but is very readily displaced by the movements of the patient, unless pinned fast to the cap first applied. When it is desirable to make pressure on the ball of the eye, as in the treatment of gonorrhceal ophthalmia, cancer, &c., &c., we will find this bandage useful ; but we prefer the simple circular bandage of the eyes, for simple dressings. THE CROSSED OF BOTH EYES, Is made by a single or double-headed roller, seven yards long and two inches wide, with compresses, if required. In its application, make two or three circular turns of the head, turning indifferently from right to left, or the reverse ; then on reaching the back of the neck, pass under the ear of either side, up over the eye, root of nose, and parietal protuberance of the oppo- site side, to return to the neck. Make two or three turns similar to these, and at the third turn, pass from the parietal protuberance, round the forehead, instead of round the occiput, cross the root of the nose, the eye, and cheek of the opposite side, making an X with the first turns, and proceed in oblique turns as before ; terminating by circular ones. Uses. — This bandage, on account of the crossing of the turns on the forehead, is much more solid than the former, and may be employed in similar cases. It will add, however, even to its solidity to cover in the head, after its application, with a handkerchief or nightcap. THE CROSSED OF THE ANGLE OF THE JAW, Requires a single-headed roller, two inches wide, five yards long, and a thick compress. In applying it, carry the initial portion of the ban- dage around the forehead, and fix it by two circular FIGURE OF 8 BANDAGES. 71 turns of the vault of the cranium, turning from the right to the left and backwards, if the disease is on the left side, or vice versa. From the nape of the neck, direct the roller close under and behind the ear of the sound side ; under the jaw to the angle of the jaw on Fig. 49. the injured side, and place the compress behind and on this angle. Then carry the roller over the com- press, up over the side of the face, between the eye and left ear, obliquely over the vertex, and down behind the ear opposite the injured side. Make thus three or four oblique turns, as seen on the right side of the cut, and ter- minate by circular turns around the forehead. Use. — This is an excellent bandage for the treat- ment of fracture of the neck and angle of the jaw, and the only one that we know of, that fulfils the indica- tions for the treatment of this injury; as it forces the angle forward to the anterior portion, and counteracts the action of the pterygoid muscles. It will also be found useful in tumours of the parotid region ; and generally, in retaining dressings to this part. No circular turns should be made around the chin and neck, as sometimes recommended in the treatment of fracture of this part of the jaw, as these tend to dis- place the fragments, and push the chin too much backwards. BARTON'S BANDAGE, OR THE CROSSED, OR FIGURE OF 8 OF THE JAW, Is formed by a single-headed roller, five yards long 72 THE CROSSED, OR Fig. 50. and two inches wide, the initial extremity of which should be placed justbelow the prominence on the os occipitis. Then continue the roller obliquely over the centre of the parietal bone ; across the junction of the coronal and sagittal sutures ; over the zygomatic arch; under the chin, and, pursue the same direction on the opposite side, until youarrive at the back of the head ; pass then obliquely around and parallel to the base of the lower jaw; over the chin, and continue the same course on the other side, till it ends where you commenced ; whence it runs exactly the same course as before^, and ends by placing a pin at the vertex. Use. — For this beautiful specimen of a bandage, we are indebted to the skill and ingenuity of Dr. J. Rhea Barton, of Philadelphia, a surgeon to whom the profession owe many very important and novel oper- ations, and whose skill in the use of bandages is un- surpassed by any one; and although it may be looked on as a small affair compared with some of his improvements, yet it is perhaps the one most likely to be tried by the generality of practitioners, being, we think, the very best dressing for fractures of this bone, anterior to its angle, and one, that will please both patient and surgeon. In order to apply it neatly, the roller should not be over two inches wide, and the turns should be made to follow as nearly as possible, tjiose which have preceded them, thus giving the appearance of but a single turn. THE CROSSED, OR POSTERIOR 8 OF THE CHEST, Requires a roller, five yards long, tw^o and a-half or FIGURE OF 8 BANDAGES. 73 three inches wide, and compresses, tow, or cotton, to place on the anterior edge of the axillse to prevent the bandage from chafing them. Then, whilst the patient is sitting with the shoulders well drawn back by an assistant, and the compresses are held in front of the axillae till after the first turns of the roller, carry the initial extremity of the roller around the superior part of one arm, say the left, and make three or four spiral reversed turns from before backwards, and from Fig. 51. within outwards. From this shoulder pass obliquely over the back to the right axilla, the shoulders being now forced backwards. Ascend in front of, and over the shoulder, pass over the back to the left axilla, over the compresses in front of this and round to the back ; over it to the right axilla ; over it in front ; and over the back to the left axilla. Pass again the same coursetill the roller is nearly exhausted, when it maybe terminated by circulars of the body, or of the right arm. 74 THE CROSSED, OR Use. — This bandage will act either as a uniting one for the back, or a divisive one for the front of the chest, and was formerly much employed in the treatment of fractured clavicle ; but as its place has since been supplied by others, which are better, it has consequently fallen into disrepute, though it may oc- casionally be a useful addition to the means of treating such accidents, especially where it is requisite to carry the shoulder well backwards. It will also prove useful in uniting longitudinal wounds of the back, or in preventing contractions from burns, &c., on the front of the chest. THE ANTERIOR 8, OR CROSSED OF THE FRONT OF THE CHEST, Is precisely the reverse in its action of the one just Fig-. 52. described, although its composition is the same. Its FIGURE OF 8 BANDAGES. 75 application can therefore be readily understood from the figure, and what has been just said. It draws the shoulders forwards — would, of course, unite longi- tudinal wounds over the pectoral muscles, and pre- vent contractions in the cicatrices of burns on the back. By placing compresses over the upper part of the sternum, it may also be usefully employed in in- juries of this part, as well as in dislocations anteriorly, of the sternal ends of the clavicles. THE SPICA OF THE SHOULDER, Like most of the spica bandages forms one of great neatness, and well calculated for making pressure on this part. It is formed by a roller, eight yards long, and two and a-half inches wide, with cotton, Fig. 53. or compresses, for the axilla of the in- jured side. In applying it, we commence the ban- dage by making one or two spiral revers- ed turns round the upper part of the arm of the injured side, passing from with- out inwards, and from before back- wards : then pass from behind the arm, up over the lower ex- tremity of the same shoulder ; obliquely downwards, over the front of the chest to the axilla of the sound side; thence round the back; obliquely upwards, 76 THE CROSSED, OR over the shoulder, and down in front, under the axilla of the injured side, which should be previously furnished with the compress or cotton, in order to protect it. From this point, we go behind and over the shoulder, to pursue exactly the same course, as before, each turn covering in, however, only one- third of the preceding turn, until the bandage is nearly exhausted ; when it should be made to termi- nate by one or two circulars of the trunk, or of the arm, or be pinned, as in the cut. Uses. — This beautiful bandage, named from the resemblance in its folds to the arrangement of the leaves of an ear of corn, exercises a very exact com- pression around the extremity of the shoulder, at a point where it would otherwise be difficult to make it. In cases of dislocation of the humeral extremity of the clavicle, it will be found of great service in keeping the clavicle reduced, especially if the arm be also well supported. But care is especially requisite to protect the edges of the axilla, as otherwise they will certainly be injured by the turns of the roller. When this bandage is made to mount gradually from the point of the shoulder towards the neck, it is called a Spica JiscendenSj but if its turns come from the neck to the shoulder, it becomes a Spica Descen- dens. Of course, it is optional with the surgeon to make either the one" or the other, as the result depends on the point where the first turn is placed after leaving the arm, in order to cross the chest. THE FIGURE OF 8 OF THE NECK AND AXILLA, Is formed by a roller, five yards long and two inches wide, the initial extremity of which is placed on the side of the neck, and fixed by one or two circulars of the neck, loosely applied ; making them, for ex- ample, from behind forwards, and from left to right. Next, direct the roller as it comes from tJie left side FIGURE OF 8 BANDAGES. 77 of the neck, over and behind the right shoulder, so as to confine any dres- sings that may be re- Fig. 54. quired either there or in the axilla ; then come up in front and over the shoulder, and round the neck to the left side, following the same course, and covering by each turn only one-third of the preceding turns, so as to make a figure of 8, one turn of which shall embrace the neck, and the other the axilla. Uses. — This bandage will prove useful in retaining dressings before, behind, or above the shoulder ; or in the axilla ; or at the base of the neck, as it is easily applied, and if not drawn too tight, does not restrain the motions of the arm. It may also be made with a double-headed roller, if the body of the bandage is applied under the axilla, and the heads crossed upon the shoulder of the opposite side, and then brought round the neck to cross on the shoulder and axilla of the injured side. It is firmer, as thus ap- plied, than the single-headed roller, but may press too much on the armpit, and interrupt the circulation, or cause cramps in the hand, if care is not used in its application. THE CROSSED OF ONE BREAST, Requires a roller, eight yards long by two and a-half 78 THE CROSSED, OR inches wide, and that the Surgeon should stand in front and on the outside of the limbs of the patient, and not in front of her knees, or behind her back, as this becomes awkward in the last turns of the bandage. In applying it, fix the initial extremity of the roller behind the shoulder of the affected side, say the right, then carry it obliquely across the back, over the op- posite shoulder, and descend on the front of the chest to pass from before backwards and under the breast and axilla of the injured side. Fix by this turn the initial extremity of the roller, and go over the same course once or twice, so as to form two or three ob- liques of the neck and axilla. Then, on coming to the axilla of the diseased breast the third time, direct the roller transversely Fig. 55. across the back, to the axilla of the op- posite or left side, and return by a horizontal turn in front of the chest, to the point of departure, in order to commence another oblique of the neck and axilla. Continue thus making obliques of the neck, and hori- zontal turns of the body, each turn as- cending and cover- ing in one-third of the preceding one till the rolleris exhausted, when we shall find that the breast is firmly slung, or supported by the oblique turns, and compressed by the circular ones (Fig. 55.) Use. — This bandage is not only useful in retaining dressings to the breast, but also in supporting the FIGURE OF 8 BANDAGES. 79 breast itself, when requisite, as in cancer, lacta- tion, &c., as it very readily keeps its place, unless handled, for thirty-six hours. It may, however, be supplanted, in cases of simple dressing, by the sling of the breast, as described hereafter, if it should be requisite to change the dressing twice or thrice a-day, as we shall thus save the fatigue of a re-application of the bandage. THE CROSSED OF BOTH BREASTS, Having more surface to travel over, requires a roller, twelve yards long, and two and a-half inches wide. Fig. 56. rolled either into one or two heads ; or, if the patient is very large, it may require a roller of fifteen yards. In order to apply it, carry the initial extremity of a single 80 THE CROSSED, OR headed roller behind the right axilla ; thence by cross- ing the back, direct the cylinder over the left shoulder ; pass obliquely across the front of the chest ; under the right breast, and under the right axilla to the point of departure. Make thus, two or three obliques of the neck and axilla, covering in the breast by the gradual ascent of each turn, and on reaching the back of the right axilla in the third turn, pass transversely across the back, to the left axilla ; under this and across the chest in front of the left breast to the right side of the neck ; thence across the back to the left axilla. Make thus two obliques of the neck and this axilla, and on coming to the front of this armpit, pass transversely under both breasts to the right axilla, and under this to the point of departure, taking care that each revolution covers successively, the breasts from below upwards, without being drawn too tight. If the course here laid down be rigorously followed, we shall have an oblique of the neck and each axilla, with horizontal turns before and behind, and the turns of the roller will be found to mould themselves with great accuracy to the roundness of the breasts, and thus make gentle and equable pres- sure on them ; a point of some importance in certain cases of mammary abscess. Use. — This, like the preceding bandage, is em- ployed to support or compress both breasts, and is exceedingly useful in patients who are annoyed by pendulous mammae during lactation, &c. It may however be as well made by means of a double- headed roller, if desired. In this case, place the body of the bandage in front of the sternum, and carry each cylinder under its respective axilla, to form an oblique of the neck and axilla, crossing on the back. After one or two obliques, carry one cy- linder horizontally in front of, the other horizontally behind the chest, to make a half transverse turn, and FIGURE OF 8 BANDAGES. 81 then make other oblique and semi-transverse turns of the body, till the whole is covered in. THE SPICA OF THE GROIN, OR FIGURE OF 8 OF THE PELVIS AND THIGH, Requires a single-headed roller, eight or ten yards long, three inches wide, and compresses, if required. Fig, 57. Having arranged the dressing, place the initial ex- tremity of the bandage above one of the iliac crests, and make two horizontal circular turns around the pelvis, in order to fix the point of the bandage, turn- ing from right to left, and from before backwards, if for the right groin, and the reverse if for the left. Arriving in front of one of the groins, say the right, descend to the inside of the thigh, between it and the genital organs, and winding round the back part, as- cend on the outside, to cross the first turn ; thence to the iliac bone of the opposite side ; across the back and round the pelvis, to follow the same course until 6 82 THE CROSSED, OR the cylinder is nearly exhausted, when it should be fixed by a circular turn of the pelvis. Use. — This is an excellent bandage to retain dressings, or make compression on buboes, venereal ulcers, abscesses, &c., situated at the groin. If it is intended to make a Spica Ascendens, the first turn over the groin should go as far down the thigh as the point we wish to cover by the bandage, and each turn, co- vering in only one-third of that which preceded it, should be made to mount gradually upwards. If, on the contrary, we wish to make pressure from above downwards, the first turn should cross the groin high up, near the abdomen, and each subsequent turn de- scend, so as to form a Spica Descendens. This bandage by covering the groin, is exceedingly useful after operations for hernia, or in other cases of hernia where compression is required, and a truss cannot be borne, or obtained. THE SPICA OF BOTH GROINS, Is formed by a single-headed roller, twelve yards Fi^. 58. long, and two and a-half or three inches wide ; two FIGURE OF 8 BANDAGES. 83 horizontal turns of which are first made about the pelvis, going, for example, from right to left and from before backwards. Upon arriving at the second turn, near the left groin, the head of the roller is made to pass obliquely downwards along the outer side of this thigh, and to ascend along its inside so as to cross the first descending turn ; after which it is conducted round the back of the pelvis as far as the right groin, and passing hence along the inner side of this thigh, remounts on its outer side, and is carried again round the pelvis in front, and to the left ; the head of the roller being then made to pursue the course just indicated, until only a sufficient quantity remains to terminate the bandage by two horizontal turns of the pelvis. Use. — Same as the former, but for both groins. The Spica of both groins may be very advanta- geously made with a double-headed roller, if the body be applied to the front of the abdomen, in a line with the crests of the ilia, and each head carried around them, to cross behind the back and come round on each groin. Then let each head descend in the line of the groin, between the genitals, on the inside of each thigh, and pass under, behind and on the out- side of them, to run, one to the right, the other to the left ihac crest, and thence round the back, to fol- low the same course. No bandages can be firmer or simpler than these Spica bandages, where it is requisite to make firm compression on each groin, but otherwise they will prove inconvenient, from the difficulty consequent on moving the patient under the circumstances in which they are most generally required. For a more simple bandage, see the triangular T of the groin. THE FIGURE OF 8 OF THE ELBOW, Is made of a roller, two yards long and two or two 84 THE CROSSED, OR and a-half inches wide, by placing the initial extre- mity on the external Fi^. 59. and upper part of the forearm, and passing obliquely over the bend of the arm to the in- ternal tuberosity of the humerus ; round and above the olecranon to the external tuberosity ; thence obliquely across the front, crossing the first turn like an X, to the inner and upper part of the forearm, and then across the back to the point of departure, to run the same course. If the arm is much flexed, make one circular over the point of the elbow, after the formation of the second figure of 8. Use. — This little bandage is very useful in cover- ing in the elbow-joint, when the arm is either flexed or extended, and is therefore added to the Spiral of the Upper Extremity for this purpose. It is also fre- quently employed to retain the compress used after bleeding, as may be seen in Fig. 59. THE FIGURE OF 8 OF THE WRIST, Is made like the preceding, by taking one or two cir- cular turns around the wrist, either on its dorsal or palmar face, to fix the end of the bandage, then on reaching its cubital side, run obliquely across to the space between the thumb and forefinger, say of the right hand ; then obliquely over the palm to a cor- responding point on the metacarpal bone of the little finger ; hence obliquely across the back of the hand to the wrist-joint ; thence make a semi-horizontal turn FIGURE OF 8 BANDAGES. 85 around the wrist to the ulnar side; run the same course over again, as seen in the Spiral of the Upper Extremity. Use. -^To cover in and compress the wrist-joint. It is also added to the Spiral of the Upper Extre- mity, in order to cover in this joint. THE SPICA OF THE THUMB, Is made by a roller, three yards long and a finger's breadth wide, of which the initial end is fixed upon the wrist by two or three circular turns; after the last turn, which should terminate upon its radial side, direct the head of the roller from ^^S"- 60. the external to the internal side of the thumb ; pass between this and the index fin- ger ; return and cross the base of the thumb, and carry it onward again, about the wrist. Repeat these double ob- liques and cover in about two-thirds of each turn, by the subsequent one, so as to form a spica, until the whole of the bandage is exhausted. Use. — This bandage will be found very useful in retaining dislocations of the first metacarpal bone of the thumb, or for making pressure on its top. THE FIGURE OF 8 OF BOTH THIGHS, Requires a few turns of a roller, two and a-half inches wide, in the ordinary figure of 8, so as to keep the thighs together, as after the operation of lithotomy, or after the reduction of a dislocation of the femur. 86 THE CROSSED, OR THE FIGURE OF 8 OF THE KNEE, . Requires a roller two and a-half inches wide, of which the initial extremity, is to be fastened by one or two circulars below the knee ; then pass obliquely over the patella, say from the outside to its inside ; make a semi-horizontal turn on the back of the thigh, above the joint, to reach the external condyle ; go thence obliquely over the patella to the inner side of the tibia ; pass round behind it, to the head of the fibula, and run the same course again till all is co- vered, as seen in the Spiral of the Lower Extre- mity. tlse. — To cover in the knee, or compress the joint in various cases. It is also added to the Spiral of the Lower Extremity, in order to cover in this joint, and is used in fracture of the patella. If it is wished to retain a dressing to the popliteal space, we have only to reverse the turns of the bandage, that is, start it by circular turns from within, outwards, and cross from below the knee behind, to above it in front. THE FIGURE OF 8 OF THE ANKLE AND INSTEP, Is made by a roller, two and a-half inches wide, and of the ordinary length. If in the right foot, place the initial extremity above the external malleolus, and make two circular turns to fix it ; then on coming to the external malleolus on the se- cond turn, pass obliquely over the front of the instep to the tarso-metatarsal articulation of the big toe; thence under the sole of the foot to the outside ; horizontally over the instep to the same point, and then pass obliquely over to the external side of the os calcis ; over this side of the bone, and round its point, up on its in- Fi^. 61. FIGURE OF 8 BANDAGES. 87 side to cross the anterior extremity of the astraga- lus ; over the upper part of the instep ; down the outside ; at the point of the cuboid bone ; under the sole to the inside of the calcis ; around its point to the outside, and up over the instep to the point where the cuneiforme internum is placed, and thence follow a similar course till the heel is covered in, which is generally done in two turns and a-half of figures of 8. To cover in the extreme point of the heel, be careful that each turn that goes over the sole, is kept as much backwards towards the point of the heel as possible, as the bandage will not slip off, if drawn moderately tight. If it is not necessary to cover in the heel, the turns may be made as in the figure. Use. — This bandage may be resorted to where we wish to retain dressings to the heel, instep, or front of the ankle-joint, as in excoriations from the extend- ing band of the apparatus for fracture of the thigh. It is also added to the Spiral of the Lower Extre- mity, when we wish to cover in the heel, as well as the whole limb, as in the Compressing Bandage. RIBBAIL'S BANDAGE, OR THE SPICA OF THE INSTEP, Js a neat bandage, made of a single-headed roller, seven yards long and two inches wide, by laying the initial extremity of the roller on the tarsal end of the metatarsal bone of the little toe, if in the right foot, or on that of tie big toe, if in the left. Then passing obliquely over the front of the foot, to the first joint of the big toe in the right foot, or that of the little toe if in the other, go under the sole of the foot horizontally, in a line with the metatarso-phalangeal articulation, to the outer or inner side of the foot, according as it is the right or left. From this point, make two obliques over the front of the foot, which will bring us to the instep on its inner or outer side, and then pass di- rectly to the point of the heel in a line, parallel with 88 THE CROSSED, OR FIGURE 8 BANDAGES. the sole of the foot, the edge of the roller projecting a little beneath the sole ; thence around the heel to come to the instep again, keeping still parallel with the sole of the foot ; cross the instep and make an- other turn similar to the first, which shall embrace Fi£: 62. the heel and instep, cover in one-third of the preced- ing turn, and form a spica on the instep (Fig. 62.) Continue these turns, gradually ascending, till the foot will hold no more, when we may terminate the ban- dage by circular turns above the ankle, or else form a spiral up the limb. Use. — This forms a most excellent bandage for cases requiring firm compression of the instep or an- kle, as in wounds of the anterior or posterior tibial arteries at these points, and is at the same time ex- ceedingly neat in its appearance. The figure shows the best position of the limb of the patient and of the surgeon. For it, as well as for many other practical details, I am indebted to M. Ribbail, of Paris, from whose excellent course on Minor Surgery, much that is of daily service has been gained. The Figure of 8 of the Toes, or the Spica of the Big Toe, is so precisely similar to these bandages in the fingers and thumb, as not to require a repetition. In applying any of them, make a few circulars of the instep instead of the wrist, and then proceed exactly as in the hand. THE KNOTTED BANDAGES. 89 CHAPTER IV. OF THE KNOTTED BANDAGES. These bandages named from their making a knot like that known as the Packer's Knot, are formed of double- headed rollers, and intended to make firm compression on particular points, as on bleeding vessels, &c. T.he only one of them of any importance, is that of the head, used for arresting hemorrhage from the temporal artery, though under the same class, we might include all those which are terminated by bow-knots, as in the 8 of the elbow after bleeding at the bend of the arm ; that of the ankle, as well as the Sailor's Knot, Clove- hitch, and others employed in the treatment of Dis- locations. THE KNOTTED BANDAGE OF THE HEAD, Is made of a band, five yards long and two inches wide, rolled up into two heads of unequal size, one J^ig- 63. being a fourth larger than the other, by placing the body of the bandage over the graduated compress covering the wounded ar- tery, and conducting the two heads one before, and the other behind, to the op- posite temple, where we reverse them in order to return to the point of de- parture. Now givethem a turn or twist, so as to enable us to carry one over the summit of the head, and the other underneath the chin, 90 THE KNOTTED BANDAGES. to the sound side, and when they meet, reverse them as in the first instance ; from thence they are to be conducted in the same course, to the point of depar- ture on the wounded vessel. A second twist being effected, conduct them for the third time to the op- posite temple, and for the third time also, return hori- zontally and knot them firmly, each knot being placed behind the one first formed ; the roller being then conducted, the one head over the vertex, and the other underneath the chin, is terminated by a few circular turns of the forehead and occiput. Use. — For arresting hemorrhage of the temporal artery, or any of its branches. It is, however, a pain- ful bandage, from the compression made on the lower jaw and point of injury, and requires attention, in order that it shall not remain on too long, or be too tight. It is useful to close the opening in the vessel first, with a piece of adhesive plaster, as will be seen hereafter when treating of Arteriotoray. THE RECURRENT BANDAGES. 91 CHAPTER V. OF THE RECURRENT BANDAGES. These are formed by convolutions or parabolic and re- current turns, which make a kind of cap for the parts to which they are applied. Unlike most caps, how- ever, they are exceedingly apt to become relaxed, and although very neat in their appearance, require more watching than is convenient, and are therefore often supplanted by other dressings. When re- quired, they may be made either with the single or double-headed roller ; but from the difficulty of re- moving the latter without its coming off in mass, and thus perhaps bringing ligatures, &c., altogether, that formed by the single-headed roller, is the one most generally employed. THE RECURRENT OF THE HEAD, Is composed of a single-headed roller, five yards long and two inches wide, of which the initial extre- mity is placed on one side of the head on a line with the supra-orbitary ridge, and the cylinder carried two or three times round the head by circular turns. On coming to the middle of the forehead in the second turn, the bandage is reversed and the re- verse confined with one hand, while the cylinder is carried over the top of the head in the line of the sagittal suture, to the occipital protuberance, re- versed here, and the reverse held by an assistant. Then come obliquely over the head to the forehead ; make another reverse to go to the occiput, each turn covering in one third of the preceding one, and con- tinue thus, till we reach the horizontal turn On the 92 THE RECURRENT BANDAGES. right or left side of the head. Cover in the opposite side by similar turns, seeing that each reverse comes to the same point, in front and behind, and terminate Fig. 64. the bandage by circular turns, firmly applied around the terminations of the reversed turn, as in Fig. 64. Use. — To retain dressings to the head, as in the application of blisters to the scalp — in erysipelas, in wounds, and in other injuries of the scalp, &c. Care, however, must be taken not to draw the hori- zontal turns too tight, lest, as in the case related by Percy, ulceration or gangrene ensue. THE RECURRENT OF THE HEAD, As made by a double-headed roller, requires the body of the bandage to be placed upon the occiput or fore- head, and after two or three circular turns, the rol- lers be made to intersect each other upon the occiput ; one of them is then reflected over the vertex to the fore- THE RECURRENT BANDAGES. 93 head, and the other continued in a circular course on Fig. 65. the side of the head. Then crossing each other upon the forehead, the first head is car- ried obliquely backwards to the occiput, and reflected by the side of the other. The last, a, is continued in a cir- cular direction, but the first, 6, is again brought over the head, from behind forwards, and carried in this way back- wards and forw^ards, in re- verses, till the head is entire- ly covered. Use. — This, like the pre- vious bandage, serves to confine dressings upon the head, but is now rarely employed for the reasons stated. The ancients exerted, by its means, compres- sion on the heads of Hydrocephalic patients. THE RECURRENT OF AMPUTATIONS, Embraces two varieties, according as it is made with a single or double-headed roller. As, however, it is difficult to remove the latter, I shall onJy give the application of the former, which is made of a single- headed roller, of different lengths according to the volume of the stump to be covered, but generally only two, or two and a-half inches wdde. The position of the patient, for the application of this bandage should be such as is most easy to him, with the stump well supported and the integuments pushed over the end of the bone, by assistants. Then having arranged the Malteese Cross and other dressings, place the initial end on the surface of the limb, three or four inches above the extremity of the stump ; make two or three circular turns to fix it, and on coming to the central point of the under portion 94 THE RECURRENT BANDAGES. of the limb, reverse the roller, so as to run up in front of the stump and over its upper surface to a point, A, (Fig. 66) four or more inches above its extremity. Fix all these reverses by the fingers of one hand, if the Fis. 66. size of the limb will permit; if not employ an assistant for the reverses on one side, and continue to make them till the whole face of the stump is covered, when we terminate itby spiral reversed turns, which, starting from the circumference of the stump, B, runs up a few inches above the first turn of the bandage, where it is to be confined by a pin. If there is a tendency to spasm of the stump, the ends may be carried on and fixed fast to the pillow or bed on which the limb lies, and will thus prevent its jumping; but care is requisite not to draw the recurrent turns at A too tight, lest, by compressing the soft parts against the point of the bone, they cause this irri- tation and spasm. This figure also show^s the application of a Sus- pensory Bandage, to the Testicles. COMPOUND BANDAGES, ETC. 95 CHAPTER VI. OF THE COMPOSITION AND APPLICATION OF THE COMPOUND BANDAGE, OR THE BANDAGE PROPER. It has been already stated, that usage had justified the application of the term Bandage, to what should be strictly known only as the Roller, and that we should therefore designate, the Bandage proper, under the head of Compound Bandages. These include a considerable number of our most useful means of retaining dressings, and their ap- plication is generally very simple, though their com- position is sometimes a little complicated. To the latter, therefore, we shall pay the most attention, be- lieving that after their construction, their application will be simple enough. THE SINGLE T, OR CRUCIAL BANDAGE, Named from its shape, is composed of a horizontal portion, of a length sufficient to go entirely round the part to be covered, and yet leave enough to ^^o-. 67. make a bow-knot, and of a vertical piece, which is half the length of the horizontal one, and generally attached firmly to its middle, so as to form the perpen- dicularportionoftheT. (Fig. 67.) Each por- tion should be rolled 96 COMPOUND BANDAGE, OR into a Fig. 68. cylinder, and confined by a pin previous to its application, in order to ensure its smoothness when applied. The vertical portion varies considerably in its shape and length. Sometimestherearetwo vertical pieces, as in the Double T ; and sometimes it is three or four inches wide, and slit into two tails to within a short distance of the horizontal band, as in Figure 68. At others a triangular piece is added, &c., &c., as will be seen hereafter in the special applications of this bandage. THE T BANDAGE OF THE HEAD, Requires a horizontal piece of bandage, two yards long and two inches wide, upon which, at about one- third of its entire length, a strip half a yard long and of the same width, is stitched at right angles Fig. 69. to form its vertical portion. The bandage is then rolled into two heads previously to its application, and the sur- geon placing himself before the patient, applies the body of the bandage to the middle of the forehead , with the edge, corresponding to the verti- cal portion of the bandage, uppermost, in order that the latter, after traversing the ver- tex, may hang loosely down the nape of the neck. He then passes the remainder of the horizontal portion along BANDAGE PROPER. 97 the temples to the occipital region, where they cross the vertical strip, which should be immediately re- flected upwards, and secured upon the brow by the last turns of the horizontal portion. A double T, may be formed by simply stitching a second strip upon the transverse portion of this, at a convenient distance from the first. Use. — This light bandage, maybe used for retain- ing dressings to the scalp when the vertical band is so placed that it may run over the point to be covered in, and where the dressing is small, is preferable to the recurrent bandage of the head, as it is not so heating. If likely to be deranged by slipping up- wards, a band may be added, which shall pass under the jaw. THE T BANDAGE OF THE EAR, Is made of a horizontal portion, two yards long, of a vertical one, a half yard in length, and of a piece of linen of the shape and size of the external ear. Sew the horizontal band to the summit of the ^^' ' ear-shaped piece of jl^ rfl^J! muslin, and attach the '*^ffiL— vertical one, to the opposite part, or that corresponding with the soft part of the ear. Then place the cir- cular band around the head, over the ear of the affected side, and the muslin over or close behind the ear ; then carry the vertical band under the jaw and up on the opposite side, where it will be confined by the horizontal turns. Use. — This modification of the T, is an excellent bandage for retaining dressings to, or behind the ear, 7 98 T BANDAGES. especially the latter. Every one has felt the difficulty of retaining blisters or dressings to this part, but the construction of this little bandage removes it entirely. If made of black silk and narrow ribbons, it would hardly be noticed in persons wearing whiskers, or in those wearing caps or bonnets. Fls-. 71. THE DOUBLE T OF THE NOSE, Is made of a band, one inch wide and two yards long ; of two other bands of the same width, but one yard long, the latter being sewed on the former, so that they may be one inch apart, and at right angles to the first band. After this the transverse band should be placed upon the upper lip, with the border to which the vertical bands are attached, turned upwards, and the two extremities being carried over each cheek, and under the ears to the nape of the neck, be there held by an assistant. Then cross the vertical bands upon the root of the nose, and carry each one over the parietal protuber- ance of its side, and down to near each mastoid pro- cess, under the horizontal band. Turn them over this to come upwards, and fix them by bringing the re- mains of the horizontalband, from its crossing on the nape of the neck, round the fore- head ; where they may be fastened either by a knot or a pin. Uses. -^This little band- age is very useful in retain- ing dressings to the upper lip and root of the nose, especially in cases of fracture of the bones of the latter, or in epiphora, or fistula- lachrj-malis, as it is easily renewed, and does not T BANDAGES. 99 interfere with the use of the eyes, nose, or mouth ; whilst it acts on the part nearly as firmly as adhesive plaster, without being liable to its objection. The single T bandage of the nose is also a useful one in retaining dressings to its surface, but as it is much improved by the addition of a suspensory, it will be treated of under the latter bandages. Fig. 72 THE DOUBLE T OF THE CHEST, May be formed of a broad piece of muslin, and of a band two feet long, split nearly to the end ; or of two distinct bands of the same length, w^hich are to be attached to its upper edge. Then pass the mus- lin around the chest and bringing the two extremities forwards, stitch them to the first piece ; or the bands themselves may be brought forward over each shoulder, and se- cured in front, so as to form shoulder-straps. Fig. 72. Use. — In cases of fractures to compress the ribs, or to retain dressings to the back. Frequently buckles and straps are fastened to the ends in front, and buttons to the upper edge to receive the shoulder straps; these make the bandage much firmer, but also a little more complicated in its composition. THE DOUBLE T OF THE ABDOMEN, Consists of a piece of muslin, to one of the borders, of which, are stitched at equal distances from its centre, two narrow bands half a yard long, to serve for thigh 100 T BANDAGES. or perineal straps. They should be attached sufficiently apart to correspond with the great trochanters. In its application, the middle of the muslin should be placed around the pelvis, and the extremities brought round, on the abdomen, where they over- lap and pin ; the vertical bands are then conduct- ed from behind forwards, crossed under the peri- neum, and fixed upon the forepart of the horizontal band. Use. — To retain poultices or other dressings upon the abdomen; to exert compression on this part after the operation of paracentesis, or after delivery, al- though its application then belongs rather to the ac- coucheur, than to the surgeon. This is the T of the chest reversed, the vertical bands being made to pass under the pelvis instead of over the shoulder. THE TRIANGULAR, OR COMPOUND T OF THE GROIN, Requires a piece of muslin, four inches wide at its base, and ten inches long, made of a trian- gular shape, in order to Fig. 73. correspond with the up- per and internal part of the thigh. To the base of this, is sewed a hori- zontal band, about a yard and a-half in length ; and to its summit, a ver- tical one, three-quarters of a yard long. The dressings being then placed on the part, the extremities of the horizontal band are car- ried round the pelvis on either side as far as the sacrum, whence they are re- turned and tied in a bow, above the pubes, whilst T BANDAGES. 101 the vertical band, and the triangular piece passing down between the thigh and scrotum, the former comes up over the outside of the thigh, and is attached to the transverse portion of the bandage. Use. — To retain dressings upon the groin of a patient confined to bed, as in poulticing buboes, or after operating for hernia, and is one of the best bandages that we can employ for retaining dressings to the groin, when it is requisite to renew them fre- quently, especially where it is difficult to move or raise the patient ; as it is only necessary to untie the vertical band and draw it from under the thigh, in order to lay open the whole groin to our view, which may be readily done without the least movement on his part. THE DOUBLE T BANDAGE OF THE BUTTOCK, Requires a roller, two yards long, and three inches wide, and also two verti- cal bands, each half a yard ^^S"- '^4. in length, and two inches broad, stitched to it at right angles, at about one- fourth of its length. Then the horizontal band being placed around the pelvis, so that the vertical bands may correspond to the me- dian line of its posterior face, its extremities are fixed with pins, and the vertical bands brought under the perineum, and fastened to its front portion. Use. — This is the common double T bandage, em- ployed to retain dressings to the perineum, anus, or vagina, in cases of piles, prolapsus ani, and fistulse. Instead of the two tails, that, formed by slitting the single T may be used, as seen in Fig. 68. mn 102 T BANDAGES. THE T BANDAGE OF THE HAND, Is composed of a narrow bandage or piece of tape, one inch wide, half a yard long ; and of a second piece, one yard long. Sew the longest piece to the other, in order to form the vertical portion of the T, and place the horizontal band on the back or front of the wrist, so that the vertical band may present to the fingers. Carry the latter over the back or front of the hand, over the inter-digital space of the first and second finger ; come up again to the wrist, and surround it by a half turn of the horizontal one ; reverse the first over the latter to return to the space between the middle and third finger, retaining the dressing, and coming up to the wrist again ; surround it again by the horizontal band ; reverse the vertical one in order to pass between the ring and little finger, and on the outside of the latter to the wrist, where it may be fastened by the turn round the joint. Use. — This is a very light bandage for retaining dressings to the inter-digital spaces, as well as the body of the hand, and offers a substitute for the gauntlet or demi gauntlet, before seen. THE PERFORATED T OF THE HAND, Is made of a two inch roller, one yard long, and of a piece of muslin of the J^'S"' 75. breadth, and twice the length, of the palm of the hand. Fold the muslin on itself in its length, and cut in it four circular openings, as at D, about three lines apart, to corres- pond with the fingers ; then sew one of its ex- tremities at right angles to the roller or horizontal band, as in Fig. 75. T BANDAGES. 103 Pass the fingers through the openings, and stretch the muslin over the back and front of the hand, con- fining the loose end by a few circular turns of the roller around and above the wrist. Use. — Same as the above. The T bandages of the Feet being similar in their formation and application to the above, do not require a special consideration. 104 INVAGINATED, OR CHAPTER VII. OF THE INVAGINATED, OR SLIT AND TAIL BANDAGES. These might be classed under the Uniting Bandages, as the general object of their application is to bring separated parts into contact, did not usage place them under the Compound Bandages. OF THE INVAGINATED BANDAGES. There are two kinds, which we shall now treat of; one, in which the same roller is formed at one end into strips or tails, and at another part, into slits or button-holes, and the other, in which two distinct bands are thus prepared. In either case, the tails of one part are passed through the openings in the other, and by acting on compresses, approximate all the portions under them. The first is employed to assist the union of longitudinal, the other of trans- verse wounds, as well as in the the treatment of certain fractures. When wounds are deeply seated, the appli- cation of adhesive strips only unites the surface and leaves the parts below separated, so that, as the secretion of pus goes on, a bag or cyst is formed, from which it cannot escape except, by burrowing underneath. When, also, divided parts have a ten- dency to contract, they very frequently tear out the stitches, and it is in both these cases, that these ban- dages will be found exceedingly useful. THE INVAGINATED BANDAGE, FOR VERTICAL WOUNDS OF THE LIP, Is composed of a roller, two or three yards long and one inch wide, rolled into two heads ; and of two small compresses about two inches square, w^hich are to be placed on the cheeks near the angle of the mouth. SLIT AND TAIL BANDAGES. 105 In applying it, place the body of the roller on the forehead, or on the nape of the neck near the occiput, and carry each head round under the lower part of the ear, over the malar bones, and -fV- '^^^ over the compresses to the lip. Then slit in one bandage a hole large enough to admit the other head ; pass it through and draw upon each roller ; car- ry them both round to the neck, and then run the same course till the parts are well supported and cover- ed in, as in Fig. 76, terminating on the forehead. Use. — In vertical wounds of the lip where other means are not at hand, or to support the hare-lip suture and prevent its cutting out. By the pressure which .it makes on the lip, it is also useful in arresting he- morrhage from the corronary arteries. THE INVAGINATED OF THE BODY, Is made by a double-headed roller, of a length sufficient to go several times round the body, and of two com- presses of the length of the wound, the body of the ban- dage being placed on the back, and the heads brought round under each axilla, and over the compresses on each side of the wound. Then make a slit in the body of one side, and pass the cylinder of the other side through it, by which means the w^ound will be well closed. Continue this as often as may be necessary. Use. — To unite Longitudinal Wounds of the chest or abdomen, or to support the parts after the removal of the breast. 106 INVAGINATED, OR THE INVAGINATED BANDAGE FOR LONGITUDINAL WOUNDS OF THE EXTREMITIES, Is made of a piece of linen, sufficiently long to make three or four turns of the part to be treated, and of a breadth correspondent to the length Fig. 77. of the wound. This is, to be divided so as to form three tails, long enough to em- brace three-fourths of the part wounded. At a convenient distance further on, three longitudinal perforations, are made oppo- site to, and of the same breadth as the tails. The remainder of the band is then rolled up, and two graduated compresses made, of such a size as may be required by the wound. If the bandage is to be applied to the upper portion of the limb, its lower part should be first covered by the turns of the spiral ban- dage, and then the undivided portion, or that situated between the tails and the slits, being applied upon the part which is ex- Fig.iQ actly opposite the wound, and the graduated com- presses placed on each side of the latter, at the distance of about three or four fingers' breadth from its edges, the tails are to be passsed through the corresponding slits, and the edges of the wound united by draw- ing the extremities of the bandage in contrary direc- tions ; after which the tails are secured by the turns of the remainder of the roller, or by those of a Spiral one. Use. — This bandage may be used in deep-seated UNITING BANDAGES. 107 wounds of the extremities, as an adjuvant to adhe- sive strips, on account of its uniting the deep-seated parts as well as the skin, thus preventing any disten- sion of the inside of the wound, and the formation of an abscess. THE UNITING BANDAGE FOR TRANSVERSE WOUNDS, Will be referred to under the head of Fractures of the Patella. THE BANDAGE OF WINSLOW FOR WRY-NECK, Requires a roller five yards long and two inches Fi^. 79. wide, and some cotton or pads to protect the pos- terior fold of the axilla from the last turns of the bandage. The initial extremity being then placed 108 INVAGINATED, OR just above the mastoid process of the affected side, the bandage should be carried thence in front of the parietal protuberance of the same side, over the top of the forehead, and then around the head by several circular turns, so as to fix the initial end, firmly. Now placing a pin or two in the turns on the forehead, as shown in Fig. 79, pass down behind the axilla of the sound side, over the cotton or compresses previously placed there, round under the axilla to the front of the chest, and see that it is fastened very firmly to the clothing of the patient, or to a band placed around the chest, the head being drawn well over to this side, before the bandage is completed. The turns of the bandage on the head, and the obliquity of its course, from the forehead, behind the shoulder, round to the front of the chest, fulfil the indications of the treatment, by overcoming the inclination to the oppo- site side and turning the head to the front, thus op- posing the action of the sterno-cleido-raastoid muscle of the sound side. It affords, however, but very slight means of act- ing upon the head, and is apt to slip or stretch. These objections and better mechanical contrivances, have therefore very nearly displaced it, though it is occasionally employed as a temporary dressing. APPARATUS OF PROF. JORG, OF LEIPSIC, FOR WRY-NECK. This consists of a pair of leather stays and of a band or fillet which goes round the head. On the, centre of the forepart of the stays, is a kind of pulley or grooved wheel, which can be turned round with a key in one direction but not in the other, as it be- comes fixed by means of a spring. From this pulley or wheel proceeds a band up the neck, to the fillet on the patient's head, to which it is fastened directly behind the ear, close to the mastoid process. The band lies in the same direction as the lengthened sterno-cleido-mastoideus muscle, and when drawn UNITING BANDAGES. 109 towards the breast by means of the wheel, pro- duces the same effect as would arise from an increase in the action of that muscle. In short, it pulls the Fig-. 80. mastoid process downwards and forwards towards the sternum, counteracts the opposite muscle of the same name, and rectifies the position of the head. Professor Jorg makes his patient wear this apparatus day and night, nor does he take it off even when the contracted rigid muscles are rubbed with the lini- ment that he recommends."* * Samuel Cooper's First Lines — by Stevens of New York. man 110 UNITING BANDAGES. THE UNITING BANDAGE FOR TRANSVERSE WOUNDS OF THE NECK, Is very useful in cases of maniacs. It requires a Fi^. 81. single-headed roller, four yards long ; a piece of bandage half a yard long and three inches wide ; a bandage for the chest with perineal bands ; and a night cap to cover the head. * Fasten this on the patient's head by a few turns of the roller, and fasten at the same time, the band by its centre upon the top of the head. The bandage being then applied round the chest and pinned, the band is secured by a few more circular turns of the roller, after which its extremities are firmly fastened to the fore- part of the body, the head being forced down on the chest so as to bring the chin near the top of the sternum. SLINGS, 111 CHAPTER VIIL OF SLINGS. Slings are light bandages of great simplicity, and very useful in retaining simple dressings, as they do not oppress the part to which they are applied. They are formed of pieces of muslin of various lengths and widths, split at each extremity into two or three tails up to w^ithin a few fingers' breadth of their centre, as seen in Fig 82. They are also occasionally formed of a piece of mus- lin of a size suffi- Fig. 82. cient to cover the part to which the dressing is to be applied, each end having two bands attached to it to serve as tails ; thus making it resemble the slings employed in war by the ancients for hurling stones, w^hence their name. In using the sling, the body or central part is first applied to the part, and the tails carried round it and cofifined by knots, or pins. THE SLING OF SIX TAILS, OR THE BANDAGE OF GALEN, Is made of a piece of muslin, a yard long, and a quarter of a yard wide, split at each end, to within three finger's' breadth of the centre, into three tails, the central tail being somewhat broader than the others. The body of the sling being then placed on the top of the head, the central tails are passed along the ears and secured underneath the chin, the tails 112 SLINGS. being smoothly folded so as to adapt them better to the f-^-^, 83. lower jaw. Thefrontal tails are then to be directed from the anterior to the posterior part of the head, where they should overlap each other, while the occipital tails are brought for- ward, and secured on the fore- head by pins, as in Fig. 83. Use. — To retain large dressings, as poultices, &c., to the whole scalp. THE SLING, OR FOUR-TAILED BANDAGE OF THE HEAD, Requires a strip of muslin, a yard long and six inches broad, to be split at each end to within three fingers' breadth of the centre. Fi^r- 84. When the wound is on the forehead, the body of the sling is applied there, and the two upper tails, carried posteriorly, and fixed at thebackof the head, whilst the lower tails are fas- tened either upon the ver- tex or beneath the chin, as the surgeon may con- sider most convenient. To confine a dressing upon the summit of the head, the posterior tails, are brought down and se- cured beneath the chin ; the anterior tails, after being carried to the nape of the neck and crossed, being fixed before the throat, or brought again on the forehead (Fig. 84). SLINGS. 113 In applying it to the nape of the neck, the upper tails are conducted over the forehead, from whence, ^^g- 85. after being made to cross each other, they are returned, and fas- tened at the occiput ; the lower tails passing round the front of the neck. This forms the sling of the neck, and is seen in Fig. 85. Uses. — These ban- dages are very simple and convenient, and of great utility in wounds of the head or neck, as they can be applied over every point of this portion, by merely changing its direction. On the neck, especially, the sling forms an excellent bandage for retaining blisters, setons, &c. THE SLING OF THE CHIN, Requiresa piece of mus- Fig.^Q^ lin,six inches by four, slit at each extremity for two inches, to each of •which is to be attached a piece of tape or band- age oneyard long. Then placing the body of the sling under the jaw, so that the chin may be ex- actly in its centre, carry the two posterior tails up over the cheeks and ver- tex, to the mastoid pro- cess of each side, where an assistant holds them. Then 8 114 SLINGS. turn the anterior part of the sling and the anterior tails upwards in front of the chin, and carry the front tails under each ear to the nape of the neck ; cross them on the neck to come forwards to the forehead, where they may be knotted, after the tails from the mastoids have been carried under their posterior portion. Uses. — In fracture of thejaw without displacement, and to retain dressings to the front of the chin, or under the jaw. THE SLING OF THE FACE, OR MASK, Is made of a body piece to fit the face, and of four tails to hold it in its position. In forming it, fold a piece of muslin, nine or ten inches square, on itself, so as to form an oblong square. Place this ^ig-- 87. on the face so that the double side may correspond exactly with the central line of the face, and mark on it, a line, A B, and a circular opening, C, for the eyes. Make also a semicircular, F, for the mouth, and a small transverse cut, E, to correspond with the end of the nose. Then cut off the angles, A H, and I K, so as to give it an oval form, and cut out at G, two triangular pieces, the edges of which are to be sewed together to adapt it to the projection of the cheek bones. Attach two ver- tical tails at G, and two horizontal ones at A ; then open it out and make a vertical cut, D, from the trans- verse line at the point of the nose, up to the point be- tween the two eyes, as in Fig. 87. Apply this to the face and carry the upper tails to the occiput; x^ -o ^i V :< SLINGS. 115 cross them ; come round on the forehead, and carry the horizontal tails to the neck, in order to return to the forehead or chin, as in the same figure. Use. — To retain dressings to the whole face, in cases of burns from blasting rocks, gunshot-wounds, small-pox, &c., in all of which it will be found to be a most useful bandage. THE SLING OF THE BREAST, Is made of a square piece of muslin, sufficiently large to cover in the breast, slit for one inch and a-half on each of its four sides, and of four bands sewed to its four angles. These must be long enough to go Fi.^. 88. round the chest. Now whilst an assistant supports the breast or retains the dressing, place the body of the sling on it, and carry the lower tails under each axilla; m 116 SLINGS. come round in front of the chest, and carry the upper tails on each side of the neck, over the shoulder, and fasten them to the horizontal band. Use. — To retain a poultice or other dressing to the breast, or to support it, as in cases of cancer, &c. ; but if compression is required, the Crossed of the Breast, answers better. This, or the Four- tailed Sling, may also be usefully employed in retaining dressings to the point of the shoulder ; the elbow ; back and front of wrist ; or to the heel and instep. In either of these cases, place the point to be covered, in the centre of the body of the sling, and carry the tails round the part, so as to fix the bandage firmly. SUSPENSORIES, SHEATHS, ETC. 117 CHAPTER IX. OF SUSPENSORIES, SHEATHS, AND LACED BAN- DAGES. Suspensories are bags of certain sizes, intended to support depending parts, retain dressings to them, or cover such portions as would not otherwise receive a bandage. In all such cases they will be found of great service, and as their manufacture is simple, we are surprised that they have not obtained a more general use. As adapted to the nose we can highly recommend them to those requiring a complete band- age for such parts. THE SUSPENSORY OF THE NOSE, Is used to retain dressings to the whole of this part, and is com- posed of a trian- gular piece, cut as in the dotted lines B C, and C D, of Fig. 89, to the sides of which are attached the vertical and hori- zontal bands of a sin- gle T. In applying it, place the nose within the suspen- sory, and. carry the vertical band over the head to the neck, confining it by the horizontal bands, which are crossed there, brought up on the forehead, and fastened as seen in the cut. The open- ing at A is to suit the position of the nostril. 118 SUSPENSORIES, SHEATHS, Fi^-. 90. THE SUSPENSORY, OR BAG-TRUSS OF THE SCROTUM, As found in the shops, consists of a network bag and bands to fasten it (Fig. 66) ; but as this cannot always be had, its place may be readily supplied by one formed as follows, the application of both being the same. Fold a piece of muslin, on itself, of a size to suit the part, say six inches by four, and cut out an opening. A, for the penis, and a curvilinear portion according to the dotted line, B C. Sew the divided edges of this together, and at- tach a horizontal band, D, to the upper part, and two verti- cal ones, EF,to the lower pos- terior angle, making an open- ing or button-hole in the end of each band. Sew on two buttons to the horizontal band to serve for the attach- ment of the vertical or peri- neal straps. Then the penis being engaged in the opening, A, and the scrotum perfectly enveloped, the belt should be carried round the pelvis ; returned in front, and tied above the pubes. The two vertical bands are then made to ascend from the perineum along the inferior border of the glutei muscles, and buttoned to the belt in front. Use. — To support and confine dressings upon the scrotum ; to serve also for points of attachment to other apparatus, and for the treatment of swelled tes- ticle, hydrocele, and irreducible scrotal hernia. This bandage should always be worn during the treat- ment of acute gonorrhoea, as it diminishes the liability to Epididymitis. AND LACED BANDAGES. 119 SHEATHS, Are coverings intended to retain dressings to the penis, fingers, and toes. They are the finger-stalls of domestic use, and employed daily by every one who has a cut finger. A very useful application of them by the surgeon can be made in casesof gonorrhoea, as when made of large size, they will readily retain a portion of charpie to the head of the penis, and by absorbing the discharge prevent its staining the linen. They are also very useful in retaining poultices to the head of the penis, or dressings to chancres, &c., as they are not easily deranged by the erections. The band in these cases passes round the hips, as it does round the wrist when applied to the finger. THE LACED OR BUCKLED BANDAGES, Are so named from the manner in which they are confined to the part. As they are usually obtained from the glovers, or bandage makers, I shall only refer to them in passing, as their application is very simple, and being somewhat ancient, their use is gene- rally understood. THE LACED BANDAGE FOR THE KNEE, Is made of any elastic substance, such as buckskin or kid, lined with Caoutchouc, &c., and laces at the side, as seen in Fig. F^sr- 9i- 91. It is sometimes employed "^ where constant compression is re- quired, as after dislocations of the patella ; in chronic enlargements of the joints, &c. When wanted they should be made to order, as their utility depends on the accuracy with which they fit. In Philadelphia, they may be found at No. 43 South 8th, or No. 32 South 6th street, or of the cutlers, or druggists, generally. 120 SUSPENSORIES, SHEATHS, ETC. Fig. 92. THE LACED STOCKING, Is employed in the treatment of varicose veins ; for the support of tender and extensive cica- trices of the leg ; and in old ulcers, &c., being occa- sionally preferable in these cases to the ordinary ban- dage, as it presses uni- formly throughout its whole extent ; may be readily ap- plied by the patient, and worn under a boot. Where this bandage cannot be obtained ready made, slit a common strong cotton stocking down the side, and hem in on each edge a ver^y thin slip of whale- bone. Then work a few eye- let-holes along the edges be- hind the bones, as in the corsets of the female, and fasten it up by lacings. THE LACED GAITER FOR THE FOOT, Fig. 93. Is constructed like the knee- cap, of buckskin, cloth, kid, and laces along the outside of the foot and ankle, as in that daily worn over a shoe. It serves admirably for supporting the parts after sprains, or weakness of the lower portion of the leg and foot; in the cure of old ulcers on the malleoli, and of oedematous swellings of the ankle generally. PART II CHAPTER I. OF THE HANDKERCHIEF SYSTEM OF M. MAYOR, OR THE SYSTEM OF PROVISIONAL DRESSINGS. Before taking up the consideration of particular fractures and dislocations, it will perhaps not be un- interesting to examine the new system of bandaging of Mr. Mayor, or the system in which he proposes and practices the employment of such simple means as are always at hand, or which may often supplant, with advantage, the means already mentioned, and supply their place whenever they cannot be obtained. " The more readily we can procure such means, the greater also their simplicity and uniformity, the less embarrassing will it be for the surgeon to fulfil his duties, the less perilous will be the progress of the treatment, and the less doubtful the chances of its termination. These observations apply w^ith particu- lar force to the circumstances in which surgeons are often placed, especially when practising among the poorer classes, in the country, in thinly-peopled dis- tricts, or in the army or navy, where hospital stores havefailed or are rapidly diminishing." In doing this, M. Mayor has made such a sim])lification of surgical apparatus, that under any, even the most disadvan- tageous circumstances, relief may be afforded, and a plan of cure employed as safe and as commodious as that generally recommended. The principle he has laid down is, to use his own 122 HANDKERCHIEF SYSTEM words : — "To reduce as much as possible all kinds of apparatus to their most simple principles, by making them dependent upon particular and uniform ideas : in order that the parts of such apparatus, or the ma- terial objects of any dressing, may be so common, and of such a nature, as to be met with under every or nearly every circumstance, no less at the dispo- sition always of the surgeon, than of other persons ; and that, in the absence of a scientific man, they may be applied with facility by the first comer, after very little instruction. In other words, to find out a means, simple, easy of application, ever at hand, or at least always to be obtained, which may replace lint, com- presses, bandages, and ligatures, such as surgery ordinarily requires for the various species of dress- ing."* This principle cannot be too highly appreciated, nor too generally adopted, and to M. Mayor is due the credit of prosecuting it to perfection ; although for many years exposed to the sneers and ridicule of his professional brethren. His plans of treatment are now meeting everywhere with the respect they merit, and daily becoming better known, not only in Europe, but also in the United States. It would be impossible in our present limits, to treat at length of all this surgeon's objections to the common modes of dressing and bandaging, or give the fullest details of his method of treatment. We will, however, refer to the most interesting of his matter, believing that many valuable hints may be derived from it, even by those who would not feel inclined to abandon, altogether, the older and still more scientific methods employed in the treatment of surgical accidents. It has not been M. Mayor's object, as he expressly * JSToiiveau Systeme de Deligation Chirurgicale, Paris, 1 838, p. 16, Introduction. Troiseme edition, avec un Atlas. OF M. MAYOR. 123 says, " to banish wholly from the domain of surgery, charpie, lint, bands, &c., notwithstanding that such would be rigorously possible ; but he has been so often struck with their abuse and their almost exclu- sive employment, that he could not forbear exposing their numerous inconveniences in practice, and en- deavouring to establish his own motives for what he admits to be their quasi-exclusion.'^^ The principal objection which he makes to the common bandage, "is in relation to its frequent ab- sence in time of need, and the occasional impossi- bility of procuring any ; then the serious inconveni- ences with which their application may be attended when performed by unskilful hands ; for even under the best opportunities the habit of applying them re- quires time, and is susceptible of being speedily lost. Bandages, also, are liable to become relaxed, easily deranged, and corded, thus inflicting injury in a va- riety of ways, and rendering their frequent re-appli- cation a matter of essential necessity ; their diversity of length and breadth is also more or less perplexing to some ; to roll them well is troublesome; and when to these Avell-founded objections to their exclusive employment, is added the difficulty of having them always clean and neat, as well, also, as the litde care that patients take of them when they are not abso- lutely wanted, it must be evident that some other means are requisite, to rid the surgeon of so many causes of vexation and embarrassment ; and that, when such are found, they must be hailed by the profession with something like satisfaction. " Now, all the inconveniences here spoken of may be avoided, and all the good desired, obtained, from a bandage either of the original form of a cravat or pocket-handkerchief, or of the principal modifications of this, adapted to the nature of the case." M. Mayor makes four modifications of a handkerchief or cravat- shaped piece of linen, subservient to all the objects 124 HANDKERCHIEF SYSTEM of a bandage ; such as, the Oblongs the Cravat-shaped y the Triangular, and Cordiform ; the latter being only employed as a substitute for a cord, or strong tie, in certain cases. None of the objections made to the ordinary band- age can, M. Mayor thinks, be applied to this. " It is found everywhere, and under every circumstance ; is easily adapted to its purpose ; is not liable to be- come relaxed or otherwise deranged, and cannot be- come corded ; it is easy to fasten ; may be changed and reapplied with the utmost promptitude, as a sin- gle circumvolution of it is often equal to a multitude of turns of the common band ; is also more econo- mical, as it may always be washed, and made ready to apply to other than to surgical purposes ; the thick- ness and breadth can be varied at will : in short, it is so much the more perfect as it forms one whole, while each turn of a common band, being considered as a piece apart, the derangement of one necessarily entails the derangement of all the rest." It is not, however, pretended by him, that this new description of bandages can supply, completely, the place of common surgical bands ; for, as he justly observes, ^' there are cases which require a methodic compression of a certain energy, more particularly some affections of the breasts and of the extremities ; but these are comparatively rare ; and exception be- ing made of such, the new description, as being the most valuable, should be employed in common, while bands should form but the exception to this general rule." In the application of the handkerchief, or triangular piece of linen, to cases in which it may be adapted, M. Mayor commences at the head, and then, as in our present arrangement, proceeds regularly to the trunk and extremities. In pursuing this course, he desig- nates his handkerchief bandages by certain names, which may at first sight appear to be unnecessary and OF M. MAYOR. 125 pedantic. But when it is recollected that the arrange- ment of the name shows the course to be pursued in the application of the handkerchief, it will be seen that it is of considerable importance, and that it aids us materially in their application ; thus, in the Fronto- Occipital Triangle, we have the shape of the handker- chief, and the statement of the fact that, it is to be first applied to the forehead and then to pass to the occiput; so inihe Fronto- Cervico-LabialiSy or the Occi- pito-Sternal, we know that it should cover, first the forehead, then the neck, then the lip ; whilst the other starts from the occiput, and ends at the sternum. THE HANDKERCHIEF, OR SQUARE LINEN, May, according to M. Mayor, replace all the bandages that we have before treated of, and in -^«^- 94. its dimensions, as well as in the tissue composing it, must be regulated by the size of the part to which it is to be applied, or the cir- cumstances of the moment. It is, therefore, a mat- ter of indifference, whether it be of silk, cotton, or linen ; and if too short to go round a part at the time of its application, may be easily lengthened by attaching to its extremi- ties, two pieces of tape or ribbon. From this original piece we may form all the others, by folding it according to the dotted lines of Fig. 94 ; thus, if the four angles are folded into the cen- tre, g-, we shall have a smaller square, which may be again reduced by repeating the process. In this shape it answers very well for the application of warm, fo- 126 HANDKERCHIEF SYSTEM meriting poultices, which may be thus easily retained between the two layers of the handkerchief. If the square handkerchief is folded from angle to angle, we shall have the TRIANGLE. This triangle varies in size according to the part to be covered in by it ; though the largest of those employed at Lausane was about a yard in length, and a half yard from its summit to the centre of its base. When we wish to have a smaller triangle, divide this according to the line c d, or cut off por- tions on each side. Thus formed, the parts of the triangle, are the Base, a 6 ; the Angles or Extremities, or points of these same letters ; and the Summit, c. In Fig. 95. order to apply it, hold it smoothly by the base, placing the thumbs above or on its upper surface, and the fingers, widely extended on its under surface ; then apply the base first, and carry the extremities around the part so as to cover in the summit, making folds or plaits in any portion of it that may project. The Oblong Square, as in Fig. 94, does not require much explanation, as it is readily seen to be formed of the common square, doubled once on itself. '''^ The Cravat, Fig. 95, is so well known, as also to require no explanation, the shape being that which we daily employ in arranging the covering to- OF M. MAYOR. 127 our necks. Like the triangle, the body, or base, a, is the part first applied, and this is retained in its po- sition by attaching its ends, b c, to other parts of the body. The Cord, is made by twisting the cravat on itself, and is of great utility in compressing vessels, espe- cially as a substitute for the tourniquet. H 128 OF THE HANDKERCHIEFS CHAPTER II. OF THE HANDKERCHIEFS AS APPLIED TO THE HEAD. The first application of the handkerchief is to cover in the whole head, and is called THE SQUARE CAP OF THE HEAD. Form the handkerchief into an oblong square, and let the edge of the Fi£^.96. side to go next the head, be two inches shorter than the other. Draw the ends of the long side down the side of the face, and tie them under the chin ; then draw the inner ends, or those of the short side for- wards, to free them from the former, and folding this part back- wards, tie the ends on the occiput. Use. — To cover in the head, ears, and jaw. IN THE FRONTO-OCCIPITAL TRIANGLE, The base is placed before the forehead, higher or lower, according to circumstances ; and the lateral angles or tails are crossed at the occiput, from whence they are to be brought forward as far as the temporal AS APPLIED TO THE HEAD. 129 regions, or on to the forehead, where they are to be fixed by means of pins. Fig. 97. Fig. 97. The summit is then conducted and fixed at the occipital region, by being made to pass under the posterior portion, from whence it is reflected upwards and pinned, as in Fig. 98. Fig, 98. Use, — To retain dressings to the head. FOR THE OCCIPITO-FRONTAL TRIANGLE, Place the base at the occiput ; cross the tails upon 9 130 OF THE HANDKERCHIEFS the forehead, and pass the summit underneath the frontal portion so as to reflect it upwards. Use, — Same as the former, but more useful when a little pressure may be required on the forehead. This is made by the crossing of the angles, or by knotting them. IN THE BI-TEMPORAL TRIANGLE, The base is placed upon one of the temples, ^nd the summit turned over towards the opposite ear and con- fined by the angles carried around the head. Use. — To retain dressings to the temples. THE SIMPLE OCCULO-OCCIPITAL TRIANGLE, Requires that the base should be stretched obliquely from the superior part of the temporal region of the sound side, over one eye, to the sub-mastoid region of the diseased side ; the summit being carried diago- nally backwards to the posterior portion, where it crosses at the side of the neck corresponding with the sound eye. Use. — To cover in one eye. IN THE FRONTO-OCCIPITO-LABIALIS CRAVAT, Place the body against the forehead, cross the tails on the nape of the neck, Fiff. 99. and bring them forwards to either lip, where one may be passed through a slit perforated near the extremity of the other. These extremities are then pulled in contrary directions, over the com- presses on each side of the wound, and secured by a couple of small pins or a few stitches, underthe ears. AS APPLIED TO THE HEAD. 131 If a triangle is used, the summit should be carried to the occiput, passed under the first inter-crossing, reflected upwards and pinned. Fig. 99. Use. — To sustain the union in wounds of the lip, or after the hare-lip operation ; and to confine the dressings, or unite wounds in the absence of other means. ■ IN THE FACIAL TRIANGLE, OR MASK, Place the base under the chin, the summit Fis^. lOO. on the forehead, and carry the angles over the ears to the vertex, where they may be crossed and brought on the forehead, in order to confine the summit. Holes or slits are then to be made for the eyes, nose, and mouth. Use. — To retain dressings to the face. IN THE VERTICO-MENTAL CRAVAT, Fiff. 101. The body of a broad cravat is placed on the vertex, and the ends carried under the chin, and fastened to the sides of the first turn, near the ears. Use. — To retain dressiftgs under the chin, or to the base of the jaw. THE OCCIPITO-AURICULAR TRIANGLE, Is made by the base being placed obliquely in front of 132 OF THE HANDKERCHIEFS the injured ear,and the summitcarriedroundtowardsthe same ear. One angle then Fi£: 102. going under the jaw of the side affected, comes up in front of the opposite ear, where it makes a knot which ties under the ear, or a turn around the other angle, so that the two may run round the head, the one in front, the other behind, to tie on its side, or on the jaw. Use. — To retain dress- ings to one ear, or to the angle of the jaw, without interfering with the oppo- site ear. Fig. 102. THE OCCIPITO- STERNAL HANDKERCHIEF, Requires two handkerchiefs, one in cravat, the other in triangle. Place the base of the triangle on Fi^. 103. the occiput, with the summit anteriorly, and bring the AS APPLIED TO THE HEAD. 133 tails down along the sides of the head and face, so as to fasten them to the front of a sterno-dorsal or dorso- thoracic cravat. Fig. 103. Use. — To unite wounds of the throat, and bring the head to the chest. THE FRONTO-DORSAL, Is the reverse of the above. The base of the tri- angle is upon the forehead ; the summit carried posteriorly ; and the tails are turned downwards and backwards, to be fastened to the back of a dorso- thoracic cravat. Fig. 104. Fig. 104. Use. — Reverse of the former, or to unite wounds of the back of the neck, &c. IN THE PARIETO-AXILLARIS, Place the base of the triangular handkerchief on one side of the head, with the summit carried to the 134 HANDKERCHIEFS AS APPLIED TO THE HEAD. opposite side, and tie the ends to an axillo-acromial cravat, as in Fig. 105. Fig. 105. Use. — To bring the head to one side, as in wry- neck, spasm of sterno-cleido muscle, &c. HANDKERCHIEFS FOR THE TRUNK. 135 CHAPTER III. OF THE HANDKERCHIEFS AS APPLIED TO THE TRUNK. The first of these is very simple, and constitutes THE CERVICAL CRAVAT (OF DAILY USE). It has the centre before the larynx, the side of the neck, or against the cervical vertebrae, according to circumstances ; constituting an anterior^ lateral, or posterior cervical cravat. Use. — As a retaining bandage for dressings ap- plied to the neck. IN THE SIMPLE BIS-AXILLARY CRAVAT, Place the centre in the axilla of the af- fected side ; cross the tails over the corresponding shoul- der, and then carry them one before, the otherround and behind the chest, to the axilla of the opposite side, where they are to be secured. Fig. 106. Use. — To retain dressings to the axilla. Fi^. 106. IN THE COMPOUND BIS-AXILLARY CRAVAT, Place the centre of a cravat on the axilla of the sound side ; carry the tails obliquely upwards to the base of the neck at the opposite side, and fasten their extre- mities ; next, apply the centre of a second, and smaller 136 HANDKERCHIEFS AS APPLIED Fig. 107. cravat, in the axilla of the affected side, and attach its tails to the corresponding portion of the first. Fig. 107. Use. — Same as former, but to both axillse. IN THE SIMPLE BIS-AXILLO-SCAPULARY CRAVAT, OR POSTERIOR 8 OF THE SHOULDER, Fig. 108. Place the centre be- tween the scapula, carry one of the tails round the corresponding shoul- der and axilla, and fasten the extremity by strong stitches to the body of the cravat ; in the next place, conduct the other tail under the corre- sponding axilla, and over the shoulder, to- ward the extremity of the first, upon which it should be similarly se- cured, as in Fig. 108. TJse. — Same as the preceding. TO THE TRUNK. 137 IN THE COMPOUND BIS-AXILLO-SCAPULARY CRAVAT, Knot together the two extremities of a cravat about one of the shoulders, so as to make of it a loose ring : next, take a second cravat ; apply the centre of this against the anterior face of the other shoulder, and conducting the tails one over the shoulder, and the Fi^. 109. other beneath the axilla, let the first embrace the cor- responding portion of the ring, in order that its ex- tremity may be united with that of the second tail, which should be made previously to pass about the first, in the manner represented in Figure 109. Use. — Same as the two preceding, but preferable to either, on account of the much greater power it may be made to exert. FOR THE DORSO-BIS-AXILLARIS, Place one handkerchief in a cravat round the chest under each axilla, and the other in a triangle on the back, 138 HANDKERCHIEFS AS APPLIED ^^^' !!<>• with its base upwards. Fix the summit of the triangle to the circular cravat,and carry the an- gles over each shoul- der and axilla to fasten to the circular hand- kerchiefbehind, and on the sides. Fig. 110. Use. — To retain dressingsto these parts. If the summit is fixed to the circular cravat in front, and the angles brought over each shoulder to fasten be- hind, it will retain dressings to the front of the chest, and form a Cervico- Thoracic Handkerchief. IN THE TRIANGULAR CAP OF THE BREAST, Place the base of a triangle obliquely across the chest Fig. 111. TO THE TRUNK. 139 under one breast, with the summit over the correspond- ing shoulder ; one angle over the opposite shoulder, and the other under the corresponding axilla, to tie on the back and confine the summit. Use. — To retain a dressing to, or support the breast. IN THE SUB-FEMORAL HANDKERCHIEF, One handkerchief in a cravat, goes circularly around Fi^. 112. the pelvis. The base of another, which is in a tri- 140 HANDKERCHIEFS AS APPLIED angle, is applied obliquely on the thigh, the angles passing circularly around its upper part, and the summit obliquely up between the nates, to be fixed to the circular band, as at A, Fig. 112. Use. — As a means of covering in the pelvic portion of the body, and the only one that does it with neatness and accuracy. THE INTER-FEMORAL HANDKERCHIEF, Requires the base on the back of the body ; the an- gles brought round the pelvis ; and the summit to be carried over the perineum, to fasten in to the angles in front, as in the diapers of children. Fig. 113. IN THE SINGLE SPICA, Place the body of a cravat in the line of the groin and carry one extremity around the pelvis, the other around and below the thigh, to meet it on the groin. If not long enough, attach tapes to its extremities. Use. — To retain a dressing to one groin. FOR THE DOUBLE SPICA, Fig. 114. Fold two handkerchiefs in cravats, and tie an extre- mity of each together. Place the knot a little on one side of the spine, and carry the other extremity of each, round over either innominatum, in the line of the groin, between the thighs, and round their TO THE TRUNK. 141 outside, to come up and fasten to the bodies of the cravats. Use — To retain dressings to both groins. TO MAKE THE SUSPENSORY OR SCROTO-LUMBAR TRIANGLE, Form a lombo-abdominal cravat for a belt, and apply the base of a triangle to the under and back part of the scrotum ; carry the tails up alongside of this •^^^' ^^^' to the forepart of the belt ; pass them about this, from before backward, as represented in Fig. 115, and tie the extremi- ties, so as to bring the knot in front, and prevent its chafing. Next carry the summit upwards, pass it under the transverse portion of the tails and under the belt, reflecting it over the forepart of the apparatus, so as to secure it with a pin. 142 OF THE HANDKERCHIEFS CHAPTER IV. OF THE HANDKERCHIEFS OF THE UPPER EX- TREMITIES. The handkerchiefs of the Upper Extremities are an excellent class of bandages, and may frequently supplant the ordinary roller with advantage. THE CERVICO- BRACHIAL SLING, Is made by placing one handkerchief in a cravat around the neck, and knotting its ends over the sternum. Place the other in ■^^^' ^^°' a triangle under the forearm, so that its base may be next the wrist; then tie its angles to the cravat, and carry the summit around the elbow to fasten it to the body of the triangle in front. Use. — To sup- port the forearm. This method of forming a Sling is better than the common plan, as the knots do not cut the back of the neck, owing to the position of the cravat, whilst the summit of the triangle, being fixed at the elbow, keeps the arm more closely to the side of the body. THE ANTE-BRACHIAL TROUGH, May be either constructed of leather or pasteboard, which latter may be covered by some appropriate OF THE UPPER EXTREMITY. 143 material with the view of preserving its form, or even giving it a sort of embellishment. It may be either straight, that is to say, open at the level of the elbow, or, as represented in Fig. 117, terminat- ing there in a cul-de-sac. A long riband or cord is required to serve for its suspension, and constitute two collateral bows to which the author applies the term arc-loops ; — lastly, a cravat, so arranged as to constitute a Cervical Cravat. Four holes be- ing previously, bored through the trough at con- venient distances apart, near its borders, the cord is run through them, in order to form the loops, which in their pas- sage, should be made either to glide through the Cervical Cravat, as represented in Fig. 117, or what is better, through a ring, which serves to connect them, and allows loops; from convenience of a free play of the this the patient will derive no small When the apparatus is thus prepared, nothing remains to be done but to introduce therein the patient's forearm, which has been, if fractured, previously furnished with its bandage. Use. — This apparatus may be worn enclosed in the patient's ordinary dress, so as not to give the appearance of the arm being subjected to confine- ment. But if, it be required to preserve the elbow fixed against the trunk, a riband must be made to pass through a couple of holes perforated in the in- ternal portion of the trough, or that which corre- sponds to the body, and embrace the trunk, as a belt or body-bandage. If it be necessary to give 144 OF THE HANDKERCHIEFS support to the hand or wrist, a thin, flat piece of wood may be laid at the bottom of the trough, and its pro- jection beyond the end of the latter regulated by cir- cumstances. IN THE TRIANGULAR CAP OF THE SHOULDER, Fig. 118. Place the base of the triangle at the insertion of the deltoid muscle, or elbow, the summit over the acro- mion, and carry the angles round the arm, and tie them on it as in Figure 118. Use. — To retain dressings to the round part of the shoulder or middle of the arm, which it does very per- fectly. IN THE TRIANGULAR CAP FOR THE HUMERUS AND ALL OTHER AMPUTATIONS, The base of a triangle is to be conveniently placed under the limb, at a convenient distance from the extremity of the stump ; the tails are then to be brought forward and overlapped, and the summit carried over the stump and fastened to the circular portion, or the angles. In this last part of the pro- cess, care should be taken that the handkerchief, or linen embraces, very accurately, the extremity of the stump, as shown at page 27. Or, instead of commencing with the lateral angles, the summit may be first carried upwards in the man- ner described, and then the tails, in encircling the limb, may be made to include its extremity. Use. — Whether employed in amputations of the upper or lower limbs, of the fingers or toes, or even of the penis, nothing can be more simple or more effectual than this bandage. In general, no further OF THE UPPER EXTREMITY. 145 precaution is necessary, than to insist upon the patient remaining quiet ; for if the apparatus be carefully- applied, there will be hardly a possibility of any de- rangement. But should it be absolutely necessary to have recourse to some expedient to prevent the apparatus from becoming detached, a cravat belt may be applied about the neck, or pelvis, the lower part of the arm, or thigh, the wrist, or ankle, according to the seat of the operation, and the limb may then be fastened to this by bands or tapes. IN THE CARPO.OLECRANIEN, Fold two handkerchiefs into cravats, and apply one circularly around the arm above the elbow. Then tie one extremity of the other around the articulation of the carpal and metacarpal bones, so that the knot may come on the back of the hand, and attach the other extremity to the circular cravat, as in the arm of Fig. 112. (B.) Use. — To keep the forearm extended. When a splint is passed under each handkerchief on the front of the arm, it answers very well in the latter stages of fracture of the olecranon. IN THE FLEXOR OF THE WRIST, Place a cravat circularly round the Fig- 119. arm above the elbow, and a trian- gle around the hand so that the summit may be folded over it, and fastened by one angle around the wrist. Flex the hand and fore- arm, and attach the other angle to the cravat on the front of the arm, as in Fig. 119. 10 146 OF THE HANDKERCHIEFS, ETC. FOR THE CARPO-DORSAL, OR PALMAR TRIANGLE, Place the base of a triangle on the dorsal or palmar surface of the wrist, and carry the angles round this and the summit over the fingers, which should be flexed, as in Fig. 120, if a dorsal handkerchief is wished. If not, slit Fig, 120. holes in the handker- chief, as in the perfor- ated T of the hands, and passing the fingers through them, attach the summits to the angles. Use. — To retain dressings to the back or front of the hand, or between the fingers. OF THE HANDKERCHIEFS, ETC, 147 CHAPTER V. OB^ THE HANDKERCHIEF OF THE LOWER EX- TREMITIES. These handkerchiefs supply a covering for parts that often embarrasses the practitioner to retain dres- sings on, by any other means. The first is : — THE METATARSO-MALLEOLAR CRAVAT. Place the body of the cravat obliquely across the in- step, and carry one extre- mity round above the mal- leoli, the other round the sole of the foot and instep, to join it on the front of the ankle. Use. — To retain d ressings to this part, as after tying the anterior tibial artery ; but where pressure is requir- ed, the spica of the instep should be substituted. TO MAKE THE TRIANGULAR CAP OF THE HEEL, Apply the base, to the sole of the foot, directly under the instep ; summit over one malleolis; angles crossed on instep, and then carried around the malleoli to confine the summit, as in the foot of Fig. 122. (A.) Use. — To retain dressings to the heel. This is an excellent bandage in the treatment of the excoriations often consequent on the use of the extending band in the treatment of fractures of the thigh. 148 OF THE HANDKERCHIEFS OF THE THE TARSO-PELVIEN CRAVAT, Requires one circular cravat around the pelvis, and the body of a second on the top of the foot, with one end tied under the sole, the other fastened to the pelvic band, as at B. Use. — To support the limb and keep the foot extended, as in ruptured tendo-Achillis. THE COMPOUND METATARSO-ROTULAR CRAVAT, Is composed of four cravats ; — a hollow paste-board or split deal splint, and some soft compresses. Then the patient's limb should be placed in the most com- LOWER EXTREMITIES. 149 plete extension, and the heel kept elevated above the level of the tuber ischi by means of a pillow. The centre of the first cravat is to be applied against the anterior part of the thigh, immediately above the pa- tella, and its extremities carried backward, crossed, and returned to the anterior part of the leg immediately below that bone ; by drawing on these, the two broken surfaces will be placed in tolerable apposition. The centre of the second cravat should then be applied against the sole of the foot ; one extremity loosely knotted upon the metatarsus, and the other subse- Fig. 123. quently carried upwards on one side of the knee to the supra-rotular portion of the first cravat, to which it is to be attached, as seen in Fig. 123. The sole of the foot here serves for a point of support ; and this second cravat, aided by the respective posi- tions of the leg, of the thigh, and of the pelvis, tends to counterbalance the action of the extensors of the leg ; but, to obviate still more any possibility of flex- ion of the latter upon the thigh, which these cravats would not in all instances be enabled of themselves to counteract, recourse is had to a hollow splint, which is well lined with soft compresses, and applied against the posterior surface of the limb. This is fastened in the simplest manner, by the two remaining cravats. Use. — In fractured patella ; incised wounds of the knee, &c. 150 OF THE HANDKERCHIEFS OF THE THE TARSO-PATELLA CRAVAT, Requires one handkerchief in a cravat around the knee in a figure of 8, so asto embrace the patella; the middle of an- other being under the instep, and one end tied on its out- side, the other passed under the cravat at the knee, as in Figure 124. Use. patella. In fracture of the IN THE MALLEOLAR PHALANGIAI, TRIANGLE, OR CAP OF THE FOOT. P/^. 125. Place the base of the triangle un- der the instep ; summit over the toes ; angles around malleoli to en- close the whole foot. Use. — To retain dressings to the foot. IN THE TIBIO-CERVICAL CRAVAT, OR SLING, Apply the body of a cravat to the shoulder opposed to the side affected, and bring down the tails obliquely, to just above the crest of the ilium of the side cor- responding to the injury, so as to give it, when knot- ted, the appearance of a band. Then, flexing the leg to a right angle, apply a triangle on its anterior face, the base corresponding to the ankle, and the summit to the knee ; then carrying the tails, one along the inside, and the other along the outside of LOWER EXTREMITIES. 151 the thigh, and attach their extremities, securely, to the cervical cravat, near the pelvis. Fig. 126, Use. — To support the limb after the treatment of fractures of the leg, or in sprains, where the patient is desirous of walking about. 152 OF THE HANDKERCHIEFS, ETC. Fig. 127. IN THE TIBIAL CRAVAT, Place the body of a broad cravat obliquely across the back of the leg, and carry one extremity round the leg below the knee, the other above the ankle ; to meet and tie, or pin, on the front of the calf, or spine of the tibia. Use. — To confine Sinapisms, Blisters, &c., to the calf. The figure of 8 turns of this handkerchief, pre- vent its becoming deranged by the movements of the patient.* BARTON'S HANDKERCHIEF. A very excellent method of making an extending band for the treatment of fracture of the thigh, has been proposed by Dr. J. Rhea Barton, of Philada. Dr. Barton was led to this application of the handker- chief by seeing how well the pressure of the boot on the heel and instep was borne, and how frequently excoriation and troublesome ulceration of the heel followed the use of the ordinary band or gaiter, which pressed directly on the sharp edge of the tendo- Achillis. With these views, he folded a handker- chief into a narrow cravat, and placed the body of it, directly on the extremity of the os calcis, below the tendo-Achillis, so that two-thirds of the cravat came round under the outer malleolus, and the other third remained on the inside. The inside portion remain- ing parallel with the sole of the foot, the outside piece is carried over the instep and passed round it, * Mayor's Nouveau System. MAYOR'S SYSTEM. 153 so as to form a sort of knot, and also passed under the sole of the foot, to be turned around the first turn, and form another knot at the metatarsal articulation, when both ends are carried off perpen- dicularly from the foot and fast- ened to the splint, the pressure coming directly on the instep and point of the heel, as seen in Fig. 128. When ulceration on the front of the ankle-joint, or on the heel, has been produced by the use of the ordinary means, this will be found to avoid the sore points, and yet keep up a permanent extension. Fig. 128. We have now given an account of the manner in which the Handkerchief is frequently employed as a substitute for the ordinary roller ; and therefore pass in order to preserve the continuity of ideas, to the Hyponarthecia of Mayor, or peculiar means of treating fractures, as described in '' Cutler on Band- aging, &c." including a detailed account of his Clinical Frame ; our wish being to offer as great a variety as possible of the means of treating surgical injuries, in the belief that each one will take from them what is most desirable. " In 1812, Mr. Sauter published, at Constance, a work entitled, ^ Instructions for treating safely, com- modiously, and without splints, fractures of the ex- tremities, particularly the complicated ones, and those of the neck of the femur, by a method new, easy, simple, and economical.' This work, published in German, was somewhat voluminous ; and in order to render the subject matter more intelligible, M. Mayor translated freely whatever appeared to be the most 154 MAYOR'S SYSTEM. prominent features of this novel invention, and pub- lished them in the work from which his system has been taken. Perceiving fully the advantages that might be derivable from the new system, he adopted it exclu- sively, and having submitted it to the test of fourteen years' experience and observation both in the Hospital of Lausanne and in his private practice in the Canton, which was very extensive, he published, under the title of * Memoire sur I'Hyponarthecia,' the various modifications he had deemed necessary, to give to this mode of treatment its greatest efficiency. His reasons for adopting the term Hyponarthecie (vro^ under ; v*/)S«|-, splint), were based upon the fact that the planchette, or Schebmachine, or support of M. Sauter, upon which the limb reposes, was in itself a splint. This term is expressive of the system, and has therefore been Anglicised. '* To set out, the problem proposed by M. Sauter, a problem so difficult that it almost seems a paradox, but which he has ably resolved, was ^ to treat a broken limb, with even the most seiious complications, by posi- tion only, and without the use of splints ; and to permit the limb, at the same time, to execute, without pain or inconvenience, every movement parallel to the horizon.'^ " This apparatus consists in a board properly cushioned, upon which the injured limb should be placed and fixed in the position which it is necessary to give it. The board thus charged, is attached to the ceiling or the top of the bed by means of cords, which are run through holes pierced in its borders and sus- pended above the bed, so as to render it freely move- able. For the purpose of fastening the limb, two or three cravat-shaped ligatures are employed, which, in case of need, and with a certain modification of this apparatus, namely, a foot-board or ladder, will equally serve for the execution of traction or extension. But these ligatures, besides fixing the limb, exert a spe- cific action upon the fragments themselves ; for, acting MAYOR'S SYSTEM. 155 in contrary directions, they keep the fractured ends of the bone themselves, as well in juxta-position, as in the most complete immobility : so that this simple contrivance not only effectually produces the neces- sary traction in the axis itself of the bone, but even similar tractions directly transverse to it ; an advan- tage by which it is distinguished above all other ap- paratus for fractures. This state of immobility is im- portantly seconded by the soft cushion, which, by moulding itself to the form of the limb, guarantees the security of its under part, or that which alone can be said to be excluded from the direct action of the transverse ligatures. " But how, it may be asked, are the involuntary muscular efforts of the limb to be controlled ? The answer to this is, that they soon terminate even under ordinary circumstances, and they do so in this case so much the sooner, as they are not stimulated and kept up by the weight or offensive pressure of ordinary apparatus. " As the whole limb rests exposed to view, the in- spection of the practitioner will discover at once the slightest possible displacement, which he will be en- abled to remedy with the utmost facility ; at the same time that he may employ every kind of therapeutic agent in the event of injury of the soft parts. And the patients possessing, even under the most serious com- plications of their fractures, the faculty of horizontal motion, their beds can be easily made, and all the other necessary offices readily performed. " Not the least advantage peculiar to this apparatus is its ready construction ; it may be made at all places and under any circumstances, even by the practitioner himself; for if, viewing the materials in detail, some of these may not be at hand, such, for instance, as the pulley for the cords to run through, affixed to the ceiling, or the hinges necessary to a jointed board (see cuts), or a gimblet to bore the necessary holes, 156 MAYOR'S SYSTEM. substitutes may be instantly found ; as, a staple for the first, a bit of strong leather for the second, and for the third, a few nails, by which the cords may be effectually fixed to the edges of the board. So also with respect to the cushion, how many substitutes may be found for this ! In short, whether a surgeon be called for, in scenes of the greatest poverty, on board ship with the fewest possible resources, or in the wildest districts, he need never be embarrassed. " On board ship it is especially serviceable, as the fracture is not easily deranged by the motions of the vessel, owing to the limb being allowed to swing as well as the body. " The reduction of fractures, by the employment of this suspension apparatus, is effected thus. The board being furnished with its cushion, which should be sufficiently thick to constitute a soft bedding, and entirely cover it, and the vertical cord, forming a loop, properly suspended from the ceiling ; the se- cond cord, destined to form the side loops, or arcs of the board, is to be run through the holes perforated through the angles of this, passing in its course through the first or suspension loop, so as to be in readiness to comply with any exigencies, in regard to length, when the suspension is about to be effected. This done, the limb is made to glide along the cush- ioned board ; and then the resistance, or counter- extension and traction, is resorted to, together with the coaptation of the fragments ; and, by means of the traction-bands, the position and coaptation of the fragments is fairly established. The ladder or foot- board, or extension band, will now keep the foot steadily fixed, while the due elevation given to the centre of the jointed board, if this be used, will con- stitute it an excellent double-inclined plane, possessed of all the advantages accorded to that species of ap- paratus. Lastly, the arc-loops and suspension loops are to be regulated so as to raise the limb to a proper MAYOR'S SYSTEM. 157 height, which will be judged of by the surgeon, in consulting at all times, however, the feelings of the patient. " As this kind of apparatus is in the way of the bed coverings, some little tact is requisite to overcome this trifling impediment; but nothing need be ob- served on the subject here, as the good sense of the practitioner will always readily suggest means to remedy an inconvenience so truly unimportant. " The use of the jointed board is strikingly evident in fractures of the femur, whether of its shaft or neck : it effects, in its quality of double-inclined plane, that which modern surgery only has succeeded in obtain- ing ; namely, permanent Extension^ joined to double Flexion, and the Fixing of the entire limb : but, be- sides this, suspension affords the utmost facility of motion in mass, by means of lateral action. It will be only necessary to observe this apparatus, as illus- trated in the cuts, to be convinced how effectually the above important objects are attained, and how totally impossible it must be for the fragments of the bone to ride in cases of oblique fracture, by reason of the powerful aid of the pelvic bandages. '" Even in fractures of the upper extremities, the hyponarthecic apparatus may be sometimes advan- tageously employed ; as, for instance, where the frac- ture is one of very serious character, and complicated, with injuries of the soft parts, which requires that the patient should keep his bed, and which precludes, from what cause soever, the application of ordinary apparatus, as tending to aggravate his sufferings, and augment the difficulties of the case. In short, the only circumstances in which the invention of M. Sauter is contra-indicated, are those in which infants, or maniacs are concerned, for reasons which the least consideration will render apparent. 158 MAYOR'S SYSTEM, THE ANTE-BRACHIAL HYPONARTHECIA, Consists in a board of convenient width, a little longer than the forearm and hand ; — a cushion ; — a cord for arc-loops ; and three cravats. Then, the fracture being reduced, the forearm is made to repose on the cushioned board, a 6, which is immediately put into suspension to the patient's neck by means of the arc- loops, e e, ring, f, and Cervical Cravat, g. The second cravat, c, is now passed under the wrist and crossed upon the back of the hand, the tails being then made to embrace the cushioned board, and knotted at its anterior border, as represented in the wood-cut. That done, the third cravat, d, is made to pass round the apparatus at its upper part, so as to Fi^-. 129. confine the corresponding portion of the forearm, and be knotted also at its anterior border. Should it be deemed expedient, a fourth cravat may be made use of, to serve for a traction-band, which w^ill, of course, be knotted at the inner border of the suspension board. " The advantages that may be derived from the hy- ponarthecic apparatus, may here be judged of; for in cases of fracture complicated with laceration, or other MAYOR'S SYSTEM. 159 injuries of the soft parts, even occurring at the upper extremities, the wounds remain under the constant inspection of the practitioner, and are not subjected to the incommodious and even dangerous pressure of the common bandage, as must be the case when re- course is had to it under such circumstances. The patient may even be permitted, by the employment of this apparatus, to take exercise, when the injuries of the soft parts are not very grave ; but if, on the contrary, perfect repose be deemed essentially neces- sary, instead of the above apparatus, a board should be procured, which, extending from the axilla to be- yond the finger's ends, should be well cushioned, and maintained in place by means of a Bis-Axillary Cravat. The board may then be put into suspen- sion, and the above cravat adapted to suit the ob- ject in view in the following manner : — The cen- tre of the cravat should be applied to the axilla of the sound side, its tails carried before and behind the chest to the opposite shoulder, crossed thereon, and then brought down, one on each side of the deltoid, to the upper part of the board, the extremities being made to pass through a mortise, perforated in each board, in order to be knotted underneath. " The bands for fixing, and the traction bands, may then be adapted according to the principles of the system. " With respect to the suspension, in such a case, it may be made either from the ceiling, or the top of an ordinary bed ; or if the hospital-bed be employed, as described hereafter, from the Suspension-Bar attach- ed thereto. A precaution perhaps not unnecessary to be given, w^ith regard to the cushion is, that this should be of sufficient length to allow of its being turned downwards at its upper part, in order to pro- tect the axilla from the pressure of the extremity of the board." This last apparatus will, of course, be equally 160 MAYOR'S SYSTEM. applicable to fractures of the humerus, if complicated with severe injuries of the soft parts, but where a carved splint, as spoken of hereafter, can be obtained, it offers such advantages as must prevent frequent re- course being had to this of M. Mayor. HYPONARTHECIA FOR THE TREATMENT OF FRACTURES OF THE LOWER EXTREMITY. " This consists of a straight board, furnished with a cushion, and suspended, something in the manner of a scale-beam, from the ceiling or top of the pa- tient's bed, by means of cords ; its object being to give support to a fractured limb, and allow of lateral movement. '' The only thing which distinguishes this from other kinds of apparatus, is the suspension. The first thing to be shown, is the method of constructing it, and the advantages to be derived from its employ- ment ; the next, its adaptation to the limb according to the nature of the injury. CONSTRUCTION. " A thin board must be procured, proportioned in length and breadth to the size of the limb, as in Figure 130 ; it should be a trifling degree broader, and a few inches longer than the limb. Thus, for fractures of the leg it should extend from the bend of the knee to three or four inches beyond the heel. This board should be covered by a cushion, of its own magnitude, made of oat-chafT, bran, cotton, hair, tow, or, in short, of anything that could answer the same purpose, and be readily procured : and it should hav€ sufficient firmness to afford a plane of some re- sistance to the limb, and yet be capable of moulding itself exactly to its form. A hole is to be pierced near each of the angles of the board for the passage of the suspension cord, as at c. Each end of the MAYOR'S SYSTEM. 161 Fig. 130. cord is then to be introduced through the correspond- ing holes at one extremity of the board from below upward, and after being drawn to the same length, passed from above down- ward through the holes of the other extremity, and firmly knot- ted. The cord will thus form two parallel bows of equal length, which, by being held at the mid- dle, will suspend the board as a perfect plane, or allow of its re- ceiving more or less inclination either way, according to the dis- tance, on one side or other of the centre, upon which the point of support is made to act- The support here spoken of, con- sists of another cord, one end of which is to be carried through a staple driven into the ceiling, above the injured limb, and the other made to pass under the collected bows. By pulling, in contrary directions, the extremities of this second cord, the board may be elevated to the neces- sary degree ; and by knotting them, the elevation thus obtained, steadily preserved. "Instead of the staple, it is better to employ a pulley, if it can be had, as seen in figure 131. A pulley would likewise be found more convenient for the connexion of the perpendicular and transverse cords, as seen in the figure at B. The first of these pulleys will afford greater facility in the elevation of the board, while the second will serve to give it the due degree of inclination, with but little effort, and without occasioning the slightest shock. " As the free sliding of the cords would be detri- mental to the treatment of this case, from the circum- stance of the board being liable to alter its position 11 162 MAYOR'S SYSTEM. by the least movement of the patient, it is advisable to tie the two bows together near the pulley, and introduce between the latter and the ligature a small splinter of wood, which will naturally prevent the bows from retrograding. '' These preliminary arrangements, with the excep- tion of the introduction of the splinter, or foot-board, should be made before the limb is placed upon the board, in order that it may be immediately elevated when the former is applied upon the cushions. Care MAYOR'S SYSTEM. 163 also should be taken to arrange beforehand the pa- tient's bed, by pressing it down at the part corre- sponding to the apparatus, in order that his horizontal movements may not be interrupted. As soon as the limb has been elevated to a certain height, it is advi- sable to place a pillow underneath the board, which should remain there till the fracture is reduced, and the position, &c., of the limb conveniently arranged. This apparatus, when isolated, yields to the slightest impulse imparted by the patient in his movements, without occasioning either shock or pain. " The facility which patients have of moving them- selves in this way is so great, that, as M. Mayor has remarked, they may be seen changing their position with the utmost facility, obeying, through means of the common utensils, the calls of nature, and even gliding upon another bed of equal height. ^' Nevertheless, as may bereadilyconceived, it would be imprudent to permit them to indulge in any incon- siderate movements, as this would occasion and keep up in the osseous fragments a mobility that would become an obstacle to their consolidation. When, therefore, it is found impossible to suppress the indul- gence of such imprudent movements, the surgeon must have recourse to the bandage of Scultetus, with the aid of splints, or else to the carved splint, to be spoken of farther on. '* It may thus be seen, that in fractures of the leg, w^here the suspension apparatus presents the most ad- vantages, a simple board suffices, if it extends from the bend of the knee beyond the heel. A simple board arranged in the same manner, and which, departing from the tuberosity of the ischium, would pass a few inches beyond the heel, would also be equally suffi- cient for a fracture of the shaft of the femur, if it was considered proper to place the limb in an extended position, upon its posterior face ; but for those sur- geons who prefer the demi-flexion of the leg upon wmm 164 MAYOR'S SYSTEM. the thigh, and the latter upon the pelvis, the follow- ing apparatus becomes indispensably necessary. Two boards must be procured, the one precisely similar to that called tibial, of which mention has been already made and represented in Fig. 131 ; the other/emora/, Fig-. 132. I as in thisfigure,extendingfrom the ham to the ischiatic tuberosity, and articulating with the preceding, either by means of hinges, or simple tapes, which should pass through the holes with which the extremities of MAYOR'S SYSTEM- 165 these boards are pierced, and be knotted underneath. The suspension of this double inclined plane is effect- ed in the same manner as the simple tibial board, with this difference only, that the two bows are ex- tended from the superior extremity of one of these boards, to the inferior extremity of the other. But in order to form the two inclined planes which are to support the limb in demifiexion, a small cord should be passed from below upward, through one of the holes of the upper extremity of the tibial board, as in the figure, across the point of support, and thence, from above downward, through the other hole of the same extremity, under which the two ends should be knotted together. In this way, the extremities of the two boards, corresponding to the bend of the knee, maybe made to describe an angle, more or less acute, according as the limb is required to be placed in a greater or less degree of flexion. '' When position alone is sufficient to maintain the fractured extremities of the bone in apposition, and it is indispensably requisite to exert continued extension, or, in short, when more solidity is required to be given to the apparatus, the femoral board should be shaped out at its internal and superior angle, and furnished with a belt, which will be spoken of farther on. " The boards thus arranged, are not only useful in fractures of the shaft of the femur, but also in the treatment of fractures of the neck of that bone ; as they fulfil perfectly, in presenting two inclined planes for the flexion of the thigh and leg, the indication of the pillows of Sir Astley Cooper, and the machines of Sir Charles Bell, Earle, Delpech, &c. ; which have the inconvenience of being much more complicated, and consequently of less easy and general application, particularly in places distant from large towns. In short, one of the advantages for which the suspension apparatus is deserving of being made known, is its simplicity, and its possibility of being constructed at 166 MAYOR'S SYSTEM. all times, and in all places. In country practice, says M. Mayor, in isolated districts, every portion of this apparatus may be readily procured without occasion- ing the least embarrassment to the surgeon. " For myself, I may say," continues this gentle- man, '^ I have never experienced the slightest diffi- culty. I have sometimes substituted any common bands, when the proper cords failed me ; I have nailed these to the board when I have had no instrument to bore the ordinary holes ; I have employed nails for screws, and to form the directing bands, tow, wool, or rags ; these last materials, as also bran, saw^dust, moss, and even soft hay, have served me in construct- ing my cushions for the boards ; the bark of a tree, moistened leather, the binding of an old book, have supplied the place of pasteboard ; and rope-ends, skin, or strong cloth, have not unfrequently replaced the metallic hinges. ''The double-boardedapparatus,it maybe observed, will be found extremely useful in the case of fracture of the leg, with tendency to displacement, more espe- cially when this occurs near the knee-joint, from the impossibility of applying the garter, {jarretiere,) one of the directing bands of which, mention will be made farther on. " Although particularly applicable to fractures of the limbs, the suspension apparatus of M. Mayor may, under other circumstances, be of important use. It will readily be conceived how great might be its utility in any painful diseases seated upon one or other of the limbs, as well as in certain white-swell- ings, in arthritic and rheumatic tumefactions of the foot, or in any other serious affections of the knee, or of the articulation of the foot and leg. Its use might be extended to the treatment of transverse wounds of the thigh, or of the tendo-Achillis, for which the most perfect immobility is indispensable. There cannot be a better means, so long as the immobility of the MAYOR>S SYSTEM. 167 fractured part is insured, of allowing the patient to vary his position in bed. ADAPTATION. " It is not sufficient, although assertions of this kind have constantly been made, to place a fractured limb, after its reduction, upon an immoveable plane, in order to effect the cure. If this were true, for very simple cases, which would be but exceptions, if, for instance, in the majority of cases of simple fracture of the femur, a convenient position and a retentive bandage might be made to replace all those compli- cated machines, which do more honour to the me- chanical knowledge of their inventors, than to their knowledge of physiology ; it is not the less certain, that other means are required also, to maintain the fractured extremities of a bone in perfect contact, to overcome the involuntary as well as the spasmodic contractile efforts of the muscles, and the indocility of the patient. But between these indications, and the necessity of violently extending in contrary w^ays the two extremities of a limb, by mechanical powers which resemble only the rack of the inquisition, there is as wide a distance, as between the glossocome of the ancients and the simple pillows of Sir Astley Cooper : the surgeon who does not dare to expose himself to the dangers of the first, or to the insuffi- ciency of the second, has recourse in cases to the ex- tension apparatus of Dessault and others, which are not, however, free from inconvenience, but more often to the simple directing bands of M. Mayor, to which the only real objection that can be made is, that they are sometimes insufficient. " In the greater number of cases of fractured limbs, the fragments face each other ; whence the necessity, of exerting pressure in the direction of their diameter, if the displacement exist in relation only to the axis of the body of the bone, or of pulling at the same time 168 MAYOR'S SYSTEM. at the lower fragment, if the displacement is longitu- dinal, or in other words, if the broken ends overlap, in order to effect their coaptation. The hands alone of the surgeon and assistant are sufficient to fulfil ef- fectually these indications ; but as they are only tem- porary means, recourse must be had, in order to ren- der the effects permanent during the whole time ne- cessary to the consolidation, to the aid of an intelli- Fig. 133. gent machine, if such an expression may be used, which, in accomplishing this end, will in no respect inconvenience the patient. '' Let the fracture of a leg be taken as an instance ; if it be of such a nature as not to exact the continued MAYOR'S SYSTEM. 169 extension of the limb, and position alone suffices to maintain the broken ends in apposition, the surgeon has only to confine himself to the application, below the knee, of a tie or garter, the central portion of which has merely to be applied upon the anterior, or one of the lateral faces of the limb, and its ends at- tached either separately on each side, or together, on the outside or inside of the board. Fig. 134. The object here in view, as will be easily perceived, is to fix the limb upon the board and give a due direction to the superior osseous fragment. The garter, like all the other directing bands,may be made of a bit of 170 MAYOR'S SYSTEM. common roller, or a longitudinal compress, but M. Mayor prefers those he ordinarily employs. These directing bands, the form of which may be seen in the figure, should be thick and soft, in order to preserve their shape, and prevent them from exercising a painful pressure. They should be constructed of two pieces of linen cloth, from three to five inches wide at the middle, with a layer of wadding, char- pie, tow, or wool, interposed between them ; to the two extremities of these bands should be sewed tapes of convenient dimensions, or padded hand- kerchiefs w^ill do as well. The figure indicates so clearly the manner of disposing them, that it is un- necessary to dwell upon them longer here : the place, however, they are to occupy upon the limb, will be spoken of by-and-by. *' When these simple bands are found insufficient to fix the limb solidly upon the board, or when it is ne- cessary, in order to maintain the fracture reduced, to exert continued traction on the limb, the following pieces must be added. To the inferior extremity of the board above spoken of, a foot-support is to be adapted, of the shape of a ladder, as in Figure 130, by means of mortises, a a, pierced in the former to receive it ; it should be from eight to ten inches high, and form with the board an angle of about eighty degrees. '-'- The object of this foot-board is to fix the heel-strap or ordinary gaiter, which, on one hand, embraces ac- curately the instep, heel, and malleoli, and on the other, is attached by means of the two tapes, which terminate it, to one of the sides of the ladder, ac- cording to the direction desired to be given to the limb. ** Thus, by means of the gaiter on one hand, and the foot-frame and heel-strap on the other, the elongation of the limb may be produced, and the overlapping of the fractured ends effectually prevented. The MAYOR'S SYSTEM. 171 extension being made, is maintained by the heel- strap, and the counter-extension by the garter, or band at the knee, without taking into account the weight of the body, and the fixture of the limb upon the ap- paratus ; while the heel-strap, by fixing the foot, prevents rotation, inwards or outwards, of the lower fragment. '' But this alone is not sufficient to restore the limb to its natural form when the fragments are displaced in respect to the diameter of the bone ; and although the shortening of the bone has been provided against, nothing has yet been done to maintain the fractured ends in apposition. The following is the manner in which this indication is to be fulfilled ; instead of resorting, as is generally the case, to the uniform pressure exerted by the eighteen-tailed bandage, or that of Scultelus, with splints applied upon the soft parts that surround the ends of the bone, M. Mayor has recommended a means much more simple and more efficacious, and one which offiirs, besides, the advantage of not covering in with the apparatus the part of the limb at which the fracture is seated ; per* mits the surgeon also to visit it as often as he pleases, without the help of an assistant ; and to remedy the displacement, if any such should have occurred, as well as to dress the wound, should one exist, without meddling with the apparatus. The means in question consists in placing upon the part of the limb toward which the end of the bone is directed, and where it makes projection, the centre of a directing band, as Fig. ]33 (B) ; and fastening the extremities to the opposite side of the board ; care being taken, how- ever, to see that the fracture is properly reduced. Two bands, which act in opposite directions, are oc- casionally necessary, but more frequently the desired effect is obtained by one alone. The middle of the band should be applied upon the most convex part of the deformed limb ; one of its extremities is to be m 172 MAYOR'S SYSTEM. passed immediately under it, the other over, and both drawn with sufficient force and fastened to a peg, inserted at the side of the board, which corresponds to the concavity of the limb, or in default of this, to a mortise pierced about this spot ; they may be even nailed at once to the board. " The directing bands should not be placed until the heel-strap and garter are adapted, the latter being fixed to the board upon the opposite side to that to- ward which the neighbouring band Fig-. 135. is to be directed ; without attending to this, the two extremities of the limb would be found to yield to the inverse tractions of the bands. The disposition of these several pieces is seen in the Figures 133, 134. In comminuted fractures with extreme tendency to displacement, a piece of pasteboard should be applied upon the anterior part of the limb, as in Fig, 135, the notched end being in- tended to touch the front of the foot. " To fix the femoral board more solidly, the sur- geon should apply the large quilted band, or padded handkerchief before spoken of. This band should be of sufficient length to pass as a belt round the body, and terminate by a strap, to be attached to a strap and buckle, fixed to the external and superior part of the board. This band serves at once as a body-bandage and perineal strap ; it passes first of all upon the groin of the injured side, then round the corresponding ilium and along the back, and is re- turned over the pubes to the upper part of the frac- tured thigh, where the buckle, fixed to the outer side of the board, receives it, or w^here, when this is wanting, it may be fastened to some other convenient point of attachment. This belt, which, as may be perceived, tends to fix securely the femoral board |ii MAYOR'S SYSTEM. 173 upon the pelvis, is employed with the notched por- tion of the board, against which the tuberosity of the ischium rests, to produce the counter-extension, or, in other words, the resistance necessary to meet the tractions of the heel-strap ; while the latter acts at the same time upon the limb, which it elongates, and upon the board which it pushes upward, first beneath the ham and then upon the ischiatic tuberosity. Lastly, it is this portion of the apparatus which per- forms the greatest part in the effort ; but as it is aided firstly by the weight of the limb, which, placed upon an inclined plane, tends to descend ; and secondly, by the effort itself, which tends to elevate the bend of the knee, there can be no reasonable apprehension of the formation of sloughs or excoriations, such as the ordinary machines for continued extension too frequently produce. *' This apparatus appears to unite all the qualities necessary for the reduction and consolidation of frac- tures of the neck of the femur. " To resume ; when it is required to maintain a re- duced fracture of the femur, of whatever nature it may be, whether situated near the knee, or in the shaft or neck of the bone, whether simple or complicated, with or without obliquity of the fragments, the thigh and leg are to be extended over the inclined plane, well cushioned, the belt applied round the thigh and pel- vis, and the foot attached to the ladder or foot-board inserted in the lower end of the tibial board. A large quilted band, or several handkerchiefs, embrace the whole apparatus to confine the limb upon the board, when there is no deformity ; or the bands of direction, already described, made use of w^hen the limb is curved, or there is any tendency to curvature. " With a view of raising patients in bed, when suf- fering from injuries to the lower extremities, M. Mayor proposes a Clinical Frame, which, from its simplicity, has many advantages over the complicated machinery 174 MAYOR'S SYSTEM, of Earle, Jenks, &c., and may be advantageously used, especially by army surgeons, as it offers an ex- cellent bed, under even ordinary circumstances, being more steady, and not liable to the objections of an ordinary hammock. In speaking of it, he says : — ''It is, doubtless, highly gratifying to have at our service, as practitioners, a number of easy and convenient kinds of apparatus, as well as appropriate and salutary therapeutic agents ; but there are circumstances in w^hich, if we have the latter at command, the former are by no means so much in our power ; whence it happens, that we are occasionally called in, under circumstances so per- plexing, nay, so truly desperate, that we are content with positive inaction, rather than allow our interfer- ence to add to the patient's sufferings. *' A large number of serious affections are daly met with which not only compel the patients to keep their bed, but even place them beyond the possibility of being removed from one part of the bed to the other, without their being subjected to the most excruciating pain, or even to actual danger. Whether they repose then upon a bed of eider-down, or are stretched upon a hard paillasse, these unfortunate individuals soon experience the want of having their bed better ar- ranged, and of being replaced in a position more sup- portable. They are excoriated at all those places where the bones project, as at the sacrum and the hips ; the skin, deprived of its subjacent fatty tissue, constantly and powerfully pressed against the bones, soon becomes irritated, and ultimately sloughs; whence result those deep and extensive wounds, which, incessantly exposed to an invariable, and one might almost say corroding, pressure, to the difficul- ties attendant upon their dressing, and, still worse, to the continual contact of urine and fsecal matter, sometimes finish existence of themselves, or rapidly abridge its duration. MAYOR'S SYSTEM. 175 " For the purpose of averting these serious incon- veniences, various mechanical beds have been in- vented, the most ingenious of which tend to elevate entirely, and with great gentleness, the unfortunate sufferers whom it would be impossible to move with the hands or any other means without occasioning the most heart-rending cries. " It will be readily conceived, that the hands of one, two, or even three persons, are wholly insuffi- cient to support the entire body of an adult ; that the parts w^hich are not sustained must be put upon the stretch, while the others are pushed up, and that, from this unequal manner of action, the most excru- ciating pains ensue. And let it be, moreover, re- marked, that the fingers do injury from their hard- ness ; w'hile, in addition to all this carrying to and fro of the body of the sufferer, the most disagreeable shocks are constantly occasioned, which infinitely augment his already intolerable pain. In point of fact, patients in general prefer supporting the w^hole of the serious inconveniences allied to their actually invariable and painful position, rather than expose themselves, by this lifting about, to absolute tor- tures ; more especially, when this has to be effected frequently. " Circumstances so melancholy have necessarily had the effect of awakening the solicitude of practi- tioners, the industry of patients themselves, and the compassion of those who are about them to contri- bute, if possible, to the palliation of such tortures, or at least to attenuate some of their more fatal conse- quences. But it has been more particularly in favour of the minority, that is to say, of the opulent, that such efforts have been crowned with success ; the lower orders of society still remaining without the pale of benefits arising from the invention of ma- chines calculated to be of avail in circumstances such as those just pointed out. The reason of this is 176 MAYOR'S SYSTEM. evident ; the means indicated, and known under the title of Mechanical Beds, are so complicated and so costly, that they can only be within reach of persons in easy circumstances ; and even in hospitals, these beds are generally few in number, and their use very limited. " So great, therefore, is the difficulty of obtaining these different kinds of apparatus, and still more the difficulty of adapting them to the exigencies of the most numerous classes of the community — classes which, be it observed, are the most constantly ex- posed to affections demanding contrivances of this kind — that it has been of the utmost consequence to consider other means, than such pieces of mechanism present, and to seek for what seems to have been, hitherto, wholly lost sight of, namely, a contrivance within the reach of every individual, and applicable in ev^ery circumstance. This desideratum, M. Mayor thinks, will be found in his Clinical Frame, which he thus describes. *' The first things to be sought for are two narrow boards or poles about the length of the patient, and two crossbars of the same nature, of about a yard only in length. With these four pieces of wood, which may be easily united at their extremities by means of nails, rivets, bits of cord or handkerchiefs, w^e shall be immediately in possession of a frame in all respects stout enough for the end in view. It now remains to fill up the intermediate space ; and recourse must here be had to bands of webbing : but if these should not be at hand, or at all events, should they be difficult to obtain, a few stout cravats would conveniently supply their place. Whether, then, the webbing bands or the cravats be employed, they must be arranged crosswise, fastened securely at their ex- tremities to the sides of the frame, and, above all things, possess sufficient strength to resist the weight of the patient when suspended in the air. Substi- MAYOR'S SYSTEM. 177 tutes for the above materials may be equally found in towels, napkins, sheets, or indeed in anything that would serve to constitute a bottom, soft, but yet suf- ficiently strong. After such simple data, it would be superfluous to point out how ingenious mechanics might modify the contrivance so as to prepare a frame more elegant, more in harmony with their own talent, their desire of gaining reputation, or indeed with the fortune of those who employ them ; on the contrary, it would be advisable to urge the necessity of pre- serving the same simplicity in the construction of this, which will be found in the means destined to effect its elevation ; for there will be quite enough of those who are ever on the alert to throw a species of luxury about a machine, who will believe that they have perfected this, when, from a simple and Fi^. 136. effective instrument, they will have converted it into a complicated one, despoiled of its best qualities. " To raise the frame, as well as the patient, who is supposed to be stretched upon its bottom, it would 12 178 MAYOR'S SYSTEM. be sometimes sufficient to employ two or three dex- terous persons, such as are met with in hospitals ; but in addition to the difficulty of finding such assist- ants, there will be always more or less inconvenience attending this operation when effected by the hands, in consequence of the shocks to which the frame will be constantly subjected, from the slightest deviation from a simultaneousness of action. It will, therefore, be found more convenient to have recourse to the means employed in the hyponarthecic suspension, and to apply to the whole body, that which so well succeeds when applied to a limb. " Thus, the four angles should be perforated with four holes, as in the Fig. 136, through which a strong cord will be run in order to form two kinds of parallel bows or arc-loops of suspension ; the one longitu- dinal, the other transverse ; the former corresponding to the sides, the latter to the extremities of the frame. " Recourse may also be had to one loop only, which will give to the frame the kind of tilting (jeu de bas- cule) observed in the beam of a scale. Movements of this kind are occasionally of importance, as when it is desired to raise the upper part of the body much above the horizon, or even the lower part alone. " One strong vertical cord, firmly attached, and passing through a pulley, will suffice for the elevation of the frame charged with the patient, and must be arranged in the same manner as for the hyponarthecia of the extremities. Thus, in the dwellings of the poor, the ceiling is usually provided with large beams ; nothing, therefore, will be found more easy than to arrange properly the staples or pulleys. Recourse may be equally had to a suspension bar of the kind represented in the figure and placed at the head of the bed. But when these resources fail, or cannot be employed without some disadvantage, let that be remembered which is done by certain mechanics, I MAYOR'S SYSTEM. 179 particularly masons, when they desire to lift a heavy weight. The tripod^ called generally the triangle, is the most easily constructed, the most firm, and in all respects the most convenient that can be employed for the object here proposed. This tripod, seen in the figure, should have a pulley attached to the iron hook observed at its upper part or point of union, in order to receive the vertical cord destined to raise the frame ; and thus provided, should be stretched across the bed. " In order to render the ascent of the frame per- fectly gradual and easy, the vertical cord should be made to pass round a cylinder, fixed to two of the legs at their upper part, which may be turned either by a winch, or, if provided with holes and a small handle, as a capstan. Instead of this, if the free end of the vertical cord, after having passed through the pulley, be firmly secured to one of the legs of the tripod, the above effect may be accomplished by means of a strong stick, which is employed to twist the cord, and which, by shortening it at each turn, elevates the frame. " But a still easier method is to employ a simple lever of the first power, — a pole, for instance, — whose fulcrum should be beside the bed, and to one end of which should be fastened the arc-loops them- selves, as seen in the figure, or, what is still better, the vertical loop, which will permit, during its ele- vation, the frame to be better balanced : in lowering, therefore, the other end of the lever, the ascent of the frame may be regulated with precision. The fulcrum, thus placed between the power and resistance, may be simply a rope end's made into a loop, and either firmly attached to the ceiling, or else to the tripod, which, in this case, instead of being stretched over the bed, should be placed beside it. '' With the ordinary hyponarthecic loops attached to the Clinical Frame, which will allow of the point 180 MAYOR'S SYSTEM. being varied where they are taken up by the vertical loop, we obtain, with the greatest facility, the power of elevating this frame in any direction we may choose, whether completely horizontal, or with an inclination towards either of its extremities or either of its borders : an advantage which will not be with- out its utility on particular occasions. " It will be hardly necessary to observe that, in order to obtain these effects, it suffices merely to place the vertical cord at the centre of gravity itself of the frame, or more or less beyond this, in the direction either of the head or feet, and to make, for producing lateral inclination, the arc-loop shorter on one side than on the other. The arc-loops, however, ought to be collateral, for all these little advantages would be far less easily obtained, were the cords, which perform the office of loops, placed transversely at either of the extremities of the frame. *' Like all frames destined for a clinical use, that just described may rest continually in place, in order that it may be raised at the moment desired, without previous preparation ; that is to say, the patient should repose upon the bottom of the frame itself ; or else this elevation may be applied only at the instant when oc- casion may require it. In the first case, we should be careful that the bands or the pieces of cloth which constitute the bottom of the frame do not annoy the sufferer, and are preserved as clean as possible. This will not be difficult if preference be given to large pieces of stout cloth, which will occasion so much the less inconvenience, as they may be stretched at will, without forming any incommodious folds. " It will be clearly seen, moreover, that, with this disposition, the surgeon may readily expose the ulce- ration, and manage the application of dressings, by displacing from the bottom of the frame that portion which otherwise masks the affected parts. *' When, on the other hand, it is found advisable to MAYOR'S SYSTEM. 181 apply and elevate the frame several times, recourse should be had to the webbing bands, which, by means of a broad, thin, pliant piece of wood, may be glided, at the very moment, under the patient, much in the same manner as we should change the bandelettes in the apparatus of Scultetus. These bands, already at- tached to one side of the frame by one of their extre- mities, are then brought to the opposite side, where they are fastened, by means of their free extremities, through the intermedium of ribbands, buttons, or buckles. This simple and easy means of gliding the bands under the patient, without at all incommoding him, and thus interposing between the bed-clothes and himself some sort of bottom proper to sustain him when elevated, would naturally suggest a still more simple support, namely, cravats or oblongs, of what- ever tissue they may be composed, or of whatever breadth it may be thought proper to afford them. The Clinical Frame may not only be regarded as a species of hyponarthecia, destined to sustain momen- tarily the entire body in any manner, or in any direc- tion desired to be imparted, but, being moveable, it will be seen to offer one very precious resource in a circumstance of the most important nature. Allusion is here made to the frightful sloughing sores common to the lower and back part of the body, and which the pressure against the bandelettes renders insupport- able, and tends constantly tc exasperate. Many are the means, without doubt, employed to attenuate this horrible pressure ; yet they not only most often fail, but are difficult to procure, to maintain in place, and preserve in a proper state of cleanliness. The Clini- cal Frame, then, with very little additional trouble, averts this inconvenience in the following manner: " Let the individual be extended over the bands placed transversely behind his back, and let us sup- pose that these bands are properly stretched from one side of the frame to the other ; it is clear that the poor 182 MAYOR'S SYSTEM. sufferer will press upon them all with his entire weight. But if we detach those bands which correspond to the ulcerations, and if, at the same time, we remove suffi- cient of the hair, wool, or straw of the mattress which exists under the bands we have just placed aside, we shall immediately obtain a sort of hollow or depres- sion, in which the ulcerated surface will be but very slightly touched. It will be even possible to afford such depth and extent to this depression that the affected parts remain, as it were, in the air, in a com- plete state of isolation. In short, the bands, placed above and below the seat of ulceration, will sustain the body with great exactness, and will leave the sore open, and at that degree of elevation which may be judged necessary, to subtract it more or less, from the pernicious influence of the pressure we are striv- ing to avoid. *■' It may be, however, observed, that, instead of the excavation already spoken of, the mattress may be cut across, and of one mattress two smaller ones formed, which may be placed so as to allow of a suf- ficient space between them to guarantee the wound from pressure, according to its extent. " The Clinical Frame may, in campaign, admirably serve for a litter, or for the transport of the sick or wounded, as it possesses the advantage of the most simple form of construction, and of being made of materials to be found on all occasions. In this case, instead of webbing or other bands, to form the bottom of the frame, recourse may be had to simple cords covered with hay, straw, leaves, grass, pieces of cloth- ing, &c. When it is found necessary to have the litter stationary, nothing would be more easy than to adapt to it a tripod or triangle, which would possess two remarkable advantages ; firstly, in forming solid feet for the support of such temporary bed ; and, secondly, in forming a frame, proper to receive a blanket, or something of the kind, to serve for the I MAYOR'S SYSTEM. 183 purpose of a curtain, and to protect the sufferer from the sun, rain, wind, &c. " Many other occasions might, doubtless, be found for the use of this frame when put into suspension. Serving as a sort of hammock, it would seem to invite officers to establish it under their tents, and would guarantee them from the humidity of the ground, from insects, and other annoyances inseparable from a bed placed directly upon the earth. The same may be said of it in a bivouac, where the triangle need only be covered by a cloak. " The suspension-bar, as seen in Figure 136, adapted to a common hospital-bed, has been already pointed out as a means of establishing the suspension of a hyponarthecic apparatus : it requires no descrip- tion, for the drawing will suffice to give the most correct idea of its construction. It will be seen therein to represent, however, only one-half of it, as the drawing of the other half would have interfered with the view of tlie tripod." i i I PART III CHAPTER I. OF THE APPARATUS FOR THE TREATMENT OF FRACTURES. GENERAL CONSIDERATIONS. The responsibility involved in the proper treatment of these injuries, renders them one of the most im- portant parts of the practitioner's duty ; as not to be able to set a broken limb, or reduce a dislocated bone, is enough to destroy all professional reputation ; the public in general not being able or willing to under- stand the distinction drawn between the duties of the surgeon and those of the physician. Indeed when a case turns out badly even in the hands of the most able surgeon, the friends of the patient, to use the language of Mr. Amesbury " sometimes think they can never injure his reputation sufficiently ; and though in many instances he is not at all deserving of blame, they usually load him with epithets of igno- rance, neglect and presumption. If we examine a little into this feeling we shall find that it is nothing more than what is naturally to be expected. Patients know nothing scientifically of the nature of frac- tures, or of the means made use of for their cure ; consequently they judge of the surgeon's ability ac- cording to the result of his case. If it terminates well, the surgeon has only done his duty ; but if the limb be deformed^ the patient will immediately say, m 186 TREATMENT OF FRACTURES. that the fracture was badly set, and be confirmed in this opinion by the observation of his friends, who seldom fail to find out cases to substantiate their belief." Yet important as the subject undoubtedly is, it would be foreign to a work of this kind, to treat of it in all its bearings, or consider its causes, and its physiological and pathological changes. We shall, therefore, in the consideration of this part of the subject, confine ourselves mainly to such points as are most connected with the treatment ; only hint- ing briefly at such general considerations, (especially as respects the causes of the defor- mity, and the indication to be ful- filled in the treatment,) as are concerned in the plans of practice ; referring those who wish a more minute knowledge of it, to the many articles to be found in all our works on Surgery. Fi9: 137. The Bones being intended for the support of various portions of the body, and acted on by the muscles, it follows that any solution of con- tinuity in their structure, must in- volve very materially the use of the part, and create deformity from irre- gular muscular action. The over- coming of this deformity, and the retention of the broken ends of the bone in such a position as will be most favourable to their union and subsequent usefulness, are then the first principles involved in the treat- ment. To prove this, a slight refer- ence must be made to the bond of union, or Callus. The first effect of fracture, being a division of the fibres of the TREATMENT OF FRACTURES. 187 bone, with more or less laceration of the soft parts, inflammation must necessarily follow. This results in fortunate cases,in the effusion and organisation of lymph, which subsequentlybecomesbone, and by its extension beyond the fractured extremities, binds them together externally, (Fig. 137), until a more perfect union is effected within their extremities. This external matter or Provisional Callus, being that which is first formed, is of course that most directly implicated in the results of the means employed, the second, or definitive callus, not being completed till long after the ordinary dura- tion of the treatment. Certain circumstances, as rest, position, and the prevention of too high a degree of inflammation, or the excitement of the necessary amount where it does not naturally exist, are therefore essential to the cure, and the creation of these circum- stances, or the fulfilment of these conditions, consti- tute therefore the general principles of the case. As the proper fulfilment and comprehension of these, can, however, only be gained from an accurate knowledge of physiology, we can do little else than lay down the general means of fulfilling them. To accomplish these indications, we must, therefore, 1st. Reduce the displaced ends of the bone ; 2d. Co- aptate and keep them reduced ; and 3d. Subdue the local inflammation, and combat the accidents that may arise from the means of treatment. 1st. Reduction. — The first indication, or the re- duction of the displaced ends of the bone, is limited to such fractures as are accompanied by this deformity ; such as those of long bones surrounded by powerful muscles, or exposed to blows, which can act directly on either fragment. To accomplish this, we must resort to what istechni- cally known as Extension, and Counter-Extension, or the use of such means as tend to bring the bone to its original length. Extension, is the force applied to 188 TREATMENT OF FRACTURES. that extremity of a broken bone which is furthest from the heart ; and Counter-Extension, that which exactly balances the extension, or prevents the whole body yielding to the force applied to the lower end of the limb. But in some instances, even in fractures of the extremities, as in fractured patella, olecranon, &c., it is improper, if not impossible, thus to make extension and counter-extension, and we are obliged to resort to position, or placing the muscles in a state of re- laxation, in order to accomplish our object. This latter point, position, has for many years been a disputed question among surgeons ; Pott, and many of the English school, contending for its advantages, w^hilst the French and American writers, advocated the more mechanical means of treatment; averring that position alone would prove injurious to most cases. Like most disputants, they carried their opinions to such extremes, as to injure all parties. That in many cases, extension is absolutely necessary to the reduction of a fracture, cannot be doubted, but that position is also not to be neglected, is equally indisputable. Take, for example, a fractured clavicle, the mere extension affected by carrying the shoulder outwards, would not relieve the deformity, without attention being also paid to its position of backwards and upwards. Again a fracture of the femur, or of the leg, would not be pro- perly reduced by mere extension and counter-exten- sion, unless at the same time, the position of the foot was looked to. The prudent practitioner should therefore bear in mind, simply the fact, that it is the force of mus- cular contraction that is to be overcome ; and whether accomplished in an extended or flexed position, by compression of bandages, or without them, not rest satisfied until he has accomplished his object. In fractures of the long bones, the weight of French and American authority is in favour of the extended posi- tion of the limb ; whilst the pupils of Pott and many TREATMENT OF FRACTURES. 189 of the English surgeons, still prefer the flexed, especially in the treatment of those of the lower extremities. 2d. Coaptation^ and keeping the hones reduced. — The accomplishment of these indications, is usually the result of the employment of certain forces, more or less directly, to the seat of fracture. Where two bones are parallel, and it is important to keep them at a certain distance, as in the bones of the forearm and leg, or 'where one fragment is liable to such irre- gularity of position as cannot be otherwise overcome, it becomes necessary for the surgeon to press upon them with his fingers, and mould them to the de- sired condition ; thus coaptating or setting the frac- ture. But where the deformity can be remedied by the action of muscles, it is better not to finger the seat of fracture, as the pressure of the soft parts on the sharp points of bone, might create such irritation, as would rather increase, than relieve the existing symptoms. As the muscles are, also, the motive powers of the body, and as they are attached to the bone, it follows, that even after the setting of a bone, any sudden action on their part would tend to displace it ; so that the common idea of a bone once set, being always afterwards in its proper position, is incorrect, the facts being most frequently the reverse, the attention of the surgeon to the state of the bone, being always required, at each dressing, until consoli- dation has taken place, lest the action of the muscles again displace it. In order to guard against this, various means, consisting of Splints, Cushions, or Junk-bags, Pads, Extending and Counter-Extending Bands, Palettes, or Hand Splints, Soles or Foot- Splints, Compresses, Pads, Slings, and Rollers, — the minute directions for the preparation and applica- tion of each of which, will be given in connection with the treatment of the particular fractures for which they are required. 190 TREATMENT OF FRACTURES. 3d. Combatting inflammation, and the accidents re- sulting from the means of treatment. — These, though placed last, are by no means the least important items in the treatment ; fractures being so generally the result of violence, that inflammation is very apt to ensue. This, provided it does not run too high, or involve neighbouring parts, need not be interfered with, a certain amount being necessary, as stated, to the formation of callus. But, if otherwise, the use of cold washes, and the anti-phlogistic system gene- rally, will be necessary to prevent its going too far. The combatting of the accidents resulting from the plan of treatment, will more frequently test the surgeon's skill, than any other portion of the case. Excoriations, ulcerations, bed-sores, and con- stitutional symptoms, such as fever, diarrhoea, &c., are all liable to complicate the case; and there are few of any experience, who have not felt the evils referred to. Every attention should, therefore, be given to the proper construction of the bed and of the apparatus ; to the room in which the patient is to be confined ; to diet, &c., &c. ; in order to guard against accidents, which sometimes will produce a result, that nothing but previous experience could have led any one to anticipate. In the plan of Pott, or the flexed position of the lower extremity, there may be sloughing and bed-sores ; in the ex- tended state of the limb, ulceration on both heel and perineum ; whilst paralysis, arrest of circulation, and excoriation, may follow the treatment of similar inju- ries in the upper limbs. As however these evils can only be hinted at here, or better referred to in each ac- cident, we shall, without further delay, pass to the treatment of particular fractures. FRACTURES OF THE BONES, ETC. 191 CHAPTER II. OF FRACTURES OF THE BONES OF THE HEAD AND TRUNK. FRACTURES OF THE SKULL. The treatment of fractures of the skull being dependent on whether or not it is necessary to trephine, their particular consideration would not be proper here. We merely therefore state that in any case where it is necessary to retain dressings to the cranium, we would resort to the Recurrent Bandage of the Head ; the Single or Double T ; the Handkerchiefs of Mayor ; the Bandage of Galen^ or to the Sling of Four Tails ^ as before given. IN FRACTURE OF THE BONES OF THE NOSE. After the fracture has been reduced by the use of a probe introduced into the nostril to elevate the bones if they have been depressed, we may employ the Double T. of the JVose^ to retain the dressings to the part, or to the internal angles of the eyes ; and combat the inflammation of the nasal duct which so often supervenes, no means being required to keep the bones reduced after the fracture is set, as they are not liable to displacement from muscular action. IN FRACTURES OF THE LOWER JAW, Anterior to its angle, we may em- ploy J9r. Barton'' s Bandage ^ p. 72 with the use of a paste-board splint, made as in the figure, like the body of a sling ; or the Sling of the Chin J as before mentioned, or the Bandage of Dr. Gibson, which is composed as follows : — 192 FRACTURES OF THE BONES GIBSON'S BANDAGE FOR FRACTURE OF THE JAW, Is composed of a roller, five yards long and two inches wide, and of a compress and splint, if ne- cessary. In its application, after having carefully examined the injured parts, and replaced any of the teeth that may have been deranged, we run the fingers along the margin of the jaw, in order to mould it into its proper shape. Then Fig. 139. closing the mouth firm- ly, make the lower teeth press fairly upon the upper, and place a compress of moderate thickness under the fractured portion, where it should be held by an assistant. The sur- geon next takes the single-headed roller, and commencing on the top of the head, passes it by several turns down the side of the face, under the jaw, and over the compress ; after the third turn of this kind, he makes a reverse on one temple, so as to run off perpendicularly and surrounds the forehead and occiput by circulars of the vault of the cranium. On the third of these turns, pass from the occiput obliquely over the back of the neck, and under the ear, to make three circulars of the chin and neck ; from the neck pass obliquely upwards, to go circularly round the forehead, and place pins at each turn. If the turns are likely to slip, fasten a small strip on the forehead, and carry it over the vertex to fasten it to the turns on the neck, and thus secure them more perfectly as seen in Fig. 139. During the treatment of fracture of the jaw, the patient must be fed on soft, semi-liquid food, and not OF THE HEAD AND TRUNK. 193 allowed to speak ; but there is no occasion for in- serting a piece of cork between the teeth, or extract- ing any of them, as there is usually enough space between them as they stand, to enable any one to suck food into the mouth. This fracture, under favour- able circumstances, consolidates in four or six weeks, but the patient should not eat hard or tough articles for some weeks afterwards ; for obvious rea- sons. FRACTURES OF THE VERTEBRAE, Require no apparatus. Our attention must here be mainly directed to the use of the catheter and of enemata ; directions for which will be given here- after. An important point to be recollected in these injuries is, not to turn the patient on his belly in order to examine the back, but to turn him only on to his side ; for as the abdominal and intercostal muscles may be paralysed by the injury, the dia- phragm alone can act in respiration ; but in order that this may descend, the abdomen must bulge out, so as to allow of the descent of the bowels and ex- pansion of the chest. If, then, the patient is kept for a length of time on his belly, there is not suf- ficient force in the diaphragm to do this, as it has to overcome the resistance made by the weight of the body on the bed, consequently, if the examination is tedious, the patient will run the risk of being suf- focated. IN FRACTURES OF THE STERNUM, The indications are, to prevent deformity from the projection, or depression of the fragments ; to keep the chest at rest, and oblige the patient to breathe by the diaphragm and abdominal muscles. These may be very well fulfilled by placing a compress over the part, and confining the chest by the Crossed Bandage, 13 194 FRACTURES OF THE BONES or by the Spiral of the Chest, as has been before shown. FRACTURES OF THE RIBS, Are to be treated on the same principles as those of the sternum, the compresses being over the parts, if the fragments project externally ; but over the ends of the rib, if internally. These compresses and the whole chest, are to be confined by the Spiral Bandage of the Chest, (Fig. 41,) which should be drawn very tight. FRACTURES OF THE PELVIS, Require no other apparatus than a broad bandage of the abdomen and pelvis ; there being here, little or no tendency to deformity, owing to the attachment of the muscles. FRACTURES OF THE CLAVICLE, Are treated by several kinds of apparatus, all having for their object the keeping of the shoulder upwards, outwards, and backwards. It is necessary that it should be kept upwards, in order to bring the fragments to the same level ; outwards, to pre- serve the proper length of the clavicle, keep the arm at its proper distance from the sternum, and preserve the pectoral space ; and backwards, to bring the bones into the proper line in front. The first means to be shown of doing this, is the old and widely known — APPARATUS OF DESSAULT. This is composed of three single-headed rollers, eight yards long, and two and a half inches wide ; of a pad of the length of the humerus, and four inches OF THE HEAD AND TRUNK. 195 Fig. 140. thick at its base, made in the shape of a wedge by- folding muslin on itself, so as to form a compress graduated from one end, as before shown, and then coveredwith a piece of muslin; — of a com- press to go over the broken bone ; of a short sling to support the fore- arm; and of a piece of muslin sufficiently long and wide, to surround the chest, arm, and bandage, and keep the whole dressing in its place. These being prepared, and the patient either seated on a bench, or chair with- out a back, or else stand- -f'-f- ^^^• ing, an assistant is to elevate the arm of the injured side, and carry it off at right angles to the body ; whilst the surgeon places the pad in the ax- illa, the thick end up- wards, where it is to be held by the assistant. The initial end of the first roller, is then placed on the middle of the pad, and two or three circular turns of the chest made, in order to fix it, when the roller should be carried up over the front of the thorax ; over the sound shoulder ; under this arm-pit to make a semi-circular turn on the front of the chest ; over the pad ; round on the back ; over the sound shoulder ; under the arm-pit, and then spirally around the chest. (Fig. 141.) 196 FRACTURES OF THE BONES The surgeon then flexes the forearm on the arm, and bringing the latter down along the pad, presses its lower extremity forcibly against the side of the chest. This, by forcing the shoulder outwards, draws the clavicle to its original length ; for the humerus being thus made a lever of the first kind, its upper end is drawn from the shoulder, in proportion as the lower end is forced against the thorax. He at the same time, directs its head upwards and backwards, and thus immediately reduces the fracture, an as- sistant holding it so until the next two bandages are applied. These, are intended to keep the fracture reduced. With this view, ^i^- 142. place the commencement of the second roller, in the axilla of the sound side ; carry it across the breast ; over the upper part of the arm of the injured side, and obliquely round the back, to the axilla, whence it started, and continue these turns down the arm to the upper part of the forearm ; drawing them gently at first, and gradu- ally tightening them as they approach the elbow, so as to force it well in- wards. (Fig. 142.) The object of this roller is, to carry the shoulder and head of the humerus outwards, by pressing the elbow inwards. In order now to keep the shoulder upwards and backwards, the third roller is placed in the sound axilla, passed obliquely over the front of the chest to the fracture, where there should be a compress ; over this, and down the back of the arm to the elbow; thence obliquely upwards to the front of the sound axilla ; under this, obliquely upwards over OF THE HEAD AND TRUNK, 197 the back, over the fracture, down the front of the arm to the elbow, and thence obliquely to the Fig. 143. back; then to the sound axilla; under this to its front part, and over the chest and fractured bone, to run the same course, and end by- circulars of the chest, so as to fix the whole. These turns form two triangles, (Fig. 143) one of which is before the breast, the other on the back, and are the only difficult turns to recollect. But when we remember, that starting from the sound axilla, the bandage is to go over the fracture, down the arm to the elbow, and from the elbow always to the axilla, there will be no difficulty in its application. After this, it remains for us to support the fore- arm by a sling, and cover the whole apparatus by the piece of muslin before spoken of, in order to pre- vent the turns of the roller from slipping. The principles upon which this bandage acts, viz., by converting the humerus into a lever of the first kind, carrying its lower extremity forwards, inwards, and upwards, and thus pushing the shoulder back- wards, outwards, and upwards — renders it exceed- ingly well adapted to these fractures. The pad placed in the axilla serves as the fulcrum ; and one of the great advantages of the apparatus is, that it may be readily constructed. The apparatus is liable, however, to some objections; thus, for instance, the compression which it exerts about the chest, renders it ill adapted to females or patients of a delicate constitution ; it is 198 FRACTURES OF THE BONES also very heating in warm weather ; requires* to be taken off and re-applied at least every two or three days, from the circumstance of its becoming easily displaced by the movements of the patient, especially if it is a child ; whilst the pressure on the axillary nerves and blood-vessels, from the too great tightness of the second roller, often causes considerable pain and inconvenience. BOYER'S BANDAGE FOR THE SAME, Is composed of a wedge-shaped pad for the axilla ; a quilted belt of webbing or of linen, about five inches wide, to surround the trunk, and fasten by means of straps and buckles ; a circular band for the arm, of the same materials as the belt, made to lace in front. Four straps are attached, two on each side, near the uniting edges, and four buckles to corre- spond with these, are fastened upon the belt, two before and two behind the FiST' 144. arm. Then the pad being placed in the axilla, and its bands carried one before and the other behind the chest to the opposite shoulder, are tied: and the belt is then passed round the body, be- neath the pad, and a little above the bend of the elbow, in order to buckle posteriorly. Next, the circular band is laced upon the arm, and brought in to the trunk by means of the straps and buckles. While the elbow is thus fixed firmly to the side, the pad tends by its resistance to OF THE HEAD AND TRUNK. 199 push the superior part of the arm outwards, and the elbow may be moved either forwards or back- wards by merely tightening the anterior or posterior straps, so as to carry the shoulder in the opposite directions. This bandage, acting upon the same principles as that of Dessault, is preferable to the latter only from the circumstances of its not being liable to become displaced, and from its causing a more limited com- pression of the chest ; the compression being capable of being regulated by means of the straps and buckles which unite the ends of the belt, better than by the turns of the roller. MAYOR'S HANDKERCHIEF BANDAGE FOR THE SAME, Requires two large handkerchiefs, one folded in triangle, the other in a broad cravat ; a cushion for the axilla ; and a soft pad forthe opposite shoul- Fig. 145. der. After which, the cushion is to be placed in the axilla, and the arm brought against it with the forearm bent ; the doubled edge of the handkerchief, folded tri- angularly, is then made to envelope the elbow by foldingitssummitaround, while the angles support the hand ; the posterior angle being carried up under the axilla and be- hind the back to the op- posite shoulder, upon which a compress is previously placed, when the anterior one is brought up in front to meet the former and tie. 200 FRACTURES OF THE BONES The second handkerchief, in cravat, is to confine the elbow and forearm more securely to the body, by being carried round the waist, and fastened upon the opposite side of the trunk. Mayor modifies this bandage in the following man- ner when intended for fracture of the acromion. After the first handkerchief or sling is applied, some com- presses should be placed upon the injured shoulder, and a few vertical turns of a roller passed round the shoulder and elbow, as in the third roller of Dessault ; after which, the second handkerchief is to be applied as above ; the cushion under the axilla should also be omitted, and a compress substituted, before ap- plying the first handkerchief, between the elbow and side. This mode of treating fracture of the clavicle an- swers very well as a provisional dressing, and better than the ordinary sling ; but where the other means can be obtained, a more perfect cure will certainly be accomplished by them. FOX'S APPARATUS, Is composed of a stuflfed collar ; a small pad ; an elbow-piece ; and a little sling for the forearm. The Collar, is made of a piece of four-inch muslin, sewed together on its sides, stuffed with cotton, and then joined at its ends. The Pad, is wedge-shaped, and like Dessault's, except that it is not so thick or so long ; being merely intended to fill up the space between the upper part of the arm and the side, and yet, leave a space between the elbow and the ribs, to which the former is brought by the action of the sling. Two tapes, attached to its thick end, fasten the pad to the collar. The Elbow-piece, or Sling, is made of strong muslin or brown holland, like half of the sleeve of a coat, and embracing the elbow, mounts half way up the arm, and descends to near the wrist. To its OF THE HEAD AND TRUNK. 201 upper and posterior ends, are attached two pieces of broad tape, long enough to reach across the back to the collar ; and on its lower portion are two loops to receive a tape, for the front. Then place the collar on the sound shoulder;the pad in the injured ax- ^^^- 1^^- ilia, and fix it there by carrying its tapes, one in front of, the other behind the chest, to tie them on the col- lar. Flex the forearm ; place the elbow-piece on it and the arm, and bring the arm against the pad by the action of the sling. Fasten the posterior tape to the collar behind ; and run a tape or band through the loops near the wrist, so as to tie the forearm well up to the collar in front, as in Fig. 146. This will generally reduce the fracture completely, and is all that is required. Observations. — Of all the means recommended for the treatment of fracture of the clavicle, none are more simple, or fulfil better the indications, than this of Dr. George Fox, of Philadelphia. Made in a few minutes of materials nearly always at hand ; reducing the fracture, yet leaving it open to inspection ; light and easy of application ; producing no constriction of the chest, or pressure on the mammae, or on the ax- illary vessels or nerves, it offers advantages that no other means possess ; and Dr. Fox, by its introduc- tion into practice, has caused the perfect cure of very many cases, and saved the patients much unneces- sary suffering and inconvenience. In the Pennsyl- vania Hospital, it is the only means employed for the treatment of this injury, and repeated testimony has 202 FRACTURES OF THE BONES been given of its ability to produce perfect cures ; it being a rare thing for a simple case of this fracture to go out of the house with any deformity, save that which time cures, viz. , the deposition of the provisional callus. From 1829 up to the year 1838, — a period of nine years, — seventy-five cases of fractured clavicle were treated in the house ; of which sixty-three were discharged cured, and twelve left the house while under treatment ; the apparatus allowing of their walking about as usual.* In the subsequent years, a large number of cases have also been treated with such success, that no one who has employed it, ever resorts to any other means of treatment, except in special cases, where an additional bandage, as a pos- terior 8, &c., may be added ; but generally when there is any derangement of the fracture, it is only necessary to tighten the anterior or posterior tapes of the sling, in order to remedy it. The effect produced on the bone by this apparatus, is well shown in the testimony of Dr. Norris, one of the surgeons of the hospital, who, in his notes to Liston's Surgery, says, " he was enabled to treat with entire success, a forward dislocation of the sternal end of the clavicle, after Dessault's bandage had been several times well ap- plied, but without success." The difficulty of retain- ing the bone in its position in this injury, being so much more difficult than in cases of fracture, speaks highly in favour of the powers of the apparatus. FRACTURES OF THE SCAPULA, Are generally accompanied by so much inflamma- tion from the contusion, as to render the removal of this an object of greater importance, than the treat- ment of the fracture itself. Warm fomentations, by means of bags of chamomile flowers, or flannels wrung ♦ Wallace's Statistics of Fracture: Med. Examiner for 1838. OF THE HEAD AND TRUNK. 203 out of hot water, leeches, &c., must therefore be first employed ; after which we may employ the pad, and first and second roller of Dessault, Fox's Apparatus, or the bandage of Velpeau, which, as the author says, is applicable to acromio-clavicular luxations; to frac- tures of the acromion or other points of the scapula ; to fractures of the neck of the humerus, as well as to fractures of the clavicle. But from numerous oppor- tunities that I have had, of witnessing the result of its application to the latter injury, in his own wards, I think it is not as perfect in its cures, as the means before referred to. To the other cases it is well adapted, and is applied as follows : VELPEAU'S BANDAGE. Make the patient embrace the sound shoulder with the hand of the injured side, placing a compress or piece of muslin between the side of the chest and the injured arm, in order to prevent excoriation of the two surfaces, from contact and perspiration. Then place the initial extremity of a roller ten yards long, and two and a-half inches wide, under, or behind the axilla of the sound side, and con duct it over the back over the injured clavi cle ; down on the fron and outside of the arm ; under the outside of the elbow; up and over the chest to the sound axilla. Make two similar turns, and on again reach- ing the axilla, pass cir- cularly around the chest to the same axilla; then make a turn over the 204 FRACTURES OF THE BONES, ETC. clavicle and arm ; then a circular, and so on until it reaches the upper part of the forearm, as seen in Fig. 147. By means of this bandage, especially when wet with starch or dextrine, the arm is supported in a firm cap, which will last for weeks without changing; but where these articles are not used, several pins must be placed at the different turns in order to se- cure them. It will require but the application of this bandage, to prove its power in the accident referred to, and dislocations of the humeral extremity of the clavicle, are so difficult to keep reduced, that the bandage becomes a very valuable addition to our other means of treatment. FRACTURES OF UPPER EXTREMITY. 205 CHAPTER III. OF FRACTURES OF THE UPPER EXTREMITY. FRACTURE OF THE NECK OF THE HUMERUS, Is generally treated by Boyer^s Bandage, which is composed of two rollers, two and a-half inches wide ; — three strong pasteboard splints, between two and three inches broad, and the length of the arm ; — a pad, four inches thick at one end, terminating at the other in a narrow point, and long enough to reach from the axilla to the elbow ; so as to serve as an inside splint, and fulcrum for the reduction of the fracture ; the thick end being in the axilla, if the lower fragment is drawn inwards, and the reverse, if the upper one is thus drawn ; — lastly, a sling to support the forearm. Then, the fracture being reduced, and maintained by assistants, the surgeon fixes the initial extremity of one of the rollers, at the upper part of the wrist by two or three circulars, and winds it round and up the arm, as in the Spiral of the Upper Extremity, until he arrives at the upper part of the limb, where several turns must be made around the fracture so as to bind it firmly, and overcome the action of the muscles. From hence he carries the head of the roller twice round the opposite axilla, and confides it to one of the assistants, who retains it upon the top of the shoulder of the injured side. The first splint being then placed in front, reaches from the bend of the arm, as high as the acromion; the second, on the outside, from the external condyle to the same height ; and the third, from the olecranon behind, to the margin of the axilla. These being given to another assistant to hold, the surgeon then takes the same roller, or a new 206 OF FRACTURES OF THE one, and fixes the splints to the arm, by moderately tight spiral turns, and while the assistants still keep up the extension, he places the cushion between the arm and trunk, taking care to put that end upwards, which the deformity calls for : lastly, bringing the arm against the trunk, he confines it there, by means of the second roller, or turns of the same one applied horizontally around the body. Each turn of this roller should be tighter below and slack above, if the lower fragment be displaced inwards ; but if it is drawn outwards, they should be slack below and tight above, in order to act on the extremities of the lever, formed by the humerus. The forearm is then to be sustained by a sling, which should not go under the elbow, lest it cause shortening of the arm ; but should merely support the hand. FRACTURE OF THE BODY OF THE HUMERUS, Is also most frequently treated by Boyer's Bandage. This requires a single-headed roller, eight or nine yards long, and two and a-half inches wide ; four splints, not quite so long as the arm, nor so broad as to touch each other when applied ; and some charpie or cotton to pad them. The surgeon then commences by applying a spiral of the limb, fixing its initial end by a few circular turns above the wrist, and proceeding as in the spiral bandage of the upper extremity before referred to. He continues the turns of the roller from the elbow to the upper part of the limb, applying it firmly over the seat of the fracture, and filling up the depression about the insertion of the deltoid muscle, in order to make uniform pressure. He next places the splints, well padded, along the arm, on its inside, front, back, and outside, and resuming the roller, covers them in by spiral turns, and fastens the bandage by pins, until the whole is rendered firm ; when the forearm should be fastened across the chest. UPPER EXTREMITY. 207 But if in these fractures this last point be omitted, and the arm and forearm are not well secured to the body ; or if the patient becomes restless ; more or less motion will be produced at the elbow-joint, which will de- range the lower fragment, and by the slipping of the turns of the spiral bandage on the forearm, necessitate its almost daily re-application. THE PLAN OF THE PENNSYLVANIA HOSPITAL, Is, therefore, to dress the case as follows: — After applying a roller from the fingers to the shoulder — place a padded, angular splint, similar to Phy- sick's splint for fracture of the condyle, on the in- side of the arm, extending from the axilla to the ends of the fingers. Place, also, three splints of the length of the humerus, on the front, back, and out- side of the arm, and bind them all to the limb by the ordinary spiral bandage ; commencing at the wrist and extending to the shoulder. During the treat- ment, the angle of the inside splint should be occa- sionally altered, and passive motion made, to guard against stiffness of the elbow-joint. The advantages of this method are, that by pre- venting motion at the elbow-joint, it keeps the lower fragment perfectly at rest, and the arm in a more con- venient position to the patient. It must, however, be recollected that this, like the previous dressing, is only applicable to fractures of the humerus below the insertion of the pectoralis major muscle. FRACTURE OF THE CONDYLE. PHYSICK'S METHOD. The position of the condyles to the elbow-joint, renders the treatment of this fracture a matter of great importance ; as, without proper attention, the inflammation may extend to the joint, produce anchy- losis, and deprive the patient of the use of the limb. When the fracture is simple, the best method of treat- ing it is that proposed by the late Dr. Physick. 208 OF FRACTURES OF THE The forearm being flexed on the arm so as to relax the flexor and extensor muscles, apply a bandage from the fingers up to the shoulder by spiral reversed turns ; making a figure of 8 around the elbow. Then prepare two angular splints like Fig. 148, of the same angle as that which the forearm takes when flexed, and covering them well with cotton, place one on the inside, and the other ^^i' 148. on the outside of the arm, from the shoulder down to the fingers, and confine __.,^ them by another spiral illllllllllllllllllllliillilllllllllllllllllllllllllllllillliliy bandage, exactly like that of the Upper Extremity. The forearm being now brought across the chest, should be placed in a sling, with the palm of the hand next to the front of the chest, and the thumb pointing upwards to the chin. In pursuing this treatment, attention must be paid to the state of the internal condyle, which, unless the splint is well padded, is very apt to ulcerate from the pressure. The angle, also, of the splint should be changed every third day during the treatment, after the first ten days, in order to prevent anything like anchylosis. If the fracture is complicated with contusion of the jomt, or if it should be compound, a better plan will be found in the use of a carved angular splint like Fig. 149, in which the arm may lie, loosely confined by a few strips of Scul- Fig' 149. tet's bandage ; while leeches, cold washes, &c., may be applied to the part, in order to combat the inflamma- tion. Or it may be simply flexed and laid on a pillow, till the swelling isreduced ; and then be treated as a simple fracture. UPPER EXTREMITY. 209 In order to make this carved splint, or in order to make a carved splint for any of the limbs, pur- sue the following plan. Lay the limb on a piece of stiff paper, or soft wood, and mark an outline of its shape with a pencil, tracing accurately its angle, its prominences, &c., by running the pencil over its surface. Then seeing that the w^ood is thick enough to allow the limb to sink into it, to the depth required, scoop it out in the lines of the pencil, and shave off the outside, with a spoke-shaver or gouge, so as to reduce its thickness and make it cor- respond externally and internally with the roundness of the limb. A piece of linen or muslin being then pasted over the outside to prevent its splitting from moisture, and the inside covered in the same way with soft buckskin to prevent the chafing of the skin, it is ready for use. These splints are of great utility in the treatment of all injuries in the neighbourhood of joints, and so simple, that any one of the least mechanical ingenuity can make one that will answer the purpose very well, though the aid of a professed carver is desirable, when a very light and perfect splint is required. Paste- board, tin, &c., are frequently used for the same purpose, but do not form as neat a dressing, and are also liable to be bent out of shape. FRACTURES OP THE FORE-ARM. Fracture of one or both bones of the forearm are dressed exactly in the same way, with the exception of fractures of the lower end of the radius, and of the olecranon, or upper extremity of the ulna. The frac- ture being reduced by means of the extension at the wrist, and counter-extension at the elbow, the muscles should be well kneaded, in order to preserve the interosseous space. Then, according to the plan of the Pennsylvania Hospital, take two straight splints, long enough to extend from the bend of the arm, to be- 14 210 OF FRACTURES OF THE yond the fingers ; half an inch wider than the forearm, and well padded with cotton, which should be con- fined to them by a roller, and thickest on their middle, so as to act as a pyramidal compress on the interos- seous space. Then apply one of these splints on the front, the other on the back of the forearm, whilst it is in a state between supination and pronation, or, in other words, while the bones are perfectly parallel, and confine them there by a roller, only moderately tight at first, so as to guard against swelling. After the lapse of a week, draw the roller more firmly, so as to cause the padding of the splints to act on the interosseous space ; but be careful that it is not too tight, and continue this dressing till the case is cured. The case of amputation of the arm, performed in this Hospital, consequent upon the mal-application of the roller in a simple fracture of the radius, as before mentioned, should caution us against the use of too much traction in the application of the bandage, espe- cially, immediately after the occurrence of the injury. FRACTURE OF THE LOWER END OF THE RADIUS. BARTON'S METHOD. This fracture, often similates a sub-dislocation of the wrist, owing to the falling of the hand, as seen in the cut, and so frequent is it, that eight out of ten Fig. 150. supposed sub-dislocations of the wrist will probably be found to be fractures of this kind. For the best treatment of it, we are indebted to Dr. J. Rhea Bar- ton. His apparatus consists of two compresses, about UPPER EXTREMITY. 211 three inches by two, or else two and a-half inches square, graduated from one end ; — two splints pre- pared as in fracture of both bones of the forearm ; and a two and a-half inch roller. Then, place one of the compresses on the front of the wrist, with its thick end downwards, and about one- eighth of an inch above the articulating end of the radius ; place the other on the back of the wrist, with its thick end upwards, so that it may be on a line with the upper row of the bones of the carpus, or on a line with the end of the first compress, so that one may begin, where the other ends, though on opposite sides of the wrist. Fasten these, by a few turns of a roller loosely ap- plied ; then place the two splints in their position, one on the front, the other on the back of the arm, ex- tending from beyond the fingers up to the elbow, and bind them there by the spiral bandage, as in fracture of both bones. After a few days, the tightness of the bandage may be increased, and motion made to a. slight extent m the joint in order to prevent anchylosis,. If instead of the bulging on the back of the hand, as, generally seen, it should be on its front, we have only to change the relative position of the compresses, and then pursue the same plan. FRACTURE OF THE METAXARPAL BONES, Is generally caused by heavy weights falling on them, and producing such a degree of contusion as to re- quire our closest attention to combat the inflammation. In this case, we should employ a splint carved out to fit the forearm and hand, placing a small mass of cotton under the palm, so as to preserve its concave character, and then allow the limb to be open in the splint, till by leeches, cold washes, &c., we have reduced the inflammation. If, however, the fracture is produced by a fall on the hand, we shall most fre« quently find it in the bone of the little finger, this being one extremity of the arch, formed by the meta- 212 OF FRACTURES OF THE carpal bones, and the one most exposed to the shock in falling. To dress this accident, place a mass of cotton in the hollow of the hand, as before done, and ban- dage the limb to a splint with a broad palmette or hand-piece ; taking care that it extends from the ends of the fingers, up to near the elbow, in order to pre- vent the action of the carpal muscles. FRACTURES OF THE PHALANGES, If simple, should be first covered in with a spiral bandage of the finger, and then kept in their position by means of four small splints of binder's board ; those on the front and back of the finger, reaching from its extremity, as high as the wrist, but the two lateral ones, extending only the length of the finger. All these should be padded with cotton, and confined by a second spiral of the fingers, the roller in each case being under an inch in width. Attention should also be especially given to the state of the joints in these fractures, and passive motion be early made ; a stiff finger being a serious inconvenience. FRACTURE OF THE OLECRANON. In this injury the upper fragment is drawn up by the action of the triceps muscle. All the means of treatment have therefore the same object, viz., the bringing it down, or the placing of the two fragments as closely in contact as possible, in order to diminish the amount of ligamentous union. When from ex- coriation, or other accidents, one method is not avail- able, another may be substituted, as all have some points which recommend them to particular cases. SIR ASTLEY COOPER'S APPARATUS, Is composed of two strips of muslin, or tape, each about half a yard long ; — two short rollers, and another roller of the ordinary length, and a light UPPER EXTREMITY. 213 Fig. Ibl. splint made sufficiently long to extend from the margin of the axilla about half way- down the forearm. Then, the pa- tient's forearm being extended, and the upper fragment pressed down until it touches the body of the ulna, a strip of linen should be ap- plied above and below the joint, and one of the short rollers passed round the limb above, and the other below the olecranon, to secure them, as at b h. The extremities of each tape being reflected and tied together, as at a, draw the rollers nearer to each other, and place the upper fragment of the olecranon in the closest apposition possible, to the lower. Lastly, the split splint, c, well padded, is applied along the front of the arm, and secured by a bandage, d d, which is to be fre- quently wetted with an evaporating lotion ; care being taken in setting the fracture, that the intesjuments are not pinched between the frag- ments, as this would prevent their union. DESSAULT'S, APPARATUS FOR THE SAME, Consists of a strong pasteboard splint, long enough to cover a part of the arm and forearm, and shaped so as to accommodate itself to the bend of the elbow, when the arm is in a demiflexed position ; — a roller five or six yards long, and two and a-half inches wide, — and some compresses or lint. Then whilst the limb is maintained by two assistants in demiflexion, the surgeon proceeds to cover in the hand and fore- arm with the roller ; as he approaches the elbow an assistant draws the skin, which is here usually wrin- kled, gently upward, to prevent it being caught be- 214 OF FRACTURES OF THE tween the fragments, and the surgeon pushes down the fractured extremity of the olecranon, in order to place it in contact with the body of the ulna. He now confines it in this situation, by means of a few turns of the roller, carried round the joint in form of a figure of 8, as in the bandage for phlebotomy ; and the elbow being at length covered, carries the roller spirally as far as the axilla, in order to compress the triceps, and prevent its action on the upper fragment. The carved splint being then well padded with the lint or compresses, is applied along the front of the arm and forearm, and fixed by a succession of oblique turns of the remainder of the roller, carried down to the wrist. THE HOSPITAL APPARATUS. At the Pennsylvania Hospital, the apparatus con- sists of two, two and a-half inch rollers ; a splint to extend from the middle of the arm to below the mid- dle of the forearm, and of the width of the arm ; and of some cotton or tow, to fill up the hollow at the bend of the arm. The forearm being then extended on the arm, and the upper fragment brought down, and held by an assistant, apply the ordinary Spiral of the Upper Ex- tremity from the fingers up to the shoulder, making figure of 8 turns around the elbow so as to keep the fragments in apposition, and applying it firmly around the arm, to prevent the action of the muscle. Then apply the tow to the bend of the arm, and bind the padded splint on its front by a second spiral bandage. After ten or twelve days, a slight degree of flexion is made at the elbow and gradually increased to prevent stiffness, the fracture being maintained in its position by the fingers of the surgeon during this movement. BOYER'S METHOD. According to this surgeon, the indications are to UPPER EXTREMITY. 215 keep the fragments as closely as possible in apposi- tion, without uselessly fatiguing the muscles by com- plete and constant extension of the forearm ; and also by rest, to favour the formation of the ligamentous substance, without allowing the joint to become stiff. In order to do this, he advises that the forearm should be slightly flexed on the arm, so as to make an obtuse angle with it, and then an ordinary spiral bandage applied from the fingers to the elbow. The fragment being now drawn down, a narrow strip, or long compress, is placed behind it, and fastened by crossing its ends in a figure of 8 around the forearm ; after which, the bandage is continued over it in the form of several figures of 8, and then carried by spiral turns up to the shoulder, so as to compress the triceps. To guard against anchylosis, motion should be made at the joint about the twentieth day, and at the forty- fifth, the cure is usually complete ; the union being then quite firm, and, as he says, as solid as it ever will be. Should there be much swelling or pain, he advises that the bandage should not be applied, or the reduction of the fracture attempted, but the limb be simply placed on a pillow, and the inflammation treated by local means. If it does not disappear by the twentieth day, the case may be left to nature ; a number of in- stances, which he reports, having shown, that even when thus left, it will gain as much strength and freedom of movement, as when confined more closely. THE CARPO-OLECRANIEN HANDKERCHIEF OF M. MAYOR, Has been already mentioned. It will answer very well, in many cases, as a provisional dressing. THE UNITING BANDAGE OF GERDY, For transverse wounds, and for fractured patella, is also applicable here, but as its use is more frequent in the patella than elsewhere, we shall reserve its description until we treat of that accident. 216 OF FRACTURES OF, ETC. When the fracture of.the olecranon is compound, or complicated with severe contusion, the effect of the inflammation on the joint renders its treatment the most important indication, and it will be better, there- fore, to place the limb in the carved angular splint before spoken of, and confine it by a few strips of Scultet's bandage, employing leeches, cold washes, &c., as in compound fractures of the condyles of the humerus, than to use either of the dressings just men- tioned. FRACTURE OF THE CORONOID PROCESS OF THE ULNA, Resembles a dislocation of the bones of the forearm backwards. By pulling the forearm, and at the same time flexing it, the dislocation is easily reduced, but returns again immediately on the force being re- moved. Jn order to prevent this, flex the forearm on the arm, as in fracture of the condyles, and bind- ing a padded angular splint along its inside, keep it flexed for several weeks ; the action of the brachialis internus, which is liable to reproductive deformity being prevented by the turns at the elbow. This accident is, however, a very rare one. Dr. Physick having seen but one case which he thus treated, and Sir A. Cooper, and Mr. Liston having, also, seen but one or two instances of it. OF FRACTURES, ETC. 217 CHAPTER IV. OF FRACTURES OF THE LOWER EXTREMITY. In few cases requiring surgical attention, has there been as many proposed plans of treatment, as in the fractures of which we are about to treat. Almost every year, and from every section of the country, we have accounts of some new modification, or some de- cided improvement in their apparatus, which, in the opinion of the in^^entor, and from the decided testi- mony of one or two^p«^fectly cured cases, must sup- plant everything heretofore known ; when, perhaps, the great and improved modification, consists only in the substitution of narrow strips for broad bands, or in the difference of a buckle, or the peculiar shape of a hinge. To refer, then, to all these, would be as useless as uninteresting ; and we shall, therefore, pre- sent only the more original plans, premising a few remarks on the duties of the surgeon in the prepara- tion of the means requisite for their treatment gene- rally. When called to a fracture, or even a supposed frac- ture of the lower extremity, our first duty should be to consider in what way the patient may be most readily moved, and prepared for his dressing, and then how that dressing is to be obtained. First. How are we to prepare for the removal and dressing of the patient '^ In cases of this kind, a shutter, door, frame, or settee, is usually selected, on which the patient is placed encumbered with his ordinary dress, and as we know that for the proper treatment of his case, per- fect repose of the limb is absolutely essential, our thoughts, naturally turn, to his place of rest during the 218 OF FRACTURES OF THE treatment, and to the selection of the bedstead and bed. The first will be readily found in the ordinary bed- stead, provided it is low and narrow ; with a low head- board ; without afoot-board ; and made into what is cal- led a Fracture Bed. This is prepared by first draw- ing the sacking-bottom as tightly and drum-like as possible ; or if slats can be had, by placing them in their position, and cutting in the centre of either, a hole large enough to admit a pot ; nailing on the underside of the bedstead, at a distance to correspond with the width of the pot, two strips, grooved or ploughed like the strips in which an ordinary coun- ter-draw runs, so that they may receive the rim of the pot, and allow of its sliding in and out under the patient. If a number of these bedsteads are required, as in a hospital, it will be found most useful and cleanly, to have them made of iron, as they are more readily preserved from bugs, &c. After the bedstead, we should prepare a hair, or firm and even mattress to fit it, by cutting out a piece to correspond with the hole in the frame, and sewing the cut edges of the ticking together; thestuffingbeing so arranged that the edges of the hole may not be hard or knotted. We then place over this, a sheet with a similar hole in its centre, and arrange on it, the preliminary portions of the apparatus to be used ; after which we may turn our attention to the patient. Having carefully removed his clothes, &c., we should prepare to remove him to the bed. To do this pro- perly, see that the open side of the settee corresponds with the side of the bed, and the head of the patient with its head, especially if the room is narrow ; other- wise we may be compelled to carry the settee out of the chamber, and perhaps down stairs, in order to turn it, as we haveoccasionallyseen done, at the expense of much unnecessary pain and trouble. We next procure three assistants, and having informed them of their duties, place one at each shoulder of the patient, so as to LOWER EXTREMITY. 219 face each other, and the third at the limb on the sound side, while the surgeon himself takes charge of the injured limb, and directs the assistants at the shoulders to pass one of their arms under the pa- tient's neck and shoulders. Then let them slide the other hand under his buttock, so as to clasp each other's fingers in what is known as the sailor's grip, or, in other words, grasp hands, by making the pal- mar side of their fingers touch. The third assistant, holding the sound limb, the surgeon places one hand under the seat of fracture, the other under the calf, if in the femur, and at the word to move, directs the assistants to lift and carry the patient down to the foot of the settee, so as to get free from it, and then passing, one on each side of the narrow bedstead, to place their burthen so that the lower part of the buttocks may correspond with the upper edge of the hole in the mattress, when the dressings may be readily applied. If instead of a fractured thigh, it is a fractured leg, the arrangements should be the same, except that the surgeon should grasp the leg with both hands, one being at the knee, and the other just below the seat of the fracture, or at the ankle. These directions, though minute, are absolutely necessary to prevent the suffering of the patient, and the awkwardness produced by want of attenton to them ; assistants or inconsiderate surgeons being very apt so to place themselves, that on moving the pa- tient, they come directly between the bed and the patient, thus necessitating their lying down, or crawl- ing across the bed in order to get out of the way. Where it is found difficult to prepare the bed as thus directed, a very excellent and simple substitute will be found in a frame made of sacking or strong cloth, nailed on two narrow strips several inches longer than the bed, and joined by two transverse ones, a little wider than the bed. 220 OF FRACTURES OF, ETC. Fi^: 152. This being placed on an ordinary firm mattress, and a sheet, with a central hole placed over it, the pa- tient will lie as on an ordinary bed till he requires a stool, when assist- ants at the head and foot of the bed, may raise the frame like an ordinary hand-barrow, and by placing its ends (Fig. 152)onfour heavy chairs, readily air the bed, or even remove it, and of course can aJso easily pass a pan under the frame to receive the discharges. Having now completed these ar- rangements, we should proceed to the Preparation and application of the apparatus. This will, of course, depend on the injury. In fracture of the femur below the neck, the extended posi- tion, as recommended by the French surgeons, is almost the only one em- ployed, as far as we know in the United States ; the apparatus of Dessault, as modified by Drs. Phy sick and Hutchinson ; the apparatus of Boyer, modified by Hartshorne; or that of Hagerdon, modified by Prof. Gibson, being almost the only ones employed, though we occasionally see the plan of Amesbury, and of Prof. Nathan R. Smith, in use, in special cases. FRACTURES OF THE FEMUR. 221 CHAPTER V. OF FRACTURES OF THE FEMUR. IN FRACTURES OF THE NECK OF THE FEMUR, Within the capsule, especially in old persons, as the union will generally be ligamentous, it is sufficient to bend the limb on itself, on a double-inclined plane, Fig. 153. such as that of Sir Charles Bell, (Fig. 153,) Ames- bury, &c., or to use the method of Dupuytren, in which a double-inclined plane is formed by cushions of different sizes, covered by a common sheet. DUPUYTREN'S PLANE, Is made by three or four cushions, decreasing in size from below upwards, being placed under the ham ; and the rest so disposed as to form a double-inclined plane. On the upper portion of this, the thigh is 222 FRACTURES OF THE FEMUR. made to repose, while the leg, in a state of flexion, rests upon the lower ; the limb being maintained in this position by means of a sheet folded like a cravat, the central part of which embraces the foot, while the extremities are attached to the sides of the bed. Simple, however, as this is, the plan frequently pursued by surgeons in this country is more so, and answers equally as well. This consists in doubling an ordinary pillow on itself, and placing it under the ham and leg ; thus making a plane of the simplest kind, and giving, by the addition of a band to fix the foot, all that is requisite for the treatment of this injury. But in fractures of the shaft of the bone, the ex- tended position being, as before stated, preferable to the bent one, the treatment is very different. Here, owing to the shortening produced by the muscles, we must employ some means of making extension and counter-extension, as it is usually termed ; though in reality, the means of extension should always be the hands of the surgeon, and the bands be used only to preserve the extension when he has made it. To keep up this extension, various bands have been employed; but it matters little of what they are made, provided they are flexible, soft, and porous, especially the latter, so as not to unduly promote the insensible perspiration, and thus favour excoriation. But as these qualities are seldom found united, most of the means of preserving extension are made of two substances, the best of which are brown holland linen, and buckskin. These may be employed either as in the band of Drs. Coates and others, or in the gaiter of Dr. Physick, which is a modification of that of Petit. DR. COATE'S BAND FOR PRESERVING EXTENSION, Is made of a piece of brown holland, slightly biassed, but leaving the central threads continuous throughout, from fifteen to eighteen inches long, if FRACTURES OF THE FEMUR. 223 designed for an adult; two inches wide in the middle and narrowing on each side, rapidly at first, then slowly, towards the extremities, which are an inch in width. This should be lined, throughout nearly its Fig: 154. whole length with thick buckskin, a very little wider than the linen, the latter being simply basted to the former, by stitches which dip but half way through the skin, in order that they may not produce irritation. Two pieces of tape, or webbing, each an inch wide, are then sewed securely to the ends of this band, so as to make it long enough to go over the lower end of the splint to which it is to be fastened. In applying this, place the centre of it over the tendo-Achillis, and bring the ends round above the malleoli, to the front of the ankle ; cross them on the top of the instep, and carrying them, down, knot them beneath the instep a short distance from the sole of the foot; when the tapes may be carried over the end of the splint, and tied. Where this band cannot be readily obtained, a common silk or Madras handkerchief, folded into a similar shape and applied like this band, answers quite as well. But in some cases, owing to the irri- tability of the patient, and the extension being made by the band, instead of by the hands of the surgeon, or owing to a want of attention to the smoothness of the band, or extreme tenderness in the skin of the patient, excoriations will happen. It is desirable, therefore, to be able, by changing the means of pre- serving extension, to bring the pressure to bear on different points, and we may then resort to 224 FRACTURES OF THE FEMUR. PHYSICK'S GAITER. This is made of buckskin and kid, of cloth and buck- skin, or hollands and buckskin; but in either case, the buckskin should go next to the skin, as it is the softest, most porous, and flexible of all these Fiff. 155. substances. Cut out of either of these substances, two pieces of the shape of the figure, and make it eleven or twelve inches long at its greatest length, and eight inches at its least, for an adult, and about four inches in its other diameter. Work eye-let holes in the ends, to receive the cord w^hich laces it to the ankle, and sew a piece of buckskin on the inside of one end, so that it may come under the lacing when the gaiter is applied, and thus prevent the cord from pressing on the skin. Lastly, sew on two broad tapes or bands, of about three-fourths of a yard long, in order to pass to the end of the splint. In applying it, place a layer of carded cotton on the surface which is to be next the skin, and lace the gaiter smoothly round the ankle, from an inch above the malleoli, down on to the front of the instep. If the use of this causes pain, we should at once look to it, and if a slight change in its arrangement does not relieve it, rub the heel with whiskey or some slightly stimulating liniment. But should it produce excoriation, we must then resort to some other band, such as the Handkerchief of Dr. Barton, (Fig. 128) before treated of, and with these means of preserving extension, we shall probably have all that is neces- sary. Let us now look to the means of counteracting them, or the means of preserving counter extension. The padded band of Dessault, or Boyer, the bandage doubled several times on its length, or the use of a thick cravat, may all be objected to, as frequently FRACTURES OF THE FEMUR. 225 causing excoriation of the part, and we shall there- fore, confine ourselves to the consideration of Coatees Perineal Band, which is decidedly the most perfect means that we know. COATE'S PERINEAL BAND, Is made of a piece of brown holland, long enough to go round the perineum, in the line of the groin, and reach above the crista ilii both before and behind. For an adult, it should be three or four inches wide. Double this in its width, and sew the edges firmly together, leaving one end open and closing the other; then turn it inside out like a bag, and pour in bran or chaff, sufficient to fill it lightly; then quilt one-third of the closed extremity so as to flatten it to the thick- ness of half an inch, and pour in a little more bran, stuffing it firmly, till the central third is quite round and firm ; after which, closing the open end, quilt the Fi^. 156. terminal one as before, attaching to each end, two broad tapes, three-fourths of a yard long. Next, take a piece of soft buckskin about three inches and a-half wide, and about half as long as the band ; double it, and stitch the edges together in order to form a tube with the ends open, so that when the band is about to be applied, it may be slipped over and cover that part of it, which is to press on the pubis, perineum, and tuberosity of the ischium ; then the seam being turned aside from these parts, secure it firmly to the band by a few stitches. When soiled, the buckskin may be easily changed, without requiring a new band. This piece is a great improvement to the ordinary band ; and, 226 FRACTURES OF THE FEMUR. according to the experience of the inventor, and from what we have ourselves seen, seldom or never pro- duces irritation. The Junct-Bags, or the stuffed cushions, are intended to prevent the pres- Fig-. 157. sure of the splints against the sides of the limb. These are made of muslin of the length of the limb ; or rather, long enough to ex- tend on its outside, from the pelvis to the external malleolus, and on its inside, from the perineum, to a point a little above the internal one. One end of this being sewed up, is then filled with bran or chaff till moderately full, and the open end being likewise closed, it forms a cushion of the width of the splint, and like Figure 157. In connection with this subject, and before describing what remains of the apparatus for fractures of the femur, let us glance at the remarks of Dr. Coates, in relation to the delay attending our preparations, as they contain points of much practical importance to the young surgeon. " There is scarcely ever," says he, " a necessity for rapid action in a case of fractured leg or thigh. But as it would be wrong to allow the patient to undergo the gradual shortening of the limb from con- tinual muscular action, while the surgeon rides off for his splints, or while he superintends their preparation in the shop of some carpenter who never saw what he is required to make : let him secure the limb by temporary means, and thus save his patient the exqui- FRACTURES OF THE FEMUR. 227 site pain of involuntary motions ; the irritation from the pressure of the fragments upon lacerated muscles ; and the increased force required to overcome their contraction. Place the patient, therefore, on the bed diagonally, and with extending and counter-extending bands,made of towels, handkerchiefs, &c., employ one head-post, and the opposite foot-post, for securing him. After which, the surgeon can proceed cooly and leisurely for his apparatus; certain that his patient suffers but little, and that scarce anything is lost by delay." THE SPLINT CLOTH, Is a piece of muslin, a yard and a-half long, one yard wide, and intended to keep the splints together, by being wrapt around them so as to form a kind of box for the limb. SCULTET'S BANDAGE, Which is also sometimes necessary, is made of strips of muslin about three inches wide, and of a length gra- Fig. 158. dually decreasing from the first strip. This, should be long enough to go once and a-third round the 228 FRACTURES OF THE FEMUR. upper part of the limb, and each succeeding strip one inch shorter. To prepare and apply these, lay them down on a pillow or board, for subsequent convenience, so that the whole may readily be placed under the limb without being deranged ; placing each strip so that it shall cover only one-third of the preceding one. Then placing the limb on these obliquely in regard to their length, in order to favour their application, commence at the lowest part of the limb, and gradually ascend, drawing each strip moderately tight (Fig. 158). When it is neces- sary to change one or more of the strips, undo the bandage, and attaching the fresh band to the soiled one, draw the latter out, and thus place the fresh one in its place without deranging the limb. THE EIGHTEEN TAILED BANDAGE, Consists of a strip, three inches wide, and as long as the limb, to which are stitched crosswise, eighteen or more strips of an equal width, and sufficiently long to make a turn and a-half about the part, and cover in each other by about two-thirds ; each having a slight degree of obliquity, relative to the longitudinal piece. It was formerly applied like the bandage of Scultet, but has been supplanted by it, as its strips could not be changed, owing to their attachment to the centre piece. The Splints for fractured femur, differ in their form. Those of Dessault, consist of one for the outside of the limb, long enough to reach from the spine of the ilium, to four inches beyond the foot; and of another, extending from the perineum to the sole of the foot; both of them of the width of the limb. In the upper part of the outside one, are holes to receive the counter-extending band, and at its lower end one hole for the extending band. To these were added a splint in front of the thigh ; junct-bags; Scultet's bandage ; &c., as shown in Fig. 159. FRACTURES OF THE FEMUR. 229 Being liable, to the objection of not preventing Fig. 159. lateral inclination of the pelvis, they are now but seldom used, except by the French surgeons. DR. PHYSICK'S SPLINTS, Are like these, except in the addition made to the length of the outer one, by which its end went nearly to the axilla ; thus making the counter-extension more in the line of the body, and preventing any inclination of the body to that side ; whilst the addition of a block, by Dr. Hutchinson, made the direction of the extending band also more in the line of the limb. To these were added the means of extension, counter-extension, Scultet's bandage, &c., before spoken of. With slight modifications, this is the apparatus now employed in the Pennsylvania Hos- pital, and, as the experience of the large number of cases there treated, proves it to be all that is requisite for simple fracture of the shaft of .the bone, we can safely recommend it, as the most simple of our means of treatment In its application, having arranged the patient, the bed, and the apparatus, as before shown, place the patient on the fracture-bed, with his buttocks corresponding to the hole, and put the counter-extend- ing band of Coates, in the groin of the injured side. Then roll the splints in the splint-cloth, on the floor, so that the splints may be of the proper distance apart, and give them to an assistant. The means of 230 FRACTURES OF THE FEMUR. preserving extension being now placed on the foot, seize the limb above the ankle with both hands, and draw it gradually and steadily down (whilst an assist- ant, makes counter-extension by the perineal band) till the limb is nearly the length of the sound one, or till the spasmodic contraction of the muscles is overcome. This may require five or twenty minutes ; after which the splints and splint-cloth should be slid under and up the sides of the limb, by other assistants. The splints now lying flat on the bed, place the junct-bags on them ; and their stufl'ing being made to correspond with the prominences and depressions of the limb, press the outer splint to its side, against the junct- bag, and tie the counter-extending tapes through the holes at its upper part. Then the extending tapes being passed over the block, and one of them through the hole at the lower end of the outer splint, both are to be tied on the extremity of the splint, so as to secure the extension gained by the hands of the surgeon ; he keeping up this extension, till the bands are fixed and the outer splint in its place. The junct-bag being then arranged on the inner splint, and it turned against the side of the limb, pass three pieces of roller under the hollow of the knee and slide them up and down the limb,to their position, tieing them on the side of the splints. Looking now to see that the patient's body is perfectly straight in regard to his limbs, which may be told by seeing that the two anterior superior spinous processes are on the same level, measure from them to the internal malleolus of each limb, to see what is the difference in their lengths. Then placing a hoop, bent as in Figure 160, over the toes, to keep off the weight of the bed-clothes, the dressing is completed. If, after two or three days, or even ten days, we find there is still shortening of the limb, make the extension with the hands as before, and thus daily drawing on the limb, pull it down and tighten the bands, till it is of the same length, or as FRACTURES OF THE FEMUR. 231 much so as possible ; a difference of an eighth of an inch, not being perceptible in the gait of the patient. Fig. 160. Generally the reduction is completed at the second visit ; but we caution the young surgeon against believ- ing that the fractured femur will in all cases, or in the majority of them, be perfectly of the length of the sound one. In favourable cases the difference will scarcely be perceptible ; but if attention is not paid to the position of the spinous processes, we may rea- dily deceive ourselves, and prove the limb as long, or even longer than the sound one ; a point of which some have boasted when speaking of the success of their treatment. If excoriation of the heel is likely to occur, the placing of a piece of kid spread with soap cerate on the part affected, or the substitution of some other means of preserving extension, so as to vary the point of pressure of the band, should be resorted to. In this meihod, it is seen that the bandage of Scultetus, and other bandages, or short splints on the front or back of the thigh, are dispensed with ; no advantage being derived from their use in the ma- jority of cases ; whilst we can, owing to their absence, examine the state of the fracture ; apply cold washes to combat any inflammatory action, and yet not de- range the limb by their application. BARON BOYER'S APPARATUS, Is composed of a splint, of particular construction, for extending the limb ; a foot-board ; a padded belt 232 FRACTURES OF THE FEMUR. or perineal band, which is buckled round the upper part of the thigh ; two common flat splints of the length of the limb, one for the anterior and the other for the internal part of the thigh ; and some junct- bags, tapes, and wadding. The outside splint is about four feet long, and three inches wide. Along half its length runs a groove, about half an inch broad, the extremity of which is covered with iron ; to this groove a screw is adapted, which occupies its whole length, one end of it being supported against the plate of iron covering the ex- tremity of the groove, and the other, made to fit a handle by means of which it can be screwed up. On the inside of this splint, a contrivance for holding up the foot-pieceisfastenedtothe screw, and the upper part of the splint is received in a sort of pouch or bag, adapted to the external side of the perineal or thigh belt. The sole-piece, or foot-board, which has two branches at its inferior part, to steady it when resting on the bed, is made of iron, and covered with soft leather. This is connected by means of a mechani- cal contrivance, as just mentioned, with the screw. To that part of the sole which is near the heel, is attached a broad piece of soft leather, which being split on each side into two straps, serves for fixing the sole to the foot. The perineal band is of strong leather, covered with buckskin, and well stuffed with wool ; near the place where its two ends are buckled together on the limb, a little leather pocket is sewed, for receiving the upper end of the external splint. The patient being then properly disposed upon the bed, a splint-cloth is passed under the limb, and laid upon five tapes. In the next place, the perineal band is applied, the surgeon having previously surrounded the upper part of the limb obliquely with a cushion of wadding, four fin- gers' breadth wide, and the length of the thigh-belt, or with the junct-bag, in order to moderate the pres- FRACTURES OF THE FEMUR. 233 sure of the latter, and render it more supportable. The hollows of the sole of the foot and lower part of the leg are also filled up with wadding or tow, and the Fi^. 161. foot-piece, is fastened to the former, by means of the soft leather straps attached to its under surface, which pass round the lower part of the leg. Should, how- ever, these straps appear insufficient to fix the iron sole firmly to the foot, an extra band of calico or linen may be applied in the same manner. Fig. 161. That done, the surgeon proceeds to the reduction of the fracture, and after adapting the upper extre- mity of the splint to the pouch of the perineal band, the foot-support being connected with the splint, and the cushions, and the anterior and internal splints applied, the whole is fixed by means of the tapes, as in the ordinary apparatus for fractures of the thigh. Lastly, by turning the winch, the iron sole is lowered, drawing the foot, to which it is attached, along with it ; and the superior extremity of the splint is pushed upward, and the member elongated to the necessary extent. DR. HARTSHORNE'S SPLINTS. These are generally spoken of as modifications of Boyer's, but differ so much from them as to be almost entirely new. They are composed of an outer splint, long enough to reach from four inches below the heel, nearly to the axilla ; and of an inner splint which 234 FRACTURES OF THE FEMUR. goes from the same point, up to the perineum. In the lower extremity of each of these is a long mor- tise, in which the foot-board slides, or is moved by the screw. The upper end of the inner splint is covered with a pad of horse-hair, which is again covered by Fi^. 162. Illlllllllllllllllllllllllllllllllll!l!l!ll! "iiifllllll|i|||l|i||ff ggillll buckskin. (Fig. 162.) An ordinary gaiter and a hand- kerchief complete it. In its application, fix the gaiter or band on the foot, and pass the splints on each side of the limb till the inner or padded one touches the perineum. Then attach the tapes of the gaiter to the upper block or foot-board, and by turning the screw, draw it down ; the limb following this movement till the perineum bears on the pad, when it is stopped, and the counter-extension made by means of the pad- ded end of the inner splint. Junct-bags may be placed between the splints and the limb if they press too much against it, but gene- rally this is not the case, and in cases of compound fracture, where they would be soiled by the discharges, it is desirable to omit them. It is chiefly we think, in cases of this kind, that these splints can be used to the greatest advantage, as the extension and counter- extension being kept up chiefly on the inner side, we can remove the outer splint and dress the wound, without taking the extension off from the limb. Care, must however, be observed in the use of this splint, that the pressure upon the integuments of the peri- neum, does not produce a slough. FRACTURES OF THE FEMUR. 235 AMESBURY'S APPARATUS FOR FRACTURES OF THE MIDDLE AND LOWER THIRD OF THE FEMUR, Is divided into three portions, independent of splints and straps ; one is for the thigh, a, Fig. 163 ; another for the leg, h ; and the third for the foot, c. There are two thigh-pieces made to each apparatus, one of Fig. 1G3. which is bevelled off at the lower end to the right, and the other to the left ; so that when one of them is fixed to the leg-piece, w^hich is hollowed out to receive the back of the leg, the leg and thigh-piece together, are adapted to the natural line of the right limb ; and when the other thigh-piece is joined to the leg-piece, they are adapted to the natural line of the left limb. This arrangement Mr. Amesbury con- siders necessary, in order to preserve the figure of a perfectly formed limb, which is not straight, but turns inwards a little at the knee. The leg and thigh portions are connected by means of a little steel or brass pin, d. Behind the apparatus is a steel bar, e, coated with brass, and fixed to the back of the leg- piece. To the upper end of this bar is fixed, what Mr. Amesbury calls a brass foot, to which is attached a bolt acted upon by a spring. There is a hole in the centre of this brass foot, which is traversed by the bolt in the transverse direction. At the back of each thigh- piece is a rack, g^ Fig. 164, with several projec- tions, each having a hole bored through the middle, for the purpose of receiving the bolt attached to the 236 FRACTURES OF THE FEMUR. brass foot-piece. The foot-piece is so connected with the steel bar, that it may be easily fixed upon any of these projections. When fixed upon either [ • ' Fig-. 164. /r^E^^ -/ S ^l i< of these, except that nearest the leg-piece, the leg and thigh-pieces become joined together, so as to form a double-inclined plane (see Fig. 163) ; the angle of which may be varied at pleasure, by altering the position of the brass foot-piece from one of the teeth or projections of the rack, to another. At the upper end of the thigh-piece, is a sliding brass plate, h, Fig. 164, so adapted that it may be applied to either of the thigh-pieces at pleasure. This contrivance allows of the thigh part of the apparatus being adapted to thighs of various lengths. The upper end of this plate is turned off, so that, when it is properly padded, it may bear against the tuberosity of the ischium, without in- juring the integuments. At the back of the sliding plate, are placed a couple of brass bars, i i, which answer the double purpose of rendering the sliding plate more secure when it is fixed upon the thigh- piece, and of preventing the pelvis-strap, to be no- ticed presently, from slipping off the apparatus. There are little studs, I, placed at the back of the apparatus, for the purpose of receiving the straps by which it is confined to the limb. The pelvis-strap is of leather, furnished with a sliding pad, and sufficiently long to reach round the thigh, and the pelvis. Three short splints long enough to reach from the upper end of the thigh to the lower part of the con- dyles of the femur, are also required to be placed upon the thigh. FRACTURES OF THE FEMUR 237 Application. — The apparatus and splints being properly padded, the surgeon places the pelvis-strap between the bars and the plate or sliding portion ; taking care previously, to apply a single-headed roller, Fig. 165. d^ as in the cut, spirally about the leg, from the toes to the knee. This being done, an assistant takes the small of the leg in one hand ; places the other under the knee to raise the limb, and at the same time to keep the knee bent and the thigh extended, while the sur- geon placesthe apparatus under it. When the limb is properly placed, the shoe, «, (Fig. 165,) previously padded in the inside, is buckled, to the foot, while the foot-board, 6, and leg-piece, are placed at nearly right angles : in order to give the foot support, and steadiness. The leg is then supported along the whole of its under surface in order to give it an equal bearing upon every point of the apparatus, and this is done by means of tow or wadding, c, placed under the small of the leg, between the long pad and the leg-piece. The leg is then fixed upon the apparatus by a roller carried spirally round both from the angle to the bend of the knee, or by straps properly padded. To confine the fractured parts in their natural posi- tion, the assistant takes the apparatus and the knee between his hands, and extends the thigh gradually, in a line with the thigh part of the apparatus, which the surgeon supports against the back of the 238 FRACTURES OF THE FEMUR. limb. Then after coaptating the fragments of the bone, he applies the splints ; the first, e, on the outer side of the thigh, from the great trochanter to the lower part of the outer condyle ; the second, on its inner side, reaching from the pubes to the lower part of the inner condyle ; and the third, /, upon the fore-part of the thigh, from a little below the superior anterior spinous process of the ilium, to the base of the patella. These splints are kept in place by the straps, g g g, fixed to the studs on the back part of the apparatus. Lastly, the pelvis-strap, h, is to be carried round the limb, under the strips of leather of the splints, and made to cross on the outer side, while the buckle-end, with the sliding pad, is carried round the pelvis and made to meet the other end in front, where it should be fastened. The tapes, i i, serve for fixing the lower part of the apparatus to the foot of the bed. This and others of Mr. Ames- bury's apparatus, are thought by him to offer peculiar advantages, and as he has written two large octavo volumes on the subject of fractures, we would refer those desirous of learning his views more fully, to the work itself. GIBSON'S MODIFICATION OF HAGERDON, Consists in two splints half an inch thick, formed at the upper extremity like the head of a crutch; five inches wide just below this head ; five feet and a half long for an adult, and tapering towards the lower end, which is about two inches wide. These lower ends for the extent of a foot, are straight, and have six or eight holes at equal distances, large enough to receive a stout peg intended to secure the foot-board. Shoulders are made in the splint just above the last peg-hole, to prevent the foot-board from ascending. The foot-board itself is made of seasoned, tough wood, an inch thick, twelve inches long, and nine wide. In this are three rows of slits half an inch wide, and an inch and a-half long, intended for the straps of FRACTURES OF THE FEMUR. 239 the gaiters which are to secure the feet to the board. Two other slits receive the ends of the splints, thus making eleven perforations in the foot-board. The Fig. 166. gaiters are like Physick's gaiter, with two additional straps ; so that there are two near the instep and two near the heel, long enough to pass through the foot- board, and tie on its back. In its application, the bed being prepared, as be- fore mentioned, and the patient placed straightly on it, the gaiters are applied to both feet, and the frac- ture set. The splints with junct-bags, or else the splints themselves padded, are then applied and the sound limb bandaged all the way up to one splint, and the foot-board fastened to both of them. The feet being then protected by two small cushions beneath them, are to be secured to the foot-board by passing the straps through the holes and tying them on the outside ; afterwhich,both splints are to be secured to the patients body by four or five pieces of bandage (Fig. 166.) In this apparatus both limbs are confined, and the counter-extension is made at the acetabulum of the sound side, by means of the sound limb. Conse- quently, we must guard against any bending of the sound knee ; as that would at once do away with the use of this limb as a splint, and permit short- ening. A very simple apparatus of the same surgeon, espe- 240 FRACTURES OF THE FEMUR. cially adapted to the treatment of fractures of both thighs, is to be found in the following plan. GIBSON'S SIMPLE INCLINED PLANE, Is composed of a board sixteen inches wide, two feetfour incheshigh, and with six mortises near itsupper extremity, which is placed vertically ; whilst another board of similar breadth and length, is placed horizon- tally ; a third, three feet long, and extending from the Fl^. 167. extremity of the horizontal one, to within ten inches of the top of the upright one, forms an inclined plane, and the whole joined together, forms a triangle, (Fig. 167). At the lower end of the inclined board, is an open- ing six inches wide and eight long, to allow of the passage of faeces and urine to a vessel below. There are likewise two mattresses ; two foot cushions, and a pair of gaiters. The larger mattress, of the length and breadth of the inclined board, is two and a-half inches thick, and fastened to the board by straps on its edges. The smaller mattress, fills up the opening for the pas- sage of faeces, &c. The gaiters and foot cushions are as before described ; and lastly, there are two round pins, each six inches long, which are passed through holes in the inclined plane. Then the patient being placed FRACTURES OF THE FEMUR. 241 on this, as seen in Fig. 167, the fastening of the feet makes the extension, and the weight of the body the counter-extension ; thus placing the limbs in an easy position ; in one very favourable to the reduction of any inflammation, and especially applicable, to the cases of fracture just mentioned. — Where, from pecu- liar circumstances, we wish to allow a certain degree of motion to the limb, we may find it useful to employ PROF. N. R. SMITH'S APPARATUS. This consists of four pieces, viz. : two concave-in- clined planes, one of which is adapted to the inferior surface of the thigh, the other to that of the leg, and united by a hinge corresponding with the knee. The third piece is for the foot, and the fourth, connected to the thigh-piece, extends up the side of the body. Fg. 168. (Fig. 168.) The limb being placed in it, asin Fig. 169, is then to be suspended. This is, however, a somewhat complicated apparatus, or at least one that is not readily prepared at the moment ; but makes when ap- plied, a very light and excellent double-inclined plane. The figures give a good idea of it, and those who may wish to construct one, will find a minute account 16 242 FRACTURES OF THE FEMUR. of it, in all its parts, by Prof, Smith, in Ged ding's Baltimore Med. and Surg. Journal, vol. i., 1833. Fi^. 169. FRACTURES OF THE PATELLA. 243 CHAPTER VI. FRACTURES OF THE PATELLA. In transverse fractures, the upper fragment being drawn up by the action of the quadriceps femoris, the indications in the treatment are, to overcome the action of this muscle, and bring the fragments as closely in apposition as possible ; in order to shorten the liga- mentous union, and thus preserve a more perfect use of the limb. To do this, various means have been proposed, as those of Dessault, Amesbury, Sir A. Cooper, Sir E. Home, Mogridge of Devon, Dorsey, Mayor, Gerdy, &c., &c. DESSAULT'S APPARATUS, Consists of a splint three inches wide, long enough to reach from the tuber ischii beyond the heel ; two, two and a-half inch rollers eight yards long ; a two inch band of the length of the limb, and some tow, &c. Then the thigh, being bent on the pelvis, and the leg extended on the thigh, the limb is supported by an assistant, and the long band placed on the front of the limb, and held by other assistants in its place, un- til it is fixed by one of the rollers in an ordinary spiral bandage up to the knee. Two slits corresponding to the knee-pan, are then made in the band, to allow the fingers of the surgeon to pass through and bring down the upper fragment ; when the roller being resumed, should be carried round the joint in several figures of 8, and then continued up the thigh, to compress its muscles and fix the end of the band. The use of this band is now seen to be, to fix the turns of the roller, by pre- venting those of the leg from descending, and those of the thigh from ascending, and also to guard against 244 FRACTURES OF THE PATELLA. flexion of the knee ; to assist in which, whilst the limb is still elevated, the surgeon applies one end of the splint under the tuber ischii, and then filling up the inequalities of the limb with cotton or tow, ex- tends it on the whole back of the leg, and confines it to the limb by simple spiral turns of the second roller. This apparatus is very simple, but would perhaps answer as well without the band, as the roller, if properly applied, will certainly not slip after the ap- plication of the splint. DORSET'S APPARATUS, Is also simple, and consists of a piece of wood, half an inch thick, three inches wide, and extending from the buttock to the heel. Near the middle of this splint two bands of strong muslin, about four inches wide each, doubled on itself, and a yard long, are nailed at a distance of six inches apart. Two ordinary rollers, two small compresses, and some tow or soft flannel complete the apparatus. Then, whilst an assistant raises the limb, as in Dessault's plan, the surgeon applies an ordinary spiral, to cover in the whole leg and foot, and on reaching the knee, brings the fragments as closely together as possible, and confines them by figure of 8 turns. He then covers in the thigh by the same sort of turns ; places the splint properly padded on the back of the limb, and fastens it by spiral turns of the second roller. On coming to the lower one of the transverse bands, it is to be passed above the upper fragment, over the compress placed there, and the upper strap passed below the lower fragment, and both secured by a pin or knot ; when the remainder of the splint is to be covered in by the subsequent turns of the roller. This apparatus is the same in principle as Boyer's, but has the advantage over it of being more simple, and easily obtained at a moment's notice; a shingle or strip of wood, a few tacks, and a piece of bandage, being all that is requisite. FRACTURES OF THE PATELLA. 245 MAYOR'S METHOD, Has been already mentioned under his system, as the tarso-patellae handkerchief. GERDY'S PLAN, Is similar to the uniting bandage for transverse wounds, and consists of two strips about half a yard^4ong, one of which is cut into three tails, and the other into three slits, and used as follows. Place an ordinary spiral bandage on the front of the leg as far as the knee ; then lay the tailed bandage so that its ends may correspond with the lower fragment, and fasten it to the leg by a second spiral, firmly applied. Place a spiral bandage on the thigh, and laying the slit bandage so that its slits may correspond with the upper fragment, bind it by another spiral bandage, or by turns of the first, also firmly to the thigh. Place the two compresses, one above the upper fragment, the other below the lower frag- ment, and passing the tails of one band through the slits of the other, press upon the compresses, and force the fragments into ap- position, by fixing the lower one, and bringing the upper one to it. Then confide the ends of the bands to an assistant, and fasten them by another spiral of the lower extremity, beginning at the ankle and reaching to the groin, with figure of 8 turns at the knee over the whole (Fig. 170). 246 FRACTURES OF THE LEG. CHAPTER VII. FRACTURES OF THE LEG AND FOOT. FRACTURES OF THE LEG. These whether of one or both bones, with the excep- tion of the lower end of the fibula, are usually treated in the same way. Here, as in other fractures, various means have been proposed, but as the most simple one has seldom or ever been known to fail, we shall confine ourselves now to a description of it. This is the APPARATUS OF THE PENNSYLVANIA HOSPITAL, And consists of an ordinary pillow, and a fracture- box. The fracture-box is made of four pieces of wood, the bottom one of which, extending from the knee to a little beyond the heel, has fastened to its lower end a perpendicular piece for the foot : to its sides are attached by hinges, two lateral pieces about Fig. 171. seven inches wide, and intended to shut up against the sides of the limb and foot-board, to form the box. Fig. 171. Then, placing a pillow in the box, and the limb on the pillow, fasten the foot to the FRACTURES OF THE LEG. 247 foot-board by a simple band over the instep ; tie up the sides of the box, and the dressing is complete. If it is desirable to apply cold washes, or to pro- tect the pillow from discharges, or if it is a compound fracture, a piece of oiled silk, or coach curtain, may be laid over the pillow. Otherwise it is not required. This very simple apparatus is all that is used at this large hospital for fractures of the leg, except where, from great lateral inclination in fracture of the lower end of the fibula, Dupuytren's splint is neces- sary. But this is seldom the case ; as the tieing of the foot to the foot-board, so as to cause an inclination inwards, and a little extra compression made at the internal malleolus by meansof a pad of cotton, isaJl that is requisite, even here. The principle thing to be attend- ed to in fractures of the tibia, is the state of the heel, which is very apt to sink on the pillow, and thus cause the lower fragment to project anteriorly. We must also see that the foot-board projects beyond the toes, in order to keep off the weight of the bed-clothes, and prevent their causing the same thing by the extension of the foot. The band across the instep prevents the inclination of the foot to either side, and the pres- sure of the pillow against the limb by the sides of the box, prevents lateral deviation of the fracture ; whilst by this apparatus, we have the parts constantly before us, can remedy instantly any deviation, and combat inflammation by cold washes, &c. A simple rule, by which to tell whether a leg is properly set or not, is to see that the edge of the first joint of the big toe corresponds with the inner edge of the patella. This, even if the patient is bandy- legged, w^ill generally keep us right as to the proper position of the limb. In cases of fracture of the leg, where the contusion is a slight one, but accompanied by a wound, attempts should be made to close it as soon as possible, and promote its union by the first intention. To do this, 248 FRACTURES OF THE LEG. draw it together with adhesive strips, and then apply over them a thick piece of patent lint, well wet with white of egg, so as to cause it to fit very closely to the limb, exclude the air, and form an artificial scab, as recommended by Sir A. Cooper. This should not be removed for several days. If, however, the wound is a serious one, and proceeds to suppuration, no dressing is equal to the plan of Dr. Barton. BARTON'S BRAN DRESSING. This requires a fracture-box ; some bran or fine saw- dust, and a little cotton. Then fill the box, with its sides shut up, (or have one made with fixed sides,) one-third full of bran ; place the limb in it, fasten the foot to the foot-board as before, and stuff some cotton between the knee and the sides of the box, to keep the bran from escaping. Then fill up the box with bran, so as to cover in the wound and whole limb. This forms a very soft and equable bed for the limb, keeps the flies off from the wound, prevents the foetor from the discharges, and owing to its ab- sorption of the blood or discharge from the wound, it swells, make pressure on the part, and thus tends to arrest the hemorrhage, or prevent the formation of sinuses. After two or three days, if we wish to change it, scrape off the bran from the limb, and cleansing it from the wound by a spatula or syringe, re-apply it fresh. In hospitals, this dressing is espe- cially useful, as it preserves the wards from the foetor of the discharges, which, without this, are some- times almost insupportable. It also answers for extensive wounds of the leg or thigh, the box, in the latter case, being made to ex- tend up to the trochanter of the femur ; and in some cases, has certainly prevented erysipelas, by keeping the limb from the action of the atmosphere. After the bony union in any case of fractured leg is tolerably firm, say after six weeks, an ordinary FRACTURES OF THE LEG. 249 spiral bandage should be applied to the limb, and over this two splints of binder's board, softened in hot water so as to mould themselves to the limb. These may be confined there by another bandage, so as to strengthen the part before the patient attempts to walk about. In very oblique fractures of both bones, extension and counter-extension is sometimes necessary to pre- vent shortening. To obviate this, we should apply Physick's modification of Dessault's splints for frac- ture of the thigh, or Hutchinson's leg splints, (though the first is preferable) till the tendency to spasm of the muscles has gone oflf, when the usual means may be employed ; but we again repeat, that it is seldom any other dressing than the fracture-box is required for these cases. AMESBURY'S APPARATUS FOR FRACTURES OF THE LEG, Is composed of a thigh-piece, properly shaped to re- ceive the back of the thigh, having a pair of lateral splints connected with it, and some studs for the reten- tion of straps ; a leg-piece, immovably connected to the thigh-piece at an angle, and hollowed out for the reception of thebackof the leg ; and afoot-piece, which admits of being so shifted as to adapt the leg-piece to the length of the leg. This should not rise higher than is suflficient to form a right angle with the leg- piece when connected with it. There are some holes in each side, and a strap is attached to it, having upon one end a buckle, and a shoe with a wooden sole, for the reception and retention of the foot, to which are attached two straps for connecting it with the foot- board. The foot-board is supported by a foot-strap, which, when in use, extends from one side of the thigh-piece round the lower part of the foot-board, where it is passed under a strip of leather placed there to keep it in its place, and then carried up to the opposite side of the thigh-piece, where it is buckled. 250 FRACTURES OF THE LEG. The apparatus to be used, ought to be first adapted to the sound limb in cases of simple fracture of the leg, and well padded as in the case of fracture of the thigh before referred to ; a small concave pad, too, should be placed on the inside heel of the shoe, and another pad upon the sole. Two side splints are re- quired, the outer one extending from the foot-board to the upper part of the outer condyle of the femur, and the inner one from the foot-board to the inner condyle ; — also a split deal shin-splint ; and in cases of oblique fracture, a thin pad to be applied upon the instep, covered with a piece of pasteboard, a little wetted, which, when dry, serves to equalise the pres- sure and keep the instep easy. Application. — In the first, or Inflammatory stage, the shoe, a, containing the heel and sole-pads, ought to be carefully placed upon the foot ; the instep pad arranged upon the instep, and the shoe closed over it, and firmly confined to the foot, by means Fi^. 172. of the buckles and straps there attached for that purpose. An assistant should next be directed to place one hand under the knee, and, taking the foot in the other, raise the fractured limb, bringing it round so as to let it rest upon the heel. When the limb is raised, the surgeon places the apparatus under it, and brings the angle of the same, opposite the bend of FRACTURES OF THE LEG. 251 the knee, directing the assistant to lower the limb upon the splint. He now neatly fixes the shoe, a, to the foot-board, 6, by means of the straps attached to the sole, and by its aid is easily enabled to raise or lower the foot according to the length of the heel or thickness of the calf, so as to bring the lower portion of the fractured bones into a proper line with the upper, as far as respects any angular projection backward or for- ward, and a padded splint being placed upon the front of the thigh, the whole of the thigh-part of the apparatus is fixed to the limb by means of the straps, c. That done, the shoe fixed to the foot-board and the thigh part of the apparatus to the thigh, the foot-board may be raised nearly to a right angle with the leg-piece, and fastened in this position by the foot-strap, c/, care being taken that the heel does not bear against the sole of the shoe. The fractured ends should next be noticed, and if the foot requires to be raised or lowered, it may be done by means of the strap which confines the shoe to the foot-board. The part of the pad, e, which lies under the small of the leg, being now raised and supported in close contact with it by means of tow or other soft material placed between the pad and this part of the apparatus, the whole length of the back of the leg will then have an equal bearing upon the apparatus. The lateral splints are next to be applied, the long- est upon the outer side of the leg, and the shortest upon its inner side, the lower ends of these splints being fastened to the foot-board by means of nar- row tapes passed through the holes at the sides, and the upper end kept close to the leg by the cir- cular strap, g, passed round the limb over the splints and the apparatus. With respect to the position of the limb thus fixed, it should be placed with the apparatus resting upon the heel, and the two planes be well connected, as seen in 252 FRACTURES OF THE LEG. Fig. 172, by means of the steel bar, which forms part of the apparatus for fractures of the thigh, the whole being steadied by tapes attached to the foot-board, and passing off from thence to the sides of the foot of the bed. Cooling lotions, leeches, &c., may be ap- plied, by unbuckling the circular leg-strap, and throw- ing back the side splints. When the inflammation is subdued, which is usually in three or four days, some strips of soap-plaster, each about an inch and a-half wide, should be applied round the limb with very moderate tightness, so that they may pass from the ankle to a consider- able distance above the fracture. The ends should then be crossed on the sides or front of the leg, and cut off, so as to be easily turned back, when it is ne- cessary to observe the state of the skin. Some strips, or a short roller, should also be passed round the foot to prevent oedematous swelling in that part. When this is done, and the side splints re-applied, the shin- splint should be properly adjusted, and the whole leg- part of the apparatus supported by three circular straps and buckles. The cross-bar may now be removed, and the appa- ratus furnished with a sling or thong of leather fixed to the lower end of the leg-part of the splint, by means of which the limb may be moved passively at pleasure, the patient reclining upon a sofa, or resting his leg upon the seat of a chair. He may walk, too, with the assistance of crutches, passing in this case the sling over the neck, as in the ordinary way ; the movements of the limb, however, should be always passive, and never by the action of its own muscles. In a fortnight or three weeks time, according to cir- cumstances, the foot board should be shifted a little higher up the leg-piece, so as to press the fractured ends together, and hasten their consolidation. When both bones of the leg are broken, and the fracture of the tibia happens to be very oblique, exten- FRACTURES OF THE LEG. 253 sion must be made until the fibula is united. For this purpose, the thigh-piece of the apparatus can be pressed up closely against the back of the thigh, and the foot-board shifted down, so as to make the space between the foot-board and the thigh-piece longer than the leg. When the limb is placed on the splint, and the thigh-piece fixed, the assistant grasps the foot and ankle in his hands, and makes gentle exten- sion in the natural line of the bone, so as to bring the fractured parts into proper adaptation; this being done, the surgeon keeps up the extension by buckling the strap, which is fixed transversely to the shoe, round the foot-board, taking care that the broken extremities unite in the relative position which they naturally occupy. For fuller details relating to this part of the treatment, the reader is referred to Mr. Amesbury's " Practical remarks on the Nature and Treatment of Fractures of the Trunk and Extremities." vol. ii. DUPUYTREN'S APPARATUS FOR FRACTURES OF THE LOWER EXTREMITY OF THE FIBULA, Consists of a wedged-shaped cushion, about two-thirds filled with bran or cotton, and of sufficient length to extend from the malleolus internus to the knee ; — a strong splint, about two feet long and three inches Fig. 173. wide ; — and two single-headed rollers, from four to five yards long. Then the fracture being reduced, the wedge-shaped 254 FRACTURES OF THE LEG. cushion, with the base directed downward, is to be applied along the inner side of the leg. The splint, is next to be applied on this, and made to extend about four inches beyond the sole of the foot, and these two portions of the apparatus be closely confined to the limb, above, by one of the rollers passed in spiral turns round it, from just below the knee to a short distance above the fracture, and thence round the foot and in- step in the form of a figure of 8, without allowing the turns of the roller to come on the seat of fracture. Care should also be taken in applying this roller, to draw the foot inward towards the splint, and maintain it firmly in the state of adduction : the posterior part of the limb being allowed to rest in a state of demi- flexion,upon pillows made to form an inclined plane. In Fig. 173, the turns of the upper roller do not come far enough down ; they should extend to within an inch or two of the fracture. BOYER'S APPARATUS FOR FRACTURE OF THE OS CALCIS, Is made of a bit of strong roller, two inches wide, and of sufficient length to extend from four inches beyond the foot to the lower third of the thigh ; — two single-headed rollers, eight yards long, and two and a-half inches wide ; — and a strong, well padded, pasteboard splint, moulded to the fore-part of the foot and leg, and reaching from the roots of the toes to a certain distance above the knee. Then the foot and leg being held by an assistant, the first in the most complete extension, and the second demi-fl^exed, another assistant should be re- quested to support the thigh, laying hold of it at its middle third. The surgeon then proceeds to apply a padding of lint, or charpie, over the toes, and extends the strip of roller from the instep, along the sole of the foot, the back of the leg, and the lower and pos- FRACTURES OF THE LEG. 255 terior part of the thigh, and the band being main- tained thus by the assistants, the surgeon equalises the posterior part of the ankle-joint, by means of the padding, and applies the graduated compresses on each side of the tendo-Achillis. Next, taking one of the rollers, he fixes its initial end by a few circu- lars applied about the ankle, which at the same time secures this portion of the band, and reflecting the remainder of the latter backward, covers in the whole of the foot. He now passes several figures of 8 about the heel, in order to embrace the separated portions of the bone, and maintain them in apposi- tion, and then carries the roller to a short distance above the knee by a simple spiral bandage of the leg, reflecting the upper part of the band downwards, so as to fix it by a few horizontal circulars just below the knee. In the last place, the padded splint is placed upon the fore-part of the limb, and confined by a second roller, carried from the roots of the toes to the middle third of thigh, and the limb is extended over a pillow, so as to form a double-inclined plane. In fractures of the Meta-tarsal bones, or of the Toes, there is generally more occasion to combat the eflfects of injury to the soft parts, than to set the fracture. We should therefore, place the limb in a fracture- box, and elevate it, to drain the blood from the part, applying cold washes, &c., to overcome the injury of the soft parts. Caries, is however very apt to follow such injuries even under the most favourable circum- stances. Fracture-bridges, etc., are often spoken of, to keep the weight of the clothes off the foot, and special directions given for their construction, but nothing more is necessary than two halves of a common hoop tied together in the centre, as shown in the fracture of the thigh, by Physick's plan. 256 IMMOVABLE APPARATUS, CHAPTER VIII. OF THE IMMOVABLE APPARATUS, OR STARCH BANDAGES. Another method of treating fractures of the leg, is by the Fecently revived method of Suetin, and Vel- peau, or the '' Appareil Immobile." In the use of this apparatus, attention must be paid to the nature of the case, the constitution of the patient, &c. ; in other words, that it is a favourable case of simple fracture, and without much contusion. It should also be re- collected that the bandages used, are to be washed rollers, applied as in the French Spiral, so as to leave the heel and toes open to our inspection ; as we may then judge of the state of the parts above. In applying them, do it with a light hand, in order that the bandages may not be too tight, and if the patient complains after its application, so as to show suffering, the whole must be removed. If thus applied, this dress- ing serves a most excellent purpose ; but is liable to abuse, without great attention on the part of the sur- geon. Indeed several cases have resulted most un- fortunately from it, even in the hands of distinguished surgeons ; but with proper attention to the points ital- icised above, and the manner of applying it, the result of the case is more certain. The success attendant on those in which I used it, (which were among the earliest in which it was tried in the United States,) may be best judged of from the following report of those treated in the surgical wards of the Pennsylvania Hospital, in 1838, at which time, I was the house sur- geon. OR STARCH BANDAGE. 257 Case First. — Fracture of both bones of the leg. George R , set. 34 years, a shoemaker by trade, and of temperate habits, was admitted into the Hos- pital, Dec. 25th, 1838, with a fracture of the tibia, oblique at its lower third, and one of the fibula at its upper third, caused by a fall upon the ice. The limb at first was placed in the fracture-box, and evaporating lotions used to reduce the inflammation, which was considerable. On the third of January, seven days after the accident, the immovable appa- ratus was applied in the following manner. A washed roller being smoothly applied, from the toes to the knee, cotton was placed along the spine of the tibia, and also in the cavity on each side of the tendo- Achillis, to prevent excoriation from the turns of the bandage. This was well rubbed over with wheat starch, made thick and smooth by being boiled for twenty minutes. A second roller was then ap- plied from the knee down and also well covered with starch. Two pieces of binder's board cut to fit the sides of the leg, and extend from below the knee to below the malleoli, were soaked in water until soft, and being well saturated and rubbed with starch, were applied to the leg over this, so as to surround the limb, except for the breadth of a finger on the front and back ; small cuts being made at the lower end. to cause it to fit the projection of the malleoli, and also at any other point where it bulged out. A third splint, made to fit the foot, and slit at the end so as to enable it to turn up behind the heel, was then applied to the foot ; starched, and secured by a third roller from the toes up. This was coated in like manner ; — a fourth applied over all, and the dressing completed by starch, which kept the whole smooth and tight, with- out the aid of pins. The limb was now carefully laid in an empty frac- 17 258 IMMOVABLE APPARATUS, ture-box ; a little cotton placed under the heel, and the foot tied to the foot-board, where it was allowed to remain for four days, at the expiration of which period the whole was dry and hard ; the limb being cased as firmly, as in plaster. The patient was then kept in bed without any other dressing except the splints ; and on the ninth of January, thirteen days after the injury, a bandage was doubled around his neck ; carried down behind the calf of the leg ; then in front of the ankle ; over the instep, and round under the foot to the instep again, so as to form a sling and raise the foot a little from the ground ; when he was allowed to walk about with crutches. In this way he con- tinued until February 7th, when the apparatus was taken off, before the medical class in attendance on the practice of the house ; the limb being perfectly straight and firm, and without the slightest deformity. On the 13th of February, seven weeks after the in- jury, the man was discharged. In this instance, the apparatus was not touched until the fourth week, when a simple roller was applied to tighten it, owing to the looseness consequent on the shrinking of the mus- cles. One of the objections raised to the use of the apparatus was thus readily obviated without injury to the patient ; for, as the splints did not meet before and behind the leg, it was easy to fold the surplus bandage in, without causing any welt on the skin ; while the bandage, having been previously washed, shrunk but little. Case Second. — Fracture of thejihula two inches above the joint. Patrick D , set. 42 years, a labourer, fell off a step on the 15th of January, and fractured his fibula obliquely, two inches above the external malleolus. Owing to the inflammation, leeches, and the anti- OR STARCH BANDAGE. 259 phlogistic course, with the use of the fracture-box, were continued until February 1st, seventeen days after the accident, when the apparatus was applied as in the preceding case, except, that the splints were continued under the bottom of the foot ; being slit up so that the fold under the foot did not inter- fere with the application of the splint to the sole ; thus preventing all motion at the ankle-joint. After the apparatus had been dried in the fracture-box, with the foot well turned in for five days, the patient was allowed to walk about, and on the 10th of Feb- ruary, twenty-six days after the accident, he walked up to the third story of the house, and was operated on by Dr. T. Harris for cataract. On February 21st, the apparatus was removed, — there being not the least deformity perceptible even to the touch. Case Third. — Oblique fracture of both hoiies of the kg. Patrick C , set. 23 years^ a labourer, whilst working on a rail-road on the I8th of January, was knocked down, by the caving in of a bank of earth, and both bones of his leg braken obliquely, near the middle. He was treated in the usual way by the fracture-box, until the 27th of January, when the starch dressing was applied. January 31st, four days afterwards, was allowed to rise and walk by degrees, more each day, until February 25th, thirty- eight days after the accident ; when the apparatus was removed. The limb was perfectly straight, without any motion between the bones, and strong enough to permit him to walk upon it. In this in- stance, the apparatus was not touched until the sixth day after its application, when on his complaining of its tightness over the instep, the foot was soaked for a few minutes in hot water, and, by introducing a spatula under the bandage, it was raised sufficiently 260 IMMOVABLE APPARATUS, to free the point of pain. Being then allowed to harden, he suffered no inconvenience afterwards. The next three cases were fractures of the thigh, in which, as there was but the one bone to act on, and other objects to be considered than the mere support of the fractured ends, it was applied, at a more advanced stage of the treatment. Case Fourth. — Oblique fracture of the middle of the femur, Francis McG , aet. 22 years, of good habits, fell, on the 23d of November, down the hatchway of a vessel, and fractured his clavicle and femur. The clavicle was dressed with the usual apparatus, and the femur treated by the long fracture-box, fas- tened on the double-inclined plane, until January 14th, fifty-three days after the injury ; when the union not being firm, although there was considerable bony deposition, the apparatus was applied as follows: — A roller was carried smoothly from the toes up to the groin, the limb being held up and extended by assistants ; this was starched as in the first case, and covered by a second roller. A long splint of binder's board was then applied, from the tuberosity of the ischium to below the knee, on the back part of the thigh, and another from the groin to the patella, in front, so as to surround the limb entirely, except for the space mentioned in the dressings of the leg. These were then covered in the same manner as the splints in the first case, and a simple roller applied from the toes, up to the lower part of the knee, so that it could be renewed at pleasure. The limb was now laid on a simple-inclined plane, until the apparatus dried. Five days were necessary to dry it, when the man was allowed to walk about ; the limb being supported by the sling before mention- ed, and the splint behind preventing all flexion at the OR STARCH BANDAGE. 261 knee. On the 2d of February, about ten weeks after the accident, the apparatus was removed, without there being found any deformity or perceptible short- ening in his gait ; the measurement showing it to be but little more than a quarter of an inch less than the sound limb ; and on the 7th of February, the patient left the hospital. Cases Fifth and Sixth. — Oblique fractures of the upper third of the femur, Thomas H , set. 26, a labourer, fractured his thigh at its upper third, December 6th, about fifty miles from town. He was dressed in the neighbour- hood, and did not arrive at the hospital till the third day after the accident, owing to the destruction of part of the rail-road. The limb was much inflamed and swollen, and was treated at first by the inclined fracture-box,* lotions, &c., until January 6th, when the starch apparatus was applied to it, and dried in the same manner as in the preceding case. On the 14th of January, the man was allowed to walk about, and the apparatus remained untouched, till its re- moval, February 12th, there being perfect union, and only one-eighth of an inch shortening by close measurement, and none perceptible in his gait. On the 21st of February, eleven weeks after the in- jury, he was discharged. The same apparatus was applied to Patrick E , (who was admitted February 6th, with an oblique fracture, caused by blasting,) on the 19th of February, thirteen days after the accident, and ena- bled him to sit up in bed five days afterwards, and on February 25th, to walk the length of the room. On his standing up, he felt too weak to walk readily, but had every prospect of doing so * Chapman's double-inclined plane, with a fracture-box on it. 262 IMMOVABLE APPARATUS, ETC. shortly. At the time, he complained of no inconveni- ence from the dressing, and was able to turn about in his bed ; the limb being but little shortened by mea- surement over the splints. This case got well, but with marked deformity; so much so, as to make me resolve never again to ap- ply this dressing to the thigh, before there was consoli- dation of the fracture. The advantages of this apparatus are, that in the case of fractures of the leg, it enables the patient to move about in fifteen days, with perfect safety. But I have never deemed it expedient to apply it so early as M. Velpeau has done, owing to the severe contusions which complicate most of the fractures to which I could apply it. With this restriction, how- ever, it might, so far as is proved by the experience of these cases, be used in all simple fractures of the leg; as few will be found, in private practice, more severe than those on which it was tried. In hospital practice, it promises to be of great utility, by doing away the risk of sloughs on the sacrum, from the pressure consequent on the long con- finement to the back ; whilst it adds very materially to the patient's comfort, by allowing him to rise to a window, or to go from one apartment to another. In case second, it enabled a man to rise and undergo an operation for cataract, in a place where the light w^as better, than in his own room. Since my residence in the Pennsylvania Hospital, I have frequently seen it employed by M. Velpeau, in his own wards, as well as by other distinguished French surgeons, and do not hesitate to repeat the assurance of its utility in such cases of fracture of the leg, as have been mentioned. But I doubt the propriety of its use in fractures of the femur, before there is considerable consolidation. PART IV CHAPTER I. OF THE APPARATUS FOR THE TREATMENT OF DISLOCATIONS. GENERAL CONSIDERATIONS. As dislocations like all affections of the joints, in- volve very materially the usefulness of the limb, their proper treatment, and consequently the diagnosis of the acccident, become a matter of equal importance with that of fractures. Indeed, as the structure concerned is much more complicated than that of the mere bony tissue, it is questionable, whether the reputation of the practitioner is not more involved in these cases, than in the previous class of accidents. It would, however, be foreign to a work of this kind, to consider such injuries at length, and we can therefore, do little more than hint at the principles involved, and the means required for their treatment. Like fractures, these accidents are mainly depend- ent for a successful termination, on the anatomical knowledge of the surgeon ; but they require even more caution, and a higher grade of professional skill, be- cause the peculiar liability of the structure involved, to take on inflammation, necessitates a resort to means generally included under the province of medicine ; in other words, requires the skill, of both the physi- cian and surgeon combined. Lined by a synovial membrane ; strengthened by fi- 264 APPARATUS FOR DISLOCATIONS. brous tissue; surrounded by muscles, and often attended by important nerves and blood-vessels: the effects of a high degree of inflammation, are nearly always destruc- tive to the tissue concerned ; so much so, that it is by no means uncommon for old, unreduced dislocations, to convert the parts around the point of pressure, into bone itself, thus completely modifying the action of the limb. This tendency should therefore, always be borne in mind by the practitioner. But even in making an attempt at reduction, there is something more than mere anatomical knowledge re- quisite, to overcome the difficulty ; because the distance between the origins and insertions of certain muscles being materially changed, it follows that some of them must be very much stretched, and that as this stretch- ing results in spasm, relaxation of the spasm must be produced, before there can be any chance of a reduc- tion. Here also, resort must be had to medicine as well as surgery ; till by means of blood-letting, anti- monials, &c., the system be placed in such a state, that the use of mechanical means may enable other muscles to act in a proper manner. Again, as a certain amount of muscular paralysis, laceration of ligaments, &c., remain, to a greater or less extent, even after the reduction, the use of cer- tain means in the after-treatment, is equally important; lest there be a recurrence of the accident. These points, however, we can merely hint at, and must refer those desirous of a more thorough investi- gation of the detailed pathology and diagnosis, to larger works ; merely giving here such points of practice, as may serve the young practitioner for the moment. DISLOCATIONS^ ETC. 265 CHAPTER II. ON DISLOCATIONS OF THE HEAD AND TRUNK. The general principles involved in this class of in- juries, being those just stated, we pass immediately to the consideration of the means required in the first of the special cases. DISLOCATION OF THE LOWER JAW. ' This whether on one or both sides, requires that the condyle should be freed from the projections of the anterior portions of the glenoid cavity of the temporal bone, see Fig. 174. Fig. 174. Reduction. — To accomplish the reduction, the pa- tient should be seated on a low chair, and his head supported against the breast of an assistant ; whilst the surgeon introducing his thumbs within the mouth, places them upon the molar teeth, and his fingers underneath the chin ; so that he may depress the pos- 266 DISLOCATIONS OF THE terior portion of the jaw by the pressure of his thumbs, and elevate the chin by that of his fingers. These movements, by freeing the condyles from bony promi- nences, will generally enable the muscles to draw the bone into its place. But as they frequently do this with great violence, and thus pinch the fingers very severely, the surgeon should slip his thumbs oflf the teeth to the outside of the gums, as soon as he finds the jaw begin to yield to his movements ; or wrap them well, before introducing them into the mouth ; or direct the assistant to place a fork-handle, or plug of wood between the teeth of the patient, in order to prevent their being bitten. After-treatment, — The after-treatment consists in the application of any of the bandages before referred to, under the head of Fractures of the Jaw ; in keep- ing the patient on soft food for several days after the reduction, and in directing him to avoid biting hard substances for some weeks subsequent to the accident, lest it again occur. Should inflammation of the joint supervene, it must be counteracted by the antiphlo- gistic treatment. DISLOCATIONS OF THE OBLIQUE PROCESSES OF THE VERTEBRA, Are so liable to produce death by pressing upon the spinal cord, especially in those of the neck, that it is better as a general rule, to permit the deformity to exist, rather than endanger the life of the patient by attempting its reduction. DISLOCATIONS OF THE RIBS, Are said to occur at their posterior and anterior ex- tremities, although many authors doubt the possibility of the first, without its being accompanied by fracture. In either case, the bandage directed for the treatment of fractures of the ribs, will be as much as we can employ for their reduction ; the compresses being HEAD AND TRUNK. 267 placed over the dislocated extremity, in order more effectually to retain it in its natural position. DISLOCATIONS OF THE CLAVICLE, May occur either at its sternal or humeral extremity. The Sternal end may be dislocated, either forwards, backwards, or upwards ; and requires that the shoulder should be carried in the opposite direction to that in which the sternal extremity rests, whilst the bone is at the same time, drawn off from the sternum by using the humerus as a lever ; on the same principles as those laid down by Dessault, in his bandage for the reduction of a fracture of the bone. Fi^. 175. Reduction. — The patient being seated, the surgeon should stand at his side, and placing his foot on the 268 DISLOCATIONS, ETC. chair orbed on which the patient rests, with his knee in the axilla, bend the arm over his knee as a fulcrum with one hand, and with the other force the shoulder forwards, backwards, or upwards, according to the position of the sternal extremity. (See Fig. 175.) After-treatment. — This consists in the use of Fox's sling, or the 2d and 3d roller of Dessault, for some two or three weeks. DISLOCATIONS OF THE HUMERAL EXTREMITY OF THE CLAVICLE, May be either above, or beneath the acromion process of the scapula, and is easily reduced when the shoul- der is drawn outwards, by acting on the humerus as a lever. But though the reduction is easy, the after- treatment will be found very difficult, in consequence of the small articulating faces concerned, giving rise to a constant recurrence of the injury. The only means that we have found certain for the retention of the bone in its position, after the reduction, is the Spica Bandage of the Shoulder, (Fig. 53,) with a large compress directly over the acromion, and the use of a sling to the elbow, to keep up the head of the humerus. DISLOCATIONS, ETC. 269 CHAPTER III. ON DISLOCATIONS OF THE UPPER EXTREMITY. DISLOCATIONS OF THE HEAD OF THE HUMERUS. These usually occur in three directions ; either into the axilla ; under the pectoral muscle ; or, on the dor- sum of the scapula ; and require, as a general rule, the application of the extending force, in the line that the limb naturally takes whilst dislocated. Thus, if the head of the bone is in the axilla, draw the arm in the line of the body ; if under the pectoral muscle, off from the body ; if on the dorsum scapulae, across the chest ; or elevate it so as to throw the head of the humerus into the axilla, and then draw parallel with the body. There is, however, some difference in the amount of force required, and the means of applying it, according as the case is recent or old ; in a strong muscular patient, or in one of less power and more delicate frame. Reduction. — The simplest means, and generally applicable only to cases of very recent occurrence, or of but slight muscular development, are those repre- sented in Fig. 175, and just spoken of under dis- locations of the clavicle. The cut explains itself. The next plan is, for the surgeon to place the heel of his foot (without his shoe) in the axilla of the pa- tient, in order to make counter extension, and then draw upon the arm by seizing the patient's wrist, or by grasping a towel fastened to the wrist or the lower end of the humerus, as represented in Fig. 176. If his own strength is not sufficient, assistants may lay hold of the towel, behind thehands of thesurgeon, and assist the extension. But should the patient be muscular, 270 DISLOCATIONS OF THE a solution of tart, emet., and such other means as will induce faintness and muscular debility, will also pro- bably be required. Fig. J 76. In old luxations, or in well developed subjects, even greater force than this may be necessary, such as the application of pullies to the humerus, and the use of more powerful means of making counter-ex- tension on the scapula. Indeed, where pullies are at hand, the surgeon will often save himself much hard work, by employing them in the first instance. In order to use them, attach the towel or band to the lower portion of the humerus by means of a clove- hitch, (as shown hereafter,) and jfastening the hook of the pulley in the other end of the towel, place a sheet or padded strap around the scapula, as repre- sented in Fig. 177. The extension may then be made either in the position exhibited in that cut, or with the patient lieing down, as in Fig. 176. In the appli- cation of these means of reduction, much will depend upon the scapula being firmly fixed, and where the UPPER EXTREMITY. 271 padded strap cannot be had, a narrow band should be applied to the acromion scapulae, in addition to the sheet used to fix its lower portion. As the axillary- vessels and nerves are apt to be acted on by the force employed to reduce the bone, their position should always be borne in mind. (See Gibson's Surgery.) Fig. 177. After 'treatment. — Keep the head of the humerus perfectly at rest, by means of a sling, for three or four weeks, until the laceration of the capsular ligament has united, and combat the subsequent inflammation by leeches, &c., when required ; cautioning the patient against elevating the arm for many weeks after the accident, lest he reproduce the injury. DISLOCATIONS OF THE FOREARM, May be divided into those of both bones, forwards or 272 DISLOCATIONS OF THE backwards, and into dislocations of the head of the ra- dius alone. As the first dislocation, viz. both bones forwards, requires the fracture of the olecranon, the treatment should be the same as that directed for this injury. In the dislocation of both bones backwards, the ole- cranon, resting on the posterior surface of the lower portion of the humerus (Fig. 178), requires that suf- Fi£: 178. ficient flexion be made, to bring it down into the sig- moid cavity of the humerus, and free the head of the radius from the condyles. Reduction. — To accomplish this, an assistant should make counter-extension by seizing the middle of the arm, whilst the surgeon, making extension at the wrist, puts his knee in the bend of the arm, and flexes the forearm upon his leg ; or, bends it around a bed-post, or upon the hands of assistants. After-treatment. — He then should apply a roller from the fingers up to the middle of the arm, and dress the case with an angular splint, as directed for frac- tures of the condyles ; making passive motion every three or four days, to guard against anchylosis. DISLOCATION OF THE HEAD OF THE RADIUS, May also be either forwards or backwards, producing either fixed pronation, or supination of the hand. UPPER EXTREMITY. 273 Reduction. — When dislocated backwards, as is most commonly the case, the hand being strongly pronated, should be raised by the surgeon and forci- bly supinated with one hand, whilst with the other he presses the dislocated extremity from behind for- wards, assisting this movement by slight flexion of the elbow. If extension and counter-extension are required, an assistant should make counter-extension by seizing the arm, whilst extension is made at the wrist by the surgeon, who also forces it into supination. If dislocated jTort^arc^^, the manipulations of the sur- geon are of course to be reversed. After 'treatment. — Place the arm in a sling, or on an angular splint, and keep it at rest ; combating in- flammation, and also any tendency to anchylosis. Although the Elbow-joint is comparatively superfi- cial, and the prominences of the different bones com- posing it sufficiently evident in its natural state, yet is it among the most difficult of the joints in which to diagnosticate an injury, in consequence of the swell- ing which so rapidly ensues. Fractures of the con- Fig. 179. dyles of the humerus ; fracture of the coronoid process of the ulna ; dislocations of different kinds, and simple contusions, have all not unfrequently been thought by different surgeons, to exist in the same case. A simple rule, which we learned under Velpeau, and 18 274 DISLOCATIONS OF THE the accuracy of which we have frequently tested, in the diagnosis of these injuries, is the following. Carry an imaginary circle round the elbow from the external to the internal condyle, and when the forearm is semi- flexed, it will include the olecranon process and the two condyles, in the normal state ; whilst the removal of either of these points out of the circle, will show the displacement consequent upon the injury, as in Fig. 179, where owing to dislocation of the forearm back- wards, the olecranon is above the circle spoken of. DISLOCATIONS OF THE BONES OF THE FORE-ARM ON THE WRIST, Are usually reduced by the application of force to the front or back of those of the forearm, accord- ing to the dislocation. But as the laceration of the ligaments here, involves a joint peculiarly liable to disease, perfect rest for several weeks, strict anti- phlogistic remedies, &c., should be insisted on ; par- ticular attention being given to guard against anchy- losis. The frequency of fracture of the lower end of the radius, and the liability to mistake it for a dislo- cation of this part, should also be borne in mind. (See Barton's fracture of lower end of radius, p. 210.) DISLOCATIONS OF ALL THE BONES OF THE WRIST, Are seldom seen, except when complicated with such severe injuries of the soft parts as may require ampu- tation of the limb. But the Magnum alone, may be forced out of the cavity formed by the scaphoides and lunare, so as to project on the back of the joint. Reduction. — Press firmly on the head of the mag- num. ^fter 'treatment. — Apply a compress over it and bind the hand firmly to a splint applied on its palmar surface. This should extend up to the arm, so as to keep the part at rest until the ligaments are united, or strengthened. UPPER EXTREMITY. 275 DISLOCATIONS OF THE METACARPAL BONES, Are very seldom seen, except in that of the thumb ; the treatment of which may be included in the con- sideration of DISLOCATIONS OF THE PHALANGES. These may be either on the metacarpal bones, or on each other. Let us, however, take the dislocation of the first phalanx of the thumb, upon the metacarpal bone, as indicating the treatment of all these cases. Reduction. — The phalanges being too short to enable us to get a hold on them, the surgeon should first surround the bone with a piece of buckskin, and apply over this, a piece of tape tied in a clove hitch. jPig. 180. Then, seizing the tape, make extension ; pulling gra- dually downwards, so that the extremity of the phalanx may describe the arc of a circle, and thus free its up- per portion from the projecting metacarpal bone ; counter-extension being made by assistants at the wrist or forearm, if required. Should the difficulty of the reduction seem to be owing to the tension of the lateral ligaments, the internal one may be divided by introducing a narrow, sharp-pointed knife or needle, and dividing it by a sub-cutaneous incision. After-treatment, — As in fractures of the pha- langes. 276 DISLOCATIONS OF THE THE CLOVE HITCH, Just referred to, offers one of the most certain means with which we are acquainted, of applying an extending force to a limb, and is, we think, far preferable to the wet rollers, and other means of fastening the extending bands so commonly re- commended. In dislocations of the humerus, or thigh, it will be found especially useful, and as we have never seen it slip, we believe that it never will, — if properly applied. Though long recommended for the thumb, our attention was first called to its ap- plication to other parts, by a sailor in the Pennsylva- nia Hospital, in 1837, with a dislocated hip ; who, seeing all the usual means of fastening the extending band slip and fail, just as the bone was nearly re- duced, suggested that he should be allowed to tie the sheet himself, which he did in a clove hitch, so that Fig. 181. it held firmly and relieved him of his injury. Since that time we have employed it, and seen it employed, in numerous cases without its slipping; and have always been pleased with the result. Sanctioned, as it now is, by Mr. Fergusson, we hope to see it sup- plant the miserable means of the wet roller, and thus save a great expenditure of time and trouble. UPPER EXTREMITY. 277 To make it, practice with a piece of twine until the turns are learned, as follows: — Turn the slringfrom right to left so as to form a circle, and bring one portion of the cord in front of the other, as in the right hand turn of Fig. 181. Then make a second turn of another por- tion of the twine, and twist it so as to place it be- hind the first turn, as in the left hand portion of the figure. On drawing on the ends, the loops will be tied so tight, that the cord will break before the knot will slip. After learning these turns of the knot with twine, no difficulty will be experienced in making it with a sheet or towel, in various other ways. 278 DISLOCATIONS OF THE CHAPTER IV. ON DISLOCATIONS OF THE LOWER EXTREMITY. DISLOCATIONS OF THE HIP-JOINT, Nearly always throw the head of the femur out of the acetabulum into some unnatural position upon the innominatum. As the sides of the acetabulum project considerably above the surface of the ilium, we require, in addition to the usual extending and counter-extend- ing bands, a lateral band, to be applied on the inside of the thigh, nearitsupperthird, in order to drawthefemur off from the pelvis, and free the head of the bone from the acetabular prominences. This band has not been represented in the cuts, owing to the difficulty of doing so, without confusing the drawings in the works from which they have been copied ; but its action is so simple, that we think it cannot be misunderstood. As the means employed for the reduction of the four different dislocations of this bone, vary only in regard to the line of extension, (which, it should be recol- lected, is generally to be made in the line which the dislocated bone naturally takes,) we shall confine our description to the dislocation upwards on the dorsum of the ilium, as the most common. The pullies be- ing required in most cases of dislocation of the femur, and as even with these the reduction is a matter oi considerable difficulty, it will save much useless ex- penditure of strength on the part of the surgeon, to apply them at once, without attempting other means. But where pullies cannot be obtained, the plan of Dr. Fahnestock, of Pittsburgh, reported by Prof. Gilbert,* * Amer. Journal Med. Sciences, No. viii., April, 1845. LOWER EXTREMITY. 279 of using the power furnished by twisted rope, will be found to form an excellent substitute. The mode of application is as follows : — " Place the patient and adjust the extending and counter- extending bands, as for the pulleys ; then procure an ordinary bed-cord, or wash-line, tie the ends together and again double it up on itself; then pass it through the extending tapes or towel, doubling the whole once more, and fasten the distal end, consisting of four loops of ropes, to a window-sill or staple, so that the ropes are drawn moderately tight ; finally, pass a stick throughout the centre of the doubled rope, di- viding the strands equally by it. Then revolving the Fig. 182. stick as an axis or double lever, the power is pro- duced exactly as it should be in such cases ; namely, slowly, steadily, and continuously ; which, with the aid furnished by the surgeon to the immediate seat of lesion, and to the system in general, cannot fail to conduct the case to a happy issue." The cut shows fully the manner of its application. But when we propose to employ pullies, proceed as follows, to the — Reduction. — Fasten a roller-towel, or sheet, upon the low^er end of the femur by a clove hitch. Attach the pullies to the free ends of the towel, and fasten the hook of their opposite extremity to a staple, bar, 280 DISLOCATIONS OF THE or other fixed point. Place a sheet thickly folded, in the perineum of the sound side, to make counter-ex- tension ; another across the pelvis from the ilium of the injured side, and a strong towel on the inside of the injured thigh, in order to draw the head of the femur off from the pelvis. Then, seeing that the bands are firmly fixed, and the patient's system re- laxed by constitutional means, direct the assistants to pull slowly but steadily on the pullies, until the coun- ter-extending band and the transverse pelvic band be- come quite tense and the muscles begin to yield to the Fig 183. power acting on them. Then the surgeon, seizing the leg by the ankle, should use it as a lever, to produce rotation of the head of the femur, and directing another assistant to draw strongly upon the towel which is on the inside of the thigh, continue the use of these dif- ferent forces until the parts seem relaxed ; when, or- dering the extension to cease suddenly, the bone will probably be drawn into its socket. Should the muscle however not do so, a repetition of the same means will frequently succeed, although at first they failed. After-treatment. — Tie the thighs together, and keep them at perfect rest ; combating any inflamma- tory symptoms that may arise. The line of direction of the extending force in the LOWER EXTREMITY. 281 other dislocations of the femur will be evident from the following cuts. In the Dislocation on the Pubis, the limb is to be carried off from the body and placed as in Fig. 184, with the addition of the towel to the inside of the thigh. In the Dislocation into the Sciatic Notch, the limb should be carried in the opposite direction, that is, over the sound limb, and rotation practised by acting on the leg. The inside femoral towel is not required here — see Fig. 185. Fig. 185. Various other means and modifications have been recommended for the reduction of these dislocations, but those referred to above, will, we think, be found sufficient in most cases, and have the sanction of some of the highest authorities in the profession. 282 DISLOCATIONS OF THE In the Dislocation INTO the Foramen Thyroideum, the application of the extending force as represented in Fi^. 186. Fig. 186, has advantages, in some cases, and the sanction also of Sir A. Cooper. The principle of its action may be seen at a glance. dislocation of the patella, Can only occur laterally, without laceration of the quadratus femoris, or ligamentum patellae. LOWER EXTREMITY. 283 Reduction. — In the lateral dislocation, the surgeon should place the heel of the patient on his shoulder, and pressing with his fingers on the edge of the pa- tella, force it inwards or outwards, according to the character of the accident. After-treatment. — Keep the limb extended for a few days, and direct the patient to wear a knee-cap or bandage (Fig. 91) for some weeks afterwards. DISLOCATIONS OF THE HEAD OF THE TIBIA, May occur in either of four directions ; forwards, backwards, inwards, and outwards. In either case, we should proceed as follows. Beduction. — Extension being made by the hands of assistants at the lower part of the leg, and counter- extension at the inferior portion of the thigh, the sur- geon should seize the condyles of the femur with one hand, and the head of the tibia wdth the other, and press them in opposite directions, as soon as he judges that sufficient extension has been made to enable the bones to take their natural position. After 'treatment. — Keep the limb extended, and combat the inflammation of the joint, which is fre- quently very great. The use of a splint, bandages, &c., may be required for some time, in order to insure perfect rest, and keep down inflammation. DISLOCATIONS OF THE FIBULA, At either extremity, are so rare, except when accom- panied by fracture, that we have little to say about them . When the luxation of the lower portion of this bone is accompanied with fracture of the tibia, it will re- quire considerable attention to save the ankle joint. DISLOCATIONS OF THE BONES OF THE TARSUS, Like those of the carpus, are generally the result of such violence, as implicates very seriously the soft 284 DISLOCATIONS, ETC. parts, inducing such violent inflammation as re- quires the greatest care, to avoid the necessity of amputation. Their treatment, consequently, could not be properly considered here, and the reader is therefore referred for them to the books on Surgery. DISLOCATIONS OF THE METATARSAL BONES AND PHALANGES, Resemble very closely the same injury to the bones of the hand and should be treated accordingly. See page (275.) But it must be recollected that if the joint of a toe remains unreduced, the pressure of the boot upon the projecting point will be liable to keep up a constant ulceration, which has sometimes been so troublesome as to induce the patient to submit to amputation rather than endure it. / PART V. OF THE MINOR SURGICAL OPERATIONS. The diversity of opinion existing, in regard to the definition of Minor Operations, leaves this portion of the field so open, that every thing not constituting a capital operation, might with propriety be here con- sidered. Not wishing however, to become too ex- tended in our remarks, nor yet to pretend to limit the range of subjects, we here merely define our own posi- tion, and shall treat under this head of such operations, as usually fall to the young practitioner, or within the range of every medical man ; such as Blood-letting, Issues, Vaccination, Extraction of Teeth, Catheterism, Incisions, Means of Arresting Hemorrhage, &c., &c. CHAPTER I. OF BLOOD-LETTING. By this term, we understand the use of every means of taking blood from the body, employed with the view of relieving or curing disease. These operations may, therefore, be divided into several kinds, according as they are practised upon the superficial veins by means of lancets, leeches, cups, &c., or upon the arteries. When the extraction of blood is made by a single opening, cut in one of the veins, it takes the name of Phlebotomy, or General Blood-letting ; when from an artery, that of Arteriotomy ; and when done by the 286 BLOOD-LETTING. aid of leeches, or cups, it is especially designated as Local Bleeding. First — OF PHLEBOTOMY, OR VENESECTION. This operation is practised upon the veins of various parts of the body, as at the bend of the arm, the back of the hand, the leg, and of the neck ; though the first is by far the most common. At the point where this is performed, we find generally five veins, arranged so as to form a figure not unlike the letter M. These are, the Cephalic, the Basilic, the Median, the Median Cephalic, and Median Basilic, a slight reference to the surgical anatomy of each of which will be necessary, before proceeding to the steps of the operation. The skin in front of the bend of the arm being smooth, soft, and thin, these veins are generally seen bulging through it,or indicated by dark blue prominences. When Fig. 187. not thus seen naturally, they may be rendered more ap- parent, by the ligature ap- plied above the elbow, pre- vious to the operation, (Fig. 187) or may be known by their elastic feel, and by their swelling under the fin- ger, when filled by friction oftheforearm. — Underneath the skin we have the adi- pose tissue, which varies considerably in its amount, but is never wholly wanting. As the superficial veins or those opened in venesec- tion, lie between this adi- pose tissue and the fascia covering the muscle, the amount of fat, consequently affects materially the opera- ration. Beneath the fascia, BLOOD-LETTING. 287 yet only at the depth of two lines, or thereabouts, lies the brachial artery, or sometimes, the radial or ulnar, according to the point of division of the bra- chial into the latter. Of the five veins before re- ferred to, the Cephalic, is on the outside ; the Basilic on the inside ; the Median in front of the arm ; and the Median Cephalic, and Basilic, run from the middle to either side, to join the main trunks. The External Cutaneous and the Internal CutaneousNerves, are those mainly liable to injury ; but their position varies so fre- quently, that we cannot pretend to give even a refer- ence to them, as it would be inadmissible, in what is only intended for an outline ; it being expected that in this, as in other operations, the anatomy of the part will be learned before operating. As from the great variety existing in the arrange- ment of the vessels of the arm, it would be almost im- possible to designate every spot where some unexpect- ed accident, especially the wound of a nerve, may not occur, we can only point out, in general terms, the best mode of operating, and then refer to the acci- dents likely to arise from it, and their means of cure. The easiest vein to bleed in, at the bend of the arm, on account of its size and fulness, is the median basilic, but it is at the same time, more dangerous than the median cephalic, on account of the position of the artery. This latter, may, however, generally be felt pulsating, and by opening the vein by a slightly hori- zontal cut, or by moderately flexing the arm, especially if the operator is cautious in his movements, there is but little risk of injury to this vessel. Some bleeders recommend turning the hand into strong pronation, as likely to avoid accidents, either by throwing the mus- cles more over the artery on the cephalic side, or re- laxing the fascia, and making it more difficult to cut, on the basilic side. The risk of wounding the tendon of the biceps, is not worthy of consideration, compared with the safety of the artery. 288 BLOOD-LETTING. The varying position, however, of both arteries and nerves, render it difficult to foretell their injury, and the general rule, is, therefore, to take the vein that is fullest, provided the artery is not too near, and leaves the nerves to chance. In several hundred cases, we have never met with the slightest accident ; whilst others, who were probably, equally, if not better informed than ourselves, have experienced consider- able inconvenience. In thin subjects, owing to the deficiency of adipose tissue, the veins are nearer the skin, but being also looser, are more liableto roll under the lancet ; whilst in fat persons, they are more firm and less moveable, although less readily seen. The depth of the incision must always therefore be regu- lated by the obesity of the patient. It will also be found advantageous to accustom ourselves to bleed by the touch, rather than the sight, and to practice the fingers on deep-seated veins, or those in fat arms, until we can distinguish the elastic feeling of a vein from the tenseness of a tendon, or the pulsating cord of an artery. With a view of softening the skin, and rendering the touch more delicate, some bleeders moisten the finger in the mouth before searching for the vein. It is, however, a filthy practice, and one that is of little assistance ; if the finger of the operator is not sufficiently delicate in its touch, he may soak it in warm water, but not spit on it. The risks of the operation will be treated of hereafter. Previous to bleeding at the bend of the arm, a sim- ple circular bandage, or a ligature, should be placed, with moderate firmness, just above the elbow, so as to arrest the circulation in the veins. It must not, however, be so tight as to arrest that in the arteries, as may be always told by placing the fingers on the pulse. After a certain amount of friction to fill the veins, the forearm is either held in an extended posi- tion by an assistant, or placed between the chest and the bend of the surgeon's arm; or in his axilla ; or the BLOOD-LETTING. 289 patient may rest his hand on the top of a stick. The surgeon then feels under the vein, by making firm pressure on it, for the position of the artery, and if it is felt pulsating, should open the vein selected, by a more horizontal cut than is usual ; or choose another vein ; or change the relative position of the vein and artery by strongly pronating the hand, as before stated. He then places the thumb or fingers of his left hand, on the vein, below the point at which it is to be opened, in order to steady it : and holding the lancet in his right hand, and facing the patient, if he is bleeding in the right arm, or in the right hand, with his back to the patient if in the left arm, he cuts through the integuments, and opens the anterior parietes of the vein ; still pressing on the vein, below the opening, with his left hand. The basin or cup to hold the blood being previously placed, and the clothes around protected by a sheet, he then removes his hand from off the vein, and immediately the blood flies into the bowl. This pressure with the fingers of the left hand below the orifice, will be found to be a neater plan, than that of allowing the blood to escape imme- diately after the vein is opened ; as it protects the clothes or bed from the blood. The Lancets with which we may bleed, are of two kinds, viz. : the Spring and the Thumb Lancet ; either being used, according to the views of the ope- rator or the wishes of the patient. The Spring Lancet is an old German instrument, of some 300 years date, and consists of a metallic case, on the outside of which is a trigger, whose point is inserted under a spring, when the instrument is set. Below the spring, on the inside, is placed the fleam or blade, which is drawn up to the spring previous to its being used. Occasionally, another and smaller spring is placed on the inside, under the fleam, in 19 290 BLOOD-LETTING. order to keep it constantly in contact with the spring moved by the trigger; but it is an unnecessary addition. The Thumb Lancet, also of very ancient origin, is made of a simple piece of steel, fastened between two handles, and intended to be pushed into the vein by the hand of the operator. Three kinds are employed, viz., the barley-corn or obtuse-pointed ; the spear or oat-pointed ; and the serpent-tongued, al- though the last is now" nearly obsolete. Considerable diversity of opinion exists, both in the minds of patients and operators, as to the advantages of these instruments, and the prejudices of some are so strong against the Spring Lancet, as to prevent its use, and vice versa. In some parts of Europe, as in England, France, &c., and in the Eastern and Northern portions of the United States, the thumb-lancet is pre- ferred ; whilst in other portions, as in the Southern, Middle, and Western portions of our country, the spring is almost entirely used. The use of the Thumb Lancet is thought by some to require less skill, and therefore to be better suited to general use ; but as far as our own individual experience goes, the spring is attended by the least pain to the patient, and danger to surrounding parts. We have known sea-captains, super-cargoes, sailors, nurses, and others, who have used the Spring Lancet without any accident, who yet were perfectly ignorant of the difference between a vein and an artery; so we look upon this objection as void, whilst very many from too great boldness and force, would inevitably transfix the artery with a Thumb Lancet; having no idea of the depth to w^hich they should go. In skilful hands, the Thumb Lancet is probably the most surgical instrument, but it gives the patient much more pain ; the vein is more apt to roll from under it, and the opening is often not suffi- ciently free to prevent thrombus. For ourselves, we infinitely prefer the Spring Lancet, as we can bleed BLOOD-LETTING. 291 with it more horizontally, in cases where the artery is near the vein ; give the patient no time to shrink be- fore its puncture ; causes him little or no pain ; regu- late very accurately the depth to which we go, by the height of the fleam above the vessel, and have never seen a vein transfixed by it ; as the resistance of the integuments, and of the vessel, generally overcome somewhat the force of the spring. Even in young children, we invariably use the Spring Lancet, and although we have operated on those as young as eighteen months, have never had any difficulty from the operation. Nevertheless, every bleeder should be able to employ either, so as to yield to the prejudices of a patient, and thus avoid drawing upon his own head, the reproaches that might ensue upon the occurrence of an accident under dif- ferent circumstances. If the Spring Lancet is preferred, it should be held Fi^. 188. between the fore-finger and thumb of one hand, with its blade obliquely to the circumference and axis of the vein selected ; so that, on the trigger or button being touched by the middle finger, the blade may be driven 292 BLOOD-LETTING. into the vein obliquely to its axis, and also a little on its side : as we are then less likely to wound subja- cent parts. If, however, the Thumb Lancet is the one used, bend its blade to a right angle with the handle, and place it in the mouth, with the point of the blade turned from the hand that is to take it. Otherwise, when, after completing the preliminaries, we put the hand to the mouth to seize the instrument, we should be apt to injure ourselves by sticking its point into our own hands. In using this lancet, seize the blade between the thumb and fore-finger of the hand that we prefer, and rest the third finger of the same hand on the arm as a point of support. Then placing the point of the lancet on the vein that we wish to open, push it suddenly inwards, upwards, and outwards; depressing the han- Fig. 189. die in a circle, so as to make a free incision in the line before spoken of : and having drawn the amount desired, undo the ligature above the elbow, seize the skin about the openingbetween the thumb and fingers, so as to close the wound, and wiping the arm clean from the blood, place a small compress over the BLOOD-LETTING. 293 opening, confining it by adhesive strips, or by a figure of 8 bandage of the elbow, as before shown, and the patient comfortable. Particular attention should be paid to the cleansing of the lancet after the operation, in order to prevent difficulty at our next call for its use : as a dirty lancet frequently causes abscesses of the part, gives rise to phlebitis, and endangers the life of the patient. If the opening in the skin and that in the vein do not correspond, a bloody tumour, called a Thrombus^ will be formed, from the blood escaping into the sub-cutaneous cellu- lar substance. To remove this, enlarge the opening in the skin, and press upon the tumour ; or else leave it to be absorbed by nature, assisted by moderate pressure. In Bleeding in the Hand, the only rule, is to open with a Thumb Lancet, that vein which is most easily seen ; these are generally the Vena Salvatella, or the Cephalic of the Thumb : avoiding the tendons, and also guarding against a deep puncture, for fear of injuring the parts beneath. Bleeding in the External Jugular Vein, is sel- dom practised, on account of the danger of the in- troduction of air into the vein. In cases however of great cerebral congestion, as in apoplexy, or in infan- tile convulsions, it is occasionally practised, and we think with advantage. When deemed necessary, it should be done as follows : — Place a thick, graduated compress on the root of the vein just above the clavicle, and fix it by a nar- row cravat, the ends of which should tie in the opposite axilla, Fig. 190; or else apply an oblique bandage of the neck and axilla, as before shown : or, we may compress the vein with the thumb, though by this plan there is more danger of the entrance of air into the vein, from the compression being more imperfect. 294 BLOOD-LETTING. If the vein does not become apparent from this com- pression, direct the patient to move the jaws as in mastication, and, it will soon fill. When filled, open it with a Thumb Lancet at its lower third, and place a bent card, or other substance likely to form a little trough, just below the opening, so as to carry the Fig', 190. blood off to the receiver, and prevent its trickling down the side of the patient. Having taken the amount desired, close the orifice, as in the arm, by pressure of the thumb and forefinger, and fasten a compress over it by adhesive strips before removing the compression which filled the vein, as we thus ensure the non-entrance of air, which is very apt otherwise to prove almost instantly fatal. Bleeding at the Ankle, is generally performed, in the internal saphena vein just above the malleolus, BLOOD-LETTING. 295 191. where it is very superficial, though it is also occa- sionally done in the foot itself, or in the external saphena vein. Operation. — In order to bleed in this part, we re- quire the ligature, &c., as in the other cases, and also, a bucket of warm water, in which to plunge the foot previous to the operation. The patient being seated, the limb is placed in the hot water as high as the calf, in order to assist the filling of the vein and ren- der it more apparent. After some few minutes, it is then to be removed ; the ligature applied about four or six inches above the malleolus, and the heel placed upon the point of the operator's knee, or on a low stool. A thumb lancetbeingpreviouslyheld in the mouth, and the vein, steadied as before shown, is then seized with the hand which is most convenient, and the vein opened by a wound which should be rather longer than the one made in the arm, in order to give a free discharge to the blood, Fig. 191,whichhere seldom escapesin a stream; it being more commonly necessary to replace the limb in the warm water, in order to facilitate the flow of it, than to see the blood flow in a jet. The wound should not, however, be allowed to sink into the water, but remain just above it, whilst the amount of blood taken, must be judged of by the discoloration of the liquid. When sat- isfied as to the proper quantity, it only remains to remove the ligature, wipe the limb, and confine 296 BLOOD-LETTING. a compress over the opening by the figure of 8 band- age of the ankle. The only accident likely to result from bleeding at this point is, the wounding of the saphena nerve : the arteries being distant. Should the nerve be wounded, either in this or any of the other operations, it will be shown by pain, by twitchings, tingling, &c. To treat this, we should apply a warm poultice ; keep the limb at perfect rest for a couple of weeks, and use the anti-phlogistic system generally. Bleeding is occasionally followed by irritation of the edges of the wound ; by abscess, or by erysipelas. Any of these will be best combated by the use of the above means in the first stage, and such subse- quent treatment as the knowledge of each practi- tioner will readily indicate. From want of proper attention in the selection of the vein, or from w^ant of skill on the part of the operator, it occasionally happens than an artery is opened. This serious accident may be readily told by the brighter red colour of the blood ; by its esca- ping in jets which are synchronous with the pulsa- tions of the heart ; by the blood continuing to flow, notwithstanding firm compression of the vein below the opening; or by noticing the change in the colour of the blood produced by a very firm compression of the artery alone, above the ligature. When thus satis- fied of the nature of the accident, we should endea- vour to guard against our suspicions of it, being seen by those around, in order to prevent alarm ; and if the state of the health of the patient does not absolutely forbid it, let the blood flow till fainting is induced, when we may arrest it by a firmer compression, than is requisite when the vein alone is opened. To do this, make, by means of several small graduated compresses, or by a thick pyramidal compress, a cone, the point of which should rest upon the wounded vessel ; fix it by a BLOOD-LETTING. 297 firm figure of 8 bandage of the elbow, and apply the Spiral of the Upper Extremity, from the fingers up to the upper part of the limb. This treatment should then be continued for fifteen days or more, by which time the closure of the opening in the vessel is gene- rally effected ; when most probably an operation for aneurism will be required, though this is not abso- lutely certain : Velpeau and others having seen cases in which the opening in the artery closed, without there having been at any time sufficient compression, to stop the pulsation at the wrist. Let it, however, be remembered, that proper attention will enable us to avoid this serious accident, and that when it happens, it will generally be the fault of the operator. Besides the veins above mentioned, bleeding was formerly practised in many others, as the occipital, auricular, frontal, sub-lingual, dorsalis-penis, &c., but the introduction of leeching has done away with these operations. Where, however, leeches cannot be had, and it is desirable to take blood directly from the part, these veins may be opened by ope- rating as in other veins. Such operations should always be performed with a Thumb Lancet, the ori- fices in the external veins being afterwards closed by a compress, adhesive strips, &c. ; and that in the sublingual, &c., by the application of cold, or salt and water, or astringents, &c. ARTERIOTOMY. This operation, which was practised to some extent by the surgeons of the sixteenth, seventeenth, and eighteenth centuries, and highly thought of by Hippo- crates, Galen, and Celsus, has been almost entirely abandoned by those of our own times, no one now ever thinking of bleeding in the radial artery, or opening the lingual, or those of the mastoid region, and very few of opening the temporal. Should this, however, be deemed proper, and should there be no 298 BLOOD-LETTING. Other way of drawing blood from the part to be bene- fited by the operation, the anterior branch of the tem- poral should be selected, and not the main trunk. Operation. — The patient being seated, with the head supported, or else lieing down, we feel for the pulsation of the vessel, about fifteen lines in advance of, and above, the meatus auditorius externus, where the artery is almost without the temporal fascia, close under the skin, and well supported by bone behind. Then, with a lancet or bistoury, we cut the vessel in half transversely, either by cutting from the skin inwards, or, what is better, from within, outwards, as in Fig. 190, the instrument being previously intro- duced below the vessel. The artery should not be opened longitudinally, as the veins were, because the contraction of its muscular coat would tend to close the orifice, and stop the hemorrhage. As soon as the vessel is opened, the blood fiies in a jet, and may be either received directly into a basin, or else drawn off by a bent card or trough, as in the operation on the jugu- lar vein. Should the bleeding tend to stop before blood enough is taken, we should apply warm clothes to the part, wash out the clot, &c. ; but if enough has been taken, compress the artery below the puncture ; close the wound ; apply a compress, and fasten it either by a simple circular bandage of the vault of the cranium, or by the knotted bandage, shown before. We repeat, however, that the ope- ration, at the present day can hardly or ever be neces- sary, whilst the subsequent effects, from the forma- tion of aneurism, or the scar from the tieing of the vessel, are disagreeable and troublesome. LOCAL BLOOD-LETTING. The name of Local Bleeding is generally given to that in which the smaller vessels and those close to the diseased part, are opened. This is practised by means of Leeches, Cups, or Scarifications. BLOOD-LETTING. 299 LEECHING. The Leech is an animal of the inter-vertebrated articulated family, Annelidese, that has been employed in medicine from almost time immemorial. This spe- cies, Hirudo Medicinalis, is an aquatic worm, with a compressed bodytapering towards each end, and ter- minating in circular flattened disks ; the hinder one be- ing the larger of the two. It swims with an undulating motion, and moves when out of the water by means of these disks or suckers: fastening itself first by one, and then by the other, and alternately stretching out and contracting its body. The mouth is placed in the centre of the anterior disk, and is furnished with three cartilaginous, lens-shaped jaws, lined at their edges with fine, sharp teeth, which meet so as to make a triangular incision in the flesh. It varies from two to three or four inches in its length, and inhabits most of the marshes and running streams of Europe, and many parts of the United States. Leeches afford the most effectual means of abstract- ing blood locally, as they are often applicable to parts which, from their situation or great tenderness, would not admit of the use of cups, and, in the case of in- fants, are always preferable to the latter. In order to apply them with ease to any part, care should be taken to free it, by washing, from all medica- ments; and by shaving off* all the hair or down on the skin. Jf the leech is very active or hungry, it will read- ily attach itself to the part when thus cleansed : but ge- nerally, it is necessary to moisten the surface with a lit- tle blood, or with milk, or with sugar and water, when the leech will readily leave the vessel containing it, and attach itself to the skin. If it is desirable to at- tach it to any one point, place it in a large quill or glass tube, and put this directly on the part ; when, as the animal cannot escape, it will readily attach itself. But when the part is not so circumscribed, it suffices to apply the edge of the cup holding them, just below 300 BLOOD-LETTING. the point, and let them crawl on to it ; or place them under a tumbler, which confines their wandering, and causes them to attach themselves to the portion be- neath. (Fig. 192.) Where blood is wanted to induce them to bite, it may be readily obtained by tieing a string tightly Fis^. 192. round the extremity of the finger so as to render it turgid, and then lightly pricking it with a lancet ; the blood escapes in points, and may then be smeared on the body. This operation causes no pain, unless very often repeated on the same finger. Leeches continue to draw blood until they are gorged, when they drop off themselves ; but if it becomes necessary to remove them before they are thus filled, it should be done by washing them with a little salt and water, and not by pulling them off; as this is very apt to leave the teeth in the wound, be- sides being destructive to the leech. Six American leeches are calculated to draw one ounce of blood ; but as their bites frequently bleed as much as the ani- mal itself drew, this is but an approximation to the quantity. Some persons are in the habit of cutting off the tail of the leech, in order to cause it to con- tinue sucking for a long time, as the blood passes out BLOOD-LETTING. 301 as fast as swallowed ; but it is a barbarous practice, and of course destructive to the utility of the animal. After the leech has come away, the bites continue to bleed, and this is often encouraged by the application of flannels, and cloths wrung out of hot water. But if we do not desire this extra amount of blood, cover their bites with a piece of linen moistened in sweet oil, or spread with fresh lard or cerate, to prevent its adherence to the wounds. Occasionally, it happens, in the case of children or weakly individuals, that the after bleeding is profuse and debilitating. To arrest it under these circumstances, it is only necessary to touch each bite with a sharp-pointed piece of lunar caustic, which will effect it almost immediately. A hot needle, stitches, &c., have been recommended, but the caustic is better, and more readily applied. In our large cities, where leeching is the peculiar business of a class of individuals, there is generally no difficulty in their employment ; but with the country practitioner it is different, as he must preserve and apply them himself, and this is thought to be very troublesome. Let it, how^ever, be recollected, that their application is sometimes a matter of absolute necessity ; that, as above shown, it is simple, and two of the objections to their use are removed. Their preservation is then the only point of difficulty. The leech, when gorged, remains inactive or unfit for use for several weeks, and is also liable to disease, by which numbers are lost. All that is necessary to guard against this, is perfect rest in a vessel of fresh water ; in a few weeks they will again be fit for use. The preservation of them by the following rules is easy, and always ensures a supply. Never squeeze them to cause them to disgorge, it brings on disease ; but place them in clean water, and change it frequently ; a glass jar answers every purpose. Then, in order to keep them in health and ready for use, place them in a large tub or trough, six or seven inches deep, in a 302 BLOOD-LETTING. cool place, with a mixture of moss, turf, and frag- ments of wood at its bottom, with a few stones on this to keep it in its place. Place also, at one end, a piece of wood or earthenware filled with small holes and covered with a bed of moss, so that the leech may keep up^ its natural habits, and by drawing itself through the holes in the board or through the moss, sticks, or stones, free itself from the secretion of slime found on its body, which otherwise becomes the cause of disease. By changing the water occasionally, and keeping the trough or tub covered with a piece of muslin, in a cellar, any practitioner can always have a supply of these useful animals at his command. Let it be recollected, however, that those which have been used, are to be kept separate from the others for about two months, when they may be replaced in the trough till again called for. If, in applying leeches to any point of the body whence they might escape to internal parts, as about the anus, the mouth, &c., they should remain in these parts, they may be at once destroyed and ejected, by the free use of salt and water, either as an emetic or enema. But the fear, of any internal injury from them is groundless, as the heat and other peculiarities of the parts will at once destroy them. CUPPING. By the word Cup, is understood a little bell-glass, three to four inches high, from which we exhaust the air, so that when applied on the skin it may cause a congestion and rising of this membrane, from the pressure of the atmosphere upon the parts around the cup itself. These cups differ chiefly in the manner in which the air within them is exhausted ; some being slightly open at the top, and fitted to receive the end of a small air-pump : others being entirely closed and exhausted by the use of fire applied inter- nally in different ways. When the flesh is cut BLOOD-LETTING. 303 after the application of the cup, the blood will flow freely from the incisions, when the exhausted cup is again placed over them, though it could not do so previously. This is termed cupping, or the applica- tion of wet cups, in contra-distinction to dry cupping, or that in which the cup is applied merely to irritate the part, without any scarification or drawing of blood. When we desire to exhaust a cup, it may be done either with the pump, by fitting it to the cup as pre- pared for it, applying the latter closely to the part, and then working the piston once or twice as in any ordinary pump : or by the use of fire to rarify the air within the cup itself. With this view, various means have been employed. It may be rarified either by the rapid insertion of a candle or little torch, and the instant application of the cup to the part ; or else, the fire may be placed in the cup and it at once put on the skin. To do this, some shake a little alcohol around the inside of the cup, pour out what flows readily, and inflame the little that adheres to the glass by a lighted piece of paper ; others introduce small balls of inflamed cot- ton saturated with alcohol ; others simply use pieces of burning paper ; but the two last cause unneces- sary pain, from burning the skin on which they fall. The best and neatest way of exhausting the cup, is the following. Cut several pieces of letter-paper slightly glazed, into strips about one inch and a-half wide. Wrap this round the end of the fore-finger, so that about one-third of its width shall project beyond the end of the finger, and having thus formed a little tube, tear off" the rest of the strip and twist the part projecting beyond the finger, so as to close up the tube, and form a little cap like a thimble. Dip the open end of this, lightly, into alcohol; a small portion will adhere to its glazed surface ; touch it in a candle ; throw it into the glass, and apply the latter at once to the part. The shape of the cone is such 304 BLOOD-LETTING. that it will nearly always fall on its apex, or the twisted end, whilst the part wet with the alcohol, or the base, will stand uppermost and sufficiently far from the skin to prevent its being burnt. Having by either of these modes exhausted the cup, allow it to remain on the surface of the part till the skin under it has become turgid, when, if blood is to be taken, cut it by means of the Scarificator, and re- apply the cup as before ; removing it when filled or half filled with blood, and again applying it, if necessary. In order to remove the cup, introduce the nail of the fore-finger under its edge, and gently force the cup on to its side, so as to allow the air to enter. After wet cupping, the parts are to be cleansed, and co- vered with cerate or an oiled rag. If the regular cupping apparatus, as furnished by the cutler, is not at hand, we may perform the ope- ration very well by using wine-glasses or tumblers ; scarifying the parts if blood is to be taken, by rapid punctures of a thumb-lancet, bistoury, or sharp pen- knife. CUTANEOUS IRRITATIONS. 305 CHAPTER II. OF CUTANEOUS IRRITATION. Another useful means of producing depletion, is by means of the cutaneous exhalents, or the establishment of serous and suppurative discharges by means of arti- ficial irritation. These inflammations are usually created on the surface of the body, with the view of relieving some internal inflammation or disorder, that is more dan- gerous to the life of the patient, than the one thus ex- cited, and when properly directed, are possessed of great power. Acting on the principle of revulsion, they relieve internal congestion and inflammation, by draw- ing the fluids to the surface : relieving internal conges- tion with as much certainty as any of the usual means of blood-letting ; whilst they are usually applicable to cases where the latter means would not be generally available, as in the chronic phlegmasiae, &c. To explain fully their modus operandi, or enter more in detail into the cases for their application, would lead to the consideration of points foreign to our present arrangement, and we must therefore con- fine our remarks to their production alone ; and first OF BLISTERS. The simplest drain that can be created on the sur- face of the body, is that arising from the formation of a Blister. This, which generally consists of an oint- ment of cantharides, creates only sufficient inflamma- tion to cause an effusion of serum under the cuticle, by which the epidermis is separated from the subjacent structure, and forms a cyst. On evacuating this cyst or 20 306 CUTANEOUS IRRITATIONS. vesicle,theslightulcerwhichisleftj usually heals kindly under the use of simple dressings, without much dis- charge. Butif it be desirable to make a more permanent impression, and continue the drain, instead of merely evacuating the fluid first secreted, we should seize the cuticle with a pair of forceps ; and either cut or tear it fromthe inflamed surface; then dress the excoriated por- tion with some stimulating ointment, as that of savine ; of cantharides; ofmezereon ; orcabbage,orbeetleaves ; or with any of the similar ointments of the Pharmaco- poeia. By these means, a permanent blister, as it is termed, may be kept up for six or eight weeks, though usually the discharge is continued with difficulty after this lapse of time. In such cases, the following plan will increase it and create an issue on the blis- tered surface. Take two or more peas, made of orris root, and bind them firmly to the part, through an opening made in the cerate which covers the rest of the sore, and continue the pressure until they ulcerate into the true skin ; when, by the use of any of the previous ointments, the discharge may be kept up for any period that may be desired. The blister, however, is not often employed in this way, as issues can be more readily created, and with less pain to the patient, by the means hereafter mentioned. When it is desirable to raise a blister in a very few minutes, as in cases of collapse, concussion, &c., the fly blister commonly employed will not an- swer, as it is too slow in its operation. Resort must therefore be had to something more active, such as compresses wrung out of scalding water and applied directly to the part ; taking care to prevent the escape of the liquid over surrounding parts. Or, a piece of thin soft paper saturated with spirits of turpentine, or alcohol, may be pressed firmly on the body ; set fire to, and allowed to burn for a few seconds. This raises a blister with great rapidity, but is extremely painful to the patient if consciousness is at all perfect. A plan recom- CUTANEOUS IRRITATIONS. 30^ mended by Sir Anthony Carlisle, was to lay a double folded piece of moistened linen upon the portion to be blistered, over which a flat cautery iron was passed, heated to a reddish-brown heat. But a neater plan than either of these will be found intheuseofGranville'sstrongrubefacientlotion,orpure Aqua Ammonia, applied directly to the spot by means of patent lint, or pieces of flannel saturated with it. This powerful remedy requires but a minute or two to raise a blister, if the ammonia is pure ; but like the hot water, requires caution, to prevent its flowing over surrounding parts. The best means of preventing this is to place the lint in a pill-box or wine-glass, and then press it against the skin : the edges of the box or glass circumscribing the action of the lotion. As the ointments before mentioned will tend to in- crease the effect of a blister, and augment the dis- charge after its production, so a mild soft poultice of any warm emollient substance, will generally diminish it when the inflammation runs too high. ISSUES, Are drains, thatare most generally caused by the action of some substance, which, by destroying the tissue, cre- ates a discharge in consequence of the efforts of nature to repair the damage. Two classes of agents possess this power : J st, Chemical Agents or Caustics, as com- monly designated, and 2d, Heat, or the actual or poten- tial cautery. Each of these, by destroying the organisa- tion of the skin, creates a dead mass called an eschar; this, being thrown off' by nature, leaves a cavity, which being filled with issue peas, or some irritating substance, keep it open and continue the discharge. Chemical Agents, or Caustics, are those most com- monly used. They may be employed in three forms, solid ; liquid ; and as paste. Of the solid kinds, we have the Potassa, or Kali Purum ; the Nitrate of Silver; the Bi-Chloride of Antimony, &c., all of which 308 CUTANEOUS IRRITATIONS. act in the same manner : though the caustic potash is the one most generally preferred. In using this article, it is desirable to select such a spot for its application as will not involve any deep- seated important parts. Thus superficial joints ; arte- ries ; nerves; bones, &c., should be avoided, less the action of the caustic extend to them, and produce serious injury. Issues are therefore, most generally established in the fleshy part of the arm, or thigh, or on the back of the neck, or along the spine. If we choose the thigh, the depression which exists on its inner side, just above the knee will be found conve- nient ; if the arm, (and this is most common) take the space between the biceps and the deltoid, near the in- sertion of the latter. Then layingupon the spot selected, a piece of adhesive plaster, or kid spread with soap ce- rate, with a hole in its centre of the size desired for the issue, (generally about three lines in diameter), rub the integuments within this hole with a piece of the caustic potassa, till they become black, and repeat the operation each day, until an eschar is obtained of the desired depth. This usually should not be deeper than the integuments, lest it extend beneath the fascia, and produce subsequent trouble. Or, place in the opening of the plaster, a piece of potassa, about the size of a hemp-seed ; cover this with a strip of adhesive plaster, and apply over this a compress and bandage. After twelve hours, on re- moving the plaster, apply a warm poultice, in order to hasten the separation of the slough : which on coming away will leave a deep circular ulcer. This should then be filled by three or four peas made of Orris Root or Gentian, which by absorbing the mois- ture, swell, and distend the ulcer. Should they how- ever not prove sufficiently irritating, the ulcer may be dressed with Basilicon, Mezereon, or some other stimulating ointment. The daily dressing, subsequently used, must de- CUTANEOUS IRRITATIONS. 309 pend upon circumstances. Thus fungous granulations must be repressed by the nitrate of silver ; suppuration kept up by moving the peas, and by the ointments just stated ; and too much inflammation prevented by the use of warm poultices, and mild cerates. The re- moval of the peas, and the use of simple dressings, will generally suffice to heal the sores. In order to protect the ulcer from accidental inju- ries, and also keep the patients' clothes from being soiled by the discharge, it is usual to cover the part with a small plate of tin, or some other light metal, moulded to its shape, and fastened by an elastic band which surrounds the limb. These little bandages are generally kept by the cutlers or druggists, and add much to the patient's comfort. When in the production of an issue, any apprehen- sion exists of the action of the caustic extending too deep, we may neutralise it by an appropriate article. Thus, washing the part with vinegar, will neutralise the caustic potash ; salt and water that of the nitrate of silver ; magnesia, or some other alkali, that of sul- phuric acid, &c. The formation of issues by incision, has so little to recommend it, that we shall pass it by. When other means cannot be had, iron heated in the fire may be substituted, for the caustics just mentioned. Heated to a white heat, and applied directly to the skin, the actual cautery immediately produces an eschar, which follows the same course asthat created by caustic. The fears of patients, and the greater convenience of other means, have thrown this out of general use. The Sulphuric, Nitric, and Hydrochloric Acids, are occasionally employed, when some objections exists to the means just stated. In order to use them, steep a small compress of patent lint fixed to the end of a small piece of wood, in the liquid, and apply it directly to the skin, guarding against the extension of the acid over surrounding parts. The esehar thus 310 CUTANEOUS IRRITATIONS. made is then treated, as before stated. In the treatment of bites from rabid animals, the liquid caustics are preferable to the others, as they spread more rapidly ; but the wound should in these cases always be enlarged, previous to their use. OF SETONS. A Seton is one of our most powerful means of keep- ing up a cutaneous discharge. Strictly speaking, the seton itself is merely the band or substance employed to irritate the part ; though the same name is given to the operation by which this band is introduced be- neath the skin. Its use is now very generally con- fined to the back of the neck, though it may be also applied to certain other parts, as the fleshy part of the thigh, or arm ; but for these points, issues are gene- rally preferred. In order to apply a seton, we require a sharp cut- ting instrument to make an opening through the in- teguments : and some strip, which, when introduced, will, by its irritation, keep up a suppuration from the part. For the insertion of the strip we have two instru- ments, Boyer's Seton-Needle, and a common straight bistoury and eyed probe. The first consists of a flat steel blade, about five inches long : six lines wide, and perforated at one end with a hole large enough to receive the strip to be introduced ; the other end is sharp, and sloping to a point like a thumb lancet. To introduce the seton with this, first fasten the substance to be used, in the eye of the needle, and then seizing a portion of the integuments of the required width, between the fore- finger and thumb of one hand, raise it up from the parts below, and transfix its base by forcing the nee- dle through : drawing it and the seton out on the opposite side to that on which it entered, so as to leave the seton in the wound. After which, its ends should be fastened down to the part by a little piece CUTANEOUS IRRITATIONS. 311 of adhesive plaster, and the whole covered for the first three days by a warm poultice, till suppuration com- mences ; when a simple dressing is all that is requisite. The objections which we have to this method are, that the seton- needle is not always at hand, that the fastening of the seton in its eye is apt to make a thick mass, which passes through the opening with difficulty, and that it is hard to hold the point of the needle, when wet with blood, so as to draw it through. We thereforepreferthestraightbistouryand eyed probe. To use this, fix the seton by a thread to the eyed Fig 193. probe ; seize the integuments as before ; cut them with the bistoury, and before removing it, introduce the point of the probe from the opposite side, and with- drawing it and the bistoury at the same time, insert the seton in its place (Fig. 193). In respect to the substance of the seton, there is much diversity of opinion. But let the substance be what it will, it must always be well anointed with 312 CUTANEOUS IRRITATIONS. ointment previous to its introduction, and also pre- vious to any movement of it through the wound in subsequent dressings, in order to facilitate its pro- gress or increase its action. For the first three days the poultice is stained by blood, or slight oozings ; but afterwards by pus. When suppuration has freely commenced, the substance of the seton becomes charged with matter, which, if allowed to remain, ren- ders it very offensive. At each daily dressing, therefore, the seton should be drawn through the wound till this soiled part is free, when it is to be cut off, and the ends fastened down and dressed as before with simple dres- sings ; the whole being confined by a circular bandage of the neck, as at Fig. 33, or by a sling, as at Fig. 85. But as the seton by this operation is soon cut up, it will be necessary to prepare for the introduction of a new one. This is readily accomplished by attaching it by a few stitches to the old one ; anointing it well, and drawing this into its place, as the old one is re- moved. A skein of saddler's silk, or a piece of silk braid, is the article most frequently employed ; but where we can obtain a strip of gum-elastic, or braid or tape coated with it, they will be found to be much more cleanly than the silk. For the cases requiring the use of the seton, and for the period of its duration, we must refer to other works. OF MOXA. This is the name given to little rolls of inflammable matter, intended to cause eschars and subsequent issues, by being allowed to burn upon the integuments until they cause its destruction. These are made of various substances, as cotton, lint, tow, &c., soaked in a saturated solution of nitre ; dried and then wrap- ped up in little bags ; or, rolls of silk, or muslin, sewed together at the sides, formed into rolls and coated with gum ; or we may use the common punk, as found in the shops of the tobacconist, cut CUTANEOUS IRRITATIONS. 313 into pieces about one inch long. The application of any of these cylinders is very simple. Having chosen a spot where the subjacent parts of importance are not likely to be injured by the extension of the inflam- mation, place upon it a piece of moistened cloth, with a hole in its centre large enough to receive the moxa. This cloth is intended to preserve the sur- rounding parts from the sparks which sometimes escape. Next see that the end of the moxa is applied to the body flatly, so that it may fit itself accurately Fis'. 194. to the surface, and moisten it with a little gum to make it adhere ; or else hold it firmly on the part, by a pair of forceps, or a porte-moxa or metallic ring, as in Fig. 194. Having now lighted one end of the cylinder, keep up the combustion by the breath, or by a pair of bellows ; the latter being necessary where the smoke irritates the bronchia too much. In its 314 CUTANEOUS IRRITATIONS. burning, the patient first feels a gentle heat, which gradually increases, until, as the fire approaches the part, the pain for the moment becomes excruciating, and then destroys entirely the vitality of the skin. The eschar thusformed is afterwards treated like the eschar formed by the caustic issue ; the subsequent treat- ment being similar to what has been there said. X PUNCTURES. 315 CHAPTER III. OF PUNCTURES. In various cases of accumulation of liquids and gases within the cavities of the body, it is found ne- cessary to evacuate them by a class of operations which divide the tissues in a manner somewhat analogous to incisions, yet differing from them in the instruments employed, and in the method of using them. In these cases, perforations are made by sharp- pointed instruments of different kinds, which are pressed or pushed beneath the skin, by a sudden movement, so as to divide the tissues by pressure, instead of by the saw-like action of the knife or bistoury. Under this head we shall therefore treat of those ope- rations requiring the instruments and movements re- ferred to ; excepting^such as have been already spoken of, under another head. OF ACUPUNCTURATION. The simplest puncture, that can be termed an operation, is that made by the introduction of needles under the skin. With the exception of their employment in exploring doubtful tumours, &c., their use is mainly confined to what is known as Acupunc- turation. This consists in making a number of small punctures in the skin by means of needles of gold, silver, platina, or steel, shaped as in Fig. 195, and introduced into the part by rapidly rotating them be- tween the fingers. Marked benefit in certain cases, was said to have been derived from their use, and as they caused but little pain, the operation was at one 316 PUNCTURES. time quite popular. Employed from an early period by the Japaneese, and others, in order to relieve va- rious internal disorders, so rapid was their action, that miraculous powers were wildly ascribed to them. Fig. 195. A Subsequent investigationshavenothowever, supported this, and the want of success drove the operation therefore into comparative disuse. Without, discuss- ing the advantages of the operation, we shall, therefore, no w simply detail the method of its performance. The place being chosen, take hold of the head of the needle, or of the handle into which it is sometimes inserted, with the thumb and fore-finger of the right hand, supporting its stem with the thumb and fore- finger of the left. Press it, with a rotary motion, to the depth of several inches if requisite to reach the seat of pain, and leaving it there, introduce several others at slight distances apart. If the needles are sharp, and rotated rapidly, the pain of their introduction is very slight, and in certain neuralgic cases especially, their use is even said to be agreeable to the patient. But without trusting to the effects of imagina- tion, we should liave more confidence in another method of treating such patients, which has an addi- tional recommendation in the employment of a nar- cotic. This consists in making numerous punctures with these needles, or with a sharp-pointed lancet, so as barely to draw blood, and then washing the part with a strong solution of sulphate of morphia. The ap- plication of the anodyne thus directly to the seat of pain, PUNCTURES. 317 is said to relieve it very quickly, and must, we think, prove serviceable : although we have never had occa- sion so to use it. ELECTRO-PUNCTURE. The advances lately made in the science of gal- vanism and electricity, has again brought into use the operation of electro-puncture. This operation is the same as the preceding, so far as the introduction of the needles : but differs subsequently, in its being aided by the action of the electric fluid directly on the diseased part. In using this fluid, we must of course be governed by its general laws, and if we wish to pro- duce only slight shocks, cause the spark of the appa- ratus employed, to fall indirectly on the head of the needle shaped as at A, Fig. 195 ; but if a more severe action is desired, keep up a continual current through the needle, by direct contact with it, of the poles of the machine. The Electro-Magnetic apparatus is ap- plied in the same way as the electrical machine, and it matters probably but little, in what way the fluid is applied to the needles, provided the circuit of the current is continued throughout them. The cases in which it is adapted, and their probable results, may be found fully treated of in most of our Dictionaries, under this head. VACCINATION. Nothing need be said at the present day as to the advantages of this operation. Trifling as is its per- formance, its proper effect, however, depends in a great measure on its correctness ; and passing by, therefore, much that has been stated in regard to the shape, size, and number of the punctures, we shall merely mention the plan that we pursue in operating, and have generally found successful. Scrape slightly the epidermis on the spot selected, 318 PUNCTURES. with a moderately dull thumb lancet, until it removes a small amount of the cuticle, in the shape of a light dust. As soon as the skin underneath becomes pink, or shows very minute points of blood, place a drop of the liquid from the pustule, or from the dried scab, softened and made liquid by water, upon it, and press it beneath the skin by three or four slight punctures with the point of the lancet (Fig. 196), just deep enough to tint the Fig. 196. matter with the blood, but not so as to make the part bleed freely ; then keep the arm exposed to the air until the matter dries or hardens. In order to guard against subsequent irritation, tie up the child's sleeve to the shoulder, or cover the spot operated on with a piece of fine linen. The choice of the lancet — the point of the arm to be selected — the age of the patient, &c., have all received much minute consideration in the different treatises on vaccination, which we think it is useless here to refer to. Suffice it to say, that the sooner a child is vaccinated after one or two months, the bet- ter ; that the point of insertion of the deltoid mus- PUNCTURES. 319 muscle on that arm which is furthest from the nurse when the child is carried, is generally the most con- venient place for the operation : and that a plan that answers well, is that just stated. The necessity for ob- taining good matter , renders the preservation of it a point of considerable importance, and various plans have been employed for this object and strenuously advo- cated by their especial supporters. Jenner received a drop of the matter, fresh from the pock, in a little hollow of a square piece of glass, which was then covered by another piece, and both luted together to keep out the air. Bretonneau, Friard, &c., of the French surgeons, employed glass tubes of a fine cali- bre, with the same view ; but in this section of the United States, the matter is generally preserved in the dried state, and transmitted from one point of the country to another by mail : being pulverised and moistened w^ith a drop of warm w^ater when required for use. A simple plan of preserving the dried scab free from the air, is to make a little hollow in a cake of bees-w^ax : then soften the surface of this and ano- ther cake by heat, or scrape them perfectly smooth, and after placing the scab in the hole made for its reception, press the two cakes together, so as to form an air-tight box. We have vaccinated successfully in several instances, with a scab nearly four months old, preserved in this manner. The appearance of the arm, on the different days after the operation, is a matter of vital importance in forming an opinion of the results of the case ; and as an error of judgment here, by giving the patient a false security might lead to sad consequences, we shall not pretend to enter fully into its appearance, but refer the reader to the larger works. Figure 197 is an attempt to represent the proper appearance of the arm at the third, seventh, eighth, ninth, eleventh and twelfth days after the operation. But it does so very imperfectly, owing to the absence 320 PUNCTURES. of color. Those unacquainted with it must, there- Fig. 197. •^li^^-' fore, consult some of the more finished plates on this subject, and only look to the cut, as an outline. PERFORATION OF THE LOBE OF THE EAR. The fashion of the day, and the taste of a numerous portion of the community, leading them to the use of rings in the lobe of the ear, it may occasionally happen that the practitioner will be called on to intro- duce them : although generally, this is the business of others. As serious inconveniences have, however, frequently resulted from this arrangement, involving materially the comfort and health of the individual, it would perhaps be better were the profession to have a closer supervision of this little operation than is now generally the case. PUNCTURES. 321 The perforation of the lobe of the ear may be ac- complished either by a large needle ; by a small trocar and canula, like that used in hydrocele ; or by a small punch similar to that employed by saddlers. In either case, the lobe should be steadily pinched between the thumb and fore-finger for a few minutes previous to the operation, in order to diminish its sensibility ; then placing a piece of cork beneath the point to be perforated, force the needle or punch rapidly through the flesh, so as to make a free open- ing (Fig. 198). Immediately on withdrawing the Fig. 198. instrument, introduce a waxed thread, or a fine leaden ligature, or a piece of catgut, and move it daily through the perforation, in order to prevent its sides from adhering. Not unfrequently this movement produces so much irritation and discharge, as to con- stitute a regular seton, and is occasionally employed by the lower orders of society with this view. But generally, after the lapse of ten days, the skin on the sides of the wound heals, and an opening is left through which the ear-ring is afterwards passed. 21 322 PUNCTURES. We have several times known instances when the needle was used, where the union of the w^ound has required the repetition of the operation : the punch by removing the piece, effectually prevents this, and is, therefore, the preferable instrument. The point selected for the perforation, should always be sufficiently far from the extremity of the lobe, to pre- vent the weight of the ring, or accidental catching of it by children, from tearing it out. When this happens, a marked deformity is produced, which, if the wound is not united soon after its production, w^ill require an operation similar to that for hare-lip. PUNCTURE OF THE MEMBRANE OF THE TYMPANUM, And that of the mastoid cells, might next be treated of; but they involve so many points of practice, as to exclude them, at present, from our consideration. PARACENTESIS ABDOMINIS, Or Tapping^ becomes necessary, whenever (owing to some general disease) a large amount of serum accu- mulates in the peritoneal cavity of the abdomen, and by its distension impedes the respiration of the pa- tient, or is otherwise productive of harm. As usually performed, a trocar and canula are employed, which, perforating the abdominal parietes, give exit to the fluid contained within it. The spot generally selected for the puncture, is in or near the linea alba, or two inches below the umbilicus: because we are here free from all danger of wounding important parts. The spot being chosen, place a broad band, slit at its extremities, into six tails, (like the bandage of Galen, p. Ill,) around the abdomen, with the tails crossed on the back of the patient, and direct two assistants to tighten it gra- dually as the fluid escapes, in order to force out the serum, and at the same time prevent the patient's fainting from the sudden loss of pressure on the abdominal vessels. The bladder being emptied. PUNCTURES. 323 the surgeon should next remove a small piece of the bandage, immediately over the point which he proposes to perforate, and holding the trocar, as represented in Figure 199, suddenly force it and the canula into the abdomen. Holding the canula Fis-. 199. in its position, and withdrawing the trocar, the fluid immediately escapes through the canula into the basin held in front of the patient. A tub or bucket should always be at hand, into which it may be emptied when required, as the amount of fluid is sometimes very large. After the evacuation of the liquid, the wound is to be closed by a strip of adhe- sive plaster ; the bandage tied tightly in its. place, and the patient put to bed and kept on strict diet. But as peritonitis frequently results from this ope- ration, simple as it appears, the young practi- tioner is advised to be careful of his patient for several days afterwards, and especially cautious of his diagnosis in the case of females. As the cause of the disease is not affected by the operation, it generally happens that its repetition is almost inde- finite, though the subsequent performance does not differ in any respect from the one just de- scribed. The kind of trocar used is somewhat a matter of taste; but we always prefer the flat instru- ment, as creating less pain and causing a smaller wound than that which is round. In either case, par- ticular attention should be given to cleansing the 324 PUNCTURES. trocars after the operation, as the rusting of the trocar in the canula frequently renders it difficult to withdraw the former. In one instance that came under our notice, the instrument was driven into the abdomen^ and the operator obliged to withdraw it, owing to his inability to free the one from the other. A little oil after using it, would have saved him this mortification. PUNCTURE OF HYDROCELE. The evacuation of serum from the Tunica Vagi- nalis Testis, is generally produced by means similar to those just detailed. The scrotum being firmly squeezed in the left hand of the operator, a small trocar and canula are forced into it, and directed ob- liquely upwards, in order to avoid injuring the tes- ticle ; this being generally found at the posterior infe- rior portion of the swelling. Should a trocar not be at hand, a thumb lancet may be used in the same way, and the wound kept open by a probe until the fluid is evacuated. But the trocar is far preferable, as it avoids the risk resulting from the escape of the liquid into the cellular tissue of the scrotum. The operation is, however, merely palliative, unless in- flammation of the serous cavity be afterwards induced. The Diagnosis of the disease concerned in these opera- tions is, we think, decidedly the most important point connected with them, and we would, therefore, invite attention to the means usually regarded as effectual in deciding it. In Ascites the previous his- tory of the case : the probability of pregnancy : or disorder of the liver, or heart, or kidney, or some other organ, will do much towards preventing mistakes. Yet even then, nothing but the absolute certainty of the effusion should render the operation justifiable. This may generally be proved beyond a doubt by placing PUNCTURES. 325 one hand, fully expanded, upon one side of the belly, and then tapping lightly and quickly, with the points of the fingers of the other hand, on the opposite side. The force of the tap acting upon the fluid, will drive it to the opposite hand, and a distinct succussion or fluctuation be perceived under the one first extended on the abdomen. Should flatus be present, the tym- panitic resonance will indicate it, but there will be no sensation given to the hand by tapping the fin- gers on the side of the belly, as is always felt, if there be a sufficient amount of eflfusion to justify its evacua- tion. In Hydrocele, the most certain test of its existence is the following : Place the patient in a dark room, and then grasping the scrotum tightly, hold a lighted candle as near it as possible, without burning the patient. The liquid, if serum, will be perfectly trans- parent, and the testicle be seen as a dark mass, wherever it may be situated. This, will also be found a most useful test in diagnosticating hernia; sarcocele, or haematocele ; as the appearances of these are en- tirely different from that of hydrocele. RANULA, Or an accumulation of the salivary secretion in the sublingual ducts, requires an operation not only to re- move the fluid, but also to guard against the perma- nent closure of the opening made. This operation may be performed either with a thumb lancet, bistoury, or trocar, by elevating the patient's tongue, and push- ing the instrument directly into the tumour, parallel with the alveolar processes of the lower jaw. After the escape of its contents, it is then necessary to introduce something into the wound to keep it open. A simple instrument, for this purpose, (analogous to that of Dupuytren,) may be made by bending a piece of fine stiff* wire, two inches long, upon itself, so as to give it the shape of the letter V, and introducing the 326 PUNCTURES. point into the cyst ; the elasticity of the wire being sufficient to dilate the opening until the chance of its union is past ; the patient being cautioned not to derange it. Breschet and others have thought that Ranula in- stead of being an obstruction of the duct, was caused by regular cysts. Be this as it may, the operation of excision of a portion of the surface usually suffices for their cure. OF SALIVARY CONCRETIONS. Depositions of earthy matter, chiefly phosphate of lime, are occasionally found in the openings of the salivary ducts, and when of any size, give rise to considerable inconvenience by impeding the enun- ciation and deglutition of the patient. When large, they may be readily removed by an incision on the parietes of the duct, and seizing them with for- ceps ; but when small, they are not so easily caught, as they slip back in the line of the duct. Under these circumstances, it has been recommended to cause the patient to chew any substance likely to excite the flow of saliva, after making a slight inci- sion ; the escape of the fluid generally bringing away the concretion. A figure of a salivary concre- tion, taken from Liston, is represented in the cut, and gives a good idea of their Fi^.2(i0, shape and size, though occa- sionally much larger. We have seen one which was so large as to fill up the space beneath the tongue, and resembles a large Ranula, except in the colour and consistence of the tumour. PUNCTURING OF ABSCESSES. The existence of pus under certain tissues, espe- cially under fascia, &C.5 renders its detection and PUNCTURES. 327 early evacuation often a matter of considerable im- portance, in order to prevent its extension, and the consequent injury of surrounding parts. To the young surgeon, and often to those more advanced, few things are more deceptive, and occasion greater doubt as to the evidences of its existence, than these accumula- tions of matter. In examining a deep-seated part where pus is suspected to exist, even when care is taken, deception is apt to follow, unless pressure is made in the proper manner, as may be readily proved by the following simple experiment : Place the mus- cles of the thigh or leg in a state of relaxation, and press on any given point with two fingers of each h?ind, aUernately ; the sensation of fluctuation will be so distinct as to deceive any one unacquainted with the fact. Now, if under the suspicion of the existence of pus, pressure is made in the same way, an opera- tion for its evacuation might be urged, and the prac- titioner mortified in not finding the matter, of whose existence he felt so certain. Previous then to opening an abscess, render the fluctuation apparent by the following means : Press one or two fingers of one hand, firmly on the side of the point suspected, and keep them thus firmly fixed : whilst pressure is first made and then removed, by the application of the fingers of the other hand. If mat- ter exists, it will be forced against the fingers first applied, and the fluctuation rendered certain ; whilst, if it does not, the deceptive movement of the muscles of the part, first referred to, will be prevented. The existence of pus being positively established, its evacuation by puncture may be performed either with a sharp-pointed bistoury, or abscess lancet, by plunging it into the collection at right angles to its surface, and enlarging the opening by cutting out- wards and upwards ; or by introducing it perpen- dicularly to the surface until it enters the cavity (as shown by the want of resistance,) and then cutting 328 PUNCTURES. outwards. Or, if the abscess is superficial, the bistoury may be thrust through it, and a free open- ing made simply by elevating the handle, and cutting from within outwards, as in Fig. 201. The subsequent treatment will depend upon the circumstances of the case. Of the use of Potassa for the evacuation of abscesses, we have nothing to say ; preferring the knife for this purpose. Fig-. 201. In large deep-seated abscesses or tumors, the con- tents of which are doubtful, the introduction of a grooved needle, or one somewhat coarser than those used in Acupuncturation, will frequently enable us to decide on their contents, and save much trouble to both patient and practitioner. ARRESTING HEMORRHAGE. 329 CHAPTER IV. OPERA.TIONS FOR ARRESTING HEMOR- RHAGE. The existence of hemorrhage generally creates so much alarm, and actually involves so much danger, that little need be here said, in reference to the im- portance of a proper plan of treatment : as common sense alone dictates the necessity of arresting it at an early period, lest its amount debilitate or affect the life of the patient. Of the various operations required for this purpose, the simplest is undoubtedly that of Pressure, which in common with the other means required, we shall treat of, without any reference to the physiology of their action. PRESSURE FOR ARRESTING HEMORRHAGE, May be applied, either by the Fingers ; by Compresses and Bandages ; by the Spanish Windlass ; or by the Tourniquet. In the first, the application of the force must de- pend much upon the position of the part, and the circumstances of the case ; and as the hemorrhage from the arteries is that which is of the most import- ance, we shall confine our remarks to it. When blood escapes from an artery, it does so in jets, cor- responding with the pulsations of the heart, and is of a bright red color. This jet generally shows the posi- tion of the injured vessel, and the origin of the he- morrhage, if superficially seated. The introduction of the point of the finger to the bleeding vessel, and pressure at that point, will therefore generally suffice 330 OPERATIONS FOR to arrest it, until more powerful means can be ob- tained. But if the wounded vessel is deep-seated, and the point wounded cannot be thus seized on, pressure must be made upon the artery, at some point of its course, above the seat of injury : that is between the heart and the wound. This pressure may be made either with the points of three or four fingers, closely placed together ; or by the thumb. If the Fingers are used, place their points close together in the course of the artery, and seize the opposite side of the limb with the thumb, so as to steady them, (Fig. 202) or place the point of the Fig. 202. thumb upon the vessel, and the fingers on the oppo- site side of the limb, and when the pressure fatigues the thumb, place that of the other hand on top of the first, and thus relieve it (Fig. 203). But even when possessed of great powers of endurance, few persons can continue this sort of effort except for a few minutes, and these means are therefore only available for a limited time, as the fatigue soon requires a re- lease of the hands employed. ARRESTING HEMORRHAGE. 331 When it is absolutely necessary to employ pressure, as upon the Sub-Clavian and Iliac arteries, a large key, wrapped around with bandage, so as to prevent the handle from injuring the soft parts, will prove an ex- cellent instrument, and far preferable to the fingers Fig. 203. or thumb, not only on account of the adaptation of its shape to the part, but also because the pressure may thus be continued for a greater length of time. The French surgeons frequently employ pressure for arresting the circulation in a limb during amputa- tions ; but as its success depends upon the strength and address of the assistant, we would not advise its em- ployment as a general thing, where a tourniquet can be had. The use of compresses and bandages for this pur- pose, has been already referred to (page 31), and require no addition to what was there mentioned. THE SPANISH WINDLASS, Is an excellent, every-day instrument, of considerable power, and yet of great simplicity ; it may be made 332 OPERATIONS FOR on the spur of the moment, by twisting a pocket-hand- kerchief, and tying a knot in its middle. Then plac- ing the knot over the vessel, tie the ends of the hand- kerhief loosely on the opposite side of the limb : and Fig. 204. introducing a stick into the loop formed by the ends, twist the handkerchief by turning the stick as repre- sented in the cut, (Fig. 204). THE TOURNIQUET OF PETIT, Which is the one most generally employed in the United States, should be applied as follows : Place a compress over the vessel, and surround the limb with two or three turns of a bandage, so as to bind the compress on the part, and thus protect the skin from being chafed by the strap of the instrument. Next place the plates, closely screwed together, directly over the compress, and strap it firmly in its place, without any reference to the position of the buckle, as the plates, and not the buckle, are to make the pressure. On screwing the instrument, the com- press will be firmly forced on the vessel, and the circulation arrested, in consequence of the separation of the plates by the action of the screw : the lower part of this being made to bear directly on the compress. Many surgeons, however, advise different plans from ARRESTING HEMORRHAGE. 333 the above, the advantages of each of which they ad- vocate ; but the one just stated, embraces, we think, the intention of the inventor, and is free from the objection of many of the accidents likely to arise from the use of the instrument, in other ways. In opera- Fig. 205. tions, the limb should be elevated a few minutes pre- vious to the application of the tourniquet, in order to empty the veins, and save the loss of blood which otherwise follows the division of the vessels. All these means of arresting hemorrhage, are however, temporary; and we caution the young practitioner against relying on them, for more than an hour, or an hour and a-half : as the arrest of the circulation in the limb for a greater length of time, might in some cases produce mortification. We once saw a thigh ampu- tated on account of a slight incised wound of the knee : which opening one of the small articular arteries of the part, gave rise to hemorrhage. This, an igno- rant practitioner attempted to arrest by the use of a tourniquet applied to the femoral artery, and kept there, notwithstanding the sufferings of the patient, 334 OPERATIONS FOR for two days ; when mortification became apparent. Whenever, therefore, it is necessary to arrest the flow of blood more permanently, the ligature or torsion must be resorted to. LIGATURES, Act by direct closure of the vessel ; and are made of various substances, according to the taste of the sur- geon. Provided they are not so fine as to divide the coats of the artery too rapidly, we believe that it matters little what material is employed ; silk, home- spun thread, shoemaker's thread, kid, catgut, lead, &c., rolled more or less round, will all answer the purpose. In order to apply the ligature to a divided vessel, it is necessary to pick it out from the surround- ing parts, and this may be effected either by the tena- culum or forceps. The Tenaculum being the instrument generally pre- ferred, is used by sticking its point into the vessel, and drawing it out from the wound, until the loop of the ligature can be tied over it. But if Forceps are preferred, seize the vessel with a pair of Liston's, which we think decidedly the best for this pur- pose, and draw out the artery as before. These forceps (Fig. 206), being fitted with teeth, and a spring Fi^. 206. in the handle, w^ill retain their hold of the vessel, even when allowed to hang, and thus enable the sur- geon to place a ligature without the aid of an assist- ant. The firmness of their hold has given them the nick-name of bull-dogs. ARRESTING HEMORRHAGE. 335 In tieing a ligature, one loop is usually thrown around the extremity of the vessel, beneath the in- strument and tied. Then forming a second knot on the first tie, draw it tight, by using the thumbs in the way that a shoemaker draws his wax-end. Various knots have been recommended, as least likely to slip ; among the most common of which are those known as the surgeon's and the sailor's knot. THE SURGEON'S KNOT, Is made by passing either end of the ligature, twice around the other, and drawing it tight. The figure (207), represents the left end, or that taken from the right hand, turned twice around the other, in order to form the knot, but not drawn tight. These turns, however, form a flat knot, like a figure of 8, and do not compress the vessel as tightly as the sailor's knot. It is therefore but little used at present. THE SAILOR'S KNOT, Like the clove hitch, is one, that when drawn tight, will hold very firmly, all that is included within it. Owing also to the firm compression that it exercises on the vessel, it is the one most frequently employed in tie- ing ligatures, as it divides the internal and middle coats more rapidly. In order to form it, tie a knot as 336 OPERATIONS FOR in the lower loop of Fig. 208, and then a second or third on top of that, draw- Fig'. 208. ing each knot firmly with the thumb as just referred to. Or, if the figure is not sufficiently plain, practise it as follows : take a turn of the ligature around the finger, passing from left to right, and bringing the right hand end around the left ; knot it firmly ; then bringing the left hand end around the right, reverse the first turns, and again knot it firmly. Should any doubt exist as to its firmness, a third or fourth knot may be formed on top of these, by the same turns : going first from left to right, then from right to left ; and afterwards continuing the turns from right to left, as required. In the application of ligatures to arteries in exten- sive wounds, one end should generally be cut off within a quarter of an inch of the knot, and the other brought out of an angle of the wound, in order to facilitate the removal. Occasionally, both ends are cut off, and the knot left to come away with the discharge ; but the first plan is preferable for many reasons. TORSION, Or twisting of the artery, arrests hemorrhage on the same principles as the ligature, so far as the coats of the vessel are involved : — viz. by lacerating the inter- nal and middle coat. It is performed by seizing the end of the vessel with a pair of forceps which close with a catch, and then rotating the instrument in the fingers, twist the artery upon itself. Although a favour- ite method with the French surgeons, and answering tolerably well for small vessels during extensive oper- ations (as it saves the time required for the application of ligatures), yet it cannot be permanently relied on ; ARRESTING HEMORRHAGE. 337 and we would not employ it except in the cases referred to, where ligatures may be subsequently applied if de- sired : as secondary hemorrhage not unfrequently re- sults from it. But if the hemorrhage comes from a deep- seated vessel, it is frequently necessary to cut down in its course, and throw a ligature by tenacula and other instruments, around the artery, above the seat of injury. These operations are, however, gene- rally so important, and depend so much upon the anatomical knowledge of the operator, that they would be misplaced if treated of here. Besides that just considered, hemorrhage not unfre- quently occurs from different cavities of the body : where, instead of one main vessel being the source, the blood comes from numerous small ones by a gene- ral oosing. Under these circumstances, styptics, or the introduction of foreign bodies into the part, in order either to make pressure or assist the formation of the clot, will be found necessary to arrest it. Among Styptics, the direct application of the Ni- trate of Silver to the bleeding surface, will, we think, prove the best, or, we may use the Tinctura Ferri Chlo- ridi, or Powdered Galls, or Sulphate of Iron, or Cop- per, or Zinc, or Acetate of Lead, or Alum, or Agaric, or Powdered Ice, or the Potential Cautery, &c., &c. But where the bleeding cannot be thus stopped, plugging up the part in order to assist in the formation of a clot, becomes necessary. PLUGGING OF THE NOSTRILS, In order to arrest excessive hemorrhage from this organ, requires the introduction of a foreign body not only into the nose in front, but also into the posterior nares. This may be best accomplished by Bellocque's canula armed with its stylet and ligatures, as follows : Pass the point of the canula along the floor of the nostril till it reaches the soft palate. Then pushing forward 22 338 OPERATIONS FOR the stylet until it comes into the front of the mouth, at- tach a ligature in the eye of the instrument ; then fast- en a small piece of lint, spread with cerate or oil, or of moistened sponge not more than an inch (Fig. E,209,) long, to the ligature; and drawing the stylet back into the canula, withdraw the latter and fasten the Fig. 209. plug in the posterior nares by pulling firmly on the ligature, or on one portion of the double thread which was attached to it : thus leaving one portion of the thread in the mouth, the other in the nos- tril. On stuffing the front of the nostril with any soft substance, the whole passage will be firmly closed, and it only remains to fasten the thread coming from the mouth to the cheek, by adhesive plaster: or to tie the end from the nose and that from the mouth loosely together to complete the operation. If the hemorrhage has been excessive, the plugs may remain three days, or at all events until a clot forms on the bleeding surface. When it is wished to remove them, pick out that in the front of the nostril, and introducing a probe, push the posterior ARRESTING HEMORRHAGE. 339 one into the throat: whence it may be drawn out of the mouth, by the thread that was left attached to it. If Bellocque's canula is not at hand, we may use a catheter with a double ligature fastened in its eye. This being passed through the nostril until the thread shows itself in the throat, it will be easy to draw the ligature out of the mouth by a pair of forceps : when after attaching the lint to it, the whole may be again drawn through the posterior nares and the thread con- fined as before. Sponge being softer and more ab- sorbent than lint, would be preferable as a plug, were it not, that it is apt to become very firmly wedged in the posterior nares in consequence of its expansion. HEMORRHAGE FROM THE RECTUM, Occasionally gives rise to most serious results, and re- quires to be arrested immediately, in order to preserve life. As in most cases it is the result of some operation upon the part, the most certain means of arresting it is to employ a rectum speculum, and if the vessel can be seen, to tie it. But when this is not possible, re- sort may be had to compression by means of cotton or lint stuffed into a bladder like a sausage, and forced into the gut. Cold water, or powdered ice may also be thus employed, provided caution is used, as to the effects of the cold on the system generally. The use of anything,however, thus introduced into the rectum, is accompanied by great inconvenience and difficulty of retention, from the expulsive efforts that it induces. In such cases, resort may be had to the actual cautery, after the plan of Dupuytren ; or where the bowel is kept distended with blood, the introduction of the nozle of a syringe, or a catherer, into the gut will probably prove useful by keeping it empty, and thus permitting the closer contraction of the parts about the bleeding vessel. 340 OPERATIONS, ETC. HEMORRHAGE FROM THE BLADDER, Is not of frequent occurrence, and still less frequently of such an extent as to require direct interference. Should it however occur, the principle to be observed would be, to keep the bladder perfectly empty by the use of the catheter, and employ cold externally or even introduced to the inside of the bladder itself, by means of a syringe and catheter. WOUNDS. 341 CHAPTER V. OF WOUNDS. These if of a simple kind and not involving parts of vital importance, generally require but little constitu- tional treatment : the attention of the practitioner being mainly confined to arresting the hemorrhage, remov- ing foreign matter, and promoting the union of the divided surfaces. Of the first, we have already spoken under its appropriate heading; the second will be treated of hereafter, and we shall therefore now confine ourselves to the third indication, or the union of the divided edges. Coaptation of wounds maybe accomplished by thriee means, that is either by Adhesive Straps; by Band- ages, as before stated, or by SUTURES. These stitches, are intended to approximate the sides of wounds, especially when seated in parts that are naturally loose and moveable. They are of five different kinds, as at present recognised, to wit : the Interrupted, Continued, Twisted, Quilled, and Dry. THE INTERRUPTED SUTURE, Which is the one most frequently employed, is made by introducing a needle similar to either of those in Fig. 210, armed with a simple ligature, through one lip of the wound from without inwards, and through the other lip from within outwards, at such a distance from their edges as will prevent the stitches cutting out too soon. Then drawing or pressing the sides of the wound together, tie the ends of the ligature moderately tight 342 WOUNDS. in a double sailor's knot, (Fig. 208) taking care not to put too much strain upon the parts, lest they cut through the skin. In using the needle, carry it deep Fig. 210. enough to obtain a firm hoJd, but not so as to in- clude the tendons or fascia : making the requisite num- ber of stitches at about an inch apart, and supporting them if necessary with a few adhesive strips or a band- F/§-.211. age (Fig. 211, A). When afterthe lapse of two or three days we wish to remove them, seize the knot with a pair of fine forceps, and cuttingthe thread, withdraw itcare- fully from the part: leavingthe adhesive plaster for a day or two longer, if required to preserve the union. When sutures are allowed to remain a longer time than this, ulceration is induced, which eventually removes them. This leaves a ragged sore, and a more marked cica- WOUNDS. 343 / trix, and as all the advantages of their use are ob- tained in forty-eight or seventy -tw^o hours, we invariably cut them out: generally at the end of the second day. Sutures are not as much employed as they might be, on account of the horror that patient's enter- tain of the use of a needle, in the flesh, and also of pre- judice on the part of some surgeons. But the more perfect adhesion gained where the parts are moveable, and the greater certainty of the continued approxi- mation of the edges by these means, are strong in- ducements to their employment ; and we must confess our predilection for them to a greater degree than that of most other practitioners. THE CONTINUED SUTURE, Also called the Glover's Suture, is made by passing a needle and thread through and through the integu- ments as in ordinary sewing, (Fig. 211, B). It is however seldom employed, except in wounds of the intestines, and in sewing up dead bodies, after post- mortem examinations. Another mode of making the continued suture, and one that answers very well where it is desirable to make considerable traction on the threads, is that re- presented in Figure 212. The needle is passed as represented in the cut, and as it includes more or less 344 WOUNDS. of the parts on the side of the wound, draws them together with almost as much firmness as the quilled suture. Like this, however, it is now but little used, but might we think be more frequently employed, in wounds of the thigh, buttock, &c. THE TWISTED, OR HARE-LIP SUTURE, Is made by introducing several pins through the sides of a wound at a depth sufficient to hold firmly, and then twisting a ligature around each extremity in the shape of a figure 8, (Fig. 211, C). In angular wounds, the first pin should be placed at the lowest angle, in order to ensure a regular adaptation of parts, and then the others introduced at equal distances, say half an inch apart. After forty-eight hours, the pins should be withdrawn by the forceps, with a slight rotatory motion ; but the ligatures may be left until loosened by the discharge, or subsequent dressings. In the selection of pins, there is much useless par- ticularity ; some surgeons directing silver pins with moveable steel points, in order that by their removal they may prevent the points injuring the adjacent parts ; others advising round, and some square points. But one great objection to these moveable points is, that if it is necessary to withdraw the pin a little, in order to vary its point of exit, the steel point is liable to be left in the flesh. Silver also has no advantage we think over other substances ; and the common cam- bric needles with sealing-wax heads, or a good stout pin of the ordinary kind will answer equally as well: as the point may be surrounded with a little pellet of wax after it is introduced, or it may be cut off by a pair of bone-nippers. A very good hare-lip pin may be made of steel wire, cut to any length and brought to a triangular point at one end, by a few touches of the file. We seldom employ any others. In placing pins after the operation for hare-lip, ron- WOUNDS. 345 isiderable advantage may be gained by passing a fine .ligature through each free angle of the part, previous to arranging the pins. By means of this ligature, it is easy to bring the edges to the same level, and guard against the central depression or indentation which so often results ; after the pins are placed, this ligature is to be removed. We have often noticed the difference in the result of the operations of the French and American surgeons in this respect, and believe the success of the former to be owing to this plan of operating. THE QUILLED SUTURE, Is intended for the union of deep seated parts ; but as its place can be well supplied by a compress and strips, or by a uniting bandage, it is not at present much employed. It is made by passing a number of Fiff. 213. double ligatures through the sides of the wound, and placing a little roll, or quill, or catheter, in the loop on one side and tieing the opposite endsaround another (Fig. 213). The ligatures acting on the quills, are en- abled to force the parts more closely together, without the risk of their cutting through the integuments. THE DRY SUTURE, Is made by fastening strips of adhesive plaster on 346 WOUNDS, each side of a wound, and then approximating them, by tying together the ligatures introduced into Fig. 214. the strips of each side. (Fig. 214.) The difference between this and the interrupted suture is, in the former being passed through the adhesive strips, instead of through the integuments, as in the latter. CATHETERISM. 347 CHAPTER VI. CATHETERISM. The introduction of tubes into the different pas- sages of the body, requires in the first place, an accurate knowledge of the anatomical relations of the parts, and then some skill in the manipulation of the instruments. In most cases, slow and gentle move- ments are to be made, rather than rapid and violent ones, and in the use of instruments, especially as applied to the urethra, the object should be rather to introduce it without attracting the patient's attention, than to take him, as it were, by storm : as we have occasionally seen done, by the would-be dexterous operators. CATHETERISM OF THE URETHRA. The passage in which catheters are most frequently employed, is undoubtedly the urethra. For this pur- pose the tubes are made of various shapes, sizes, and substance ; but to one acquainted with the anatomy of the part, their shape is a matter of little importance Fig-, 215. — a straight instrument passing quite as readily as a curved one. Generally, however, the male catheter is bent to the curve represented in Fig. 215 ; made 348 CATHETERISM. either of silver or caoutchouc cloth, and with an eye on each side, or with several perforations, according to the taste of the operator. When the gum-elastic one is employed, a wire or stylet is generally required to be introduced into it, in order to give the requisite stiffness, and prevent its yielding to any temporary Fig-. 216, obstruction that may be met with. In the introduc- tion of the instrument, the simplest proceeding will be found to be the following : Place the patient on his back, with the limbs and shoulders slightly elevated, in order to relax the abdominal muscles. Then, having oiled the instrument, take it in the right hand, by its mouth, and seizing the head of the penis between the finger CATHETERISM. 349 and thumb of the left, so as to hold it perpendicularly to the patient's abdomen, place the catheter in the orifice of the urethra, and, whilst his attention is en- gaged by conversation or otherwise, slide the point of the instrument gently down the urethra until it has reached the arch of the pubis, or can be felt deep in the perineum. Then, gently depress the penis and catheter until the instrument is parallel with the pa- tient's thighs, when the point will suddenly slip over the triangular ligament and enter the bladder, as is at once known by the escape of urine. The cut (Fig. 216), represents the position of the instrument at the moment when it is to be laid parallel with the thighs. Should the patient strain, or resist the ope- ration, let him rest for a moment, and pass the left hand gently over the abdomen, so as to promote re- laxation of its muscles ; then try again to keep him in conversation, so as to prevent his holding his breath. But should there be no stricture of the urethra, little difficulty to the introduction of the catheter need be anticipated. Various other plans have been recommended, either for the surgeon's convenience, or to enable him to astonish the by-standers ; but the above plan embraces the simplest means, and is the practice of M. Civiale, who is probably the most beautiful operator in such cases, at present existing. In old men, the introduction of the catheter is occa- sionally a matter of considerable difficulty, owing to the enlargement of the third lobe of the prostate gland, which, from its projection into the canal, re- quires a modification of the instrument. In order to overcome this difficulty, it is necessary to elevate the point of the instrument more than in ordinary cases, as in Fig. 217. This may be accomplished either by bending the point slightly, previous to its introduc- tion, by passing it for an eighth of an inch into the barrel or ward of a pocket-key : or by introducing a 350 CATHETERISM. finger into the rectum, when the catheter has reached the gland, and thus elevating the point. Or if the flexi- ble catheter is used, withdraw the wire for a short i'V-217. distance, and then pass the instrument forwards to- wards the bladder. In cases of paralysis, or of a tight stricture, it is frequently necessary, in order to save trouble, to re- tain the catheter in the bladder for several hours. In such patients, after having evacuated the urine, place a little plug or cork in the extremity of the instrument, Fig, 218. in order to prevent the constant flow of water, and fasten the catheter either by attaching it with tape to a suspensory bandage, as represented in Fig. 218, CATHETERISM. 351 or, tie the tapes firmly around the end of the in- strument ; surround the body of the penis with a few turns of narrow bandage : and then either sew the tapes to it, or confine them by circular turns of another piece of tape, as represented in Fig. 219, taking care not to draw them too tight. As the organ is, how- ever, liable to changes of size, the plan first treated of (Fig. 218), is, we think, preferable to this, or most of the others that have been proposed. CATHETERISM OF THE STOMACH, Or the introduction of a tube for the use of the sto- mach-pump, is performed generally without any diffi- culty, except that arising from the resistance of the patient in certain cases. Guarding, then, against the closing of the patient's teeth upon the fingers of the operator, or upon the tube, by placing a plug of wood or a knife handle between the jaws, pass the point of the tube directly back into the throat with the right hand, and with the fore-finger of the left, depress 352 CATHETERISM. its point, when it is not bent in consequence of the resistance of the posterior walls of the pharynx, as represented in Fig. 220. The course of the oesopha- Fiff. 220. gus renders the subsequent progress of the instrument perfectly easy. When it is necessary to w^ash out the stomach, or to introduce food, any of the various stomach-pumps that please the fancy of the operator may be used ; but a common injection syringe will be found to equal all the purposes of the more complicated instruments. In the use of the liquids to be introduced into the stomach, particular attention should be paid to their temperature : as the patient, from being de- prived of the use of his mouth during their introduc- tion, might otherwise be seriously scalded, either in the oesophagus, or stomach. Some practitioners re- CATHETERISM. 353 commend smearing the tube with molasses, oil, or mucilage, previous to its introduction. To this there is no objection, except that it is not absolutely ne- cessary, as dipping the tube into simple cold water answers equally as well, and is generally more con- venient. On withdrawing the tube from the stomach, the operator should be careful, always to place a finger on its open end, so as to close it tightly, and thus prevent the escape of any liquid that might remain in the tube, into the trachea, as the tube passes the pha- rynx. CATHETERISM OF THE EUSTACHIAN TUBE, Is occasionally required, in order to overcome ob- structions in the passage, which produce deafness by preventing the passage of sound along the canal. Without, however, pretending to define the cases re- quiring this operation, we shall here simply refer to the operation itself, from a belief that many who are fully aware of its utility would perform it, were it not from some indefinite idea, drawn usually from the prolix directions of the French aurists, that they pos- sess of its difficulty. A slight reference to the anatomical structure of the part will show that there can be no very great mystery in the operation. The opening of the Eustachian tube into the pharynx, being about a quarter of an inch be- hind the soft palate, is placed on a line with the poste- rior end of the inferior turbinated bone. Its orifice is rounded or oval ; is capable of receiving the tip of the little finger, and reposes against the side of the internal pterygoid process of the sphenoid bone. Its size, consequently, enables it to receive the point of the catheter for this tube, with little or no difficulty. In introducing it, place the patient's head firmly against the back of a chair, and having oiled the end of the instrument, pass it through the nostril of the side affected, with its point resting on the floor of the 23 354 CATHETERISM. nose, and with its convexity upwards, until it reaches the posterior nares and the rounded edge of the soft palate, which may be readily told by the patient's gaging. Then turn the point of the instrument out- wards, towards the side affected, and it will generally slip into the tube (Fig. 209, B). As the operation, when employed in deafness, requires to be frequently repeated, it is well to mark upon the catheter the dis- tance from the front of the nose to its point, when in- troduced into the orifice ; in order to facilitate its sub- sequent application . The inj ection of air, or of liquids, will, of course, depend upon circumstances. INJECTIONS. 355 CHAPTER VII. INJECTIONS, Or the introduction of liquids into the various passages of the body, are generally performed with a view to the relief of local derangement or to excite local action. They are used in the lachrymal ducts, the urethra, the vagina, rectum, &c. INJECTION OF THE LACHRYMAL DUCTS, With the view of removing inflammation, or some obstruction to the passage of the tears, is performed by means of a fine capillary pointed syringe, known as Anel's. In using it, take the syringe in the right hand, between the thumb and middle-finger, with the fore-finger on the piston, so as to enable the operator to throw in the fluid : and standing either in, front or behind the patient, according to the eye to be ope- rated on, place the point of the syringe in the lower punctum, and introduce it only sufiiciently far to pre- vent the escape of the liquid. Then, closing the punctum of the upper lid, throw in the fluid by moving the piston with the fore-finger of the right hand. If it passes through the duct to the nostril, its passage will be shown by its escape either from the nose in front, or into the mouth of the patient behind. Simple water, or that containing a little astringent solution, is generally used where the object is to clear the passage and overcome the inflammation of the ductus ad nasum, &c., and, when the syringe is pro- perly employed, is a useful means of preventing the production of fistula lachrymalis. Another plan, lately proposed, of cleansing this 356 INJECTIONS. duct, is by the introduction of a catheter into the opening of the duct in the nostril, as in A, Fig. 209. Though comparatively simple, it is much more diffi- cult than the plan just stated, and being opposed to the natural course of the tears and the anatomical structure of the part, is not generally resorted to. As the capillary perforation of the point would ren- der it difficult for us to fill the syringe with it on, they should always be made moveable, and only ap- plied as a nozle to the syringe, after the latter is filled. Sometimes, when the puncta lachrymalia as well as the ducts are closed, it becomes necessary to dilate them previous to the use of the syringe. This may be done by a fine hair-like probe also known as Anels's, or by the blunt end of a fine cambric needle, nicely rounded oflf and fastened in a light handle by its point. INJECTION OF THE LUNGS, Is confined, of course, to the use of air, where the patient, from any circumstances, is incapable of car- rying on his own respiration. In cases of asphyxia or drowning, especially the former, whether in adults or infants, it is often an operation of vital importance, and one which has consequently given rise to various plans and instruments for its performance. Being generally an act of great emergency, it is fortunate that the operator always has the best and simplest means about him ; in the use of his own lungs. In order, then, to fill the chest and keep up artificial respiration, place the thumb and fore-finger of one hand closely around the patient's lips, and let the operator adjust his own mouth to this, whilst, with the other hand, he presses the pomum adami back against the vertebrae, so as to close the oesophagus, and prevent the air passing to the stomach. Then direct an assistant to compress the patient's nostril and to press upon his ribs whenever the lungs have INJECTIONS. 357 been inflated by the breath of the operator ; the latter of whom should free the patient's mouth after each infla- tion, — thus inflating and expelling the air, so as to imi- tate as much as possible the natural process of respi- ration. In cases of drowning, no time should be lost before commencing this operation, as it is generally the only chance that the individual has for life. INJECTIONS INTO THE URETHRA, Of the male, are generally performed by the patients themselves. But as many are ignorant of the proper mode of perfoming them, and bring on inflammation by bruising the sides of the urethra upon the syringe, it is better for the surgeon to give them special direc- tions in regard to the manner of employing it, or per- form the operation himself once or twice, until the Fig, 221. patient has learned how. In order to use these injec- tions properly, the patient should be directed to fill the syringe and insert its end gently within the ure- thra, closing the orifice around its point, as in Fig. 221. Then sitting down on the edge of a chair or 358 INJECTIONS. bed, or upon a ball made by rolling up a handkerchief or stocking, so as to press upon the perineum, throw the fluid in by a motion of the piston, as in the figure, and, withdrawing the nozle, close the urethra quickly and hold the injection for a few minutes ; then repeat the operation twice or three times as before. An attempt to urinate will evacuate it without difficulty. INJECTIONS INTO THE VAGINA, Like those into the urethra of the male, are not often required to be performed by the practitioner, yet, owing to the ignorance of the patient, much of the benefit likely to result from their proper performance is lost. In the use of the ordinary female syringe, the patient should always be directed to lie down on her back, with the hips raised, and to retain the liquid used, as long as possible, by pressing a cloth against the vulva. But wherever it can be done, the substi- tution of the French clyso-pompe or self-injecting apparatus, should always be insisted on : as by using this instrument, a much larger amount of fluid can be thrown into the passage, and its whole surface more thoroughly acted on by it. The vaginal nozle of the self-injecting apparatus being placed on the tube and the patient seated over a basin, she can herself use a pint or more of any fluid for a considerable length of time, or, if necessary, by being down and arranging the instrument, have the syringe used by an assistant without exposure. In cases of leucorrhoea, &c., ac- companied as it often is by extreme debility, this plan will be found highly serviceable. INJECTIONS INTO THE RECTUM, Although generally performed by the attendants, yet occasionally fall to the lot of the practitioner, espe- cially after operations in the neighbourhood of the part; and the comfort of the patient will be found to be much involved in their proper application. In France, INJECTIONS. 359 these useful means of treatment are very frequently- resorted to, whereas it is but seldom a patient can be persuaded to employ them in this country, owing, in a measure, perhaps, to prejudices, but also, as we have been often told, to the pain they cause. Now, if properly given, their use is productive of little or no pain, even in cases of hemorrhoids. In order to give one without causing pain, oil the fore-finger of the left hand, and press its point gently against the sphincter ani muscle, till its contraction is overcome and the finger enters the gut. Then pass the nozle of the syringe, also well oiled, along the fin- ger, as a director, till it also enters the gut, when, with- drawing the finger, the fluid can be thrown in without difficulty ; care being taken to keep the point of the syringe in the line of the concavity of the sacrum. The position of the patient and the liquid employed, must depend upon circumstances: but generally the patient is most comfortable lieing on the left side, with his back to the attendant. 360 EXTRACTION OF CHAPTER VIII. EXTRACTION OF FOREIGN BODIES, &c. Under this head, we propose to arrange a class of minor operations, which require very little division of tissue, yet involve the performance of duties which to be successful must be learned rather from practice and common sense, than from detailed directions. We shall here, therefore, as in other parts, be very brief in our remarks. In some of these operations, we know also, that we trench upon the specific duties of those, without the bounds of the profession ; but as the sur- geon may often supply their places, with great ad- vantage to the public, we have deemed it best not to pass them by. EXTRACTION OF TEETH. The operations upon the teeth being very generally performed by a particular class of persons, the sur- geon is seldom consulted in regard to them, except w-hen connected with other affections. Were it not then for these cases, and for the fact that in country practice, the medical man is often the only one who can render assistance, we should omit them entirely : as beneath the position which the practitioner holds in the estimation of the public. We shall, therefore, con- fine ourselves to such portions only of this subject, as are likely to be required of the surgeon, viz.. Extraction. The Extraction of teeth may be performed either with the Forceps or with the Key : the former being generally, the preferable instrument. The instru- ments, however, as employed by dentists, are va- ried in number and shape : but for ordinary use the straight, curved, and hawk-bill forceps, are all that are necessary. As certain teeth require some little FOREIGN BODIES. 361 modifications of the general plan of operating, we shall treat of each respectively. In extracting the Incisors and Canine Teeth of the Upper Jaw, the operator should grasp the straight Fi^. 222. forceps, firmly, and seize the tooth just at its junction with the gums, taking care not to compress it with such force as to crush the crown of the tooth in the instrument. Then giving it a slight twist, so as to loosen the tooth in the alveolar process, pull it per- pendicularly downwards and slightly backwards, in the direction of the alveolar cavity. In extracting the Bicuspid and Molar Teeth of the Upper Jaw, use the hawk-bill forceps, or those es- pecially made for the molar teeth, and moving the tooth from side to side, pull perpendicularly down- wards. (Fig. 223.) The extraction of these teeth in the Lower Jaw, is similar to those in the upper, except, as to the dif- ferent direction required in extracting them, which common sense will render sufficiently apparent. 362 EXTRACTION OF Many operatorslance the gums, previous to the appli- cation of the instrument to the tooth, especially in the Fiff. 223 molars and bicuspides ; others, again, deny the neces- sity of it, except when the key is employed. It may, we think, safely be left to the judgment of the operator. In extracting the Molars and Bicuspides, with the Key of Garangeot, or its modifications, wrap the ful- crum with some soft substance, in order to protect the soft parts from pressure. Then place the fulcrum on the inside of the jaw, so that the claw may em- „. 224 brace the tooth, just at its junction * with the alveolar process, (Fig. 224) and rotating quickly the handle of the instrument, draw the tooth from the socket. Should it not be freed en- tirely, by these means, it must be seized by the forceps, and extracted as before mentioned. For those, who by practice have ac- quired the command of this instru- ment, we believe that it will be found to answer exceedingly well for the extraction of these teeth, or of stumps. Care, however, is required, lest the claw be placed upon the edge of the alveolar process, and the bone be thus fractured, as is occasionally done. If, through inattention, or owing to the seat of decay in the tooth, the fulcrum is not placed on the inside of the jaw, crushing of the alve- olar process is very apt to follow ; and special attention FOREIGN BODIES. 363 should be given to the action of the fulcrum, in such cases, in order to avoid it. The extraction of Stumps, when not accomplished hy the Key, requires the use of the Elevator ; the point of which should be firmly thrust down between the stump and the socket, and then using the finger : a sound tooth, or the edge of the alveolar process, as a fulcrum, pry out the roots. But as the point of the elevator is exceedingly liable to slip and wound the cheek, the point of another finger, wrapped with cloth, should always be placed between the stump and cheek. The excessive hemorrhage, which sometimes fol- lows the extraction of teeth, not unfrequently causes considerable trouble, although generally it may be arrested like that following leeching, by the use of nitrate of silver, or by a compress, forced into the cavity, unless it should arise from constitutional causes. A prescription recommended by Dr. God- dard, in his work on the teeth, is the following : — *' Cause some alcohol to dissolve as much of the fol- lowing substances, as it is capable of doing, so that it may be a saturated tincture ; namely, Secale Cor- nutum, and Gallic acid ; then add about one-fourth of Creosote, by measure. This tincture may be ap- plied, by holding it to the part, or may be used to satu- rate the lint used in plugging the cavity, should that measure become necessary. Ergot, in the form of a watery solution, may, also, be used with success in many cases, as a gargle or mouth wash ; especially when the hemorrhage comes from the gums." Those practitioners who may be compelled to ope- rate upon the teeth, will find much valuable, scien- tific, and practical information, in the work referred to. EXTRACTION OF CILl^. In Trichiasis, or turning in of the eye-lashes, or in a supernumerary growth of the individual cilise, the constant rubbing of the hairs against the delicate sur- 364 EXTRACTION OF face of the eye-ball, produces congestion of its vessels, and more or less serious inflammation ; often indeed to such an extent, as to impair the transparency of the cornea. Under these circumstances, the lids should be slightly everted, and their edges examined, so as to detect the seat of irritation : when the cilise may be pulled out by a pair of forceps, accurately adjusted at the points of the blades. But in obstinate cases, the most careful extraction of the lashes will not remedy the disease ; because, as long as the follicle remains in the lid, the hair may be reproduced. Having then carefully removed the lash, the bulb or follicle should be thoroughly cauterised by passing a piece of nitrate of silver along the edge of the lid, or into the opening left by the extraction of the eye-lash. EXTRACTION OF FOREIGN BODIES FROM THE EYE-BALL. Blacksmiths, and other workers in metals, not un- frequently suffer from sharp particles of foreign matter being driven into the eye-ball, so as to become firmly imbeded in its outer coats ; thus producing a most painful affection. These little particles are also often so fine and brittle, as to render it impossible to ex- tract them by forceps, and all such attempts not only fail, but render the matter infinitely worse, by breaking the piece. It will, therefore, frequently be found to be a better plan, to take a fine cataract needle, wuth a slight curve, and opening the lids widely, place the convex surface of the needle flat against the ball of the eye, and glide it gently over its surface. On reaching the piece it will generally draw it out, and cause it to fall upon the lid, or into the hand of the operator. But if this fail, the touch will indicate precisely the point of the particle, if it projects at all beyond the surface, and its extraction may then be eventually effected by repassing the edge of the needle against the foreign substance, and moving it downwards or upwards, ac- cording to the angle at which it projects, so as to FOREIGN BODIES. 365 shave or chip it out ; an expression which we presume will be understood. EXTRACTION OF FOREIGN MATTER FROM THE EYK-LIDS. In these days of locomotives and rapid travelling, the introduction of sparks and particles of sand be- tween the lids and the ball, is frequently productive of considerable trouble ; so much so, that the appoint- ment of an eye-cleanser to such public conveyances w^ould be a desideratum. When all simpler means have failed, and application is made to the surgeon, he should seize the edge of the lid with the fingers of one hand, and pressing the point of a pencil, or other round instrument, against its outside, evert the lid, so as to turn it completely inside out. Then, when its inner surface is thus exposed, a camel's hair pencil, a fine rag, or a piece of moistened soft sponge, will easily wipe away the offending matter. EXTRACTION OF FOREIGN BODIES FROM THE NOSTRIL. Coffee grains, pebbles, ribbon, &c., are occasionally introduced and become fastened in the nostrils of chil- dren ; thus giving rise to violent inflammation and suffering, and causing considerable difficulty in their removal. With a proper knowledge, however, of the structure of the part, a scoop, or the curette of Leroy d'Etiolles, or polypus forceps, will generally suffice to accomplish the desired end. But if these fail, resort may be had to sternutatories, or to washing out the nostril with a syringe, and to the use of such means as will combat the inflammation. EXTRACTION OF FOREIGN BODIES FROM THE EAR, Is to be accomplished by somewhat similar means, although the operation here is by no means an easy one. When sufficient space exists between the sides of the external meatus and the foreign substance to 366 EXTRACTION OF permit the use of a syringe, a full stream of tepid water, thrown in whilst the ear is drawn upwards and backwards, will generally be found to answer for its removal. But in the use of the forceps, care must be taken not to force the substance further in. In the case of insects, as earwigs, &c., which occasionally get in as far as the membrana tympani, and cause excruciating pain, the free use of warm olive or al- mond oil, by closing their pores, will generally pro- duce their death, or cause them to seek the open air at the orifice : when subsequent syringing with tepid water will generally remove them. The use of lauda- num, and other stimulating articles, should be avoid- ed, as they increase, instead of relieving the distress. EXTRACTION OF FOREIGN BODIES FROM THE THROAT, Is an operation which frequently affords the practi- tioner but little time to make his arrangements, and in which, therefore, it is desirable that the instruments required should be made of materials readily obtained. We find, therefore, probangs, or pieces of whale- bone with a lump of sponge tied fast to one end, the handle of a riding-whip, the fingers of the ope- rator, &c. , among those most frequently recommended. As the nature of the object swallowed may not, how- ever, be such as to cause instant suffocation, but, on the contrary, allow suflScient time to elapse for the development of inflammation, we shall confine our remarks to the latter ; simply glancing at the causes of the spasm and irritation usually produced by bodies lodged in the pharynx. In the North American Medical and Surgical Jour- nal, for October, 1828, will be found an extensive article on this subject, by Dr. Henry Bond, of Phila- delphia, from which we shall mainly condense our statement. Dr. Bond states that foreign bodies are most frequently arrested so high in the fauces or pha- rynx, that they may be seen, simply by depressing the FOREIGN BODIES. 367 tongue, and that in such cases, the finger or dressing forceps will suffice for its removal ; whilst it is at this point they induce spasmodic action of the muscles of the glottis, by which the matter becomes im- pacted between the bones of the oshyoides and the top of the thyroid cartilage. This spasmodic closure of the glottis, produced by the irritation of the foreign body, induces spasmodic efforts of coughing, in order to throw it off. But the pressure upon the epiglottis preventing the inspiration necessary for coughing, suffocation ensues, unless the article is quickly removed. Now, in such cases. Dr. Bond recommends that the patient's head be held erect, and in such a manner as to make the chin project as little as possible beyond the pomum adami, so as to render the intro- duction of the finger more easy, and thus release the article from its position, so that it may readily be ejected. But where the objects are smaller, where they descend further and pass the larynx, though the risk of suffocation is diminished, the difficulties of ex- traction are increased. For such cases, resort must be had to forceps, of which nothing can be better than the oesophagus forceps of Dr. Bond, which are now generally kept by the cutlers, and which every prac- titioner should possess. These forceps are twelve and a-half inches long, and curved to suit the shape of the throat, so that they will reach as far as the top of the sternum — a point, beyond which little difficulty is usually felt from foreign bodies. The blades being also bevelled off so as to avoid pinching the coats of the oesophagus, and serrated, are capable of seizing even small bodies, as a pin or fish-bone, without risk of injury to the passage. When coins, pieces of glass, or similar articles, are in question, the use of the forceps is decidedly the best way of removing them ; but when these are not at hand, a piece of common wire, bent round and formed into a loop, with the free ends firmly twisted 368 EXTRACTION OF together, and the loop then bent into a hook, may- supply their place, or in some instances supplant them. Dr. Bond makes several other excellent sug- gestions, which, for want of space, we must refer those desirous of learning, to the original article, as quoted. THE EXTRACTION OF FOREIGN BODIES FROM THE TRACHEA, When not affected by coughing, cannot be readily accomplished by mechanical means, without making an incision into the anterior parietes of the tube ; but sudden blows w^ith the hand upon the cervical verte- brae, the use of sternutatories, or the efforts to cough induced by irritating the larynx with a feather, will occasionally suffice. Should the substance, however, so obstruct the passage as to threaten death, an in- cision one inch and a-half long, directly on the me- dian line of the trachea should be made, so as to di- vide the integuments ; the blood be thoroughly sponged off, and then two or three of the rings divided. The entrance of air through the opening will generally drive out the foreign substance. But, if it does not, a probe or director should be introduced through the wound, and the body pushed upwards. Tracheotomy is, however, an operation of consider- able danger, and we only call attention to it as thus performed, in cases where, without it, certain death would ensue ; it being, we think, a good rule to give every man a chance for his life, or to let him die of his doctor as soon as from his disease — provided the latter point is certain. THE EXTRACTION OF FOREIGN MATTER FROM WOUNDS, Requires the use of forceps which are modified ac- cording to circumstances, and generally treated of in the works on Gun-shot Injuries. But when the sub- stance is only particles of dirt, or such fine matter as FOREIGN BODIES. 369 cannot well be seized by the forceps, the free use of a stream of tepid water either by means of a syringe or from a sponge, will suffice. THE EXTRACTION OF FOREIGN BODIES FROM THE RECTUM, May be accomplished by the use of a scoop or spoon handle : especially when employed with a speculum, and when the body is seated near the verge of the anus. But in the case of such substances as by their sharp projecting points would be likely to become im- peded in the side of the gut, the means employed by iMarchetti in extracting the tail of a pig with stiff bristles from the rectum of a courtesan (as reported in Gibson's surgery,) may be resorted to. This consisted in the introduction into the rectum of a hollow reed, the end of the tail being passed throuq^h the reed so as to incase it : thus protecting the gut from the action of the sharp projecting points. The recollection of this simple plan will, we think, enable any one to apply its principle to numerous other instances, both in the rectum and elsewhere. When glass pessaries, &c., become broken in the vagina, some such contrivance, which common ingenuity will- readily suggest, would prove highly useful for its re- moval, without injuring the sides of the canal. THE EXTRACTION OF FOREIGN BODIES FROM THE URETHRA, Embraces so much that is connected with the treatment of Calculus, that we must refer to the works upon Stone and Gravel, for the consideration of the means required. EXTRACTION OF CORNS. Cornsare a thickening ofthe Epidermis in consequence of pressure, and resemble a nail in shape : cause pain by pressure of the point on subjacent parts, and are generally treated by the public at large by filing, 24 370 EXTRACTION OF scraping or cutting off the upper layer : which by pre- venting the boot from pressing the central hardening, upon the sensitive cutis vera, relieves the pain. In the same way the various corn plasters &c., era- ployed for their relief prove serviceable ; that is either by softening the induration and favouring its exfolia- tion, or by removing pressure. Now without pretending to interfere with the busi- ness of certain Chiropodists, we would state two plans of treatment which the practitioner can em- ploy with marked benefit. First, the corn plasters of Sir Astley Cooper. These consist of pieces of buck- skin of the size of a ten cent piece, spread with adhe- sive plaster and having an opening in the centre of the size of the corn. This plaster being warmed, is so placed that the corn will project through the opening, and if one piece is not thick enough to rise above the top of the corn, one or two more must be placed on top of it, until the corn being relieved from pressure ceasesto act upon the true skin : thus removing the pain. The application of the pressure of the boot upon the circumference of the plaster, tends also ra- pidly to remove the corn, by forcing its central portion out through the opening. But should more permanent relief be desired, the corn may be entirely removed by the following plan : Soak the foot thoroughly in warm water for an hour. Then with a small round-bellied scalpel, cut through the first layers of the hardened skin just on the edge of the healthy tissue. Seize the edge thus loosened with a pair of dissecting forceps and con- tinue to dissect round the corn, on the edge of the healthy skin, but not cutting into it, till the pink cutis vera is reached at the bottom of the little cavity thus made. Then to ensure the entire destruction of the spot, touch the bottom with nitrate of silver, and thus prevent the re-appearance of the disease at this point. But if tight shoes, continue to press upon the skin, new corns will inevitably be created. In this little y" BUNNIONS AND CORNS. 371 operation, no blood should be drawn, and relief will be afforded for a long period. EXTRACTION OF BUNNIONS. When the anterior portion of the metatarsal bone of the big toe is subject to long continued pressure, a bursal formation is induced, which by its increase, creates severe and painful inflammation or even ab- scesses in the surrounding soft parts (Fig. 225). These, Fig. 225. like corns, may be cured, simply by removal of pres- sure. The use of Cooper's plaster, cut to fit the increased size of the tumour, will therefore prove ser- viceable. But when they produce more serious effects than mere pain, the only plan will be to excise the cyst by careful dissection and cauterisation, guarding of course, against any injury to the subjacent joint. Connected with these parts, wehave now to consider a small sore that is often productive of such serious pain and inconvenience, as to have engaged the atten- tion of surgeons for a long period, and called forth many proposed plans of cure. We refer to THE TOE NAIL ULCER, Or that state of things which is induced by what is improperly termed the Inverted Toe Nail. This as seated in the Big Toe is usually the consequence of 372 TOE NAIL ULCER. the pressure of the boot upon the inside of the toe, in consequence of which the skin on the opposite edge of the nail becomes bruised and inflamed. Or it may arise from the integuments being forced up over the nail, thus inducing inflammation, ulceration and the fungus represented in Fig. 226. Various means have been proposed for the relief of this truly painful aflection, in nearly all of which the nail has been treated as the *' fons et origo" of the dis- ease and we have excision, eversion, cauterisation and Fi^. 226. numerous other equally agreeable means, highly lauded: all of which if efl^ectual (and this seems doubtful) create a degree of pain which whilst it lasts is not surpassed by any other operation in surgery. Now all this we would humbly suggest, may be avoided by the following plan which we believe is due to Dr. Charles D. Meigs of the Jefferson College of Philadelphia, and which we have several times found efficacious. Scrape the nail or soften it in warm water so as to render it moderately flexible, and then introduce under its angle on the sore side, some soft lint or charpie, so as to fill entirely, the space beneath its edge. Next apply a very small compress upon' the granulations or tumefied or projecting integuments, in order to force them off' the edge of the nail, and confine it there by a few turns of a little strip of ad- • INSERTION OF EYES. 373 hesive plaster. The continued pressure of the com- press, the action of the lint and the use of a loose shoe, will suffice for mild cases. But in more severe ones, the reduction of the surrounding inflammation, the removal of the granulations by nitrate of silver or excision, should precede the other means. We shall now treat of several other operations likely to invite the daily attention, of the young prac- titioner, but which, we cannot class under any par- ticular head, such as the following : INSERTION OF GLASS EYES. When from any cause, the ball of the eye has been injured and vision destroyed, it becomes desirable to conceal the deformity, the use of a Glass Eye must be resorted to. These consist in sections of spheres accurately coloured to suit the different appearances of the human eye, and intended to be placed in front of the remains of the injured ball: where the pres- sure of the eye-lids retain it in its position, and the action of the stump or remains of the eye, gives it motion. So perfectly is this sometimes the case, that unprofessional observers have not been able to tell the glass eye from the sound one. These eyes being now imported in considerable numbers and at moderate prices by Bauersach, Mar- ket Street, Philadelphia, Milhaud, Broadway, New York, and many others : and as their insertion is very simple, we hope the Profession will more fre- quently employ them to conceal deformities, which are often a constant source of mortification to the pa- tient. They will do away with the advantages now reaped by charlatans, at their expense. Introduction. — After having selected an eye of the color, size of pupil, and prominence of ball, that is desired : seize it between the thumb and fore-finger of the right hand, and dip it into a glass of tepid water. Then elevate the upper eye-lid, by the thumb of the left hand, and sliding the glass eye under its edge, 374 GLASS EYES. • let the lid fall gently upon it. Next, depress the lower lid by the middle-finger of the left hand, and slip the false eye within it : when the subsequent action of the lids, will retain it in its place, and give the proper central position in the orbit. In order to remove it, take a bodkin, or short probe, and depressing the lower lid, slip its triangular end be- tween the lid and the ball and slightly under the edge of the glass eye. Then depressing the other extremity on the cheek, so as to make it act as a lever, catch the eye with the left hand, or in a handkerchief held to re- ceive it. After its removal, cleanse it in a little water ; dry it thoroughly and put it away in soft cotton in order to preserve an equaltemperature,tillit is again wanted. These movements are so simple that patients readily introduce and remove the eye themselves- At first the glass eye should only be worn three or four hours, lest it produce inflammation of the ball on which it is placed : but afterwards, it may be worn for any length of time. In the selection of eyes, care should be taken to see that they are perfectly smooth on the edges, as other- wise they will irritate the ball. But we do not think it necessary to use first a small eye and then another dur- ing several weeks, in order as is said, to dilate the lids, unless we wish as eye doctors do, to mistify the patient with the difficulty of the operation. EXCISION OF PTERYGIUM. When the vessels of the conjunctiva become per- manently enlarged, a thickening of this membrane and of the sub-conjunctival cellular substance results, which by extending over the cornea, interferes with vision. This diseased portion is usually of a trian- gular form, and commencingat the inner canthus of the eye, gradually diminishes in breadth, till it terminates by a sharp apex, somewhere on the edge of the cor- nea. Though generally single, we occasionally find more than one, (Fig. 227), and in such cases their PTERYGIUM, ETC. 375 continued growth soon destroys the patient's sight. When the prolongation of a pterygium seems likely to extend to the pupil, and to interfere with vision, it should be operated on. This may be done, either Fi^. 227. by seizing the enlarged conjunctiva with a pair of fine forceps, or with a hook. Then drawing it off from the sclerotic coat, cut out the central portion, with its vessels, by a snip of the scissors : cutting from the cornea towards the internal canthus of the eye, and taking care not to include the plica semilunaris. Or if the base of the pterygium is not very wide, make a simple transverse incision through it, down to the sclerotica, at a point half-way between the internal canthus and the edge of the cornea, so as to divide entirely, the vessels supplying the growth. Then pass a sharp-pointed stick of nitrate of silver in the line of the incision, and cauterise its edges; so that the circulation being destroyed in the part, the enlarged membrane may shrivel away. EXCISION OF THE UVULA, Is frequently rendered necessary, in consequence of the elongation of the extremity of its mucous mem- brane, which falling upon the posterior portion of the tongue and pharynx, or even in some instances, into the glottis, or upon the epiglottis, keeps up a con- 376 EXCISION OF UVULA, ETC. stant tickling, which induces so much coughing, and often copious expectoration, as to similate the com- mencement of phthisis pulmonalis. As this elonga- tion is at first merely the result of a slight oedema of the mucous membrane, resulting from inflammation, common astringent gargles, of oak bark, powdered galls, tannic acid, powdered alum, tinct. ferri chloridi, nitrate of silver, &c. , may reduce it. But if when free from inflammation, itcontinues permanently elongated, its removal by the knife becomes necessary. This may be readily eflfected by seizing the point of the uvula with a pair of dressing forceps, and clipping oflf merely the tip, with a bistoury or apair of blunt-pointed scissors ; care being taken not to cut oflf so much of the point as will involve the muscle ; as this by destroying the action of the part, may impair the voice, &c. This operation causes little or no pain, is quickly done, and requires no further after-treatment, than the use of a gargle of cold water, (or of some mild demulcent, as gum arabic or slippery elm,) from time to time, with attention to diet. EXCISION OF THE TONSILS, In consequence of their chronic enlargement and in- duration, is very often required, in order to relieve the irritation of the throat, and the effects upon the voice and respiration, which they produce. Two means were formerly recommended for their removal, to wit, the ligature and excision ; but one only is now generally resorted to, and we shall, therefore, confine our remarks to Excision. When all acute inflammation is removed, and the means of scarification, touching with tincture of iodine &c., havefailed, the upper portion of the gland, or that next to the velum pendulum palati, should be removed. Of the various instruments employed for this purpose, the modification by Schively, of Dr. Phy- sick's instrument, or that of Fahnestock, may be em- EXCISION OF TONSILS. 377 ployed. Of the two we prefer the former, as the latter, although a good instrument in some respects, is objectionable, from its manufacture being restricted by an act of the inventor. With either, however, the operation is simple, and performed as follows : Seat the patient on a moderately low chair, and direct the assistant supporting the head to place his fingers beneath the angle of the patient's jaw, so as to force the gland into the throat, and render it more promi- nent in the pharynx. Then whilst the mouth is widely opened, the surgeon should pass the instru- ment into the throat, with its flat surface parallel with the tongue, and on reaching the gland, turn the han- dle up, so as to include the tumor in the ring of the in- strument : when a rapid movement of the concealed knife, clips off the portion coming within its range. This is sometimes brought out by the withdrawal of the instrument, or is spit out by the patient. In this operation, we would advise the young prac- titioner not to be too anxious about the size of the piece to be removed : as the excision of the projecting third of the gland, will generally be followed by the ab- sorption of the remainder, and is all that is necessary. We have now considered most of the simpler operations of surgery, or such as do not involve an extensive division of tissue, and are likely to fall to the daily lot of most practitioners : excepting some few upon the organs of generation, such as stricture, phymosis, &c., which it would be difficult to treat of here in the brief manner that we have laid down as our plan, without doing injustice to the subject, or perhaps causing injury to the patient. We feel ourselves, therefore, compelled to pass them by. INDEX. Abdomen Bandage of, 61 Paracentesis of, 322 Abscesses, Puncture of, 326 Diagnosis of, 327 Acids, Issues from, 309 Acupancturation, 315 Adhesive Strips, 31 Amesbury, 235, 249 Amputations, 93 Anatomy of Veins, 286 Angle of Jaw, Bandage of, 71 Ante-Brachial Trough, 142 Hyponarthecia, 158 Anterior 8 of Chest, 74 Apparatus for Dislocations, 262 for Fractures, 186 Immovable, 256 of Dressings, 19 T Bandage of, 99 Application of Bandage, 51, 57 Dressings, 19 Arrest of Hemorrhage, from Bladder, 340 Leeches, 301 Rectum, 339 Arteriotoray, 297 Bandages, Circular, 52, 55 Compressing, 52 Dividing, 52 Double-Headed, 50 Expelling, 52 Manufacture of, 49 Oblique, 52, 56 Retaining, 53 Reverses of, 59 Simple, 48 Single-Headed, 49 Spiral, 66 Uniting, 52 Bandaging, 48 Barton's Bandage for Jaw, 71 Bran Dressing, 248 Fracture of Kadius, 210 Handkerchief, 152 Bell's Inclined Plane, 221 Bi-Temporal Triangle, 130 Bladder, Hemorrhage from, 340 Bleeding, 285 at Ankle, 294 in External Jugular, 293 in Hand, 293 Blisters, 305 Blood-letting, Local, 298 Body, Invaginated Bandage of 105 Bond's Forceps, 367 Bones of Fore-arm, Disloc'n,274 Fracture, 209 Metatarsal, Disl'd, 284 Fractured, 255 Tarsus, Dislocation, 283 Fracture of, 254 Boyer,for Fract. of Clavicle, 198 Fracture of Calcis, 254 Fracture of Femur, 221 Frac of Olecranon, 212 Neck of Humerus, 205 Shaft of Humerus, 206 Bran Dressing, 248 Breast Bandages, 77 Buckled Bandages, 119 Bunnions, 371 Buttock Double T of, 101 Calcis, Fracture of, 254 Carpo-Dorsal Triangle, 145 Carpo-Olecranien Hand'c'f, 145 Carpus, Dislocation of, 274 Fractures of, 211 Carved Splint, 208 Catheterism, 347 Cervico-Brachial Sling, 142 Charpie, 23 Chest, Bandage of, 69 T Bandage of, 99 Chin, Sling of, 113 Ciliae, Extraction of, 363 Circular Bandage, 55 Clavicle, Dislocation of 267 380 INDEX. Clavicle, Fracture of, 194 Clinical Frame, 176 Clove Hitch, 276 Coates' Extending Band, 223 Perineal iJand, 225 Compresses, 27 Compress, Cribriform, 28 Compressing Bandage, 52 Concretions, Salivary, 326 Condyles, 207 Corns, Extraction of, 369 Continued Suture, 343 of Eustachian Tube, 353 of Stomach, 351 of Urethra, 347 Cooper, Sir Astley, 212 Coronoid Process, Fract. of, 218 Cotton, 26 Court Plaster, 38 Cravat, 136 Crossed Bandages, 69 Cupping, 302 Cutaneous Irritation, 305 Definition of Minor Surgery, 285 Demi-Gauntlet, 65 Dessault's Apparatus for Clavicle, 194 for fracture of Olecranon, 213 Apparatus for fracture of patella, 243 Splints, 228 Dislocations, 263 Disl'ns of Bones of Fore-arm, 274 of Bones of Tarsus, 283 of Clavicle, 267 of Fibula, 283 of Fore-arm, 271 of Head and Trunk, 265 of Head of Humerus, 269 of Head of Radius, 272 ofHead of Tibia, 283 of Hip-Joint, 278 of Lower Extremity, 278 of Low^er Jslw, 265 of Magnum, 274 of Metacarpal Bones, 275 of Metatarsal Bones, 284 of Patella, 282 of Phalanges, 276, 284 Disl'ns of Ribs, 266 of Upper Extremity, 269 of Vertebrae, 266 of Wrist, 274 Dividing Bandage, 52 Dorso Bis Axillaris, 137 Double Spica Handkerchief, 140 Double T of Buttock, 101 Hand, 102 Dressings, 19 Apparatus of, 19 Instruments of, 19 Pieces of, 22 Dry Suture, 345 Ear, T Bandage of, 97 Eighteen-tailed Bandage, 228 Electro-Puncture, 317 Elevator for Fractures, 220 Epididymitis, strips in, 36 Eustachian Tube, Cath'm of, 353 Excision of Pterygium, 374 of Uvula, 375 of Tonsils, 376 Expelling Bandage, 52 Extending Bands, 222 Extraction of For'n Bodies, 360 of Cilife, 363 of Foreign Bodies from Eye, 364 from Kar, 365 from Nostril, 365 from Throat, 366 from Rectum, 369 from Urethra, 369 of Bunnions, 371 of Corns, 369, of Teeth, 360 of Foreign Matter from Eye-lids, 365 from Wounds, 368 Eye, Crossed of, 69 Facial Triangle, 131 Fahnestock, Reduc of Dis., 279 Femur, fractures of, 221 Fibula, Dislocation of, 283 Fracture of, 253 Figure of 8 Bandages, 69 of Ankle, 86 both Thighs, 85 Elbow, 83 INDEX. 381 Fig. 8 Ban. Instep, 87 Knee, 86 Ts'eckand Axilla, 76 Wrist, 84 Finger, Spiral of, 64 Flexor of Wrist, 145 Foramen Thyroideum, Disloca- tion into, 282 Fore-arm, Dislocation of, 271 Fracture of, 209 Foreign Bodies in Eye-Ball, Ex- traction of, 364 from Ear, 365 from Nostrils, 365 from Throat, 366 Dr. H. Bond's For- ceps, for, 367 from Trachea, 368 in Rectum, 369 in Urethra, 369 Matter in Eye-lids, 365 in Wounds, 368 Formation of Issue, by Potash, Acids, &c., 309 Four-Tailed Bandage of Breast, 115 of Chin, 113 Face, 114 Head, 115 Neck, 113 Fox's Bandage for Clavicle, 200 Fracture-Box, 246 Fractures, 191 of Condyles, 207 Coronoid process, 216 Femur, 221 Fibula, 253 Fore-arm, 209 Leg, 246 Lower end of Radius, 210 Metacarpal Bones 211 Neck of Humerus, 205 Olecranon, 212 Os Calcis, 254 Patella, 243 Phalanges, 212 Shaft, 216 Skull, 191 French Spiral, 67 Fronto-Dorsal, 133 Fronto-Occipital Triangle, 128 Occipito-Labialis, 130 Gaiter-Laced, 120 Physick's, 224 Galen, Bandage of. 111 «launtlet, 64 Demi, 65 Gerdy's Bandage for Olecranon, 215 for Patella, 245 Gibson's Bandage for Jaw, 192 Hagedorn, 238 Simple Inclined Plane, 240 Glass Eye, Insertion of, 373 Graduated Compress, 30 Granville's Lotion, 307 Groin, Spica of, 8 1 Triangular T of, 100 Half Malteese Cross, 29 Hand, T Bandage of, 102 Perforated of, 102 Bleeding in Disl'n of, 293 Hare Lip, or Twisted Suture, 344 Head, T Bandage of, 96 Dislocations of, 265 Four-tailed sling of, 112 Handkerchiefs for, 128 ofHumerus, Disl'n of, 269 Knotted Bandage for, 89 of Radius, Disloca'n of, 272 of Tibia, Dislocation of, 283 Recurrent, 91, 92 Square cap of, 128 Hemorrhage, Arrest of, 301 from Bladder, 340 Rectum, 339 Hip-Joint, Dislocation of, 278 Hospital Fracture Box, 246 Humeius, ^eck of, 205 Dislocations of, 269 Immovable Apparatus, 256 Inclined Plane, 221 Injections, use of, 355 into Rectum, 358 Urethra, 357 Vagina, 358 Lachrymal Ducts, 355 382 INDEX. Injection of Lungs, 356 Insertion of Glass Eye, 373 Instruments of Dressing, 19 Inter-Femoral Handkerchief, 140 Interrupted Suture, 341 Introduction, 17 Invaginated Bandages, 104 for Wounds of lip, 104 of Body, 105 Longitudinal Wounds of Extremities, 106 Transverse, 107 Wry-neck, 107 Irrigation, 41 Isinglass Plaster, 37 Issue Peas, 308 Issues, 307 Jaw, angle of, 71 Barton's Bandage for, 71 Crossed Bandage of, 71 Dislocation of, 265 Fractures of, 191 Gibson's Bandage for, 192 Jorg's Apparatus, 109 Jugular Vein, Bleeding in, 293 Junct-Bags, 226 Knee, Laced Bandage for, 119 Spiral, Lower Ex- tremity of, 66 Knotted Bandages, 89 Laced Bandages, 119 Lachrymal Ducts, injection of, 355 Lancets, 289 Spring, 289 Thumb, 290 Leeches, Preservation of, 302 Leeching, 299 Leg, Fractures of, 246 Ligature, 334 Lips, Bandage for Wounds of, 104 Local Blood-letting, 29^ Lower end of Radius, Fracture of, 210 Lower Jaw, Fractures of, 191 Dislocations of, 265 Lungs, 356 Magnum, Dislocation of, 274 Malteese Cross, 28 Manufacture of Bandages, 49 Mask, 114, Matter from Eye-lids, Extraction of, 365 Wounds, 368 Mayor's Apparatus for Clavicle, 199 Clinical Frame, 176 Hyponarthecia, 153 Olecranon, 216 Patella, 245 System, 121 Meigs' Plan of Treating Toe-Nail Ulcer, 372 Membrana Tympani, Puncture of, 323 Mental Cravat, 131 Meta-carpal Bones, Frac'e of, 21 1 Disi'n of, 275 Meta-tarsal Bones, 284 Meta-tarso Malleolar Cravat, 147 Rotular, 148 Moxa, 312 Neck and Axilla, Figure of 8 Bandage of, 76 and Brachial Sling of 142 of Humerus, 205 Sling of, 113 Uniting of Wounds of, 110 Wry, 107 Nose, Fractures of, 191 Suspensory of, 117 T Bandage of, 98 Nostrils, Plugging of, 337 Extraction of foreign bo- dies from, 365 Notch Sciatic, Disloc'n into, 281 Oblique Processes of Vertebrse, 266 Occipito-Auricular Handkerchief, 131 Frontal Handkerch'f,129 Occulo-Occipital Triangle, 130 Olecranon, Fractures of, 212 Operation with Spring Lancet, 291 Thumb, 292 Paracentesis Abdominis, 322 Parieto-Axillaris Handk'ch'f, 133 Patella, Fracture of, 243 Dislocations of, 282 Penis, bandage of, 61 INDEX. 383 Pennsylvania Hospital in Fract'e of Humerus, 207 of Olecranon, 214 Pennsylvania Hospital Fracture- box, 246 Pelvis, Fracture of, 194 Perforated Bandage of Hand, 103 Perforated (compress, 30 Perforation of Lobe of Ear, 320 Petit Tourniquet of, 332 Phalanges, Disloc'n of, 275, 284 Fractures of, 212 Phlebotomy, 285 Physick's Dressing for Fracture of Condyles, 207 Gaiter, 224 Splints, 229 Pieces of Dressing, 22 Plasters, 40 Court, 38 Plugging of Nostrils, 337 Posterior 8 of Chest, 72 Poultices, 38 Preface, 3 Preservation of Leeches, 302 of Vaccine, 319 Pressure, 329 Processes of Vertebrae, dislocation of, 266 Pterygium, Excision of, 374 Pubis, Dislocation on, 281 Pnllies, 273 Puncture Electro, 317 of Mem. Tympani, 323 Hydrocele, 324 Purses, 117 Pyramidal Compress, 31 Quilled Suture, 345 Radius, Dislocations of, 272 Fracture of, 210 Ranula, 325 Recurrent of Amputations, 93 Head, 91 Reducing Dislocation of Hip, Fahnestock's Mode of, 279 Reduction of Dis. by Pullies, 273 Retaining Bandage, 5 3 Retractors, 29 Reverses of Bandage, 59 Ribbail's Bandage, 87 Ribs, Dislocations of, 266 Fractures of, 1 94 Roller, Double-headed, 50 Manufacture of, 49 Simple, 48 Single-headed, 49 Rule for Diagnosis of Injuries of Elbow, 273 Rules for Dressing, 45 Sailor's Knot, 335 Salivary Concretions, 326 Scapula, 202 Sciatic Notch, Disloc'n into, 281 ScuUet's Bandage, 227 Setons, 310 Shaft of Humerus, 206 Sheaths, 119 Simple Bis-Axillary Cravat, 135 Axillo-Scapulary, 136 Simple Roller, 48 Single-headed Roller, 49 . Single Spica, 140 Skull, fractures of, 191 Slings, 1 1 1 of Breast, 115 Chin, 113 Face, 114 Head, 111 Neck, 113 Spanish Windlass, 331 Spica Handkerchief, double, 140 of Groin, 81 both Groins, 82 Instep, 87 Shoulder, 75 Thumb, 85 Spiral Bandage, 52, 57 of Abdomen, 61 all the Fingers, G4 Chest, 60 Finger, 64 French 67 Lower Extremity, 66 Upper Extremity, 62 Penis, 61 Splint Cloth, 227 Splints, 228 Amesbury's, 235 Boyer's, 231 Dessault's, 228 384 INDEX. Splints, Gibson's Hagedorn, 238 Hartshorne's, 233 N. R. Smith's, 241 Physick's, 229 Spring Lancet, 289 Sternal Handkerchief, 132 Sternum, 193 Stocking-laced, 120 Stomach, Catheterism of, 351 Square Cap of Head, 128 Square Compress, 27 Sub-Femoral Handkerchief, 139 Surgeon's Knot, 335 Suspensories, 117 of Nose, 117 Scrotum, 1 18 Suspensory Handkerchief, 141 Sutures, 341 Continued, 343 Interrupted, 341 Tailed Bandage, 228 Tarso-Patella Cravat, 150 Tarso-Pelvien Cravat. 148 Tarsus, Bones of, Dislocation, 283 T Bandages, 95 of Abdomen, 99 Chest, 99 Ear, 97 Head, 96 Nose, 98 T double of Buttock, 101 Hand. 102 Perforated of, 102 Teeth, Extraction of, 360 1'hroat, Extraction of Foreign Bodies from, 366 Thumb Lancet, 290 Spica of, 85 Tibial Cravat, 152 Tibio-Cervical Sling, 158 Tonsils, Excision of, 376 Torsion, 336 Tourniquet of Petit, 332 Tow, 27. o I Transverse wounds of exttemi- ties, 107 of Neck, 102 Triangle Handkerchief, 128 Bi Temporal, 130 Carpo-Dorsa), 145 Facial, 131 Fronto-occipitai, 128 Occulo-Occipital, 130 Triangular Cap of Breast, 1 38 Amputations, 144 Foot, 150 Heel, 146 Shoulder, 144 Compress, 28 T of Groin, 100 Trough Ante-Brachial, 142 Twisted or Hare Lip Suture, 344 Ulcer, Toe.Nail, 37 1 Uniting Bandage, 52 of Transverse Wounds of Neck, 102 Upper Extremity, Disl'ns of, 269 Urethra, Catheterism of, 347 Injections into, 357 Uvula, Excision of, 375 Vaccination, 317 Vaccine, Preservation of, 319 Vagina, Injection into, 358 Venesection, 286 Veins of Arm, Anatomy of, 286 Velpeau's Bandage for Acromion, 203 Velpeau, use of Adhesive Plas- ter, 35, Vertebrae, Fracture of, 193 Dislocation of, 266 Vertico-Mental Cravat, 131 Wounds, Foreign Matter in, 368 Windlass, Spanish, 331 Wrist, Disl'n of Bones of, 274 Bones of Fore Arm on, 274 THE END.