LIBRARY OF CONGRESS. Sbelft 'XI* UNITED STATES OF AMERICA. OCT 20 V- PRACTICAL SURGERY: INCLUDING SDRGICAL DRESSINGS, BANDAGING, FRACTURES, DISLOCATIONS, LIGATDRE OF ARTERIES, AMPUTATIONS, AND EXCISIONS OF BONES AND JOINTS. BY ^ — ■/ J. BWING MEAES, M.D., LECTUREK ON PRACTICAL SURGERy AND DEMONSTRATOR OF SURGERY IN JEFFERSON MEDICAL COLLEGE, PROFESSOR OF ANATOMY AND CLINICAL SURGERY IN THE PENNSYLVANIA COLLEGE OF DENTAL SURGERY, SURGEON TO ST. MARY'S HOSPITAL, GYNECOLOGIST TO JEFFERSON MEDICAL \) COLLEGE HOSPITM,, FELLOW OF THE AMERICAN SURGICAL ASSOCIATION, ETC. WITH FOXJB HUNDRED AND NINETY ILLUSTRATIONS. PHILADELPHIA TON, 1885. BLAKISTON, SON & CO. Eutered accordiug to Act of Congress, in the year 1S85, by J. EWING HEARS, M.D., In the office of the Librarian of Congress, at Washington. COLLINS, PlilNTEK. (3n XHemoriam.) TO SAMUEL D. GROSS, M.D., LL.D. Cantab., LL.D. Edin., D.C.L. Oxon., PROFESSOR EMERITUS OF SURfiEUY IX JEFFERSON MEDICAL COLLEGE, AVHOSE EMINENT SERVICES AS AUTHOR, TEACHER, AND PRACTITIONER CONFERRED HONOR UPON HIS COUNTRY, HIS PROFESSION, AND HIMSELF, ®|is look IS (5RATEFULLY INSCRIBED TITE AUTHOR. PREFACE TO THE SECOND EDITION. The author desires to express his appreciation of the favor with which the first edition of his work was received by both Practitioners and Students of Medicine. In the preparation of the present edition, he has endeav- ored, by the addition of new, and the revision of the original matter, to extend its usefulness. To the illustrations, for which acknowledgment was made in the preface to the first edition, he has added many others reproduced from the works of Gross, Agnew, Stephen Smith, Cheyxe, MacCormac, Pilcher, Hamilton, and Gray. Messrs. Gemrig and D. W. Kolbe & Son, of this city, and Tiemann & Co., of New York, have again placed him under obligations for the loan of cuts of splints and instru- ments. Philadelphia, 1429 Walnut Street, October, 1885. PREFACE TO THE FIRST EDITION. This book has been written in response to the request of students who have been from time to time under the in- struction of the author, and who have expressed a desire for a work which should embrace in a condensed form the subjects herein treated of. It has been the endeavor of the author to present these subjects in as concise a manner as possible, and at the same time to omit nothing which might be deemed necessary to render the instruction complete. While he has aimed to embody chiefly the results of his own experience as a teacher and as a practitioner, he has not hesitated to make use of the standard text-books on surgery and of such works as are devoted to the consideration of the special topics presented in this. With a few exceptions, the illustrations are reproductions from the works of Gross, H. H. Smith, Stephen Smith, AsHHURST, Packard, Maunder, Heath, Bellamy, and Bernard and Huette. The anatomical relations of the arteries are largely those which are given in " Gray's Anat- Vlll PREFACE TO THE FIRST EDITION. omy," tlie correctness of which has been verified by dissec- tions and operations. Messrs. Gemrig and Kolbe, instrument- makers, of this city, and Messrs. Stholmann, Pfarre & Co., of New York, have placed the author under obligations for the loan of cuts of instruments. To Dr. John W. Barr his thanks are especially due for valuable aid in correcting the proof of the work. Philadelphia, 1429 Walnut Street, October, 1878. CONTENTS. PART I. SURGICAL DRESSINGS. PAGE Tompresses .......... 13 Plasters 20 Poultices or Cataplasms ....... 23 Methods of Irrigation 25 Sponges 27 Instruments used in Dressing Wounds . • . . 29 Dressing a Wound 32 The Antiseptic System of Dressing Wounds ... 35 Agents employed in diiferent Antiseptic Methods . . 47 Important points involved in Treatment of Wounds . . 58 PART II. BANDAGING. The Simple Bandage or Roller 65 for the Head, Body, Extremities 67 for the Hand 68 Bandages of the Head 72 of the Trunk 79 of the Extremities ........ 89 of the Superior Extremity ...... of the Inferior Extremity . . . . . • • &• 89 X CONTEXTS. PAGE General Bandages 98 The Compound Bandages 102 Mayor's System of Handkerchief Dressings .... 104 Immovable Bandages 108 PART III. FRACTURES. Complete Fractures 117 Incomplete Fractures 119 Causes of Fracture . . . . . . . .121 Symptoms of Fracture 122 Diagnosis of Fracture ... . . . . . .124 Prognosis in Fractures 125 Treatment of Fractures 128 of Complicated Fractures 144 of Compound Fractures 145 of Fractures united with Deformity ..... 147 Ununited Fracture or Pseudarthrosis ..... 149 Special Fractures 152 Cranium .......... 152 Face 155 Trunk 164 Upper Extremity ........ 173 Lower Extremity ........ 226 PART IV. DISLOCATIONS. Traumatic Dislocations 299 Pathological Dislocations ....... 300 Congenital Dislocations 301 CONTENTS. XI Causes. of Dislocation . Symptoms of Dislocation Diagnosis of Dislocation Prognosis Treatment . Complicated Compound . Old Special Dislocations Head and Face Upper Extremity Pelvis Lower Extremity PAGE 301 305 307 308 309 313 314 317 320 320 339 412 416 PART V. LIGATURE OF ARTERIES. Positions of the Knife 476 Incisions 478 Closure of Wounds 479 Sutures .......... 479 Needles 481 Operations upon the Living and Dead Subjects . . . 482 Instruments used in the Ligature of Arteries . . . 484 Operations for the Ligature of Arteries .... 486 Ligature of Special Arteries ...... 493 PART VI. AMPUTATIONS. Instruments used in Amputations Methods of controlling Hemorrhage in Amputations Methods of Amputation ..... 571 576 580 Xll CONTENTS. PAGE After-treatment in Amputation . . . . . .597 Affections of the Stump ....... 600 Synclironous Amputation 605 Re-amputafions . . . ' 607 Intra-uterine Amputations 607 Constitutional effects after Amputation .... 607 Special Amputations ........ 610 Lower Extremity ........ 610 Upper Extremity 662 PART VII. EXCISIONS OF BONES AND JOINTS. Conditions demanding Excision Contra-indications in Process of repair after Instruments used in Incisions employed Special Excisions Cranium . Face Trunk Upper Extremity Lower Extremity 699 699 700 703 709 709 717 731 735 762 Index PRACTICAL SURGERY. Practical Surgery may be divided conveniently into two ^Kirts : First, that part which relates to the preparation and application of surgical dressings — mechanical ; and, second, that which embraces surgical operations — the use of cutting instruments and the production of wounds — operative. PART I. SURGICAL DRESSINGS. Under this term may be included all appliances which are employed in the treatment of wounds, made either by tiie surgeon in performing operations, those which are caused by injuries, or those conditions which are the results of mor- bid processes. They consist, in general, of Compresses, Plasters, Poul- tices, Bandages, and Splints, and are prepared in such manner as to fulfil the indications presented in each indi- vidual case. Compresses are folded pieces of various materials, such as lint, charpie, cotton, wool, oakum, muslin, linen, etc., which are placed upon a part and retained by means of bandages. 2 14 SURGICAL DRESSINGS. Lint is a soft, flocculent substance prepared by scraping the surface of a piece of old linen. That known as patent lint is made by machinery. Recently another form of lint, made from paper and called paper-lint, has been prepared, which possesses remarkable absorbent properties. Lint, rendered antiseptic by boracic acid and other agents, is also found in the shops. Charpie This consists of a mass of loose sliort threads, made by separating pieces of linen or muslin measuring four or five inches square. It may be either fine or coarse, ac- cording to the character of the material employed. It can be arranged into a variety of forms, so as to be adapted to the various kinds of wounds ; these are called tents, pledgets, etc. Cotton-wool In the raw state or arranged in sheets, this material is used as a dressing. In this respect, its value has been increased recently by the introduction of various pro- cesses which are employed to render it antiseptic, and give to it absorbent properties. It can be made hygroscopic by boiling it in lye. In addition, cotton charged with boracic acid, carbolic acid, benzoic acid, subsulphate of iron, per- chloride of iron, tannic acid, corrosive sublimate, iodine and iodoform, forming the borated, carbolated, benzoated, haemos- tatic or styptic, tannated, corrosive sublimate, iodized and iodoform preparations are now employed largely in surgical dressings. Absorbent cotton takes up fifteen times its weight of water. When the cotton-wool, which has not been ren- dered antiseptic, is used, care should be taken to see that it is clean and free from particles of dirt. The eggs of the fly are sometimes deposited in it, and under the action of the heat developed when in contact with the surface of the body these develop into maggots. SURGICAL DRESSINGS. 15 Wool Finely carded wool has been employed as a dress- ing ; it possesses no advantage over cotton, and is more expensive. Oakum — This material is made by untwisting and sepa- rating pieces of old tarred rope ; it is subsequently cleaned, and forms an excellent dressing ; is cheap, readily obtain- able, and possesses decided advantages by virtue of the tar it contains. Oakum has been rendered antiseptic in the same manner as cotton, forming various preparations. Jute — A substance resembling hemp. It is prepared for use as a surgical dressing by cleansing it thoroughly, and then treating it with carbolic acid, resin, glycerin, and alco- hol, in the following proportions : To each pound of jute add carbolic acid 2J ounces (50 gram.) ; resin, 6J ounces (200 gram.) ; glycerin, 8;^ ounces (250 gram.) ; and alcohol, 18J ounces (550 gram.). In order to reduce the cost of prepa- ration, benzine can be substituted for the alcohol. It has the power of absorbing from four to six times its weight of water. It should be soft and silky, and free from coarse fibres. As the carbolic acid disappears rapidly from it, that used should be freshly made. It retains corrosive sublimate ibr a longer period. Sublimated jute is made by macerating twelve hours in a solution of corrosive sublimate 1 to 1000 parts of water, and glycerin 50 parts. It serves in general the same purpose as oakum. Tenax or Tow A preparation of flax or hemp is also used as a dressing ; it is not as available as oakum. Gauze — This material is now used much as a dressing, owing to its porous character, which permits of the free escape of discharges from the surfaces of wounds. Dairy or cheese cloth is usually selected, and it is rendered antiseptic by different agents, as carbolic acid, boracic acid, corrosive 16 SURGICAL DRESSINGS. sublimate, iodoform, etc. Its cost is so slight that it can be used as a substitute for the ordinary dressings. Mosquito netting, which has not been dyed, can be used in place of the cheese cloth if desirable. Glass-wool. — This substance consists of finely spun strands of glass, and has been suggested recently as an article of dressing. Its place can be supplied by other dressings. Peat This substance possesses great absorbent proper- ties. It was first employed mixed with iodoform as a dress- ing in the hospitals at Kiel, in Germany ; two varieties, the white and black, are used ; sometimes they are mix«d, four parts of the former to one of the latter. It is said to absorb sixteen times its weight of water. Wood-wool This substance is obtained from the pulp of wood during the process of paper manufacture. It possesses great absorbent qualities, and is used in the same manner as peat. Moss The ordinary moss of the forests, introduced by Dr. Weir, of New York. It should be dried in an oven to kill the insects it may contain, and can then be treated and used in the same manner as jute, peat, and the wood-wool. Sawdust Dr. A. G. Gerster, of New York, has em- ployed sawdust, wliich has been soaked in a solution of cor- rosive sublimate (1 to 500) and afterwards dried, and has found that it gave great satisfaction as a dressing. Bran. — This substance has been long used as a dressing in compound fractures. Recently it has been rendered anti- septic by carbolic acid, and in this way its value has been increased. It can also be treated with a solution of corro- sive sublimate. Dry Earth. — Clay dried and finely powdered was intro- duced by Dr. Addinell Hewson, of Philadelphia, as a dress- SURGICAL DRESSINGS. 17 ing some years since. It has also been treated with carbolic acid and corrosive sublimate solutions. Charcoal. — Charcoal in the powdered state has been long employed as a wound-dressing. Sand Kiimmell, of" Hamburg, has recently introduced this substance as a dressing, using for that purpose white quartz-sand. It is prepared by passing it through a fine sieve, and then heating it in an oven in a covered pan for several hours. Sublimated sand is prepared by mixing 10,000 parts of sand in 10 parts of corrosive sublimate and 100 parts of ether, and should be kept in glass-stoppered bottles. It is used to fill wound cavities, being covered with the sublimated gauze, which is held in place by a gauze bandage. Coal-ashes. — The absorbent properties of finely sifted coal- ashes render them serviceable for the purpose of dressings. Tlieir antiseptic power can be increased by saturating with an antiseptic solution, as corrosive sublimate. Kiimmell has employed the ashes in the shape of cushions, which are of varying sizes, to adapt them to different wounds, and are wet with the antiseptic lotion before being applied. Spongio-piline is made by felting together layers of lamb's wool and sponge, and coating one of the surfaces with rub- ber, which renders it impermeable to moisture. This is an elegant preparation, but too expensive for general use. Muslin and Linen Pieces of old muslin or linen are most frequently used as articles of dressing,, and are fre- quently quite as serviceable as the more costly materials. The various articles of dressings can be formed into dif- ferent shapes, as the square, oblong, triangular, cribriform, or graduated compress, the Maltese cross, etc. The forma- 2* 18 SURGICAL DRESSINGS. Fig. 1. tion of the square, oblong, and triangular compress is quite easy, the name indicating the form. The Cribriform Compress is made by folding a square piece of muslin four or five times on itself, and then nicking the border in a number of places with the scissors. When opened, it will present a cribriform appearance. The open- ings whicli are made permit the free escape of discharges (Fig. 1). The Maltese Cross derives its name from the sliape, and is made by folding a square piece of the material from which it is to be formed into an oblong square, fold- ing this into a smaller square, then into a triangle so as to bring the free edges in contact, and slitting the base of this triangle to two-thirds of its extent, the in- cision beginning at the end formed by the joining of the free edges (Fig. 2). On opening the piece it will be found tliat a regular Maltese cross has been formed (Fig. 3). M I f M > 4 ' ft! Ml ) t p i ) f i 1 i i S * ! i » M } M [ t I n I it , » f M J M f I M M M M If M. * 5 J f ; Fig. 2. Fig. 3. The Half Maltese Gross is formed by folding an oblong square into a smaller square, then into a triangle, and incis- ing the base as above described (Fig. 4). SURGICAL DRESSINGS. 19 These forms are useful in dressing stumps after amputa- tions. The Graduated Compress consists of a number of folds, so arranged that each succeeding fold covers about one-half of that preceding it (Fig 5). Fiff. 4. Fig. 5. The Pyramidal Compress is prepared by sewing together square pieces which gradually de- crease in size, so placed as to form a pyramid (Fig. 6). These are used for making pressure. Fig. 6. It is frequently desirable to cover dressings with an impermeable covering, so as to retain moisture or prevent the escape of discharges upon the bedclothes or clothing. Among these articles are oiled silk, waxed paper, oiled paper, and gum tissue or rubber cloth. Oiled Silk is made by coating pieces of silk with layers of boiled oil, containing the oxide of lead to render it dry. This was formerly much employed; lately it has been sup- planted largely by less expensive articles. Waxed Paper — This can be readily prepared by passing sheets of strong tissue paper through melted white or yellow wax or paraffin, and then hanging tliem up to dry. It serves 20 SURGICAL DRESSINGS. the same purpose as the oiled silk, is quite inexpensive, and can be thrown away after being used. A few drops of lin- seed oil added to the melted wax will render the coating less brittle. Oiled Paper is made by brushing sheets of paper with boiled oil, which has been reboiled with oxide and acetate of lead, sulphate of zinc, and burnt umber. Gutta Percha or Gum Tissue is a liglit and elegant article, and is in general use in the antiseptic dressings. Rubber Cloth. — This material, prepared in very thin sheets, may be employed as an impermeable covering. Plasters. — Adhesive Plaster (Emplastrum Resinas). This plaster is found already prepared in the shops, spread upon cotton, twill, or swans' down. Care should be taken to select that which has been recently made ; when old it becomes dry, cracks, and loses its attachment to the cloth upon which it has been spread. In cutting strips, the scissors should be applied with the blades very slightly open^ using the cutting edges of the points only, and dividing the plaster lengthwise, and not crosswise. The division should be effected by pushing the scissors along, and not by closing the blades, the piece being firmly held by an assistant (Fig. 7). If cut crosswise, the cloth stretches, and thus interferes with proper application of the strips. The width and length of the strips will vary according to the wants of each case ; as a rule, they shoidd be three-quarters of an inch wide, and long enough to ex- tend three inches beyond the edges of the wound. In ap- plying them, they should be placed first in contact with the central and the most dependent part ol' the wound, in order to draw it up and afford support from below upward. Small SURGICAL DRESSINGS. 21 triangular pieces may be cut out of the strips at the points of contact with the surface of the wound, so as to permit the discharge to escape. The strips may be made to adapt themselves smoothly and evenly to a round or irregular sur- face by nicking the edges. Before applying the strips of plaster, it is necessary that they should be heated, and ^^^' '' the most efficient, and, at the same time, most con- venient method is to place the cloth side of the strips in contact with the surface of a tin can or bottle con- taining hot water ; in this way the surface is equably ^heated and softened, so as to adhere to the >-kin. At- tempts to heat adhesive strips over the gas-light, candle-light, spirit-lamp, over the surface of the stove, by dipping them in hot water, or by applying such an agent as chloro- form, usually result in fail- ures to secure that equable heating and softening of the adhesive surface which is so desirable in securing a firm attachment to the surface of the skin ; besides, the strips are liable to be scorched and discolored, and thus detract from the neat appearance of the dressings. In order to remove the adhesive strips, warm water should 22 SURGICAL DRESSINGS. be applied to the surface by means of a sponge or cloth. The ends should then be taken hold of, and the strip gently raised from each side of the wound to within an inch of the line of the incision (Fig. 8). The edges of the wound should now be supported by the thumb and index finger of one hand, while the strip is lifted in a vertical direction from the part. Sufficient space should always be left between the strips to permit free escape of the discharges. In order to avoid giving pain to patients, and disturbing the wound in removing the strips of plaster from surfaces, especially those which are covered with hair, the late Mr. Cal- lender, of London, employed the simple expedient of cutting out the spaces over the dressing at the points the strips left the wound and passed on to the surface of the skin. In re- newing the dressing the divided plaster is rejoined by strips laid over the first applied; this can be repeated, leaving the strips first applied still adherent to the skin until the wound is healed. A very good form of adhesive plaster has been introduced sukCtICal dressings. 23 recently, which is " self-adhesive." The heat of the body is sufficient to render it firmly adherent. It comes in sheets or in strips of various lengths and widths rolled on spools, and is thus prepared very conveniently for use. Besides the officinal adhesive plaster, other varieties are employed, such as Isinylass Plaster, Court Plaster, etc. These require to be moistened, and not heated, in order to be made to adhere to the surface, and are more desirable applications in wounds of the face and head. Fig. 9. Poultices, or Cataplasms, are soft, moist substances which are employed in the treatment of wounds (Fig. 9). They are designated as the emol- lient, astringent, stimulating, fer- menting, rubefacient, narcotic, etc. The Emolient Poultice is that form most commonly used, and may be made of bread and milk, corn meal and water, flaxseed meal, ground elm bark, or any unirritating substance. The flax- seed or linseed meal poultice is made thus : A quantity of recently ground meal is put into a basin which has been scalded, and boiling water is poured into it gradually, the mixture being well stirred, until it acquires a consistence which will prevent its running out when the basin is inverted. It is then to be spread with a spatula or table knife, to a thickness of one-quarter to three- quarters of an inch, upon a piece of strong muslin of the proper size, a border of an inch in width being left un- covered. The corners of the cloth are now incised with the scissors, and the borders folded over so as to form a margin, r— — -Ti !■: ! •"' ^:^'A.:.^:■■Kl\•^ ^^M — ^— " - p-==-=---:-rt r 1 24 SURGICAL DRESSINGS. which will prevent the adhesion of the edges to the surface, and also the escape of the contents of the poultice. A piece of fine white gauze or mosquito netting (that which has been dyed should not be used) may be placed over the poultice to prevent it from adhering, and folded down with the edges of the cloth. A few drops of olive oil may be poured over the surface to soften it, or any article with which it is thought desirable to medicate the poultice, as tincture of opium, etc. In order to retain the moisture in the poultice, it should be covered with a piece of oiled silk, or with waxed paper. As a rule, poultices should be renewed twice in twenty- four hours — more frequently if the conditions of the case demand it. The Astringent Poultice can be made by adding the astringent substance to the linseed meal or bread and milk poultice. The Stimulating Poultice may be made of various sub- stances, as grated boiled carrot, horseradish, garlic, black pepper, brine and corn meal, etc. The Fermenting Poultice is usually made by mixing corn meal with yeast or porter. The Rubefacient Poultice is made by mixing flour of mustard with water until a proper consistence is obtained. Its strength may be reduced by the addition of flour, in the proportions of one-quarter or one-half. Vinegar should not be used in preparing these poultices, as it destroys their rubefacient properties. A poultice of great value in the treatment of cases of hos- pital gangrene may be made of equal parts of powdered animal charcoal and brown sugar. The Iceland moss instantaneous poultice has been lately SURGICAL DRESSINGS. 25 introduced, and is found for sale in the shops. It is claimed to possess special advantages in not undergoing fermentation and in the ease with whicli it can be saturated with medi- cated lotions. Poultices may be confined to the part by a few turns of a roller or by broad strips of adhesive plaster. When ap- plied to such a part as the breast, they should be cut in a circular form and the circumference nicked to the extent of an inch or more in order that they may adapt themselves to the surface. Methods of Irrigation It is frequently necessary, in the treatment of surgical affections, to apply water dress- Fig. 10. 26 SURGICAL DRESSINGS. ings, or heat or cold either in the dry or moist form. The simplest method in the moist form is to apply compresses wrung out in warm or cold water ; this is inconvenient, however, and does not secure a uniform effect. A simple and efficient plan is to put a piece of lamp-wick or a number of threads into a reservoir of water placed some distance above the level of the patient's body, which, acting as a siphon, conveys the fluid uniformly over the part. Dry cold and dry heat may be conveniently applied in the form of the rubber bags or thin metallic boxes — con- taining in the one case ice, and in the other hot water. The most efficient method of applying dry cold or heat is by Fig. 11. SURGICAL DRESSINGS. 27 means of the rubber tubing as suggested by M. Petitgand. A flexible rubber tube sixteen to twenty feet in length and one-half of an inch in diameter is applied around the part in a spiral manner and held in position by a few turns of a roller or by adhesive strips. The walls of the tube should be not more than a line in thickness, and the end which is placed in the reservoir should have a metallic cap heavy enougii to sink it, and so arranged that the water can have free access to the tube. The other end should be provided with a stopcock and nozzle, so that the floAv of the water tlirouorh the tube can be regulated. The reservoir of water is placed above the level of the patient, as in the other forms. In all cases where water-dressings are employed, the bed should be protected by a rubber cloth or other suitable material (Figs. 10 and 11). Sponges. — These play an important part in all surgical operations and in the dressing of wounds. They should be selected with great care, and none but those which are of fine and soft texture should be used. When obtained in the shops, it will be found that, as a rule, they contain particles of sand and sometimes other foreign substances. Before using, therefore, they should be thoroughly beaten, washed, and allowed to soak for a number of hours, if practicable. When the calcareous particles cannot be entirely removed by washing, the sponges should be placed for a short time in a dilute solution of hydrochloric acid, one part to thirty of water, which will dissolve the particles, and then washed in an alkaline solution (aqua? ammonias fort., 5ij to Oj of water) to neutralize any acid remaining in the meshes. Sometimes sponges contain prickles derived from plants which grow in contact with them, and with which they become 1^8 SURGICAL DRESSINGS. thoroughly irrpreojnated during tlie process of cleaning and preparing for market. During the use of tliese sponges the prickles penetrate the fingers of the surgeon, and must, of course, cause much irritation of the wounded surfaces upon which the sponges are placed in operations ; care should be taken to reject all sponges containing these substances. It is of great importance that they should be perfectly free from all foreign matter, and should be made scrupulously clean before using. It is a good and safe rule to have neiv sponges for each patient, which will be used only for that person. When new sponges cannot be procured, those which have been used can be thoroughly cleansed by soaking them in a four per cent, solution of permanganate of potassium, then in a twenty-five per cent, solution of sulphurous acid, and finally washing thoroughly in water ; or, they may be well washed in a solution of carbolic acid (1 to 20), or of corrosive sublimate (1 to 1000) and kept constantly in the solution. Under no circumstances should sponges which have been employed in dressing erysipelatous or gangrenous wounds, or those of a contagious character, be used in dress- ing the wounds of another patient. If this precaution be neglected, the gravest consequences may ensue in the con- veyance of infectious diseases. In dressing a wound the sponge should never be placed in contact with the ojranulating surfaces. The water should be allowed to flow upon the surfaces by compressing the sponge raised some distance above. About the edges of the wound and adjacent surfaces the sponge should be applied gently, so as to remove discharges. When operations are performed in connection with the cavities of the body, or in cases of necrosis, the sponges should be counted before the operation SURGICAL DRESSINGS. 29 and after its completion^ in order to avoid the grave error of leaving any, or pieces of any, in the cavity. Fatal results have resulted and heavy damages have been paid on account of failure to attend to this injunction. In using the sponges in operations they should be tho- roughly squeezed out so as to absorb readily the blood, and should l)e pressed upon the denuded surfaces and not rubbed. They should never be used for removing the blood from the floor after operations, or for any purpose other than that for which they were intended. INSTRUMENTS USED IN DRESSING AVOUNDS. The instruments which are usually required in applying or removing dressings are few in number, and consist of a pair of Dressing Forceps, Dissecting Forceps, and Scissors. The Dressing Forceps are shaped like the ordinary scis- sors, terminating in rounded, spoon-shaped ends, the edges and inner surfaces of which are serrated. They are used to seize hold of dressings and remove them from the surface of wounds (Fig. 12). The Dissecting Forceps are employed to remove minute pieces of dressing, foreign bodies, etc., doing this more readily than the dressing forceps (Fig. 13). .q* 30 SURGICAL DRESSINGS. Fi-. 13. The Scissors may be either straight or curved, and are used to give shape to the articles of dressings, etc. They should not as a rule be used to divide the tissues, as they produce a contused edge in the wound which interferes with the union (Figs. 14, 15). Fiff. 14. Fi{?. 15. These are found in the Pocket Case, with other instru- ments which are used in operations and in the treatment of disease (Fig. 16). As it is quite desirable to have the Pocket Case small in size and not too bulky, and yet contain all of the instru- ments required, some tact has been displayed in arranging them. That known as Professor S. D. Gross's case con- SURGICAL DRESSINGS. 31 tains : One Scalpel and Straight Bistoury ; two Curved Bistouries, probe and sharp-pointed ; one Tenotome and Tenaculum ; one pair of Artery and Needle Forceps com- bined ; one pair of Scissors ; one pair of Polypus and Dress- ing Forceps ; one pair of Dissecting Forceps ; one -Exploring Needle; one male and female Catheter; one Porte-caustique; one Gross's Ear Instrument ; one Grooved Director ; one pair of Probes ; one half-dozen Needles, and one skein of Silk. The cutting instruments are double-bladed, with slide 32 SURGICAL DRKSSTNGS. locks to secure the blades, either opened or closed (Figs. 17, 18). Dr. W. W. Keen has suggested a modification of Fiz. 17. Fi^. 18. the pocket case which materially reduces its size, and at the same time adds three instruments. As arranged by him it measures 4^x2^x1^^ inches, and contains in addition a hypodermic needle, a thermometer, and a tubular needle. DRESSING A WOUND. In order to dress a wound the following articles and in- struments should be at liand : Water, both hot and cold ; SURGICAL DRESSINGS. 33 receptacle for the soiled dressings, basins, sponges, lint or other material to form compresses, syringes, including a fountain syringe, rubber-clotli to protect the bed, towels, bandages, adhesive plaster, tin can containing hot water to heat the plaster, needles, pins, and pocket case containing dressing forceps, dissecting forceps, and scissors. A sufficient number of assistants should always be present, in order that the dressings may be removed and applied with as little dehiy as possible. Usually three are required : one to support the part, one to attend to the sponges and supply of water at proper temperature, and a third to hand the dressings and instruments. Before exposing the wound, the assistants should be assigned to their respective posi- tions, the dressings prepared, and everything in readiness. The rubber cloth should be placed so as to protect the bed, and the part lifted by the assistant and held in a comfortable and easy position. The soiled dressings should be removed carefully and placed in a covered receptacle and taken from the room. The wound should be cleansed by allowing the water to flow over it, from the tube of the fountain syringe, or squeezed out of a sponge held some distance above its margin, or vertically over it. If cavities exist, these can be thoroughly cleansed by throwing water into tliem with a syringe, being careful .to avoid giving too much force to the stream. The borders of the wound and adjacent surfaces should be gently wiped with the sponge, wnth regular and even motions^ carrying it toward the edges so as not to cause them to separate or to pull upon the sutures if they still re- main. Short, jerking movements should be avoided in using the sponge, as they give pain and are liable to cause separa- tion of the edges of the wound. The sponge should not be placed in contact witli the denuded surfaces. Collections of 34 SURGICAL DRESSINGS. pus can be removed by a gentle stream of water thrown by the syringe, and foreign bodies can be picked off readily with the dissecting forceps. When cleansed, the borders should be dried by pressing a clean, soft towel upon them, care being taken to avoid bringing it in contact with the wound. If required, the adhesive strips already cut should be applied in the manner directed above (page 21). The compress, upon which has been spread the cerate or substance employed, is placed over the wound, and held in position by turns of the roller or broad adhesive strips. The more important points in applying dressings, to which the attention of the student is directed, may be expressed in a few general rules : — I. The position of the patient should be that which is most comfortable and free from restraint. The bed or table should be placed so as to afford ample light and space to those enojaged in the dressinoj. II. Every article required in the dressing should be prepared and arranged before the wound is exposed. They should be placed in order, so that they can be easily and quickly reached. III. The removal of the old dressings, the cleansing of tlie wound, and the application of the new dressings should all be performed in such manner as to avoid giving unne- cessary pain to the patient. Every movement of the sur- geon and assistants should be made with care — rough handling of the patient or of the wound should not, under any circumstances, be permitted. If tlie removal and appli- cation of the dressings cause great pain, the patient should be placed under the influence of an anaesthetic agent. IV. The wound should be exposed for as short a time as SURGICAL DRESSINGS. 35 possible. Renewal of the dressings, unless the discharge is excessive, is not usually required oftener than once m twenty-four hours. Frequent dressings disturb and expose the wound, and thus interfere with the process of repair. Y. The fingers should not be used in removing the dress- ings or foreign substances from the wound, lest disease should be thus conveyed from one to another patient, or the surgeon become infected by the discharges. YI. The hands of the surgeon and assistants should be carefully washed both before and after the dressing. YII. All of the instruments used should be kept scim- pidoiisly clean. THE ANTISEPTIC SYSTEM OF DRESSING WOUNDS. The System of Lister. — This is a system introduced by Sir Joseph Lister, who defines it as " the dealing with sur- gical cases in such a way as to prevent the introduction of putrefactive influences into wounds." The following articles are necessary in order to properly carry out the antiseptic method in surgical operations and dressings : — 1. Two solutions of carbolic acid, 1 in 40 (twelve grains to the ounce), and 1 in 20 (twenty-four grains to the ounce), should be prepared, — the first for the protective and loose layer of gauze, the second for the spray, and in w^hich the sponges, instruments, and drainage tubes are immersed, and also which is used to wash the part and the hands of the surgeon and assistants. 2. Steam Spray Apparatus. — This consists essentially ot a spirit lamp with a hollow wick, a boiler to contain w^ater, a bottle to hold the solution of carbolic acid (1 in 20), and a 36 SURGICAL DRESSINGS. spray-tube. An excellent and inexpensive apparatus has been devised by Dr. R. F. Weir, of New York (Fig. 19). Fig. 19. 3. Antiseptic Gauze. — This is prepared as follows: — Coarse-meshed cotton cloth, known as dairy or cheese clotli, is heated above 212°, and then sprinkled with its own weight of a mixture of carbolic acid one part, common resin four parts, and paraffin four parts, the latter being melted together in a water-batli, and the acid then added by stirring. Pressure is then applied, so as to disseminate the liquid equally through the cloth. Old mosquito netting, which has been boiled in lye, can be used in place of the dairy cloth. In cases in which it is desirable to economize with regard to the use of the guaze, the larger and least soiled pieces can be washed and re-charged and used in future dressings as loose gauze. The expense of preparing the gauze can also be much reduced by the substitution of SURGICAL DRESSINGS. 37 castor oil for the paraffin as practised by Von Briins, accord- injj to the followinij formula : — c Carbolic acid . . . . .1 part Resin 4 parts Castor oil 8 " Alcohol 20 " The resin is dissolved in the alcohol and then the castor oil and carbolic acid are added by stirring in well. The gauze is simply soaked in this solution and then hung up to dry ; in a few minutes it will be ready for use. Benzine may be used in the place of alcohol, still further reducing the cost of preparation. Its purpose is to absorb the fluids from the wound, and to prevent their decomposition. 4. The Mackintosh — This is a material used in the manufacture of hats, and consists of thin cotton cloth with a layer of red vulcanized rubber on one side. Thin rubber cloth, oiled silk, or gutta percha tissue will be found proba- bly as effective. The material used should be free from holes. The Mackintosh is used to compel the secretions to permeate the whole dressing, thus being constantly in con- tact with the carbolic acid. It is placed between the seventh and eighth layers of the gauze. 5. Rubber Tubings These are used for drainage, and vary in size from one-eighth to one-half of an inch. Numerous openings, each half the diameter of the tube, are made on the side. Red rubber tubes should be used as they contain no free sulphur. (Fig. 20 ) When introduced into a wound or cavity, the outer end of the tube should be cut flush with the surface of the skin, and should be secured in place by two threads of carbolized silk, fastened into the end and tied in a knot, which can be 4 38 SURGICAL DRESSINGS. placed between the skin and dressings. In order to obtain greater security strips of gauze wet with carbolic lotion can be inserted between the loops. Fig. 20. The tubes should be kept constantly in a la^ge vessel con- taining 1 to 20 carbolic acid solution. Tubes which are to be returned should not be removed from the wound until the third day, by that time a channel in the lymph has been formed which permits of an easy reintroduction. Before re- turning, all drainage tubes should be washed with a 1 to 20 lotion of carbolic acid. In the place of rubber tubes catgut threads and horse hair have been employed. The former were introduced as means of drainage by Mr. John Chiene, and are used as follows : a bundle of the finest catgut threads, fifteen to twenty in number, is tied at the middle by a single thread which is passed through the eye of a curved needle (Fig. 21). By means of this needle the bundle is fastened to the deepest part SURGICAL DRESSINGS. 39 of the wound and three or four smaller bundles, of five or six threads each, are formed which pass out of the wound at the angles and at intervals between tlie sutures. (Fig. 22.) Fiff. 21. The ends of the threads should be long in order to facilitate the capillary action. In five to six days these ends become detached and the portions within the wound disappear by ab- sorption. Drainage by bundles of horse hair has been employed with good results especially in joint wounds. The bundles are placed in such parts of the wound as may be requisite. The hairs can be removed one at a time, as the conditions of repair require ; they are not absorbable. Dr. Neuber, of Kiel, has employed decalcified bone tubes in place of rubber. They are made by drilling long bones and cutting holes in the sides, and possess the advantage of 40 SURGICAL DRESSINGS. being capable of undergoing absorption. Dr. MacEwen has substituted chicken bones, which are prepared by scraping Fig. 22. and immersing in a solution of hydrochloric acid 1 to 5 of water. When sufficiently softened the ends are cut off, the interior cleaned out, and they are re-immersed in the acid solution until they become quite pliable. Holes are cut out of the sides at proper intervals and they are placed in a solu- tion of carbolic acid and glycerine (one-to-ten). At the end of two weeks they may be used. Horse hair is passed through the tubes before introduction into the wound, which prevents collapse of the tube and also facilitates drainage by capillarity. SVllGICAL DRESSINGS. 41 6. The Protective is a piece of oiled silk wliich is placed over the wound to protect it from the irritating effects of the carbolic acid in the antiseptic gauze. It is prepared by coating it with a thin layer of copal varnish, and then brush- ing over with a mixture of dextrine one part, starch two parts, and sixteen parts of the one-to-twenty carbolic acid solution. 7. CarhoUzed Catgut Ligatures are made by putting cat- gut ligatures into a mixture of carbolic acid one part, dis- solved in one-tenth its weight of water, and then added to five parts of olive oil. A stronger article of catgut ligature may be obtained by immersing the ordinary catgut for forty- eight hours in a solution formed by dissolving one part of chromic acid in 4000 parts distilled water and adding 200 parts of pure carbolic acid. It is then taken out and dried and put in the one-to-five carbolic oil. It is important to employ a convenient receptacle in which the catgut can be kept for use. Glass vessels or bottles con- taining carbolic oil one to five, and holding two or three glass reels upon which ligatures of different sizes are wound, with openings through the lid or with tubes passing through the stopper for the passage of the ends of the ligature, serve the purpose well. Sir Joseph Lister has devised a catgut holder — consisting of a reel placed within a German silver case — it can be carried in the ordinary pocket-case. 8. CarhoUzed Silk Sutures are prepared by placing them in a mixture of melted wax nine parts and carbolic acid one part, and afterward drawing them through a folded cloth to render them smooth. They should be kept in closely stop- pered bottles. 9. Sponges — These are carefully beaten, cleaned, and washed in lukewarm water, and kept in the one-to-twenty 4* 42 SURGICAL DRESSINGS. solution of carbolic acid. After use they are cleaned and returned to the solution. Sponges frequently become filled with fibrin during operations. In order to clean them they should be allowed to soak some hours in a solution of car- bonate of sodium — one-quarter pound to one gallon of water — during which time tlie fibrin is dissolved, and can be re- moved readily by repeated washings. They should be then placed in the one-to-twenty carbolic acid solution. An operation under the system is performed as follows : Three shallow basins (those which are oblong in shape are more convenient) should be at hand ; one containing the one-to-twenty solution to hold the instruments ; the second, containing the one-to-forty solution, for the sponges. The hands, and particularly the finger ends, of the surgeon and all of the assistants are to be washed in the tliird basin, con- taininoj a solution of the same strenorth. The bottle of the spray apparatus is filled with the one-to-twenty solution, and the apparatus set in operation. The surface is washed with the one-to-twenty solution, and the spray directed upon the part. The incision is made, the blood cleared away by the sponges, vessels ligatured with the catgut ligatures, which are cut off short ; drainage tubes introduced into the depths of the wound and brought out to the surface at the most dependent part and cut off short, and the wound closed with the carbolized silk sutures. If complete drainage can- not be effected through the wound, a counter opening should be made, and tlie drainage-tube introduced through it. A piece of the oiled silk protective, which lias been kept in one-to-forty solution, of a size to barely cover the edges, is now placed over the wound, then a piece of the gauze in one layer and wet in the one-to-forty carbolic lotion, and of such size as to largely overlap the protective. This consti- SURGICAL DRESSINGS. 43 tutes the ileep dressing (Fig. 23). The uneven surfaces must be then covered with loose gauze so as to fill up all depres- Fiff. 23. sions, and the outside gauze dressing, consisting of a piece of suitable size, folded in eight layers, with a piece of Mack- intosh with rubber side inwards, between the seventh and eight)], then applied. This dressing is held in position by a bandage, and an elastic bandage is applied around the edges of the dressing to keep them in contact with the sur- face of the body during movements of the patient. Safety pins are used to secure the elastic bandage to the edge of the dressing. Wet carbolized towels should be placed over the blankets covering the patient, or near at hand on the table upon which the instruments may be laid, and a towel, w^et in the one-to-forty lotion, should be placed conyepiently, so as to 44 SURGICAL DRESSINGS. cover the wound, in case of failure of the spray apparatus, or to be thrown over a portion while operating in large wounds. If, .during the operation, the spray apparatus fails, the wet towel, called the guard, must be quickly applied over the wound, and kept there until the spray is again directed upon the part. The dressing is, as a rule, renewed in twenty- four hours, and this is done under the spray, the same pre- cautions being taken as in the first dressing. If the piece of oiled silk protective is unchanged in color, the wound is aseptic. If it shows dark-brownish spots, which are caused by the action of the liberated sulphur in the pus upon the lead in the oiled silk, the wound is septic, and should be washed out with the one-to-twenty solution, or with a solu- tion of chloride of zinc (forty grains to the ounce of water), one part of the solution of the chloride of zinc to three parts of water. In redressing, everything is renewed except the Mack- intosh, which can be washed off with the one-to-twenty solution, and reapplied. The extent of the discharge, the sensations of the patient, and the temperature elevation, are the guides which direct with regard to a renewal of the dressings. If the dressing has been successfully applied, the temperature should be normal or but little elevated. So long as everything is favorable the dressings need not be disturbed, though they should not be allowed to remain in place for more than a week. In cases of wounds not made by operation, as lacerated wounds, compound fractures, etc., a somewhat different plan of treatment is to be adopted, although the articles of dress- ing and their method of application are the same. The wound is to be treated as a septic wound, and is to be thoroughly washed out with a one-to-twenty carbolized solu- SURGICAL DRESSINGS. 45 tion, or a solution of one part of carbolic acid to five parts of spirits of wine, and then dressed as before described. In cases of suppurating wounds, old ulcers, etc., they should be first swabbed out with a solution of chloride of zinc, forty orrains to the ounce, and then dressed with the usual anti- septic dressings. This plan of treatment has been modified recently in the use of boracic instead of the carbolic acid dressings. All recesses and sinuses should be freely opened up, and the un- healthy granulating surfaces thoroughly scraped by curettes which may be made of different shapes and sizes (Figs. 24 Fig. 24. and 25), and th( n purified by washing out with solution of chloride of zinc, forty grains to the ounce of water, and the surrounding skin thoroughly cleansed by washing with the one-to-twenty carbolic lotion. Then the ulcer is covered, as in the former dressings, with a piece of pro- tective which has been dipped in a boracic acid solution, saturated solution in water — one part in thirty parts of cold water ; over this is applied a piece of boracic lint of suflficient size, secured in place by an ordinary bandage. In the place of the chloride of zinc solution iodoform has been recently used; it is powdered freely over the surface, and gives no pain, having rather an anoesthetic power. If putrefaction does not cease after one application of the zinc or iodoform, a second may be made. The dressings should be renewed on the second day, but after that an interval of three or four days may be allowed to elapse if the discharge is not 46 SURGICAL DRESSINGS. great. In changing the dressing the spray is not required. The boraeic lint may be made by soaking ordinary lint in a Fiff. 25. hot saturated solution of boracic acid, and contains about one-half of its weight of crystals of the acid, and its anti- septic qualities, therefore, last for some time. The borated cotton-wool is made in the same manner. Both the lint and lotion are tinted with litmus to distinguish them from carbolic preparations. The chloride of zinc solution can be used for the purpose of purifying ulcers, sinuses, etc., by SURGICAL DRESSINGS. 47 waf^liing out witli a piece of lint, or by injection by means of a syringe, and, if necessary, for the deeper parts, a catheter. Care should be taken, to afford a free exit lest gangrene should result from retention of the fluid. Boracic, salicylic, or eucalyptus ointments may be used in superficial wounds especially, instead of the protective. These ointments are made according to the following for- mula : A basis of tioo parts of paraffine and one of vaseline is made. Boracic ointment is made by mixing one part of the acid and Jive parts of the basis. Salicylic ointment consists of one part of the acid and twenty-nine parts of the basis. Eucalyptus ointment is made in the proportion of one part by measure of the eucalyptus oil, and /bz/r parts by weight of the basis. Full strength and half strength pre- paration of these ointments can be made. Since the introduction of the antiseptic system of dressing wounds by Lister, a number of modifications of the plan, both as to the agents employed and the manner of applica- tion, has been suggested and carried into practice with more or less success. Owing to the irritating and poisonous pro- perties of carbolic acid and its claimed inferiority as a ger- micide, endeavors have been made to obtain a substitute. For this purpose the following agents have been employed : Salicylic Acid. — This was introduced by Prof. Thiersch, of Leipzig, and is used in the form of a solution, one part of the acid to three hundred parts of water, at the ordinary temperature. Salicylated Cotton-wool and SciUcylated Jute are em- ployed as dressings. Salicylated Cotton-wool is made of two strengths, 3 per cent, and 10 per cent. The first is made by immersing twelve pounds (5^ kilogrammes) of absorbent 48 SURGICAL DRESSINGS. cotton-wool in a solution of six ounces (170 grammes) of salicylic acid, one gallon (3099^ grammes) of alcohol (sp. gr. 0.830) and nine gallons (33 litres) of water at a temperature of 150° F. The second (10 per cent.) is made by immersing 22 pounds (ten kilogrammes) of absorbent cotton-w'ool in a solution of 34 ounces (one kilogramme) of salicylic acid, 20 gallons (10,000 grammes) of alcohol (sp. gr. 0.830) and 16 gallons (60 litres) of water. Salicylated Jute, 3 per cent., is made by immersing 83^ ounces (2500 grammes) of jute which has been cleaned, in a solution of 2^ ounces (75 grammes) of salicylic acid, 16§ ounces (500 grammes) of glycerine, and 150 ounces (4500 grammes) of water at 158-176° F.. (70-80° C). In this preparation the glycerine holds the salicylic acid in the jute. In the application of the dressings the solution used for the spray is the 1-300 salicylic acid. The instruments must be placed in solution of carbolic acid, owing to the oxidizing effect of the salicylic acid on the steel. A piece of perforated gutta-percha tissue, covered with a piece of gauze three fingers' breadth in thickness, is placed over the wound. Over this a layer, one finger's thickness, of the 10 per cent, salicylated wool, and two fingers' tliickness of tlie 3 per cent, wool is placed, and all is secured in place by a bandage. If no pain is complained of, the dressing remains in position for eight or ten days, when it is changed to re- move the drainage-tube; if any discharge appears through the dressing, fresh wool is applied outside. The second dressing is not disturbed until healing is completed. The protective and JNIackintosh are not required. Thymol. — This agent was introduced some years ago by Ranke of Halle as a substitute for carbolic acid. Its use lias SUK(UCAL DKESSINGS. 49 been largely abandoned on acount of its very feeble antiseptic properties and of the objections made to its sweetish odor, which produced headache and attracted swarms of flies. Eucalyptus Oil. — Schulz of Bonn, Germany, has recently suggested the use of this oil as possessing valuable antiseptic qualities, and Sir Joseph Lister has made trial of its virtues in the treatment of wounds. Its odor is pleasant, it is non- poisonous, and unirritating. Preparations of gauze and ointment have been made and have been found satisfactory. A solution can be made, in varying proportions, with olive oil or dissolved in alcohol. Acetate of Alumina Quite recently the acetate of alu- mina has been suggested by Prof. Maas, of Freiburg, he claiming that with a 2.5 percent, solution he obtains aseptic results. A protective is^ applied over the wound and over this compresses soaked in the solution, the whole dressing being covered by an impermeable tissue. The dressings require to be removed at rare intervals. A ceto-tartr ate of Alumina has been introduced as an anti- septic by Kiimmel, of Hamburg. It is used in J to 3 per cent, solutions and mixed with charcoal, three parts of the salt to seven of baked cliarcoal. This form of dressing may remain undisturbed for one or two weeks. Iodine This agent has been long employed as a topical application. Mr. Bryant has used a solution of iodine and water in the proportion of twenty drops of the tincture to one ounce of water to wounds for the purpose of checking hemorrhagic oozing, and for purification of the surfaces. Iodoform contains ninety-six per cent, of iodine, and is a much more eligible preparation. As an antiseptic dressing its use was first recommended by Prof. Von Mosetig Moor- hof of Vienna. While it is quite soluble in ether and the 5 50 SURG1CAI> DRESSINGS. oils, less so in alcoliol and water, it is best used in the form of the powder and the iodoformized gauze. The ''absorbent iodoform gauze" is pi-epared by rubbing into the meshes roughly the powder of iodoform. The loose gauze is placed in a basin which has been washed out with carbolic lotion and freely sprinkled with iodoform powder, a pepper box being used for that purpose. The powder is worked in with the hands until the gauze is of a uniform yellow color. The excess is shaken out and the gauze, now ready for use, is put in sealed glass jars. It contains from 10 to 20 per cent, of iodoform. Adhesive iodoform gauze is made by soaking gauze in a solution of resin 100 parts, alcohol (95 per cent.) 1200 parts, and glycerine 50 parts, and then dusting iodo- form upon the surface after it has been wrung out and parti- ally dried. This form contains nearly four times more of iodoform than the ordinary gauze. Iodoformized cotton- wool may be used, and is prepared by soaking in the follow- ing solution : Iodoform 50 parts, ether 250 parts, and alcohol 750 parts. It may be made extemporaneously by rubbing the powder into the substance and shaking so as to git rid of the excess. Owing to its slight solubility in water, iodoform is not adapted for the disinfection of sponges, instruments, etc., or for application to surfaces which have not been purified by other antiseptic agents, as carbolic acid, corrosive sublimate, etc. Over fresh or puri- fied wounds it may be gently powdered, the wound closed and dressed with several layers of the iodoformized gauze, this covered by gutta-percha tissue, and tlie whole secured in place by a bandage. In open wounds the surfaces are sprinkled over lightly, the cavity packed w^ith iodoform gauze and the dressing completed as in the fresh wound. Objections exist with regard to the use of iodoform as a SURGICAL DRKSSINGS. 51 dressing on account of the odor and of the very decided toxic qualities it possesses. The disagreeable odor can be masked by the use of various agents, as Peruvian balsam, musk, the essential oils, as bergamot, clove, and peppermint, and the Tonka bean. In order to avoid producing toxic effects great caution should be excerised in its use ; it has been ascertained by Neuber from the experience he has gained that not more than forty to forty-five grains can be placed safely upon a fresh wound-surface, and this amount cannot be taken as the limit as the susceptibility varies in different cases. The symptoms of poisoning are headache, loss of appetite, wakefulness, the constant taste of iodoform, and, in the severer cases, mental derangement to the extent even of acute mania. The treatment consists in the prompt removal and discontinuance of the dressings, and the use of alcoholic stimulants. Naphthalui. — This agent is one of the products of coal tar, and was first used as a dressing by Dr. Fischer of Strassburg. It is employed in the form of powder and is applied in the same manner as iodoform. While its antiseptic power is less than iodoform, it possesses the advantage of being free from toxic properties, and can be substituted, therefore, for it. Gauze coverings may be impregnated with it. Subnitrate of Bismuth Finely-powdered subnitrate of Bismuth suspended in water so as to form an emulsion is advocated by Prof. Kocher of Berne as an efficient anti- septic wound-dressing. A one per cent, watery mixture is used for sprinkling over wound surfaces and spread over the line of sutures with a brush after closure of the wound in operations. Gauze which has been immersed in a ten per cent, mixture of bismuth and wrung out is applied, then a layer of cotton-wool covered by gum tissue, and over the 52 STJUGICAL DRESSINGS. whole a bandage to secure the dressing in place. Toxic effects manifested, it is stated, by the symptoms of acute stomatitis, intestinal catarrh, and desquamative nephritis, have been produced by the use of strong mixtures which are now abandoned, and the excessive application of the powder to cavities. These conditions are transient, and subside after discontinuance of the dressings. The value of sub- nitrate of bismuth is impaired by reason of its want of con- trol over erysipelas. Permanganate of Potassium This agent has long been in use as a wound-disinfectant in the form of aqueous solutions of 5 to 20 parts to 100. Prolonged antiseptic effects can- not be accomplished by it, owing to the rapid decomposition which occurs when it is brought into contact with organic substances. Chloride of Zinc The chloride of zinc, as is well known, possesses powerful caustic properties, and it has taken part in antiseptic dressings usually in such strengths (40 grains to the ounce) as to secure purification of septic M'ounds. Dilute solutions, 1 to 500, are advised for washing out large suppurating cavities which are protected against the entrance in the future of septic agents by an external antiseptic dressing. Its action on the tissues interferes with union by the first intention. Terehene Tliis is a product of the oil of turpentine, and is used as a wound application by saturating sponges with it and placing them over the Avound. It is stated that Mr. Furneaux Jordan after amputations places one between the flaps and allows it to remain for several hours. Corrosive Sublimate. — Of all the substances introduced as wound dressings none seems to have met with more general favor than corrosive sublimate, possessing all the advantages SURGICAL DRESSINGS. 53 of powerful germicidal properties, ease of application in many forms, and freedom from danger of producing toxic effects, in solutions of efficient antiseptic strengths. It was first used as a wound dressing by Kiimmell and Schede in the Hamburg General Hospital in 1881. It has been used in solutions varying in strength from 1 in 100 to 1 in 5000. It has been found that a solution of 1 in 1000 (7 J grains to the pint of water) is in all respects reliable as an antiseptic and free from danger, and therefore it has been adopted as the standard. The articles which are used in the corrosive sublimate dressing are prepared in a very simple manner. According to Dr. Weir, jute and moss are dipped into a solution of corrosive sublimate 1 part to 1000 of water and 50 parts of glycerine. They are soaked in this solution from ten to twelve hours, then wrung out and allowed to dry to the extent permitted by the glycerine. The gauze and cotton-wool are treated in this way. Deprived of oily matters they are immersed in a solution composed of corro- sive sublimate 20 parts, water 4480 parts, glycerine 500 parts. A slight aniline tint is given to the gauze to distin- guish it. It is desirable that these preparations should be freshly made, as often a slight change occurs owing to the conversion of the corrosive sublimate into calomel. Prof. S. AV. Gross finds that the addition of common salt to the solution prevents the change of the corrosive sublimate into calomel, and suggests the following formula : — Corrosive sublimate 1 part . . grs. T^. Common salt 5 parts . . . grs. 37|. Glycerine 10 parts .... 3J-gtts. vij. Water 1000 parts . . . . Oj. A simple test may be applied to the dressings by the ap- plication of a few drops of lime-water ; if this is followed by 5* 54 SURGICAL DRESSINGS. the formation of a yellow spot, corrosive sublimate is pre- sent ; if by a black spot, calomel has formed. Sublimated catgut is used both as ligatures and sutures, and is prepared by placing it for ten minutes in 1 to 100 solution ; then into a 1 to 1000 for ten to fifteen hours, and afterwards it is wound on glass spools and kept in absolute alcohol, or it may be put in oil of juniper for twenty-four hours, and then in pure alcohol. Silk sutures are immersed for two hours in a 1 to 100 solution of corrosive sublimate, and kept for use in a 1 to 1000 solution. Drainage-tubes, either of rubber or decalcified bone, are used ; in order to prevent the two rapid absorption of the latter, they are kept in pure alcohol which hardens them. Sponges after being cleaned are kept in the 1 to 1000 so- lution of corrosive sublimate ; preferably in that to which the salt has been added, as suggested by Dr. Gross. Neither protective nor impermeable outer covering are required in the dressing. Before an operation the surfaces about the points of in- cision are scrubbed with soapsuds, and afterwards painted over with an iodoform solution or washed with a solution of turpentine and alcohol, two ounces to the pint, in order to dissolve all greasy matters and to purify the parts. The hands and nails of the surgeon and assistants are publicly and thoroughly washed and disinfected. The instruments, owing to the corroding effect of the corrosive sublimate upon the metal, must be immersed in the 1 to 20 solution of carbolic acid. If the spray is used, it must be formed from the carbolic acid solution. In the dressing, bandages, one and a half to two inches in width, made from the sublimated gauze or crinoline, are employed. SURGICAL DRKSSINGS. 55 During the operation, without the spray, the solution (1 to 1000) is allowed to run continuously over the incision, the patient being protected by a rubber blanket, which is arranged so as to expose only the part operated upon. In order to avoid any danger as to the toxic effects of the solu- tion, Tliiersch has suggested the boro-salicylic solution con- sisting of boracic or boric acid 6 parts, salicylic acid 1 part, and water 500 parts ; this is employed during the operation, the wound being finally washed with the corrosive sublimate solution. After the vessels have been ligatured, and hemorrhage has ceased, drainage-tubes of rubber or bone are put in place, the wound is cleaned and then closed with catgut sutures, using the continued instead of the interrupted suture for that purpose. The interior of the wound is cleaned by injecting the sublimate solution through the drainage-tubes, and the surfaces compressed by several sponges until a piece of sub- limated gauze can be applied over the centre of the wound. The pressure being maintained, several layers of the gauze, not too wet, are applied and secured in place by turns of a sublimated gauze bandage. Over the dressings, carried thus far, the absorbent materials are placed, being retained in bags of suitable size and shape. These are from one to two inches in thickness, and may contain peat, wood-wool, or any other substance which may be selected. Those of smaller size are packed about the wound and then covered by a large one, and over all a crinoline bandage wet with the subli- mated solution is applied. If the discharge appears upon the surface of the dressing, the parts can be douched with the sublimated solution, and cotton-wool or gauze applied over the part. The dressings may remain in place for several days if no elevation of temperature occurs. In most instances 56 SURGICAL DRESSINGS. but one change of dressing is required until healing has taken place. A dressing, according to this method, may be made extem- poraneously by dissolving seven and a half grains of corrosive sublimate in a pint of warm water, dipping ordinary absorbent cotton into the solution, wringing it as dry as possible, and securing it in place over the wound bj^ a bandage wet in the same solution. Drainage can be effected by the introduction of the perforated rubber tubing. This dressing may remain until one more elaborate is prepared if deemed necessary. Modifications of the Antiseptic Method Various modifi- cations of the antiseptic method of wound-treatment liave, from time to time, been introduced. Trendelenburg has published the results obtained by him in operations and treatment of wounds without the use of the spray. During the operation he allowed the carbolic acid solution to run over the wound, and, while filled with the solution, it was closed. At the time of changing the dress- ing, the same precautions were taken. The late Mr. Callender, of St. Bartholomew's Hospital, London, employed carbolic acid and olive oil, one to twelve, having first brushed over the cut surfaces a solu- tion of chloride of zinc, forty grains to the ounce of water, or washed the wound with the one in twenty solution of car- bolic acid. He then covered the wound with lint saturated in this solution, and surrounded the part with cotton-wool. Hemorrhage was controlled by torsion of the vessels. Methods of wound-treatment not strictly antiseptic: — Guerin^s Cotton-wool Dressing. — Originally this method, introduced by Alphonse Guerin, consisted in the application of large masses of the ordinary cotton-wool which were firmly secured in place by a bandage, the wound having SURGICAL DRKSSINGS. 57 been washed out with tepid water. At present the wound is washed out with a carbolic acid solution, and the deep layers of the cotton-wool are wet with the carbolic lotion. Between the layers of cotton the powder of camphor is sprinkled, layer after layer of cotton is applied and very firmly secured wnth the bandage, so as to make uniform compression. As much as five pounds of cotton have been sometimes applied. Formerly no sutures were employed, but recently, with a view to obtain primary union, they have been introduced. The precautions to be taken in ap- plying this dressing are important: 1. The dressing must not be applied or renewed in the ward, but in a room some distance from it. 2. The cotton-wool should not be opened in the ward, owing to danger of contamination from the air. The dressing is allowed to remain undisturbed from two to three weeks; if the discharge comes through, the dress ing may be washed with carbolic acid solution, and a fresh layer of cotton applied. The object sought to be accom- plished by this dressing is to exclude, by filtration, septic agents, and also to maintain elastic compression and constant temperature. It is also claimed that it secures the suppres- sion of pain, absence of traumatic fever, and diminution of suppuration. The dressing has been modified by M. Oilier, who soaked the deep layers of the cotton-wool in carbolic oil. Alcohol has been employed as a dressing with good results. The method of Mr. Jonathan Hutchinson is as follows : Hemorrhage having been controlled chiefly by torsion, the wound is washed out with pure alcohol, drainage-tubes in- serted, and sutures introduced. Over the wound, thin com- presses of lint, soaked in a solution of absolute alcohol six parts, liquor plumbi one- half of a part, and distilled water 58 SURGICAL DRESSINGS. sixteen parts, are applied and are kept constantly moist pre- ferably by a drop irrigator. The compresses are clianged daily. The alcohol acts as an antiseptic, and primary union is generally obtained. Tile Open ^Jethod Tliis method was first employed by Dps. Bartscher and Yezin. wlio practised it in the following manner : after the cessation of hemorrhage, the wound is cleansed by washing out with cold water, and, in case of an amputation, the stump is placed on a soft pillow and over it a piece of gauze or linen to keep out the flies. On the next day a clean pillow is placed beneath the limb without any cleansing of the wound being made. No sutures are em- ployed ; by this method primary union is not accomplished. Modifications of the method have, from time to time, been introduced. In some the edges of the wound are brought together by sutures or strips of plaster, and antiseptic solu- tions are used to clt-anse tlie parts. The late Dr. Wood, of New York, employed this met hod in a number of cases, modifying it, however, by tlie free use of carbolic acid and devoting great attention to tliorough cleanliness. Surgical Dressing Cases Cases, of ditferent sizes, con- taining all of the agents employed as wound dressings, are to be found in the stores of the instrument makers. Thus provided, the surgeon is enabled to make the primary dress- ing complete in all wounds the treatment of which he is called upon to conduct. In the treatment of wounds the great object to be attained is to secure if possible primary union, if this is not possible then to employ such means as will facilitate repair with as little delay as possible and with the least drain upon the vital power of the patient. Certain points of great importance are involved in the SURGICAL DRESSINGS. 59 treatment of all avouikIs, and should always claim careful attention. 1st. Accurate coaptation of the wounded surfaces should, if possible, be always secured. This is accomplished by means of sutures which may be introduced, superficially for the purpose of coaptating the superficial tissues or deeply for the approximation of the deeper tissues ; these sutures have been designated respectively as sutures of coaptation and Fis. 26. sutures of approximation. There are also other sutures called sutures of relaxation, which are introduced some dis- tance from the margins of the wound for the purpose of re- laxing the tissues near the wound and thus preventing tension of the sutures of approximation. (Fig. 27.) The perfect coaptation of wounded surfaces prevents the accumula- tion of wound fluids and thus contributes to rapid healing. In securing it, however, great care should be observed that it is not accomplished at the expense of producing undue tension, which I'eacting upon the wounded tissues provokes iiTitation and induces conditions which interfere with and greatly retard the reparative process. If tension occurs during the progress of the healing process, it should be re- lieved by division of the sutures and the employment of such other means as may be found necessary. 60 SURGICAL DRESSINGS. Perfect Drainage. — The free escape of all fluids from a wound is essential to prompt repair and to the good condi- Fig. 27. Fiff. 28. tion of the wound. This is accomplished by means of tubes or other means which conduct the fluids from the SURGICAL DRESSINGS. 61 wountls SO that they be washed away or may be rendered innocuous by agents incorporated in the dressings. The proper introduction of drainage tubes is important in order that the deeper parts of the wound should be drained and accumulations of fluids prevented. It can be understood readily in what manner the collection of fluids between wound surfaces interferes with repair. The fluids may act either mechanically by separating the surfaces or chemically by the septic influences exerted by them. Cleanliness. — In its fullest extent this term, as it relates to wound-treatment, includes cleanliness in the wound, or the parts about the wound, of all substances and instru- ments coming in contact with it and of the hands of those who, in any way, have anything to do with it. In wounds in which the surfaces are brought into contact, as after ampu- tations, excisions of tumors, etc., it is essential that the sur- faces should be thoroughly cleansed before approximation, so as to remove all blood-clots or shreds of tissue. In wounds which are treated aseptically the blood clots which may re- main disappear by a process called organization, young cells developing in them, and new tissue being thus formed, the blood clots affording the pabulum for the cells. The cleans- ing of wound surfaces which are in contact may be effected by injecting tepid water or warm antiseptic solutions through the drainage tubes which have been introduced. This should be done at the time of the first dressing, and also at the redressings. Open wounds may be washed by injections with the syringe ; for this purpose the fountain syringe is preferable, as a larger column of water can be obtained from it, and also the fluid is tlirown with less force from it upon the surfaces. In the absence of a fountain syringe, the nasal douche bottle can be used. A gallon tin measure can be 6 62 SUEGICAL drp:ssings. readily adapted by the tinsmith to the purpose of a wound douche. Cleanliness about the wound is effected by scrubbing the parts with soapsuds for some distance in all directions about the intended site of an operation, and afterward wash- ing w^ith an antiseptic lotion. In the redressings these sur- faces are kept clean by w^ashing carefully Avith the antiseptic solution, usually carbolic acid solution one-in-twenty. Cleanliness with regard to the dressings, sponges, and instruments is of paramount importance in preventing the entrance into the wound of septic agents. The general in- troduction of antiseptic methods permits of the employment of chemically clean dressings at slight cost and of processes by which sponges and instruments may be kept clean. With our present knowledge of wound-treatment no surgeon can be excused for want of care in this respect. Cleanliness of the hands of the surgeon and assistants is important, and thorough washing should be practised before operations or redressings. Especial attention should be given to the folds of the skin about the finger nails and to the removal of dirt beneath the nails. The one-to-forty solution of carbolid acid is of sufficient strength to render the surfaces free from septic matter. Rest. — Perfect rest of a wounded part is essential to prompt repair. This may be accomplished by means of position and the use of bandages and splints. Position In all cases, that position should be selected which affords the most comfort to the patient and promotes the free escape of fluids from the wound. In injuries of the lower extremity it is desirable to elevate the limb either in a fixed apparatus or in a swing. When the limb is swung the parts are not disturbed by movements of the patient, SURGICAL DRESSINGS. 63 and in this way great comfort is obtained as well as freedom from pain. In the treatment of wounds of both extremities elevation of the limb should be secured so as to maintain the free circulation of the blood through the part. Bandages By means of bandages equable compression may be made which will control muscular spasm and afford support to the bloodvessels. They should be applied from the distal extremity, and should be carried over the wound to some distance above it. Great care should be exercised in order to avoid making undue pressure. Sufficient trac- tion should be made to give comfortable support to the parts if it is carried beyond that point harm may be done. Splints — The use of splints is important in obtaining rest of a wounded part. Immobilization of the entire limb may be obtained by the employment of the plaster dressings. In the treatment of injuries of the joints fixation of the limb is very desirable. In applying splints care should be taken to protect the surfaces by covering them with cotton-wool or some soft material which w|ll adapt itself to the inequalities of the part. Splints should be made of light material which can be moulded to the part. In the treatment of wounds the surgeon should always bear in mind the great importance of maintaining the patient in the most favorable hygienic conditions possible to be attained, and of giving attention to the state of the general system. The relation which the condition of a wound may have to the constitutional state of the patient should not be overlooked, otiierwise the healing process may be seriously interfered with, despite the most perfect dressings. As per- fect ventilation as is possible of the apartment in which the patient is placed should be secured, in order not only that a full supply of fresh air should be admitted, but also that 64 SURGICAL DEESSINGS. the air which is charged with the exhalations from the body and with other contaminations should escape. While it is hoped that pus will not form under the anti- septic method of dressings, yet it is not claimed that it will not occur. In such cases the " antiseptic suppuration/' as it is called, is said to be " due to the direct chemical stimulus of the antiseptic." PART 11. BANDAGING. Bandaging is tlie art of applying bandages. Bandages are substances which are employed in the treatment of sur- gical affections, and consist of the simple and the compound. They may be made from various materials, such as muslin, flannel, etc. For general use the material best adapted is unbleached muslin; that which is firm, smooth, soft, and closely woven should be selected. THE SIMPLE BANDAGE OR ROLLER. This may be from one to four inches in width, and from six to twelve yards in length. The ordinary roller used in practice is six to eight yards long, and two to two and a half inches wide. In preparing the roller a piece of muslin, six to twelve yards in length and one yard in width, should be soaked in water for some time in order to cause shrinkage, then dried, and smoothly ironed. The selvage is removed, the free edge divided by the scissors at the points marking the widths of the bandages, and the strips torn rapidly, so as to avoid too much unravelling. In order to apply the bandage it should be formed into rollers or cylinders : this can be done by a machine (Fig. 29) or by the hand. It is quite desirable that the student 6* 66 BANDAGING. should learn to roll the bandage firmly by the hand, as the machine is not always convenient, and, besides, constant Fig. 29. handling of the bandage gives him better knowledge and control of it. The strips can be conveniently made into rollers in the following manner: Having arranged a strip in regular folds, a graduated compress is formed at one extrem- ity and turned over firmly upon the thigh and rolled a fe\y times until a cylinder is formed of such size as to be readily grasped by the hand ; then it is placed between the thumb and index and middle fingers of the left hand, the body of the bandage being held by the thumb and extended index finger of the right hand, while the remaining fingers grasp the cylinder. The cylinder thus held is made to revolve upon its axis by the left hand, while the right revolves par- BANDAGING. G7 tially around the roller itself, Fig. 30. these movements soon complet- ing its formation. In forming the roller in this manner, the cylinder may be held in either the right or left hand, as is most convenient (Fig. 30). The roller should be firmly and compactly formed, so that the central portion or axis cannot be pushed out readily. Prac- tice will enable the student to accomplish the formation rapidly and firmly. After forming the roller it should be firmly grasped and all loose threads removed, as these interfere with its proper application. Rollers are of two kinds, Sin- gle-headed and Double-headed. The single-headed roller consists of a body or central part, an ini- tial and a terminal end, and an external *nd internal surface (Fig. 31). The double-headed roller has the same parts as the single-headed, both ends being formed into rollers (Fig. 32). The dimensions of the roller for the different parts of the body vary. For the Head — Five yards long and two inches wide. For the Body — Twelve yards long and four inches wide. For the Extremities — Eight yards long and two to three inches wide. Fig. 31. 68 BANDAGING. For the Hand — From five to eight yards long and one inch wide. The application of the roller should begin by placing the external surface of the initial end in contact with the part, securing it in position by a circular turn, and the cylinder should be held firmly in the palm of the hand. When the application is completed, the terminal end should be fastened by folding in the edge and introducing a pin transversely or horizontally as may be most convenient, the head being directed upward or outward (Figs. 33, 34), care being taken Fig. 33. Fig. 34. to cover the point. Pins should be introduced at the points where turns of a roller cross one another, so as to hold them in place. In applying a bandage to an extremity, it should begin at the distal part, in order to make equable pressure upon the bloodvessels. If a wet bandage is to be applied, it should be soaked in the lotion before application, otherwise, undue contraction will ensue if made wet when it is on the limb. The amount of traction to be used in the application of a bandage is a matter of the utmost importance, and should RANDAGINCr. 69 I be very carefully considered by the student; practice alone will enable him to acquire a proper knowledge upon this point. A band- age too tightly applied may do great harm, even to the production of gangrene (Fig. 35), the loss of a limb, and possibly the loss of life. The sensations of the patient and the condi- tion of the circulation in the limb, as shown at the distal points, are the best guides. These should be carefully noted a short time after the application of the bandage. If the patient complains of pain and numbness in the limb, and if the temperature of the partis lowered and the skin gives evidence of retarded circulation, then the band- age should be immediately removed. With regard to the tension the patient should always be consulted, and inspections at short in- tervals should be made. In applying the bandage Fig. 35. Gangrene from tight bandaging. 70 BANDAGING. to the head or trunk, the student should stand at the side of the patient, not in front of or behind, and in making the various turns of the roller he should not walk around the patient but maintain a fixed position. In conveying the turns about the part, the bandage should be unrolled with an even and steady movement, not by short jerks. In re- moving the bandage from a part, each turn should be care- fully taken off and folded in the hand. Bandages are designated as the Circular, Oblique, Spiral, Spiral-reverse, Figure-of-8, Spica, and Re- current, according to the direction they take in applica- tion. The Circular bandage consists of circular turns about the part. The Oblique bandage covers the part by very oblique turns (Fig. 36). Fiff. 36. The Spiral bandage is applied by making spiral turns, each succeeding turn covering one-half of the preceding (Fig. 37). The reverse turn in this bandage is made in order that the bandage may adapt' itself equably and with more firmness to the part. In making it, the limb should be grasped by the left hand, so as to retain the preceding turn by the thumb and fingers; the roller, with not more BANDAGING. 71 than three inches unrolled, should be held above the part, the hand being in a state of supination. The unrolled por- Fiff. 37. tion of the bandage being kept perfectly lax, the right hand, holding the roller, should be turned from supination into Fis. 38. pronation (Fig. 38), making in this movement a short turn, and passing the roller under the limb into the left hand. 72 BANDAGING. The position of the roller in the hand should not be changed, nor should traction be made until the limb is passed. The reverse turns will be in a line, if care is taken to keep the spaces between the successive turns of the bandage equi- distant; they should not be made over a joint or a subcuta- neous bone, owing to the increased pressure they exert. In the Figure-of-% bandage the turns cross each other so as to resemble the figure after which it is named. The Spica bandage is so named from its resemblance to the arrangement of the leaves of an ear of corn. The Recurrent Bandage In this the turns return suc- cessively to the point of origin, so as to form a covering for a part. The simple bandage consists of the Roller, either single or double headed, and is applied to various parts of the body. BANDAGES OF THE HEAD. Length of roller five yards, width two inches. 1. Circular bandage of the forehead. 2. Circular bandage of the eyes. 3. Crossed bandage of one or both eyes. 4. Crossed bandage of the angle of the jaw. 5. Knotted bandage of the head. 6. Recurrent bandage of the head, with single or double- headed roller. 7. Gibson's bandage for the body of the lower jaw. 8. Rhea Barton's bandage for the body of the lower jaw. 1. Circular Bandage of the Forehead. Origin — Side of the head. Course— ThvQQ or four turns encircling the vault of the cranium. BANDAGlXCr. 73 Termination — Side of the head o})posite to the point of origin. Use — To make pressure or retain dressings to the head. 2. Circular Bandage of the Eyes. Origin — Temporal region. Course — Three or four turns over tlie eyes and around the head. Termination — Temporal region, opposite to the point of origin. Use — To retain dressings to the eyes. 3. Crossed Bandage of the Eyes. Origin — Side of the head. Fi-. 39. Fig. 40. Course — Two circular turns around the head, in a direc- tion from right to left to cover the right eye, from left to 7 74 BANDAGING. right to cover the left eye, thence to the nape of the neck, adapting the bandage to the surface by a reverse turn, if necessary, under the ear, over the eye, across the root of the nose to the side of the head, on a level with the parietal eminence, then circular turn around the head, making two or three turns in this manner alternately, and covering two- thirds of each preceding turn. Termination — Circular turn around the head. Use — To retain dressings to the eye (Fig. 39). To cover in both eyes, after the first turn over the eye has been made, the bandage should pass around the head and then down across the forehead, the root of the nose, over the other eye, under the ear, to the occiput and side of the head, thence around the head to the nape of the neck, and pass in the same direction as in the first turn. Applying these turns alternately, both eyes will be covered. Use — To retain dressings to both eyes (Fig. 40). 4. Crossed Bandage of the Angle of the JaTV. Roller and compress. Origin — Side of the head. Course — Two circular turns around the head, in a direc- tion from right to left to cover left angle, and left to right to cover right angle, to the nape of the neck, making a reverse turn, if necessary, behind the ear, under the jaw, over the angle of the jaw, up in front of the ear, over the vertex obliquely, down behind the ear of the side opposite, under the jaw and repeat the turns, advancing from the angle of the jaw to the corner of the mouth. Termination — By a reverse turn on the side of the head opposite to the injured side, and making two circular turns from before backward around the head. BANDAGING. Fi-. 41. 75 Use — To support parts in the treatment of fracture of the angle of the jaw (Fig. 41). 5. Knotted Bandage of the Head. Double-headed roller and compress. Origin — Body of the bandage over the compress covering the wound in the artery. Course — Carry both heads of the roller around the head in opposite directions, passing at the temporal region of the opposite side and returning to point of origin. Change the direction by making a half turn or twist over the compress, carrying the heads of the roller in opposite directions over the vertex and under the chin to the temple of the opposite side, passing and returning to point of origin, where a second turn or twist should be made and the heads of the roller con- 76 BANDAGING. ducted as in first turn, placing tlie knots behind each other in order. Continue these turns until three or four knots are formed. Termination — Circular turns around the liead, covering the knots. Use — To make compression in wound of the temporal artery (Fig. 42). Note This bandage, being applied with great firmness, makes great pressure upon the parts, and should be watched carefully in order to prevent injury. Fig. 42. Fis-. 43. 6. Recurrent Bandage of the Head. Single- headed roller. Origin — Side of the head. Course — Two circular turns around the head to the middle of the forehead, then reversing the bandage and carrying it from before backward to the middle of the occiput, making lANDAGING. 77 a reverse turn and returning to the forehead, covering one- half of the preceding turn and continuing recurrent turns on alternate sides, covering one-half of each preceding turn, until the vertex is covered. Termination — By a reverse turn and then circular turns around the head to secure recurrent turns (Fig. 43). Recurrent Bandage of the Head. Double-headed roller. Origin — Body of the bandage over the middle of the fore- head. Course — The heads of the roller are to be carried in oppo- site directions around the vertex to the occiput, passing and Fi-. 44. returning to the point of origin ; the recurrent turns are to be made by the head of the roller held in the right hand, 78 BANDAGING. each turn being secured by circular turns made bj the head of the roller held in the left hand (Fig. 44) ; continue these turns until the vertex is covered. Termination — Circular turn around the head. Use — Both bandages are used to retain dressings to the head. 7. Gibson's Bandage for the Body of the Lower Jaw. Origin — Temporal region. Course — Down in front of the ear, under the chin, up in front of the ear of opposite side, over the middle of the ver- tex to the point of origin, making two turns ; then reverse the bandage from before hachiuard, making two circular turns around the head to the point of origin; thence to the nape of the neck, making reverse turn if necessary, carrying under the ear, in front of the chin, and back to nape of the neck. Repeat this turn, make a reverse turn and go to side of the head, and around the head by two turns to the middle of the occiput ; make a reverse turn and carry bandage over the vertex to forehead (Fig. 45). Termination — Either by circular turns around the head or by turn from occiput to forehead. Use — To support parts in treatment of fracture of the body of the lower jaw. 8. Rhea Barton's Bandage. Origin — Beneath the occi[)ital protuberance. Course — Obliquely upward over the parietal eminence, across the junction of the sagittal and coronal sutures, down in front of the ear, under the chin, up in front of the ear of the opposite side, across the junction of tlie sagittal and BANDAGING. 79 coronal sutures, over the parietal eminence to the point of origin; thence obliquely downward and forward over the Fiff. 45. Fig. 46. angle of the jaw, in front of the chin, over the angle of the jaw of the opposite side, obliquely upward and backward to the point of origin. Continue these turns until the bandage is exhausted (Fig. 46). Termination — Occipital region, or by a turn around the head. Use — To support the parts in treatment of fracture of the body of the lower jaw. BANDAGES OF THE TRUNK. 1. Circular bandage of the neck. 2. Figure-of-8 bandage of the neck and axilla. 3. Anterior figure-of-8 bandage of the chest. 4. Posterior figure-of-8 bandage of the chest. 5. Crossed bandage of one or both breasts. 80 BANDAGING. 6. Spica bandage of the shoulder. 7. Spiral bandage of the chest. 8. Circular bandage of the abdomen. 9. Spiral bandage of the abdomen. 10. Spica bandage of one or both groins. 11. Spiral reverse bandage of the penis. 1. Circular Bandage of the Neck. Length of roller, two yards ; width, two inches. Origin — Side of the neck. Course — Three or four circular turns around the neck. Termination — Side of the neck. Use — To retain dressings to the neck. 2. Figure-of-8 Bandage of the Neck and Ax- illa. Length of roller, five yards; width, two inches. Origin — Side of the neck. Course — Two circular turns around the neck ; thence over the point of the shoulder, backward and downward to the axilla, under the axilla, up in front over the shoulder to the point of origin, repeating these turns two or three times. Termination — Circular turn around the neck. Use — To retain dressings over the shoulder or in the axilla (Fig. 47). 3. Anterior Figure-of-8 Bandage of the Chest. Length of roller, seven yards 4 width, two and one-half inches. Origin — Axilla of either side. Course — Two circular turns around the chest to the point of origin, thence obliquely upward across the chest to the point of the shoulder, over the shoulder backward and down- ward to the border of the axilla, under the axilla obliquely BANDAGING, 81 upward, across the chest to the opposite shoulder, over the shoulder, backward and downward to the border of the axilla, Fi-. 47. under the axilla, repeating these turns three or four times (Fig. 48). Termination — By circular turns around the chest. Use — To draw the shoulder forward, and to retain dress- ings on the anterior surface of the chest. 82 BANDAGING. •Fig. 48. 4. Posterior Figure-of-8 Bandage of the Chest. Tliis bandage is applied in the same manner as that just de- scribed, the turns being carried over the posterior instead of the anterior surface of tlie chest (Fig. 49). BANDAGING. 83 Use — To draw tlie shoulders back in the treatment of frac- ture of the chivicle, or to retain dressings on the posterior surface of the chest. 5. Crossed Bandage of one or both Breasts. Length of roller, eight yards ; width, two and one-half inches. Origin — Axilla of the affected side. Coarse — Two circular turns under the breasts, around the chest to the point of origin, thence obliquely upward under the affected breast, across the front of the chest to the shoul- der, over the shoulder, obliquely downward across the back Fig. 50. of the chest to the point of origin; then, by a circular turn, under the breast, around the chest to the point of origin ; continue these turns alternately, gradually advancing forward 84 ■ BANDAGING. in the oblique turns, and upward in the circular turns until the breast is fully supported (Fig. 50). Termination — Circular turns around the chest. Bandage for both Breasts. Length of roller, twelve yards ; width, two and one-half inches. This bandage is applied in the same manner as that just described, with the addition of oblique turns, supporting the other breast, which begin when the bandage, in the second circular turn, the first oblique turn having been made, has reached the opposite axilla ; then pass across the back of the chest over the shoulder down obliquely across tlie front of Fig. 51. the chest under the breast to the point of origin. These turns are continued, the circular and oblique turns alternat- ing, until both breasts are supported (Fig. 51). Use — These bandages are used to support the breasts in excessive lactation, or in abscess. BANDAGING. 85 6. Spiea Bandage of the Shoulder. Length of roller, eiglit yards; width, two and one-half inches. Origin — Arm of the injured side. Course — Circular and spiral reverse turns to the point of the shoulder, over the shoulder, obliquely downward across the front of the chest, for the right shoulder, and the back of the chest for the left shoulder, to the axilla of the sound side, under the axilla, obliquely upward across the front or back of the chest to the point of the shoulder, down in front or behind to the border of the axilla, under the axilla to the point of the shoulder, covering one-half of the preceding turn, thence to the axilla of the sound side. Continue these turns, covering one-half of each preceding turn, until the shoulder is covered (Fig. 52). Termination — Circular turns around the chest. Use — To retain the head of the humerus in place after dislocation has been reduced. 8 86 BANDAGING. 7. Spiral Bandage of the Chest. Length of the roller, ten yards ; width, three to four inches. Origin — Circular turns around the waist. Course — By spiral turns around the chest, ascending to the axilla, covering one-half of each preceding turn. Termination — Circular turns around the upper part of the chest. Use — To make compression in fracture of the sternum or ribs, and to retain dressings (Fig. 53). Fiff. 53. 8. Circular Bandage of the Abdomen. Length of the bandage, from one-and-a-half to two yards ; width, from ten to twelve inches. Origin — Over the crest of the ilium. Course — Circular turn around the abdomen. Termination — Over the crest of the ilium. Use — To support the abdominal walls. 9. Spiral Bandage of the Abdomen. Length of the roller, ten to twelve yards ; width, three to four inches. BANDAGING. 87 Origin — Around the waist, or over the crest of the ilium. Course — Spiral turns from above downward, or from below upward. Termination — By circular turns around the pelvis or around the waist, according to the course taken. Use — To make compression of the abdomen or to retain dressings. 10. Spica Bandage of one or both Groins. Length of roller, eight to ten yards ; width, two-and-a-half to three inches. Fi^. 54. Origin — Above the crest of the right ilium. Course — Two circular turns around the body above the 88 BANDAGING. crests of the ilia, thence obliquely downward across the groin to the inside of the right thigh to cover the right groin, to the outside of the left thigh to cover the left groin, around the thigh, across the groin obliquely upward to above the crest of the left ilium, and then to point of origin; repeat these turns, and cover one-half of each preceding turn, until the groin is covered (Fig. 54). Termination — Circular turns above the crest of the ilia. Fig. 55. Use — To make compression over the groin, as in case of bubo, or to retain dressings. To cover both groins, the turns, as described above, should be made to alternate (Fig. 55). BANDAGING. 89 11. The Spiral. Reverse of the Penis. Length of roller, eighteen to twenty-four inches ; width, one inch. Origin — Behind the glans penis. Course — Spiialand spiral reverse turns to the root of the penis. Termination — Root of the penis, fastened by slitting the terminal extremity and tying the two ends. Use — To retain dressings to the penis. Fig. 56. BANDAGES OF THE EXTREMITIES. SUPERIOR EXTREMITY. Bandages of the Hand. 1. Spiral bandage of the finger. 2. Spiral bandage of all of the fingers, or the gauntlet. 3. Spiral bandage of the palm, or demi-gauntlet. 4. Spica bandage of the thumb. 1. Spiral Bandage of the Finger. Length of roller, one yard ; width, one inch. Origin — Circular turns around the wrist. Course — From the wrist across the back of the hand to the base of the finger, thence by very oblique turns to the point of the finger, returning to the base by spiral or spiral- reverse turns, and thence to wrist (Fig. 57). Termination — Circular turns around the wrist. Use — To retain dressings or to support parts in fracture. 8* 90 2. Spiral Bandage of all of the Fingers, or the Gauntlet. Length of roller, eight yards ; width, one inch. Origin — Around the Avrist. Course — By turns, taking the same direction as those in the preceding bandage, each finger being covered separately, Fiff. 58. and the palm covered by spiral turns ascending to tlie wrist (Fig. 58). Termination — Circular turns around the wrist. iJse — To cover all of the finojers. BANDAGING. 91 3. Spiral Bandage of the Palm, or Demi- Gauntlet. Length of roller, six yards ; width, one inch. Origin — Around the wrist. Course — By circular turns around the wrist, thence down- ward across the back of the hand to the first interdigital space around the base of the finger, across the back of the hand to the wrist. Repeat these turns around the base of each finger until the back of the hand is covered. Termination — Circular turns around the wrist. Use — To retain dressings on the back of the hand. 4. Spica Bandage of the Thumb. Length of roller, three yards ; width, one inch. Origin — Around the Avrist. Course — From the wrist across the base of the thumb to the phalangeal articulation, around the thumb, across the Fi?. 59. base of the thumb to the wrist, and continue these turns, covering one-half of each preceding turn, until the thumb is covered (Fig. 59). Termination — Around the wrist. Use — To make pressure over the base of the thumb, or to confine dressings. 92' BANDAGING. Bandages of the Arm. 1. Circular bandage of the wrist. 2. Figure-of-8 bandage of the wrist. 3. Figure-of-8 bandage of the elbow. 4. Circular bandage of the arm. 5. Oblique bandage of the arm. 6. Spiral bandage of the arm. 7. Spiral-reverse bandage of the arm. 1. Circular Bandage of the Wrist. This bandage consists of two or more circular turns around the wrist. The spiral-reverse bandage of the upper extremity may begin by these turns passing by figure-of-8 to the hand and back to the wrist. 2. Figure-of-8 Bandage of the Wrist. Length of roller, two yards ; width, two inches. Origin — Around the wrist. Course — Two circular turns around the wrist, over the back of the hand, to the palm of the hand, across the palm and over the back of the hand to the wrist; make two or more turns, covering one-half of each preceding turn. Termination — Around the wrist. Use — To make compression over the joint, or to confine dressings. 3. Figure-of-8 Bandage of the Elbow. Length of roller, two yards; width, two inches. Origin — Around the upper part of the forearm. Course — Two circular turns around the upper part of the forearm, then obliquely upward across the front of the elbow to the lower part of the arm, making circular turns around r.ANDAGING. 93 the arm and returning obliquely downward across the front of the elbow to upper part of the forearm ; then by ascending spiral turns covering the entire joint. Termination — Circular turn around the arm. Use — To make pressure over the elbow-joint, or to retain dressings. 4. Circular Bandage of the Forearm or Arm. The application of tiiis bandage consists in making circular turns around any part of the forearm or arm. Use — To retain dressings or to compress the superficial veins in venesection. 5. Oblique Bandage of the Forearm or Arm. Length of roller, two to three yards ; width, two inches. Origin — Around the hand. Course — Two circular turns around the hand, thence by very oblique turns up the forearm and arm to the shoulder. Termination — Circular turns around the upper part of the arm. Use — To retain dressings. 6. Spiral Bandage of the Arm. Length of roller, three to five yards ; width, two inches. Origin — Figure-of-8 turn of the wrist and hand. Course — By spiral turns up the forearm and arm to the shoulder. Termination — Circular turns around the upper part of the arm. Use — To retain dressings. 7. Spiral-Reverse Bandage of the Upper Ex- tremity. Length of roller, eight yards ; width, two inches. 94 BANDAGING. Fig. 60. Origin — Around the wrist by two circular turns. Course — From the wrist obliquely downward across the back of the hand to the metacarpo-phalangeal articula- tion, one or two circular turns around this articulation, thence obliquely up- ward across the back of the hand to the wrist, completing figure-of-8 turn of the wrist ; then spiral turns over the wrist-joint, ascending the forearm by spiral-reverse turns to the elbow, crossing the elbow-joint by figure-of-8 turn and covering with spiral turns, and ascending the arm to the shoulder by spiral-reverse turns (Fig. 60). Termination — Circular turns around the upper part of the arm. Use — To support the arm in the treatment of fractures, dislocations, etc. This bandage may begin by circular turns around the hand, over the meta- carpo- phalangeal articulations, and then pass to the wrist by figure-of-8 turns-. In passing over the wrist and elbow-joints, simple spiral turns should be made ; reverse turns increase the pressure and may do harm. BANDAGING. 95 BANDAGES OF THE INFERIOR EXTREMITY. 1. Figure-of-8 bandage of the ankle. 2. Figure-of-8 bandagre of the knee. 3. Figure-of-8 bandage of the thighs. 4. Spica bandage of the instep. 5. Spiral-reverse bandage of the lower extremity covering the heel. 6. French spiral bandage. 1. Figure-of-8 Bandage of the Ankle. Length of roller, two yards ; width, two inches. Origin — Around the leg, above the malleoli. Course — Two circular turns around the leg above the malleoli, thence obliquely downward in front of the ankle to the side of the foot, under the sole of the foot to the oppo- site side, obliquely upward in front of the ankle to the point of origin, making as many turns as may be required. Termination — Circular turns above the malleoli. Use — To cover in the ankle or to retain dressings. 2. Figure-of-8 Bandage of the Knee. Length of roller, two yards ; width, two-and-one-half inches. Origin — Side of the upper part of the leg. Course — Two circular turns around the upper part of the leg, thence from side of the leg obliquely upward across the front or back of the knee to the side of the lower part of the thigh, circular turn around the thigh, then from opposite side of the thigh obliquely downward across the front or back of the knee to side of the leg, making the required number of figure-of-8 turns, and covering the joint by as- cending spiral turns. Termination — Circular turns above the knee. Use — To cover in the knee or to make compression. 96 BANDAGING. 3. Figure-of-8 Bandage of the Thighs. Length of roller, live to six yards ; width, two and one-half" to three inches. Origin — Above the knees. Course — Beginning by circular turns above the knees, and making as many figure-of-8 turns as may be required to secure the limbs firmly together. Termination — Circular turns around the upper part of the thighs. Use — To fasten the thighs together after operations or injuries. 61. 4. Spiea Bandage of the Instep. Length of roller, six to eight yards ; width, two inches. Origin — Around the metatarso-phalangeal articulation. Course — By two circular turns around the foot, ascending by spiral-reverse turns to the instep, then obliquely downward to the point of the heel, the edge of the bandage projecting slightly below the border of the sole of the heel, around the heel, obliquely upward to the instep, downward to the side of the foot, under the foot to the opposite side of the foot and to the instep ; con- tinue these figure-of-8 turns, cover- ing one-half of each preceding turn until the instep is entirely covered (Fig. 61). Termination — Circular turn above the ankle. Use — To make firm compression over the instep or ankle. BANDAGING. 97 Ficj. 62. 5. Spiral-reverse Bandage of the Lower Ex- tremity covering the Heel. Length of roller, ten to twelve yards ; width, two-and-one- half inches. Origin — Around the foot at the metatarso-phalangeal articulation. Course — Two circular turns around the foot, ascending by spiral-reverse turns to high up on the instep, thence over the point of the heel, back to the instep, under the sole of the heel, over the side of the heel, around the back of the heel, up to the instep, under the sole of the heel, over the opposite side of the heel, around the back of the heel up to the instep, then figure-of-8 turns of the ankle, spiral turns over the joint, spiral-reverse turns to the knee, figure-of-8 turn of the knee, spiral turns over the joint, and ascending the thigh to the hip by spiral-reverse turns (Fig. 62). Termination — Circular turns around the upper part of the thigh. Use — To support the limb after fracture, etc. This bandage may begin around the ankle and pass to the foot, covering it, and return by figure- of-8 turns to the ankle, and then ascend the limb. Reverse 9 98 BAXDAGING. turns should not be made over the ankle or knee-joints, or over the crest of the tibia, owing to the increased pressure they exert. 6. French Spiral Bandage. This bandage is ap- plied in the same manner as the preceding, the covering of the heel being omitted, passing from the foot to the leg by figure-of-8 turns. Fig. 63. GENERAL BANDAGES. Bandage of Seultetus. This bandage consists of a number of separate pieces varying in length, the first being sufficiently long to go once and a third around the upper part of the limb, each succeeding piece decreasing one inch. The pieces should be arranged so that each strip covers in one-third of that preceding. The limb is placed upon the strips arranged in order, and the application is commenced at the low- est part, crossing one strip over the other in an oblique direction (Fig. 63). Use — To support the limb in cases of com- BANDAGING. 99 pound fractures, etc., where it is advisable to avoid motion in removing dressings. Recurrent Bandage for Amputations. Length of roller, four to six yards ; width, two to two-and-one-half inches. Origin — Three to six inches above the end of the stump. Course — Two circular turns around the limb to the centre of the under surface, thence by recurrent -^^°* ^^' turns over the ex- tremity of the stump to the centre of the upper surface ; con- tinue these recur- rent turns on alter- nate sides of the cen- tral turn, covering in one-half of each preceding turn, un- til the stump is cov- ered. Fix the re- current turns by spiral or spiral-re- verse turns descend- ing to the end of the stump (Figs. 64, 65). Termination — Circular turn around the stump. Use — To support the flaps of the stump after amputation. Figr. 65. 100 BANDAGING. Fig. 66. Velpeau's Bandage. Position of the arm; hand of the injured side grasping the sound shoulder. Length of roller, ten to twelve yards ; width, two-and-one-half inches. Origin — The axilla of the sound side. Course — Obliquely upward across the back of the chest, to the seat of the fracture, over the compress, covering the seat of the fracture, down across the outside of the arm to under the elbow, in front of the chest to the axilla of the sound side, thence by a circular turn across the back over the outside of the point of the elbow to the axilla of the sound side. Con- tinue the oblique and circular turns alternately, advancing over the arm and ascending from the point of the elbow until the arm is firmly supported (Fig. 66). Termination — By circular turn around the chest. Use — To support the arm in the treatment of fracture of the clavicle, the neck, or acromion process of the scapula. In applying this bandage, a compress of soft material should be placed between the arm and the surface of the chest to prevent excoriation. Desault's Apparatus. This consists of three single- headed rollers, a triangular pad to place in the axilla, and a sling to support the hand. The pad sljould be of such length as to extend from the axilla to the point of the elbow, and measure in width at BANDAGING. 101 the base from three to four inches. Length of rollers, eight yards ; "vvidth, two and one-iialf inches. First Roller. Origin — Over the apex of the pad ; placed in the axilla of the injured side. Course — Two circular turns around the chest over the apex of the pad, thence by spiral turns upward to the axilla, covering the pad and securing it in place. Termination — By circular turns around the chest. This roller can be dispensed with to advantage, and the pad held in place by tapes attached to its base passing around the neck. ' The arm should now be flexed at a right angle, pressing slightly against the side of the chest. Second Roller. Origin — Axilla of the sound side. Course — Circular turn across the front of the chest, over the upper part of the arm of the injured side, across the back of the chest to the point of origin, then by spiral turns de- scending to below the point of the elbow. Termination — Circular turns around the body. Use To throw the shoulder outward by pressing the elbow inward, using the pad as a fulcrum. Third Roller. Ori- gin — Axilla of the sound side. Course — Obliquely up- ward across the front of the chest to the seat of the fracture, over the seat of the fracture, down back of the arm to the elbow, under the elbow, across in front of the chest to the Fis. 67. 102 BANDAGING. point of origin ; tlience obliquely upward across the back of the chest to the seat of the fracture, over the seat of the frac- ture, down in front of the arm, under the elbow, across the back of the chest to the point of origin (Fig. 67). Termivation — Circular turns around the chest. Use — To carry the arm upward and backward. It will be observed that two triangles are formed in apply- ing the third roller, the first having the base behind the arm, the sides across the front of the chest, and the apex in the axilla of the sound side; while the second has the base in front of the arm, the sides across the back o^ the chest, and the apex in the axilla of the sound side. Use of the Apparatus. — To support the arm and over- come its displacement in the treatment of fractures of the clavicle. THE COMPOUND BANDAGES. Under this name are included — 1. The T bandages. 2. The invaginated bandages. 3. The sling bandages. 4. The suspensory bandages. 1, The T Bandages. These derive their name from their resemblance to the letter T, and consist of a horizontal portion, sufficiently long to surround the part to be covered, and a vertical piece half the length of the horizontal, firmly attached to its middle (Fig. 68). The bandage thus formed can be applied to various parts of the body. It is most fre- quently employed in retaining dressings to the perineum, when the horizontal portion is fastened around the body and the vertical band passed between the thighs and then attached BANDAGING. 103 to the horizontal piece. The Fig. 6S. napkin worn by women during (jjt menstruation is a familiar ex- ample of this form of bandage. 2, The Invaginated Bandage. This bandage is formed by making strips or tails at the free extremity and at the proper distance cutting slits in the body of the band- age through which these tails pass. It was formerly used for the purpose of approximating the edges of wounds, but is now largely, if not altogether, discarded. Fiff. 69. Fig. 70. 104 BANDAGING. 3. The Sling Bandages. Tliese are made of pieces of muslin or other material of various lengths and widths, torn at each extremity into two or more tails, leaving a central portion or body (Fig. 69). They are quite useful in retaining dressings or supporting parts. In applying them, the central portion or body is placed upon the part, and the tails are carried in different directions about the part, and secured by pins or knots. The Four-Tailed or *' Poor Man's" Bandage is used in the treatment of fracture of the body of the lower jaw (Fig. 70). 4. The Suspensory Bandages. These are made in the shape of bags or sacs of various sizes, and are used for the purpose of retaining dressings or supporting parts. They may be made of such material as is deemed most desirable. MAYOR'S SYSTEM OF HANDKERCHIEF DRESSINGS. This system of provisional dressings was introduced by M. Mayor, of Switzerland, in 1838. It consists in the use of the simple handkerchief, folded into various shapes, so as to accomplish the purposes of the roller. The dimen- sions of this kandkerchief vary according to the part to which it is applied, and may be made of any material which happens to be at hand. The forms into which the handker- chief may be made are : The Square, The Triangle, The Crayat, and The Cord. The Oblong Square is made by folding the handker- chief once on itself. BANDAGING. 105 The Triangle is made by folding the square so that the angles which are opposite come in contact. The Cravat is made by folding the handkerchief in the form of the ordinary cravat. The Cord is formed by twisting the cravat on itself. The handkerchief in the form of the Square may be employed to retain dressings over the head. In the form of the Triangle it can be used for the pur- pose of retaining dressings over the head (Fig. 71), the trunk, the shoulder, the elbow, the hand, the hip, the knee, and the foot ; also to support or retain dressings over the mammary gland (Fig. 72), to act as a sling for the arm (Fig. Fior. 72. r 106 BANDAGING, Fig. 73. Fig. 74. Fis. 75. base is to be applied to the part, and the angles carried about it and fastened by a knot. Tlie Cravat may be used to retain dressings, to make pres- sure, or to support parts, as the arm (Fig. 75). The body should be applied over the part, and the ends carried once or twice around the part and fastened by a knot. The handkerchief in the shape of the cravat may be used to fasten the foot to the end of the fracture-box in cases of fracture of the leg. It should be applied by a figure-of-8 turn, the body being placed over the tendo Achillis, and the ends carried across the instep and BANDAGING. 107 passed through the openings made in the end of the box, and then fastened by a knot. The Cord is used where it is necessary to make firm pres- Ficr. 76. Fior. 77, 108 BANDAGING. sure, as when it is applied over a compress in cases of hemor- rhage. It may also be used in the form of the clove hitch for the purpose of making traction. The clove hitch is made by holding one end of the cord with the left hand and forming from the body a simple loop with the right (Fig. 76) ; holding this between the thumb and finger of the left hand, a second loop is made from the remaining portion of the body of the cord and lield by the thumb and finger of the right hand ; passing the second loop beneath the first, the hitch is formed (Fig. 77). IMMOVABLE BANDAGES. The Starch Bandage, the Plaster of Paris Band- age, AND the Silica Bandage. 1. The Starch Bandage. In this form of bandage, the starch should be prepared so as to be of the same con- sistence as that used in the laundry. Before applying the roller, two compresses made of some soft material, folded so as to be at least one inch in thickness and of the same breadth as the limb, should be applied along each side, ex- tending from the point at which the application of the band- age begins to the point at which it terminates. Holding these carefully in position, the first roller is applied to the limb. This roller is now thoroughly coated with the starch by means of a medium-sized paint brush, the interstices and spaces being well filled. Over this a second roller is applied and coated with the starch in the same manner. In this way a sufficient number of rollers should be applied until the parts are properly supported. If necessary, strips of pasteboard which have been soaked in the starch may be BANDAGING. 109 placed on the sides of tlie limb, after the second bandage has been applied, about those points requiring most support. The compresses, which are placed on the sides of the limb, serve the purpose of protecting it from undue pres- sure caused by the drying of the starched bandages. They may be applied dry, or they may be soaked in the starch and then applied. In the leg they are especially service- able in preventing pressure over the crest of the tibia, the two borders of the compresses, which are separated to a slight extent, supporting the bandage and keeping it from too close contact with the limb. 2. The Plaster of Paris Bandage. This bandage may be applied with rollers made of some loosely woven material, such as crinoline, Swiss muslin^ cheese cloth, mos- quito-netting, or with the ordinary muslin. When the first is used, it should be cut into strips, and dry plaster rubbed with the hand into its meshes on both sides, and then the strips should be formed into rollers and put in an air-tight tin vessel. A^arious forms of apparatus have been devised to accomplish the impregnation of the material with plaster. That of Dr. William Judkins, of Cincinnati, is shown in Fig. 78. When required, the rollers should be placed ovi end in a basin, containing w^ater enough to cover them entirely, for one or two minutes, in order that they may become thoroughly wet, and in this condition they should be applied rapidly to the part ; a free escape of bubbles of gas through the water takes place, and when this has ceased, the bandages are ready for application. The roller, made of ordinary muslin, can be prepared by unrolling it in a basin containing water, thus becoming wet as it unrolls, and re-rolling it in a basin containing a 10 110 BANDAGING. mixture of plaster and water of the consistence of cream. In this way the surfaces become well coated with the plas- ter, and the roller can be applied directly to the part. In applying the plaster bandage, the mixture of plaster should be rubbed over each roller with the hand after it is applied. The setting of the plaster may be retarded by add- ing a little size, a small quantity of borax, or stale beer. If salt is added, its tendency to set will be increased. Gum- water, white of egg, or flour-paste should be applied to the surface after hardening has occurred, in order to prevent chipping ; a coat of varnish will render it impermeable to moisture. In this form, the compresses should be placed along the sides of the limb in the same manner as in the starch bandage. In order to remove the plaster from the hands after the application of the dressing the white of egg may be used. BANDAGING. Ill 3. The Silica Bandage. In preparing this bandage a solution of the silicate of potassium or sodium is used. The roller is applied to the limb over the compresses, placed as above described, and it is thoroughly coated with the solution by means of a medium-sized painter's brush. As many rollers as. may be deemed necessary are applied, each being thoroughly coated with the solution. This is an excellent form of the immovable bandage, being easily applied, lighter than the plaster bandage, and hardening in a very short time. 4. The Dextrine Bandage. The solution of dex- trine is prepared by mixing thoroughly ten parts of dextrine with six parts of brandy or camphor, and adding to it four parts of warm water. In these proportions the mixture assumes the consistence of molasses, and may be applied in the same manner as the starch. 5. Tripolith. This substance has been recommended by Prof, von Langenbeck as possessing advantages over plaster of Paris. It consists of lime, silicon, and oxide of iron, and after application it is stated to be lighter and more durable than plaster of Paris. Dr. Nelson, of Boston, has made several trials of it, and pronounces it to be unsatisfac- tory as a dressing. In addition to these forms of immovable bandages there are the Gum-and-Chalk, the Glue, the Glue-and-Oxide-of- Zinc, and the Paraffin bandages. These do not possess any advantages over those described above ; the end to be ac- complished — immobility of the parts — being secured by one as well as by the other. Great caution should be observed in applying the rollers in these forms of bandaore lest too much traction be em- 112 BANDAGING. Fig. 79. ployed ; they should be applied with less traction than the ordinary roller, owing to the shrinkage which occurs in some of them after application, and which thus increases the pres- sure. The parts should be carefully watched after the appli- cation has been made, in order to note any changes which may occur, indicating too much pressure or interference with the circulation. Should evidences of these conditions manifest themselves, the bandages should be immediately removed, the limb sponged with soap liniment or alcohol and laudanum, and the dressings re-applied with more care. In some forms of the immovable ban- dages, great difficulty is experienced in effecting their removal. Strong cutting pliers have been made, with which the bandages can be divided, the instrument being carried along the side of the limb (Fig. 79). To facilitate the removal of a plaster of Paris bandage, a band of flan- nel, saturated with unboiled linseed oil, with 5 per cent, of carbolic acid added, may be laid up and down the limb where the bandage is to be divided ; or, if very thick, dilute hydrochloric acid may be applied along the side for a few minutes, softening the plaster, so that it can be divided by the scissors. Saws with widely set teeth in the shape of that of Hey's, or the circular saw of Collin & Co., of Paris, are also used with advantage. The large burr or the circular saw of the surgical en«>ine can be applied, and in this way the bandage expedi- BANDAGING. 113 tiously divided. The starch bandage may be removed by one of these instruments. The phister of Paris bandage in some instances may be unrolled from the part. The silica bandage may be readily removed after soaking it for a time in warm water. Sayre's Sus- pension Appa- ratus for apply- ing the Plaster Jacket. This is an apparatus devised by Prof. Lewis A. Say re, of New York, for the purpose of suspending patients sufFeringfrom antero- posterior curvature of the spine during the application of the plaster of Paris baud - age. The object to be accomplished by the suspension of the patient, is the sepa- ration of the diseased vertebrae, and the straightening, to a certain extent, of the column, the bandage being applied when the patient is sus- pended. When it Fiff. 80. 10* 114 BANDAGING. Yig. 81. hardens, it prevents the re- currence of the curvature to the same extent as before, by offering a firm support to the parts. The apparatus consists of a curved iron cross-beam, to which is attached an adjust- able head and chin collar, with straps fitted to axillary bands. To a hook in the centre is fixed a compound pulley, the other end of which is secured either to a hook in the ceiling, or to the top of an iron tripod about ten feet in height (Fig. 80). In ap- plying the plaster jacket, " the surface of the skin should be protected by an elastic but closely fitting shirt or vest, without armlets, with tapes to tie over the shoul- ders, and composed of some soft, warm, or knitted mate- rial ;" a thin and closely fit- ting merino undershirt can be thus prepared. When the patient is a developing girl, pads should be placed over each breast, to be re- moved just before the plaster has completely set. Another BANDAGING. 115 pad, composed of cotton loosely folded up in a handkerchief, is to be placed over the abdomen ; it should be very thin at its lower part, so as not to make the jacket too loose. On the same principle, small pads are applied at either side of tender spots over prominent bony processes, and two folded cloths, three or four thicknesses each, just over the anterior iliac spines. The shirt being accurately applied, and kept smoothly stretched by means of the shoulder-tapes above and two tapes below, one in front and the other behind, tied over a handkerchief placed in the perineum, the patient is to be drawn up gently until he feels comfortable (Fig. 81). A prepared and saturated roller, gently squeezed so as to get rid of all surplus water, is now applied around the smallest part of the body, and carried around the trunk downwards to a little below the crest of the ilium, then spirally from below upward until the entire trunk is encased from the pelvis to the axillae. The bandage should be applied smoothly, and not drawn tight. " After one or two thicknesses of bandage have been thus applied, several narrow strips of roughened tin are laid on either side of the spine, so as to surround the body, with intervals between them of two or three inches. Over these another plaster bandage is applied ; very soon the plaster sets so firmly that the patient can be removed and laid upon his face or back upon a hair-mattress or air-bed. The pads are then removed, and the plaster gently pressed in with the hand in front of each iliac spine, so as to widen the case over the bony projections. While the patient is thus lying, it is sometimes "necessary to wet the jacket with a little water, and then dust on some more plaster. As soon as the plaster has hardened, the patient may be allowed to walk about." 11 G BANDAGING. The jacket is generally removed, after two or three months, by dividing it with the cutting pliers, knife, or a very narrow saw, from the pubes to the sternum, and gently stretching it apart. Dr. Thos. J. Walker, of the Peterborough Infirmary, Eng- land, has described a method of applying the plaster of Paris jacket to the patient in the recumbent position. Bandages made of Victoria lawn are saturated with the plaster in an apparatus devised by him, then cut into strips and arranged as in the bandage of Scultetus (p. 98). One layer of strips (extending from the ilia to the axillse) is placed over the other usually to the number of two or three, until the requi- site firmness is obtained in the jacket. On these layers the patient is placed and the strips are overlapped one after the other in order. Mucilage is added to the plaster cream so as to retard the setting and thus give ample time for the application of the dressing. By this plan the dangers and discomforts of the suspension method are avoided as well as the alarm in case of children. PART III. FRACTURES. Definition. — A fracture of a bone is a solution of the continuity of its fibres. Varieties. — Complete and Incomplete. Complete fractures embrace, Simple or Single — Commi- nuted or Multiple — Impacted — Compound — Complicated — Epiphyseal. Incomplete fractures include Fissures — Punctures — Partial fractures. Complete Fractures Simple or Single Those in which there is one point of fracture only, dividing the bone into two pieces or fragments (Fig. 82). Comminuted or Multiple Fractures Those in which more than one point of fracture exists, the lines of separation communicating and dividing the bone into a number of pieces or fragments (Fig. 83). Impacted Fractures. — In this form one fragment of the bone is driven forcibly into the other so as to become fas- tened firmly in its position (Fig. 84). Compound Fractures In these there is a wound of the soft structures overlying the bone, so as to permit com- munication between the external surface of the part and the point of fracture. Where the fracture of the bone is com- 118 FRACTURES. minuted it is designated as a Compound-comminuted frac- ture ; or where complications exist, a Compound-complicated fracture. A fracture may be compound from the Jirst, or become so secondarily, as the result of morbid conditions Fiff. 82. Fig. 83. Fig. 84. which produce destruction of the overlying soft structures (Fig. 85). Complicated Fractures. — Fractures accompanied by dis- location of an adjacent joint, injuries of important blood- vessels or nerves, or extensive contusion and laceration of the soft structures, are designated complicated. Epiphyseal Fractures In this form of fracture a sepa- ration takes place between the epiphysis and the shaft of the bone — a condition liable to occur in young persons before ossific union has been accomplished (Fig. 86). FRACTUKES. 119 Ficr. 85. Fig. 86. Z^' Incomplete Fractures Fissured fractures A fis- sured fracture is one in which there is a fissure or cleft in the fibres of the bone not extending through the entire structure. Lines of fracture radiating from a central point form the "stellate" fractures. Punctured Fractures. — In these there is a perforation of the osseous structure, without such separation of the fibres as to cause displacement. Partial Fractures This form of fracture is known com- monly as the " green-stick" fracture, in which part of the fibres break, the rest bending under the force applied : it 120 FRACTURES. occurs in young subjects, at that period of life when the animal matter predominates. Direction of the Line of Fracture The direction in which the fibres of the bone separate in fracture varies, being transverse^ oblique, or longitudinal. Transverse Line Tlie fibres of the bone separate at right angles to the long axis of the bone (Fig. 82). Oblique Line The oblique line of separation is that which occurs most commonly in fracture of the long bones as the result of force applied indirectly ; the fibres separate Fiff. 87. Fi-. at an angle of varying obliquity to the long axis of the bone (Fig. 87). Longitudinal Line. — The division of the fibres is parallel with the long axis of the bone (Fig. 88). FRACTUKKS. 121 CAUSES OF FRACTURE. Predisposing and Exciting. — The predisposing causes include age^ sex, occupation, and diathesis. Age As age advances the relation between the propor- tion of organic and inorganic elements in the bones changes, the inorganic or earthy predominating to such extent as to render the bones fragile and liable to fracture on the ap- plication of force. Sex Males, by reason of their modes of life, are more exposed to the conditions which produce fractures than females. Occupation Occupation contributes to the occurrence of fractures in a marked degree. The daily work of the me- chanic and laborer exposes them to causes from which the merchant and professional man are exempt. Diathesis. — Certain diseases, as cancer, syphilis, rachitis, and other constitutional affections, produce such morbid con- ditions in the osseous system as predispose to the occurrence of fracture. The exciting causes of fracture are mechanical or external violence and muscular action. Mechanical violence is the most frequent cause, and may be applied in two ways : directly, or by direct application of the force to the part, and indirectly, or by counter-stroke, where the force is transmitted from a point of contact more or less remote. Muscular Action — Certain bones of the skeleton, as the patella, os calcis, and the olecranon process of the ulna, receive the attachments of powerful muscles, which, when called into extraordinary action, may exert such force upon the bones as to cause a separation of their fibres. Other 11 122 FRACTURES. bones, as the humerus, femur, and clavicle, may be subjected to fracture as the result of contraction of muscles attached to them, the body or limb being at the time in such position as to permit the bone to be taken at a disadvantage, as it were, the opposing action of other muscles being prevented. SYMPTOMS OF FRACTURE. The symptoms may be divided into the rational and 'physical. The rational symptom are -pain and loss of function of the part or limb. Pain The degree of pain experienced varies in accord- ance with the nature of the fracture. A compound fracture, with extensive contusion and laceration of the soft structures would naturally cause greater suffering than a simple frac- ture ; frequently this symptom is absent, being elicited only in attempts at manipulation of the part. Loss of Function This condition may be complete or partial, depending somewhat upon the bones involved. Frac- tures of the femur and tibia prevent locomotion, while that of the humerus, ulna, and radius interfere with prehensile efforts. If not entirely destroyed, the function of the part may be stated to be always more or less impaired, the pain caused by efforts at movement contribute to this condition. The physical symptoms or signs include Deformity^ Mo- bility , and Crepitus. Deformity is the condition produced by the displaced fragments of bone, and is the result of various causes : — Is^. The force which is applied and which produces the fracture, continues to act upon the fragments and causes their displacement. 2d. Muscular action The resistance offered to muscular I FRACTURES. 123 contraction by the bone in its integrity is, after fractures, partially or entirely destroyed, and, as a result, displacement occurs in the direction of the muscular action. Direction of the Displacement The displacement may be longitudinal, angular, transverse, or rotatory. The longitudinal displacement is in the direction of the long axis of the bone, and causes, according to the bone involved, either shortening or lengthening; the former occurs most frequently in the fracture of the long bones where the line of separation is oblique and the ends of the fragments, as the result of muscular contraction, overlap each other; it also exists, to a less degree, in cases o^ impacted ivsidiwve. Lengthening, due to longitudinal displacement, is observed in fracture of the patella where the fragments are separated by muscular action. In angular displacement the fragments are placed at an angle to each other ; the fracturing force, assisted by mus- cular action, produces this form of displacement ; the angle, usually obtuse, may be increased in rare instances to nearly that of a right angle by the superincumbent weight of the body as in fracture of the femur, and union take place in this position. Displacement in the transverse direction occurs in frac- tures in which the line of fracture is transverse and the ends of the fragments are only partially separated. Rotatory displacement is tliat form in which one of the fragments rotates upon its axis so as to change the relative position of the surfaces ; it may take place in either frag- ment, and is the result of muscular action alone, or that combined with the weight of the limb. 3c?. The weiglit of the part of the limb below the seat of 124 FRACTURES. fracture, combined with muscular action, contributes to de- formity. Mobility. — Mobility is the movement which exists be- tween the ends of the fragments of bone, and is a character- istic siofti of fracture. In fractures near to or involvino^ an articulation, this symptom is of less significance unless it should be preternatural in character. In impacted fractures it is absent, or present in slight degree. In fractures of the forearm or leg in which but one bone is broken, the mobility is limited by the support given by the sound bone. Crepitus, — This is the sound produced by rubbing together the ends of the fragments of bone. It is most distinct in fractures involving the large bones of the skeleton, and can be in most cases as readily /e/^ as heard. It is to be distin- guished from the crepitation elicited in moving articulations in a state of disease, from that of inflamed bursae and sheaths of tendons, and from the crackling produced in emphysema- tous tissues ; the former is more of a dry, harsh, grating sound ; while the latter is softer and of a moist character. In incomplete and impacted fractures it is absent. In addition to the symptoms stated above and which are diagnostic in character, there may be enumerated swelling, discoloration, numbness, and muscular spasm. Swelling and discoloration accompany fractures in which more or less injury has been inflicted upon the soft tissues, producing extravasations and ecchymoses. Numbness and muscular spasm proceed from injury to adjacent nerves by the sharp, jagged ends of the bone-frag- ments. DIAGNOSIS OF FRACTURE. The diagnosis in fracture is to be made by careful exami- nation of the parts and study of the symptoms presented. FRACTURES. 125 The eve, the ear, and the hand sliould be employed in tlie examination. Interrogations as to the manner in which the injury was received : inspection of the injured limb or part ; comparison with the sound side as to function, contour, po- sition, and relation of prominent surface markings; measure- ments from fixed points, and finally manipulation to ascertain mobility and elicit crepitus — all of these should be made in a careful and systematic manner. The examination should be made as soon after the receipt of the injury as possible. It is necessary, in cases w^here the pain caused by manipu- lation is severe and the symptoms are obscure, to administer an aniesthetic, so as to avoid giving pain and to overcome muscular resistance. In order to elicit crepitus, the ends of the fragments should be brought into apposition, the part grasped firmly above and below the seat of fi-acture, and gentle movement should be made in different directions. In fracture of the ribs crepitus can be sometimes felt and heard by placing the hand and then the ear over the seat of sus- pected fracture. In compound fractures the finger can be introduced into the wound and the seat of fracture explored. In all manipulations required to establish the diagnosis, the utmost gentleness consistent with thorough examination should be practised in order to avoid the infliction of addi- tional injury. PROGNOSIS IN FRACTURES. The prognosis as to the results after fractures, depends upon the age, condition of health, and habits of life of the patient, his co-operation with the surgeon during treatment, and the nature and extent of the fracture. The processes of repair in bone are favored by the vital energies of youth, robust health, and correct habits of life. A very important 11* 126 FRACTURES. element of success is perfect obedience on the part of the patient to the rules of treatment prescribed by the surgeon. In cases in which the directions of the surgeon are not fol- lowed by the patient, it is desirable to call a fellow-practitioner in consultation, in order that he may, in the event of the occurrence of a bad result, be able to bear testimony to the treatment instituted and thus exonerate the surgeon. The nature and extent of the injury influence largely the result. Fractures of bones of the trunk which enter into the forma- tion of cavities, as the vertebrae, ribs, pelvis, are liable to be complicated with injuries of the contained viscera and thus render the prognosis unfavorable. Compound and compli- cated fractures in any part of the body, and fractures near to or into an articulation, involve a doubtful prognosis. Process of Repair in Fractures. — The parts involved in the fracture of bones are the external covering, the perios- teum ; the bone tissue proper, compact and cancellous ; and the medulla, with its membrane, the medullary membrane or internal periosteum. For the purpose of convenient study the processes concerned in the repair may be divided into stages. 1st Stage, In all fractures, an extravasation of blood to a greater or less extent occurs as a result of the laceration of the bloodvessels of the tissues involved. The removal of this extravasated blood may be accomplished by absorption, ejection by suppurative action, or it may become organized and form part of the reparative material. '2d Stage. The second stage includes all of the processes which are concerned in the union of the fragments, and may be designated the "uniting stage." After the removal of the extravasated blood is accomplished, or while this is being effected, the true reparative material begins to be formed, FKACTURES. 127 the periosteum and the medullary membrane taking active part. This material, known as callus, appearing first as a granular substance, may, according to circumstances, pass through several transitional forms before ossification is ac- complished, as fibrous tissue, fibro-cartilaginous tissue, and cartilage, or it may be transformed from rudimentary states directly into bone. It is deposited by the osteo-genetic layer of the periosteum about the external surfaces of the ends of the fragments forming the external or ensheathing callus, within by the medullary tissue forming the internal or pm callus, and, finally, by the bone tissue between the ends of the fragments constituting the intermediate or defini- tive callus. The extent of production and deposit of this callus depends upon the adjustment of the ends of tlie frag- ments and their maintenance in a fixed position. Accurate coaptation of the extremities of the fragments and absolute immobility reduces its production to a minimum degree by the protection afforded the lacerated surfaces by their coap- tation and the prevention of irritation by immobility. In compound fractures where the wound is exposed to the air, and more or less suppuration occurs, the callus or repara- tive material is developed through the medium of granula- tions, which finally undergo ossification. In some cases an arrest in the complete development of the reparative material may take place and the fragments may be united by fibrous tissue forming an ununited frac- ture. 3rf Stage. This stage in the repair is occupied in the " modelling" or shaping of the parts about the seat of frac- ture. If the coaptation has been accomplished accurately, and the fragments kept quiet, there is little to be done in this stage. If the adjustment has been imperfect, the frag- 128 FRACTCli£S, OTcrlappeds and the nedoDaij t --^ - ^ - "? w«Mt of this sta^ win cosast in tbe Tr _ ^^ caJliK if present^ and the roondii^ off ot the sharp ends of the fiagmenls 1^ ahsmpcion, the capping of the exposed ends of the fin^ments by new bone formation, the shaping of the cdoe deposited b^twe^i the fragments and the fonaation of an external wall and a eanedloQs inteiior for it continiioas with the <^ and, finalfy, the lestoraticm of the mednllaij The time leqaired for the enajj^etion of Ae rqpaiatiTe pnice^ varies aceoidiii^ to the bone initdved and the na- ture and extent id the fiactore. In simple fiactmes the first wedk aSkct the injoiy is occaqpied in the maoTal of the inflammation which is consequent opon the injoij to the parts and of its products. From this period to the end of the third we^ the formation of the caDos and its gradnal deT^opaient oecms; after the third wec^, and to the tenth and twelfth, oi^fication is perfected and the ftagments are eoDfifdidated. TUEJlTHEST of FJLLCTITKE^, The treataMnt of fiactores indodes the trai^portation of the patient, prqiaration of the bed, the lednctioB or setting of the fn^moiis, then* retention in place until onion k ae- co mpljylie d, and, finallj, the treatmoit €if all conditioiK aiiai^ during the period cf r^air. TrttmsjtnwtaAvm. ^ U» PaticHL — ^In fiactores other than those of the i^per extranitj it is neee^arj that the patioit ^oold be carried to the place of treatm»it. When the dis- tance is great, thisshooldbedoneinaTeiiicleof somekind, prefeiaM J an ambolance lished by flexing the knee and 22* 258 FKACTL'KES. making extension, with the forearm in the popliteal space. Where comminution has taken place, manipulation should be employed to mould the fragments into position. After reduction, if it is found that there is little or no tendency to displacement, the limb may be treated in the straight posi- tion with w^eights and sand-bags. In very oblique fractures it will be found sometimes that adjustment can be better maintained with the limb in a flexed position, over a double- inclined plane. In compound fractures Packard's bracketed splint (Fig. 140) should be used in order that the wounds Fiff. 140. may receive attention without disturbance of the limb. An- tiseptic dressings, with careful drainage, should be employed in order to avert the dangers attending extensive suppuration in the joint. Passive motion may be instituted at the expi- ration of the fourth or fifth week, when consolidation is suffi- ciently advanced. When anchylosis is inevitable the limb should be placed in a slightly flexed position, in order that the patient may walk with comfort and with but little lame- ness by wearing a high-heeled shoe. VKACTURES. 259 Patella. — In discussing fractures of this bone, it is desirable, in order to comprehend fully the symptoms which attend them, as well as the indications for treatment, to consider its anatomical relations. An examination shows that the common tendon of the group of muscles forming the quadriceps extensor, passinjj^ from the anterior and lateral aspects of the thigh, is inserted into the superior and lateral borders of the patella, covering by an expansion of its fibres the anterior surface, and extending to the apex, to the under surface of which it is attached, then is continued as a broad strong band to its insertion in the tuberosity of the tibia, this portion being designated as the ligamentum patellae. With the exception of the internal surface, which is articular and covered with cartilage, the entire bone is enveloped in the fibres of the tendon, and becomes a part of the tendon as it w^ere. It may be stated, therefore, that the quadriceps muscle is inserted into the tuberosity of the tibia by an osseo-tendinous band, the bone being placed in the tendon for the purpose of affording protection to the knee-joint in front, and to increase the leverage of the extensor muscle. The bone being so much a part of the tendon, it is necessary, in considering fractures of it, to examine into the conditions which take place in the tendon. Fractures of the patella caused by muscular action are always accompanied by rupture more or less complete of the tendinous structures. In frac- tures due to direct violence, rupture of the tendon rarely occurs; when it does occur it is partial in character. In fractures which are the result of muscular action, the line of separation is transverse. Violence applied directly may produce fracture in the transverse, oblique, or vertical direc- tion. In fractures caused by muscular action the important point is to direct the treatment so as to secure firm and close 260 FRACTURES. union of the torn tendinous structures, as well as of the frag- ments of the bone. The failure to maintain the permanent close union of the bony fragments obtained by treatment has been due, in my judgment, to the failure to secure suffi- ciently accurate approximation and contact of the torn edges of the tendon by the apparatus employed. Causes Muscular action or direct violence. The former may produce fracture in the violent effort to maintain the erect position when the body is thrown forcibly backward, the knee being, in the meanwhile, in a state of flexion. Direct force, as a kick from a horse, a blow with a bludgeon, or a fall upon the knee, may cause a fracture, the line of separation being either in the transverse, oblique, or vertical direction. Compound and comminuted fractures are the result of very severe violence or gunshot wounds. Symptoms. — In fractures caused by muscular action the symptoms are well marked. Those most prominent are loss of function and deformity. The patient may have heard -the snap produced by the fracture of the bone. He at once recognizes his inability to extend the limb in progression, the effort being usually followed by a fall. The deformity is caused by the swelling which ensues, and by the drawing up of the upper fragment, which forms a prominence at a greater or less distance above the knee, with a marked sulcus or depression over the anterior surface of the joint. The extent of separation of the upper from the lower fragment varies in accordance with the more or less complete rupture of the tendon. If the rupture is complete the contraction of the muscle may cause a separation of from two to four inches. Crepitus may be elicited by extending the limb so as to bring the fragments into contact. Usually this is diffi- cult, on account of the swelling which occurs. Pain is FRACTURES. 261 sometimes quite marked, experienced more especially at the time of the receipt of the injury. In fractures produced by direct violence the injury to the joint is of such character as to render the symptoms more or less obscure. Pain is marked. The separation of tiie fiagments is much less, the deformity being caused largely by the swelling ; loss of function varies in accordance with the severity of the injury. Crepitus can be more readily detected, owing to the slight separation of tiie fragments ; in vertical and comminuted fractures it is readily obtained. Diagnosis In transverse fractures caused by muscular action the symptoms are so distinct as to render the diagnosis usually easy, especially if the examination has been made before the supervention of much swelling. Transverse frac- tures produced by direct violence are sometimes difficult to recognize by reason of the slight separation of the fragments, owing to the non-occurrence of rupture of the tendon. In oblique or vertical fractures, or where the bone is commi- nuted, crepitus may be readily distinguished. In compound fractures the wound can be explored with the finger and the condition determined. As little movement as is consistent with a thorough examination should be made, so as not to increase the separation of the fragments. Prognosis Fibrous union, with more or less separation of the fragments, and, as a result, with more or less disa- bility, is liable to follow transverse fracture of the patella, with rupture of the tendon, due to muscular action. In transverse fracture caused by direct violence, close union by fibrous tissue is frequently accomplished. Rare instances are recorded in which bony union has follow^ed transverse fractures produced by muscular action. The fragments in transverse fracture caused by direct violence, owing to the 262 FRACTURES. non-rupture of the tendon, can be more readily approximaled and maintained in coaptation, and in this form bony union may frequently occur. The disability varies very much in different individuals. I have observed instances in which patients, M^ith wide separation of the fragments, apparently suffered no inconvenience, the full and free use of the limb being present. I have at this time a patient under observa- tion, who had sustained transverse fracture of both patellae, the result of muscular action, one fracture occurring a year subsequent to the other. Wide separation of the fragments exists, and the patient is liable to fall in walking rapidly. A peculiar form of disability accompanies this case, in that, while the patient is able to ascend the stairs naturally and without great effort, she is compelled, through the fear of falling, to descend backward. More or less weakness of the limb is liable to follow in all cases. This fact explains the liability to the subsequent occurrence of fracture in the same bone, as well as in the bone of the other limb. In cases of wide separation, the bond of union is formed between the upper borders of the fragments, and consists of the expansion of fascia covering the anterior surface of the bone, increased somewhat in thickness by inflammatory action. When the separation does not exceed one inch and a half, fibrous tissue is devel- oped between the ends of the fragments, filling up the space and forming a stronger connecting bond. Treatment. — The indications for treatment are to overcome by proper measures the inflammatory conditions which are very frequently present, and then to apply sucli dressings as will maintain the fragments in close contact until union takes place between their surfaces, and in transverse fractures, of the edges of the torn tendinous structures. In order to FRACTURES. 263 remove the inflammatory conditions present, it may be necessary to deplete tiie parts by the application of leeches and to apply evaporating lotions subsequently. In some cases the effusion of synovial fluid is so great as to demand its removal by the aspirating needle. Collections of blood in the joint require to be removed in the same manner. It may be desirable to place the limb at rest for a period of time — from four to six days — while this treatment is being carried out, and before any permanent dressing is applied. A large number of appliances and dressings have been devised to maintain the fragments in proper coaptation. A few of them are effective, while a great number are not only not effective, but productive of bad results. In fractures due to muscular action, the limb should be placed in a com- plete state of extension upon a single inclined plane, with the body in the semi-erect position, so as to relax the quad- riceps extensor muscle, and the dressings should be applied in such manner as to hold the upper fragment, after being placed in accurate contact with the lower, firmly in place. Bearing in mind the attachment of the tendon of the extensor muscle to the entire border of the bone, as well as to its anterior surface, suitable pressure should be made over the sides and anterior surface to prevent tilting upward of the edge of the upper fragment, and folding and wrinkling of the tendinous structures. A simple and effective dressing fulfilling these indications was employed by the late Prof. Gross, and consists of a strong, well-padded tin or wire case, long enough to reach from the middle of the thigh to the middle of the leg. A bandage having been applied to the limb from the toes upward, stopping below the knee, and another beginning at the groin and carried as far as the middle of the thigh, the limb is then placed in the case. 264 FRACTURES. The upper fragment having been brought into contact with the lower, is confined by numerous adhesive strips carried around the bone above and below the joint, and connected by vertical and transverse pieces. A long, thick, and rather narrow compress is now extended around the upper border of the patella, and is secured in place firmly by the two bandages, which are continued upward and downward, and surround the knee-joint by figure-of-8 turns. By means of this dressing the limb is held by the case in a state of exten- sion, the upper fragment is secured in place by the adhesive strips, and muscular action is controlled by the two bandages, applied in opposite directions. Prof. Agnew employs with success an apparatus consisting of a piece of pine board, somewhat convex longitudinally on the upper surface, thirty inches long, five inches wide above, and four inches wide below. Two holes are made on the sides, above and below the middle, to receive four pegs with square heads. The splint must be well-padded and placed beneath the thigh and leg, the limb being moderately elevated. Two or three strips of adhesive plaster, each thirteen inclies long and three-quarters of an inch wide, are applied below the lower fragment, partially overlapping each other. The ends of these strips are wrapped around the upper pegs. The upper fragment is held in position by five strips applied in like manner. The fragments are brought into contact by turning the pegs, and the tilting forward of the borders of the fragments is prevented by the application over the anterior surface of the bone of a broad strip of plaster, which is fastened to the splint below. The splint is secured to the limb by rollers applied above and below the knee (Fig. 141). Prof. Hamilton's apparatus consists of three pieces of board FRACTURES. 265 hinged together so as to form a single inclined plane with a foot-board. The piece for the limb is notched so as to hold securely the roller wliich envelops the knee. The plane having been padded, the limb is placed upon it, and the foot Fig. 141. at right^angles to the leg, is fastened to the foot-piece (Fig. 142). The body is placed in the semi-erect position. so as 'ig. 142. to assist in relaxing the quadriceps muscle. The preliminary treatment of the fracture consists in the application of a 2o 266 FRACTURES. Fi-. 143. roller by oblique and circular turns above and below and over the knee, each turn passing through the notch. The limb is fastened to the splint by turns of the second roller, beginning at the ankle and passing over the knee by oblique and circular turns through the notch in the same manner as the first roller, and terminating at the groin. About the tenth day, the swelling having subsided, the permanent dressing, consisting of strips of adhesive plaster, may be substituted for the first or uniting bandage. Careful inspection of the parts should be made daily for some time, the retaining bandage being removed for that purpose, and reapplied carefully with increased firmness as the swelling disappears. The covering in of the entire knee by the turns of the bandages prevents the tilting up- wards of the edges of the fragments, and secures their perfect coaptation. Recognizing the difficulty, by other dressings, of securing accurate contact of the fragments and of preventing the ever- sion of their edges, Malgaigne devised his hooks (Fig. 143). They consist of double hooks, at each end of sliding plates con- trolled by a screw, by which they can be approximated or separated. The hooks are inserted into the tendon at its point of insertion into the edge of the patella above and below — they are so shaped that they cannot penetrate the bone or the joint. Before applying the hooks, preliminary treatment should be instituted, if neces- sary, to remove all inflammatory conditions. Although a few cases have been reported in which erysipelas and even FRACTURES. 267 fatal results have followed the use of the hooks, many have been treated without any complications and with the best results. They should be employed, however, with caution, careful attention being given to the condition of the parts during the progress of the treatment. It is desirable to place the limb upon an inclined plane, with evaporating lotions applied over the knee, and permit it to rest in this position for a period of six to eight days before applying the hooks. At the time of application the integument should be drawn very tense so as to prevent tiie formation of folds and its consequent contusion by the instrument. Very little dressing is required. Around and between the hooks lint charged with carbolized oil may be packed. If there is undue action of the extensor muscle present, the body may be kept in the semi-erect position and the limb placed upon an inclined plane. To secure complete relaxation of the quad- riceps muscle, and as well quiet the fears of nervous patients, it is desirable to employ an anaesthetic at the time of the application of the instrument. Opinions differ as to the length of time required to keep the instrument in position. Some authorities state that they should remain from a period of six to eight weeks. Others believe that consolidation is effected in from two to three weeks. So long as they do not provoke irritation, it would seem desirable to permit the instrument to remain in position at least four weeks, and after its removal the knee should be covered by a firm bandage applied in figure-of-8 turns, and kept in a slightly elevated position. It is my belief that separation of the fragments has occurred in many cases, in which good approximation had been effected during treatment by permitting the patient to use the limb at too early a period after union. It matters 268 FRACTURES. not what form of dressing has been employed, the patient should be forbidden to use the limb in any effort under three ov four months. If stiffness of the joint has occurred as the result of confinement of the limb in the fixed position, or as the result of inflammatory action, passive motion should be employed very cautiously by the surgeon during this period. Drs. Levis and Morton of this city have used modifica- tions of Malgaiixne's hooks with orood results in cases treated at the Pennsylvania Hospital. Dr. Levis separated the original instrument into two hooks, while Dr. Morton modi- fied it so as to form a double triangle (Fig. 144j. The Fi^. 144. ■^ objects to be accomplished by these modifications is the distribution of the pressure over a greater surface, and as a result the obtaining of more perfect coaptation. Besides the appliances above described, many have from FRACTURES. 269 time to time been devised and employed with varying success. The appliances of Lonsdale (Fig. 145) and of Boisnot (Fig. Fis. 145. 146) are simple in construction, and act upon tiie same principle as those of Profs. Agnew and Hamilton. Fis. 146. In cases in which wide separation of the fragments has followed, despite of careful treatment, the disability conse- quent thereupon may be relieved by use of the apparatus devised by Messrs. D. W. Kolbe & Son, instrument makers, of this city (Fig. 147). Compound fractures of the patella are very grave injuries, and may be followed by fatal results by the supervention of inflammation of a severe form. If the inflammation involves the structures of the joints and passes on to tlie stage of sup- puration, the destruction of the joint is inevitable. The in- dications for treatment are eminently antiphlogistic in the first 23* 270 FRACTURES. Stage, and tonic and supportive in tlie second. An effort should be made to convert, if possible, the compound nature of the injury into that of a simple one by closing the external wound. The limb having been placed on a bracketed splint (Fig. 140), antiseptic dressings should be applied, and on the occur- rence of suppuration, free incisions should be made, and complete drain- age should be accomplished by the in- troduction of drainage-tubes. The question of primary amputation, or of excision or amputation as a secondary operation, will present itself in many cases for serious consideration. In comminuted fractures all of the loose pieces should be removed. The value of antiseptic dressings is best shown in the treatment of injuries of this character. Leg — Fractures of the bones of the leg are of very frequent occur- rence owing to their exposed position and to the fact that the violence sustained in falls upon the feet is liable to be expended first upon these bones. Examinations of records and museum collections of specimens show that both bones sustain fracture more frequently than either the tibia or fibula alone, and that the level at which the separation ceours is not the same ; the point of fracture is most frequent in the lower third, and next in the middle. When both bones are broken the fracture of the fibula is usually at a level above that of the tibia. Of the two bones the fibula is FRACTURES. 271 more frequently broken in the superior extremity than the tibia. Fractures of tiie bones of the leg are divided, for the purpose of study, into those of both bones — those of the tibia, those of the fibula. Tibia and Fibula. Causes Direct and indirect vio- lence, as well as muscular action, are the causes concerned in the production of fractures of both bones. The applica- tion of direct force in producing fracture is observed in the passage of a wheel of a wagon over the leg, the kick of a horse, or the crush of a mass of earth, or debris from the falling walls of houses in the process of demolition. Frac- ture, as the result of violence, applied indirectly, occurs in persons jumping from a height, and alighting on the feet, or from a railway train in lapid motion. When the fracture is caused by the direct application of force, the bones are severed at the point of contact of the force, and usually at the same level, the direction of the line of separation being more or less transverse. The application of indirect force produces fracture most frequently in the lower third, the separation taking place at different levels, and the direction of the line being oblique, either from behind downward and forward, or from without downward and inward. In fractures, the result of muscular action, the cause is found in the violent effort made by the person to regain his equilibrium at the time of a fall in which the body is thrown forcibly back- ward. The line of separation is, in this variety, frequently very oblique, and is usually from behind downward and forward. The level at which separation occurs in the two bones also varies. A man, thirt}^-five years of age, is now under my care for fracture of both bones, the result of mus- cular action. In walking upon the wet floor of the Morocco leather factory in which he was employed, he slipped, and- 272 FRACTURES. in the effort to prevent falling he sustained a very oblique fracture of both bones, at nearly the same level. Compound fractures occur very frequently as the result in many instances of the fracturing force, and in some cases also of the protrusion through the soft structures of the pointed extremity of one or both bones. Symptoms The symptoms of fracture of both bones of the leg are well-marked, and are those which character- ize fractures generally, as pain, discoloration, deformity, preternatural mobility, and crepitus. The displacement of the fragments causing deformity depends largely upon the direction of the line of fracture and the nature of the injury. In transverse fractures and in those in which the point of separation is not on the same level the displacement is usually not great. In oblique fractures the tendency to overlapping of the fragments is very great, owing to the action of the gastrocnemius and soleus muscles, which draw up the lower fragment, producing an anterior or lateral dis- placement. In these cases shortening is marked. Preter- natural mobility is quite prominent, and crepitus can be both heard and felt on movement of the fragments. Diagnosis. — The prominent character of the symptoms renders the diagnosis easy. It may be difficult in cases in which the point of fracture is not on the same level to dis- tinguish the site of fracture in the fibula. As a rule, it is generally at a point higher than that at which the tibia yields. This will, to a certain extent, be a guide in seeking for the line of separation. Crepitus can be readily elicited by making extension and then rotation. If the fracture is very oblique, care should be exercised in making manipula- tions, in order to avoid giving a compound character to the FRACTURES. 273 injury, by causing the protrusion through the integument, of the sharp points of one or both of the fragments. Prognosis The prognosis varies in accordance with the nature and extent of the fracture. In cases in which the line of fracture is very oblique and the displacement great, more or less deformity with disability will be liable to accom- pany the union of the fragments. Extensive overlapping of the fragments interferes very seriously with the repara- tive process, retarding it greatly, and in some instances causing non-union. In simple fractures the laceration of the tissues by the ends of the fragments may be such as provoke suppuration, and thus complicate the case by the development of a compound fracture. The laceration of the tissues with the involvement of the tibial arteries in compound commi- nuted fractures demands amputation as the means of afford- ing the most favorable prognosis. Treatment — Fractures of both bones, the result of direct force and in which the line of separation is transverse or very slightly oblique, require very simple dressings. After reduction, which is easily effected, they may be treated either in the fracture-box, or by the application of two short, straight splints, made of light wood, five inches in width, and long enough to extend from the knee to two inches below the sole of the foot. In preparing the latter dressing two or three strips of a broad bandage should be placed beneath the splint cloth, which should be about two feet long and three feet wide. Upon a soft feather pillow placed on this cloth the injured limb should be laid, and the splints rolled in the cloth so as to bring the sides of the pillow firmly in contact with the limb. The foot can be supported by a strip of broad bandage tied around its middle, and secured by the ends to the pillow on either side. 274 FRACTURES. Fiff. 148. The fracture-box (Fijr. 148) is prepared to receive the broken limb by placing a soft pillow in it. The limb is placed upon the pillow, the sides are drawn up and fastened with sufficient force to press the pillow equally and firmly against the leg so as to support it, and the foot is secured against the foot-piece by a soft handkerchief, rolled in cravat form, passed in figure-of-8 turn about the ankle and foot, or simply over the foot, the ends being carried through the slits and tied on the outside (Fig. 149). Fig. 149. A great deal of comfort is afforded the patient, as well as success gained sometimes, in overcoming displacement by swinging the limb in the fracture-box. A very simple ap- pliance for this purpose, and one which can be quickly made, is seen in Fig. 150. By shortening the anterior or posterior cords of suspension attached to the box, the limb can be placed in the position of the single or double inclined plane. FRACTURES. 275 as may be desired. By this means the displacement in oblique fractures may be relieved in some cases without a resort to extension. Another method of suspension is seen Fi-. 150. in Fig. 151, which is more elaborate, and requires, for its manufacture, the intervention of a mechanic. In cases in which the line of fracture is very oblique, producing short- ening or marked lateral deviation, reduction should be effected by extension and counter-extension, and, when the displace- ment is lateral, replacement of the limb in the long axis ot the body. The displacement in these cases may be overcome by treatment in the straight or flexed position. When 276 FRACTURES. treated in the straight position, extension should be made by weights and pulley adapted to the limb placed in the fracture- FRACTURES. 277 box, as seen in Fig. 152. Counter-extension can be effected, if necessary, by raising the foot of the bed as in fracture of the femur. Lateral support is secured by raising the sides of the box, in which a pillow has been placed. If the frac- Fiff. 152. ture is so near the ankle-joint as to prevent the attachment of the stirrup of plaster to the leg in the ordinary manner, strips of plaster may be applied in the form of the spica of the instep, as practised by Prof. Agnew (Fig. 153). Fi^. 153. The apparatus of Dr. Levis, for making extension by weights and pulley in fractures of the femur, may be adapted 24 278 FRA.CTUKES. to use in these cases. The upright supporting the pulley can be attached to the foot-board of the bed, and the weights, equalling twelve pounds, are so arranged that they cannot be easily dislodged (Fig. 154). ¥m. 154. Treatment in the flexed position may be accomplished by suspension of the limb, by means of the appliances used in fracture of the femur or leg, and by the double inclined plane, as modified in the method of Pott. The latter consists of a wooden splint made to adapt itself to a portion of the thigh, the entire leg, and foot wlien the limb is in the semi-flexed position (Fig. 155). An opening is made to receive the external malleolus, and the entire splint should be well padded so as to avoid pressure. The deformity being corrected by extension and counter-extension, and the limb placed in the semi-flexed position, the splint is applied to the external surface, the spaces intervening between the limb and splint being filled with masses of oakum or cotton-wool. An internal splint, made of binder's board, FRACTURES. 279 extending from the knee to tlie ankle, sliould be moulded to the surface after having been moistened. Jt should also have an opening for the internal malleolus, and should be well padded. Both splints should be held in place by turns of a roller carried from the foot to the groin. With this splint in position the patient can rest upon the injured limb if desired without displacing the fragments. AVlien other appliances fail to secure coaptation of the fragments in oblique fractures, Malgaigne's steel pin may be employed. This consists of a segment of a circle formed of steel in the ends of which are slits to receive the straps which secures it to the inclined plane upon which the limb rests. The pin passes through an opening in the centre of the arch, and works by a screw. In using it the pin is screwed down, the point of the pin penetrating the tissues to the bone. The strap is drawn with requisite firmness to hold the pin whilst it is screwed down, so as to place the fragments in contact. The use of this instrument is condemned by some surgeons, and with justice, as it is liable to cause such in- flammatory conditions as may give rise to erysipelas and suppuration, and produce, besides, the unfavorable conditions of a compound injury. In simple fractures, in which the tendency to displacement is slight, an immovable apparatus may be applied at the end of the second or third week, and the patient may be per- mitted to leave the bed. This appliance may consist of two pieces of binder's board fashioned to the shape of the leg and foot (Fig. 156). A roller should be applied first, and then the splints, after being wet in hot water, should be moulded to the limb, well padded and secured in position by a bandage. This may be removed in three weeks, and a simple roller applied. Stiffness of the knee and ankle-joints 280 FRACTUEES. should be relieved by friction and passive motion. A wire splint of Bauer (Fig. 157), or one made of tin, may be em- ployed in the place of that made of the binder's board, although this form possesses no advantage over the latter. Fio:. 156, Fi^. 157. A silicate of sodium or potassium, or a plaster-of-Paris bandage, may be used with comfort to the patient and with freedom from danger to the recently united bones. The limb should not be allowed to sustain the weight of the body until two mouths have elapsed from the time of the receipt of the injury. Fractures of the Tibia Fracture of the tibia occurs less frequently than that of both bones, and about in the FRACTLKES. 281 same proportion of cases as the fibula. The site of fracture may be in the upper, middle, or lower third, occurring most frequently in the lower third or the junction of the middle with the lower third. The line of separation is usually oblique and from without, downward and inward. Separa- tion of the upper or lower epiphysis may occur, although the former is quite rare. Two years since I treated in the surgical ward of St. Mary's Hospital a child five years of age. who had sustained a compound comminuted fracture of the upper third of the left tibia, with separation of the epiphysis and dislocation at the superior tibio-fibular articu- lation, the result of a crush under the wheel of a street car. "With the exception of severe contusion, the knee-joint was fortunately not seriously involved. The compound character of the wound permitted free inspection and digital explora- tion of the seat of injury. Under the use of the bichloride of mercury dressings, combined with through-and-fh rough drainage, the limb was saved, with the loss of some pieces of necrosed bone and slight impairment of the function of the knee-joint. An interesting feature of this case was the straightening of the injured tibia by reason of the loss of bone and readjustment of the epiphysis and shaft. Owing to a rachitic condition of the child, the bones of both legs were curved outward. Fracture in the upper extremity, extending into the knee- joint, is a very grave injury, and complicates the fracture in a serious manner, especially if compound in character. Fracture of the internal malleolus may occur through the base at the point of junction with the shaft, in the middle or at the apex, the result of a twist of the foot, with forcible abduction or adduction. Causes — The causes of fracture of the tibia are similar to 24* 282 FRACTURES. those productive of fracture of both bones, namely, direct and indirect violence, as blows, kicks, and falls, and muscular action. The effect of muscular action is seen in old persons in whom a brittle condition of the bones exists. Symptoms The symptoms of fracture of the tibia are sometimes less distinct than those of the fracture of both bones. Owin^ to the support afforded by the fibula, the deformity is, as a rule, not very great, although the over-lapping of the fragments may exist to some extent.- Pain, discoloration, and swelling are usually present. Crepitus is difficult to elicit when the fracture is in the middle portion of the bone. At either extremity the parts can be manipulated in such manner as to develop it. Shortening to any marked extent is pre- vented by the resistance ojffered by the fibula. Preternatural mobility is more appreciable in fractures involving either extremity than in the shaft proper. Diagnosis. — The subcutaneous position of the crest of the tibia will enable the surgeon, if the swelling is not too great, to detect the seat of fracture by passing the finger over the surface of the bone. In the upper extremity crepitus may be elicited by grasping the head and shaft and making rota- tion. In the lower extremity and in the malleolus crepitus may be detected by grasping the foot and making the move- ments of abduction and adduction. Pressure over the mal- leolus with the finger may distinguish the depression, wiiich indicates the position of the site of fracture ; if the fibres of the internal lateral ligament have been torn, the displacement of the fragment will be more marked, and the depression can be more distinctly felt. Prognosis. — With regard to the results which follow frac- tures of the tibia the prognosis is generally favorable. In fractures of the upper or lower extremity involving the knee FKACTUKES. 283 or ankle-joint anchylosis to a greater or less extent may supervene. Union is sometimes retarded, and non-union may occur. The bond of union after fracture of the malleo- lus is usually fibrous in character. Deformity may follow after union by reason of the projection of the sharp end of one of the fragments. This process in time is generally absorbed, leaving a smooth and rounded surface. If this does not occur, and the point is painful and the patient appre- hensive of injury occurring on account of the projection, it should be removed with the chisel or cutting pliers, or, what is preferable, with the large burr of the surgical engine. Union of the lower fragment to the fibula may occur, in this way, obliterating the interosseous space. Treatment. — The treatment of fracture of the tibia is similar to that employed in fracture of both bones, and may be effected by the use of the wooden side splints, the frac- ture box, splints of binder's board, felt, tin, or wire in the m^inner already described for those fractures. It is not regarded as essential in most cases to confine the patient in bed during the entire time required for union of the fragments, and it is desirable, after the subsidence of the swelling, which occurs at the expiration of ten days or two weeks, to apply an immovable dressing, which will afford sufficient support, and permit the patient to walk with the aid of crutches. The silicate bandage, with the addi- tion of pieces of binder's board or tin to give firmness, may be applied, or the plaster-of-Paris bandage in the ordinary form or in that known as the Bavarian splint. The Bava- rian splint or movable-immovable apparatus is made in the following manner : Two pieces of flannel of sufficient length and width to cover the leg and foot are cut and sewed together as is shown in Fig. 89. The limb is laid upon the 284 FRACTURES. flannel, and each half of the inner layer is folded over the leg, and dorsum of the foot, joining at the median line, where the edges are fastened temporarily by pins (Fig. 90). Plaster, of proper consistence, is now applied over the inner layer, adapting it to the surface of the limb by a spatula or the fingers. When completely covered the outer layer is folded over the plaster, and pressed into place by the hand so as to conform to the shape of the limb. The pins fastening the edges of the inner layer are now removed, and the two layers of flannel, with the plaster between forming a firm splint, are bound together by three or four strips of bandage carried about the leg and foot. The double row of stitches fastening the two layers together forms a hinge at the back of the splint, so that it can be readily opened, and the parts inspected, or it can be removed, if necessary, and reapplied. Firm union of the fragments does not occur until the expiration of five or six weeks, up to which period the dressings should remain in position. In fractures of the upper extremity extending into the knee-joint careful attention should be given to the inflam- matory conditions which are likely to occur and complicate the case. The appliance, which fulfils best the indications present in this form of fracture, is the long fracture-box with compresses under the knee to afford support. If much displacement of the upper fragment exists, it may be neces- sary to place a short splint, ten to twelve inches in length, beneath the seat of fracture, and then place the limb in the long fracture-box. Fractures of the malleolus may be treated in the short fracture-box, the foot being placed in sucli position as to secure perfect coaptation of the fragments, and fastened securely to the foot piece. Lateral support should be FRACTURES. 285 afforded by tlie sides of the box, protected by the pillow and masses of oakum or cotton-wool. Fractures of the Fibula. — Examination of tables of fractures shows that this bone suffers fracture in about the same propoi-tion of cases as the tibia. Fracture occurs most frequently in the bone of the right leg, and oftener in the inferior third than in either the upper or middle portion. Between the ages of thirty and forty is the period of life when fracture occurs with the greatest frequency, the largest number being in males. Causes — The majority of fractures of the fibula are caused by violence indirectly applied, producing a separation of the bony fibres at a point from one inch and a half to three inches above the external malleolus. The application of the violence is accompanied by a forcible abduction of the foot, by means of which the astragalus is rotated and pressed with great force against the external malleolus, causing, in some instances, rupture of the internal lateral ligament, as well as fracture of the fibula. This takes place in twists of the foot or in falls upon the inner border of the foot. According to Boyer, fracture at the same point may occur as the result of forcible adduction of the foot in falls upon the outer border. Direct violence may cause fracture at any point of the bone. Symptoms. — In fractures occurring in the upper and middle portions of the bone the symptoms are usually not very distinct. Careful examination is required to detect them. In the lower third, in that known as Pott's fracture, the symptoms are more prominent. Those which attend fractures generally are present as pain, swelling, discolora- tion, preternatural mobility, deformity, and crepitus. The displacement of the foot is characteristic, being markedly everted, and resting upon the inner border. 286 FRACTURES. Diagnosis — The protected and fixed position occupied by the upper two-thirds of the bone renders detection of the seat of fracture somewhat difficult. Pain, increased on movement, swelling, and discoloration are usually present, deformity and mobility are not marked ; crepitus may be elicited by deep pressure exerted upon the fragments. The superficial position of the lower third of the bone, associated w^ith its relation to the ankle-joint and foot, gives a more prominent character to the symptoms of fracture, and renders the diagnosis much easier. Great pain is experienced on motion. Swelling and ecchymosis are very marked ; preter- natural mobility is readily distinguished. The deformity varies in extent in accordance with the nature of the injury. In cases in which rupture of the internal lateral ligament co-exists with fracture of the fibula, the eversion of the foot is much greater than in fracture of the fibula alone. Crepitus may be elicited by grasping the foot, and making abduction and adduction alternately. The depression formed by the inversion of the ends of the fragments can be detected, if the swelling is not too great, by passing the finger over the surface of the bone ; this sulcus can be in- creased in depth by abducting the foot. Dislocation at the ankle-joint may be distinguished from fracture of the fibula in tlie lower third by the absence of crepitus and the perma- nent removal of the displacement after efforts at reduction. Fracture of the external malleolus may be detected by grasping the process, and establishing the existence of crepi- tus and mobility by movement of the fragments. Prognosis. — Union by bone takes place in fracture of the fibuhi at all points, with the exception, possibly, of the exter- nal malleolus, where the union may be sometimes fibrous in character. More or less disability, with chronic enlargement FRACTURES. 287 about the joint, is liable to follow cases in wliicli the inter- nal lateral ligament has been torn, accompanied by partial dislocation and injury to the ankle-joint. In neglected cases, or in those in which the treatment has not been properly conducted great deformity may ensue. Treatment. — Fractures of the fibula in the upper and middle portions require in their treatment very simple dressings. Two pieces of binder's board, well padded, may be placed on either side of the leg, and secured in place by turns of the spiral reversed bandage, extending from the foot to the knee. This dressing will afford sufficient support to the fragments to maintain them in proper adjustment until union occurs. An immovable dressing, the silicate or plaster bandage, may be applied, and the patient be per- mitted to walk about with the aid of crutches. Fractures of the lower third of the bone, with slight displacement, may be treated by placing the leg in the fracture-box, care being taken to overcome completely the displacement by securing the foot, in proper position, to the foot-piece of the box. In cases in which rupture of the internal lateral liga- ment or fracture of the internal malleolus has occurred, the dressing must be of such character as will overcome the marked displacement which exists. That form which best accomplishes the purpose is known as Dupuytren's splint, and consists of an internal wooden splint, extending from the knee to a short distance below the foot, with a wedge- sliaped pad of such length as will reach from the knee to the internal malleolus. The splint being well padded, is placed, with the wedge-shaped pad, upon the inner surface of the leg, the large end of the pad resting just above the inter- nal malleolus. The upper end of the splint is fastened to the limb by a bandage, which is applied from the middle of 288 FRACTURES. the leg to the knee. The foot is now adducted, bringing it in contact with the splint, and securing it in place by a figure-of-8 bandage, the turns of which should extend to the apex of the external malleolus, and not beyond (Fig. 158). In applying the two bandages care should be observed to Fig. 158. avoid beginning the application of the upper one too near the seat of fracture, and extending the lower one beyond the position of the external malleolus. In either event the objects of the dressing will be defeated in preventing the e ver- sion of the fragments, so as to phice them in coaptation. Attention should be given to the condition of the internal malleolus, and measures should be taken to avoid undue pressure upon it. After the lapse of eight to ten days, the reparative process having progressed far enough to main- tain the fragments in place, the leg may be placed in the fracture-box, the foot being secured to the foot-piece, and lateral pressure exerted by the pillow, supported by the sides of the box. Masses of cotton-wool or oakum may be placed over the external malleolus to assist, if necessary, in making pressure. Compound Fractures of the Boxes of the Leg Of the bones of the leg the tibia suffers more frequently from compound fracture than the fibula, and, as a rule, more frequently than any other bone of the skeleton. The FRACTURES. 289 explanation of this fact is to be found in the exposed posi- tion occupied by the bone, and in tlie relation it occupies to the foot and lower extremity as a portion of the column of support to the body. The character of the injury in com- pound fractures of the bones of the leg differs very much in different cases. In some the injury consists of a slight puncture of the soft tissues, produced by the sharp end of one of the fragments ; in others, the rent in the overlying structures is very large, caused by the protrusion, to a marked extent, of the end, usually, of the upper fragment, with laceration of the soft structures, and in still other instances, as the result of great violence, there exists exten- sive protrusion of one of the fragments, with pulpification of the tissues and destruction of the arteries. Causes The cause of compound fracture of the bones of the \iig is usually great violence applied directly or indirectly. The effect of direct violence is seen in crushes by the wheel of a railroad car, a heavily loaded wagon, the falling of a wall, the kick of a horse, or a blow from a bludgeon. Indirect violence operates in producing compound fractures of these bones in falls upon the feet from a great height, or in a wrench of the leg, the foot being firmly fixed. Six years since, a lad, seventeen years of age, was admitted into the surgical wards of St. Mary's Hospital, who, in reaching out of an unguarded door, lost his balance, and fell to the ground, some forty feet distant, alighting upon his feet. He sustained a compound fracture of the left tibia, a simple fracture of the right fibula in the inferior third, and a simple fracture of the radius, also in the inferior third. The line of fracture of the tibia was very oblique, and the upper fragment, stripped of the periosteum, was protruded through tlie soft tissues to the extent of four inches. The 25 290 FRACTURES. protruded fragment, covered with the detached periosteum, was replaced, and the patient at the end of four months was able to leave his bed with a useful limb. Symjjtoms — The symptoms of compound fracture of the leg are sufficiently distinct, and do not require description in detail. Diagnosis — In all cases careful examination should be made, in order that the exact nature of the injury may be determined, and that proper treatment may be adopted. Exploration with the finger, previously washed and immersed in an antiseptic solution, should be made. Much information as to the condition of the parts will be gained by this plan of examination. If hemorrhage is present, careful inspec- tion and digital exploration will be necessary, in order to ascertain its extent and character. Prognosis — In compound fractures of the leg of not a severe character, the prognosis may be regarded as generally favorable. In those in which the soft structures have been much contused and lacerated, the inflammatory conditions which are liable to ensue will complicate the case, and render the prognosis doubtful. In fractures, caused by the applica- tion of very great violence, in which the bones are exten- sively comminuted, the soft tissues ground into a pulpy mass, and the bloodvessels lacerated, the prognosis is most unfavor- able, the removal of the limb being demanded as necessary to save the life of the patient. More or less deformity is liable to follow union in all compound fractures, and anchylosis when the knee or ankle-joint is involved. Treatment — The question of making an attempt to save the limb in the treatment or remove it, is one which the surgeon is called upon to decide in cases of compound frac- ture of the leg. Good judgment is, therefore, to be exer- FRACTURES. 291 cised, with careful consideration of all the conditions which present themselves in each individual case. The general condition of the patient's health, his habits of life, as well as the nature of the injury, are to be taken into careful con- sideration. In cases in which the external wound is small, and but slight laceration of the tissues has taken place, the limb should be placed on the pillow in the fracture-box, and an effort should be made to convert the fracture into a simple one by closing the wound. This may be accomplished, after cleansing it thoroughly and bathing with a dilute solu- tion of carbolic acid, by introducing silver-sutures or drawing the edges together with adhesive plaster. An effort should be made to seal the wound hermetically, so that air cannot gain admission, by the application of collodion and gauze or other agents. Antiseptic dressings should be applied over the wound, and the limb kept at rest, in the hope that tlie external wound will promptly heal. When the injury is of a more serious character, with pro- trusion of the fragment, and extensive laceration of the soft structures a different plan of treatment should be pursued. The protruding fragment shoukl be replaced by manipulation — flexion and extension, with counter-extension of the limb, being employed in turn, if necessary, to effect this. Sepa- ration of the edges of the wound with retractors, or enlarge- ment of tlie opening by incision may be practised if replace- ment is found difficult. It may be necessary, in some cases, to remove w^ith the cutting-pliers or saw, a portion of the fragments, in order to reduce the fracture. All other means should be exhausted before resorting to this operation, as it leaves the fragments in sucli condition as to interfere with the reparative process. The fragment being replaced, the edges of the wound may be drawn together, and secured by 292 FRACTURES. sutures if the laceration of the tissues is not too great. It is desirable, in these cases, to introduce drainage-tubes, and bring the edges of the wound together about them. By this means the wound-fluids will be removed, and the tendency to suppuration averted. Antiseptic dressings should be applied to the wound, and the limb placed in the fracture- box or in an immovable dressing, with a fenestrum over the wound, as shown in Fig. 91. A favorite plan of dressing employed in this city in these cases, consists in placing the limb in the fracture-box, and surrounding it with coarse bran, as originally practised by Dr. John Rhea Barton. The bran affords equable pressure, and absorbs the discharges from the wound as they appear. Removal of the soiled bran, and the addition of that which is clean is readily effected. In compound comminuted fractures the loose and detached pieces of bone should be removed, and drainage-tubes should be introduced, so as to drain the wound thoroughly. If suppuration occurs, counter-openings may be made, if found necessary to secure complete drainage. Antiseptic dressings should be employed in all cases of compound frac- tures of the leg, and immobilization of the fragments should be secured by appropriate appliances. With the aid of this form of dressing limbs formerly condemned for removal are saved and made useful. Hemorrhage, venous or arterial in character, frequently occurs in connection with compound fractures of the leg, and increases their gravity. Venous hemorrhage may be controlled by pressure exerted uniformly upon the parts, or by the application of cold compresses. Care should be taken that the blood is not confined in the wound, where it may collect and lead to suppuration. If arterial hemor- rhage does not yield to pressure or other simple measures, FllACTUKES. 293 the wound should be enhirged, if necessary, the bleeding vessel sought, and a ligature applied. Hemorrhage from the nutrient artery is sometimes severe. It may be con- trolled by plugging the canal temporarily with a piece of soft wood, or permanently with a piece of animal ligature. Foot Simple fractures of the bones of the foot are rare. The astragalus and os calcis are the bones of the tarsus which most frequently sustain fracture. Of the metatarsus and phalanges those of the great toe are most frequently broken. Compound fractures occur very frequently. Causes Direct and indirect violence and muscular action are assigned as causes. The os calcis, with the metatarsal bones and phalanges, sustain fracture as the result of direct force, as in the crush of the foot under the wheel of a car. Instances are recorded in which forcible contraction of the calf muscles has produced fracture of os calcis. The astra- galus is generally broken by force transmitted through the OS calcis, as in falls upon the feet. The direction of the line of fracture varies in the different bones, being transverse, vertical, and horizontal. Astragalus. Symptoms. — AVedged in as the astragalus is between the malleoli, it is impossible, as a rule, in simple fractures, to observe any symptoms characteristic of fracture. Pain and swelling, with loss of function may be present. Crepitus may be detected by manipulation, flexion and extension, or abduction and adduction of the foot. Defor- mity is not usually present. Diagnosis — The absence of marked symptoms in simple fractures renders the diagnosis very difficult. If displace- ment exist the seat of fracture may be detected. Crepitus, if obtained, will assist in making the diagnosis. In com- 25* 294 FRACTURES. pound fractures the parts can be inspected and explored with the finger. Prognosis — Favorable in simple fractures. In compound and comminuted fractures the involvement of the ankle- joint, and, in some instances, of the adjacent tarsal joints renders the prognosis very unfavorable. If amputation or excision is not demanded, anchylosis, more or less complete, will follow repair. Treatment. — In uncomplicated cases the treatment con- sists in placing the limb for a few days in the fracture-box, and applying the applications locally to allay the swelling. When this has subsided an immovable dressing of plaster or silicate of sodium should be applied, and the patient should be permitted to walk about with the aid of crutches. When displacement of one of the fragments exists, an effort should be made, by manipulation, to reduce it, which is frequently an unsuccessful operation. If reduction cannot be effected it is thought desirable by some authorities to permit the fragment to remain in its displaced position, with the accompanying deformity. Other authorities are equally strong in their opinion that excision, not only of the fragment, but of the whole bone, should be performed, in order to remove deform- ity and disability. The excision of the entire bone is recom- mended, on account of the danger of the occurrence of necrosis in the remaining fragment, and of the consequent involvement of the bones of the ankle-joint. In compound and comminuted fractures the question of amputation or excision presents itself for serious considera- tion. The action of the surgeon should be based upon a careful consideration of all the conditions present. Os Calcis. Symptoms The symptoms of fracture of the OS calcis vary in accordance with the position of the FKACTUKES. 295 fracture. If it is sub-astragaloid in character, the trans- verse diameter of the bone is increased, while the vertical is diminished, giving rise to a decided flattening of the heel. Pain, increased on movement, is present, whilst the swelling is circumscribed in character, being confined, according to Malgaigne, as quoted by Prof. Agnew, " to the parts below the front of the ankle and the malleoli, and to the sole of the foot." In this form of fracture the bone is generally comminuted, and sometimes impacted. Crepitus is difficult to elicit by reason of this impaction. In fracture of the post-astragaloid or heel portion of the bone, the symptoms, owing to its connection with the calf muscles and its promi- nent projection, are more distinct. Pain and swelling are present, with mobility and deformity. The deformity is produced by the action of the gastrocnemius and soleus muscles, w^hich draw backward and upward the posterior fragment. This displacement upward is especially marked if the line of separation is near to the insertion of the tendo Achillis. Crepitus can be detected by flexing the knee and ankle-joints, and, after grasping the fragment, making rota- tion. Diagnosis — The diagnosis is made by a careful examina- tion and study of the symptoms as they present themselves in the two forms of fracture. In the subastragaloid variety they are somewhat difficult of recognition, whilst in fractures of the heel portion they are sufficiently distinct to render tiie diagnosis easy. Prognosis — Disability to a greater or less extent is liable to follow fracture in the sub-astragaloid portion of the bone. In the post-astragaloid variety of fracture union occurs, under ordinary conditions, in the usual period — five or six weeks — and usually without great disability. 29G FKACTURKl Fiff. 159. Treatment — In the post-astragaloid variety of fracture the indications for treatment are to adopt such an appliance as will place the fragment in contact with the bone, and maintain it in this position. This can be accomplished by flexing the leg upon the thigh, and the foot upon the leg. The fragment should then be drawn down into place, and secured by the application of a strip of adhesive plaster, or the turns of a figure-of-8 bandage of the instep. Tiie limb in the flexed position should be secured to a double angular splint (Fig. 155) by turns of a roller carried from the foot to above the knee. When tlie swelling has dis- appeared an immovable dressing may be ap- plied in place of the splint. Other forms of dressings have been employed. Fig. 159 shows that of Monro, which consists of a wooden splint, placed on the front of the leg and over the dorsum of the foot. In the sub-astragaloid variety of fracture, an immovable dressing may be applied when the inflammatory conditions have subsided. Metatarsus. Symptoms The symptoms of fracture of the metatarsal bones are well marked. Occurring as the result of direct violence the displacement is not great. Mobil- ity and crepitus are present, and easily recog- nized. Diagnosis. — As in the metacarpus, the parts are so readily accessible that the diagnosis is not attended with any diffi- culty. Crepitus can be easily elicited by grasping the parts and moving the fragments upon each other. Prognosis. — The prognosis in fractures of the metatarsal FRACTURES. 297 bones is favorable, union taking place without difficulty. In compound and comminuted fractures deformity may follow as .the result of the injury. Treatment Tn simple fractures the fragments should be reduced, and the limb placed in a fracture-box, with the foot secured to the foot-piece by a handkerchief in cravat form, or a splint of binder's board may be moulded to the posterior surface of the leg and plantar surface of the foot, and, after being well padded, may be secured in place by turns of a roller. An immovable dressing applied to the foot and leg will aflbrd an excellent support in fractures of this kind. Compound fractures should be treated with anti- septic dressings and appropriate splints to secure rest. Phalanges. Symptoms Simple fractures of the pha- langes are attended by the usual symptoms of fracture, as pain, swelling, mobility, and crepitus. Deformity is not usu- ally well marked, except, perhaps, in cases of fracture of the phalanges of the great toe. Compound fractures, the result of a crush by the falling of a piece of timber or metal upon the toes, present prominent symptoms. The parts can be examined easily, and the nature of the fracture determined. Diagnosis The diagnosis may be difficult in simple fractures of the smaller toes. In the great toe, where frac- ture occurs most frequently, the symptoms are so distinct as to render the diagnosis easy. Prognosis. — Union may occur with some deformity, otherwise the prognosis is favorable. Treatment. — In simple fractures, a wooden splint or one made of binder's board, after being well padded, may be secured to the plantar surface of the foot by turns of a roller. Strips of adhesive plaster may be applied about the toe to maintain approximation of the fragments, if found 298 FRACTURES. necessary. If anchylosis is threatened, the toe should be placed in the straight position, so as to avoid pressure of the shoe on a permanently flexed joint. An immovable dress- ing extending to the leg may be substituted for those described. PART IV. DISLOCATIOXS. Definition. — A dislocation or luxation is a separation of the surfaces of the bones entering into the formation of an articulation or joint. Varieties 1. Traumatic; 2. Pathological; 3. Con- genital. 1. Traumatic Dislocations are the results of injuries, and are divided into Complete — Incomplete — Simple — Com- plicated — Single — Double — Unilateral — Bilateral — Primi- tive — Secondary — Recent and Old. Complete Dislocations are those in which an entire sepa- ration of the articular surfaces occurs, accompanied by an elongation or rupture of the ligaments of the joint. Incomplete or Partial Dislocations are those in which the separation of the articular surfaces is not complete, a portion of the surfaces remaining in contact, with, as a rule, elongation and not rupture of the ligaments. Simple Dislocations — Dislocations are designated as sim- ple when they are unaccompanied by any other condition than sepai-ation of the articular surfaces, with or without rupture of the ligaments. Complicated Dislocations Those which are attended by lesions in addition to the separation of the articular surfaces, 300 DISLOCATIONS. as fracture of one or all of the bones entering into forma- tion of the joint, the production of a wound of the soft tis- sues communicating with the articulation, wounds of im- portant bloodvessels or nerves, or extensive contusion and laceration of the soft structures. Single Dislocations Dislocations involving one joint only are designated single. Double Dislocations are those in which the luxation oc- curs in corresponding articulations on both sides of the body. Unilateral Dislocations These take place in one articu- lation of a single bone. Bilateral Dislocations The dislocation is bilateral when a separation of the articular surfaces occurs in both articula- tions of the bone. Primitive Dislocations The term primitive is used in connection with dislocations to designate the original posi- tion in which the bone is placed. Consecutive Dislocations A consecutive or secondary dislocation is one in which the bone, for some cause, assumes a new position. Recent Dislocations — The term recent is applied to dis- locations occurring within a short period of time — as a few days or weeks — before any changes have taken place in the parts. Old Dislocations Dislocations are designated as old when some time has elapsed since the receipt of the injury — from a few months to a year or more — after the occur- rence of such changes in the articulation as to greatly im- pair or destroy it. 2. Pathological Dislocations are those in which the separation of the articular surfaces has taken place as the result of disease in one or both. This condition is most fre- DISLOCATIONS. 301 qiiently observed in tlie hip- and knee-joints consequent upon chronic inHammation. As a result of the inflamma- tory action the structures of the joint are partially or com- pletely destroyed, so that they cannot resist the muscular contraction exerted, and therefore the distal or movable bone is drawn away from the articular surface or cavity, in con- tact with which it is normally placed. The separation is progressive, and extends sometimes to the distance of three or more inches (Fig. IGO). Fig. 160. 3. Congenital Dislocations are those which occur during the life of the fcetus in utero, and may be caused by external violence, disease of the articulations, or arrest of development. They occur most frequently in the shoulder-, w rist-, or hip-joints, and in females oftener than in males. Accompanying the dislocation, and in some instances caused by it, are marked alterations in the articulations and in the structures about them. Causes of Dislocation. Predisposing and Exciting. — Predisposing causes em- brace age, sex, occupation, articular disease, and peculiar formation of the articulation. 26 302 DISLOCATIONS. Age.— Age exercises an influence in the production of dis- locations in the development and decline of the muscular power. Dislocations occur most frequently in middle life — rarely, as a rule, in very young or old age. The develop- ment of the muscular structures in middle life contributes to the occurrence of those luxations caused by muscular action. Sex Dislocations occur more frequently in males than in femaks, the explanation of which is to be found in their different modes of life. Occupatio7i. — This cause conduces to the occurrence of dislocations in the exposure to injury incident to the occu- pation of the individual. Articulm^ Disease The chancres occurrinoj in an articu- lation due to morbid conditions predispose to dislocations. Peculiar Formation of the Articulation ^The construc- tion of the articulation influences largely the occurrence of dislocation. Those in which motion is extensive, as the ball-and-socket joints, are much more liable to suffer from luxation than the hinge-joints. The EXCITING causes of dislocations are external violence and muscular action. External violence mny exert Its influence in two ways — directly and indirectly. The effect of the former is observed in the application of force directly over the articulation, and of the latter in the transmission of the force from a distal part to the joint, upon which it is expended. Muscular Action This cause is effective in violent and j^^smodic action of the muscles, the articular surfaces being at the time in a position favorable to separation under its influ-ence. In discussino; the causes of dislocation it is desirable to DISLOCATIONS. 803- » consider, as an important factor in tlieir production, the rela- tive position of tiie articular surfaces at the time of the ap- plication of the force. A partial separation of the surfaces, with a relaxed condition of the surrounding structures, and the position of the distal bone at an angle to the articular surface above, favor very materially the production of dis- location. Patholoyical Characters — An examination of an articu- lation recently the subject of a complete dislocation, will reveal a laceration of the ligaments more or less extensive with separation of the articular surfaces. The condition ob- served in the ligaments varies — in some instances there is an elongation, with a slight rent sufficient only to permit the escape of the bone — in others, the laceration is extensive, the ligaments being torn from their bony attachments. In dislocations, the result of very violent force, the muscles and tendons are contused, and in some cases lacerated. In luxa- tions caused by muscular action the laceration of the ligaments is much less extensive, the displacement being accomplished rather by elongation with slight rupture. Capsular liga- ments, it is observed, suffer more extensive laceration than those formed of bands. As a rule, the large bloodvessels in relation with the ar- ticulation escape injury, the bleeding which follows luxation being caused by the rupture of the small articular branches. Laceration of the large nerves is an extremely rare accident. Frequently they are subjected to pressure producing numb- ness, and in some instances neuralgic pains and paralysis. The separation of the articular surfaces varies in accord- ance with the amount of force applied in producing the dis- location, the extent of rupture of the ligaments and the manner in which the muscular action is expended upon the; 304 DISLOCATIONS. displaced bone. The articular surfaces may be partially in contact or entirely separated, the luxated bone resting upon an adjacent muscle, tendon, or surface of bone, or upon all of these conjointly. Blood partially fluid or coagulated oc- cupies the cavity of the joint. If the dislocation is allowed to remain unreduced for several days, inflammatory exuda- tions will be deposited in the cavity of the articulation and in the surrounding tissues, uniting them in a mass. If a still longer period is permitted to elapse, marked and important changes take place in all of the structures entering into the formation of»the joint. The ligaments undergo atrophy and become lost in the surrounding tissues. The articular sur- faces of the bones lose their cartilajjinous coverins^s and be- come smooth and hard. An atrophic change takes place in these, and they become flattened. In the enarthrodial or ball-and-socket variety of articu- lation, the articular cavity may disappear either by absorp- tion or by the development of fibrous or bony tissue from the surface. The head of the displaced bone, if resting upon a muscle, is soon surrounded by a deposit of plastic matter which is converted into an adventitious capsule of a dense fibrous character, resembling in some respects the original capsule. Similar action takes place if it is lodged upon the surface of a bone, with the addition of the foraiation of an osseous rim about the cavity, produced by absorption of the bone. The surface of the cavity as well as of the articu- lating bone becomes eburnated and the movements in the improvised articulation are accompanied by a grating noise. Changes occur also in the muscles and tendons surrounding the articulation. By reason of the disuse, consequent upon tlie condition of the articulation, they become contracted and rigid, and may finally undergo fatty degeneration. The large DISLOCATIONS. 305 bloodvessels and nerve trunks may be embraced in tlie gene- ral mass of inflammatory deposit and become attached to the newly-formed capsule or by bands of adhesions to the dis- placed bone. As a result of this gluing together of the structures these vessels and nerves are liable to sustain rup- ture under efforts made at reduction, exposing the patient to the dangers of fatal hemorrhage or the condition consequent upon laceration of a large nerve. The new joint formed by the process above described, whilst in many respects very imperfect, may permit the pa- tient to enjoy very good motion which may -be improved under use. On the other hand, its functions may deterio- rate and the joint finally become useless. Tlie entire limb participates in the changes occurring as the result of the loss of function in the articulation as manifested by atrophy of the muscular structures and diminished circulation. In ginglymoid articulations the changes following unre- duced dislocations of recent or long-standing are less exten- sive than those observed in the enarthrodial variety. At the same time, they are of such character as to render re- duction impossible in a much shorter period than in the ball- and-socket joints. Symptoms of Dislocation. The symptoms of dislocation are pain, loss of function, deformity, and immobility. Pain — This symptom varies greatly in extent and char- acter. In some instances it is slight and experienced only on attempts at making movements, and is due to the contu- sion of the soft tissues and laceration of the ligaments. In other cases it is very severe, produced by pressure by the 2G* 306 DISLQCATIOXS. displaced bone upon a large nerve. Instead of pain, patients will sometimes complain of numbness extending the entire length of the limb. Loss of Function As a rule, loss of function is very marked in dislocations, the patient being unable to make, if any, but the slightest movement of the limb. Deformity Deformity manifests itself in different ways, as to change in the contour of the joint, the length of the limb and its axis. The configuration of the joint is always more or less affected ; this is observed in some articulations in the absence of the natural rotundity of the parts, a flat- tened appearance being presented in its place, with the prominent projection of the bony processes. With few ex- ceptions the limb is shortened under the infiut.nce of the muscular action, the extent of shortening varying in different dislocations. In some forms of dislocation great distortion attends the condition, and the axis of the limb is notably affected, being markedly abducted, inverted, or everted, as influenced by the position of the displaced surfaces and the muscular action. Immobility Immobility is one of the most prominent and constant symptoms of dislocation. In complete luxations the interference with tlie normal movements of the joint is very marked and most readily recognized. In dislocations affecting certain articulations the immobility is almost abso- lute. The patient is unable to exercise any control over the movements of the limb, and the efforts of the surgeon are unavailing in effecting more than a very limited motion. The rigidity of the limb is due to various causes which may act separately or conjointly ; these are muscular action, the obstruction offered by prominent bony processes, and the constriction produced by the ruptured ligamentous structures. DISLOCATIONS. 307 In addition to the symptoms above enumerated, there may- be swelling, discoloration, and crepitus, or friction sound. Swelling, if it occurs immediately or very soon after the receipt of the injury, is due to hemorrhagic eifusion and is soon followed by marked discoloration. Appearing at a later period it may be regarded as the result of inflammation, and increases with greater or less rapidity in accordance with the intensity of the action. Effusions of blood may precede and accompany the deposition of inflammatory pro- ducts, and their combined efi'ect will increase the swelling and discoloration, rendering tlie part hard,* glossy, very painful and intolerant of manipulation. Manipulation of the injured joint in some instances gives rise to a sound which has been designated by some authori- ties as crepitus. The sound produced is quite different from that elicited in fractures as the result of moving the frag- ments of broken bone upon each other with their surfaces in contact. Friction expresses better the sound heard, and is properly applied to indicate the cause which is ascribed to the presence of an exudation of plastic matter in the joint. It is a very uncertain symptom and cannot be relied upon in making a diagnosis. Diagnosis — There is no class of injuries in which a thorougk knowledge of anatomy is more requisite, in order to comprehend the conditions present, than in dislocations. The surgeon must have a knowledge of the normal anatomy of the articulation before he can appreciate the departure from this which exists in luxation. He must understand the relations of the different surface markings to the articu- lation and to each other to enable him to recognize any change which may occur in them. In arriving at a correct interpretation of the symptoms present, careful examination 30S DISLOCATIOXS. is necessary. The injured joint should be inspected and compared ^vith that of the opposite side as to contour, mo- bility, and function. Measurements should be made to de- termine any differences which may exist as to length and width of the limb and affected part. It is desirable, in almost all cases, especially in luxations involving the larger joints, to make the manipulations necessary under the influ- ence of an anaesthetic agent. The removal of muscular spasm and the complete relaxation of the muscular system obtained by anaesthesia is essential to a satisfactory exami- nation of the part. Moreover, reduction may be effected whilst the patient is in this condition if dislocation is found to exist. The differential diagnosis between dislocations, fractures near to or involving a joint, and sprains, requires a careful study of the symptoms of each and their comparison. Pain, loss of function, and deformity, are common to all, although differing in character in each ; the characteristic symptoms- of fractures are preternatural mohility and crepitus, while those of dislocation are preternatural immobility and absence of crepitus. In sprains the normal movements are limited only, not abnormally increased or entirely prevented, and crepitus is absent. In both dislocations and sprains friction sounds may be detected after the supervention of inflamma- tion. It is desirable to make the examination in cases of dislo- cation as soon after the receipt of the injury as possible, be- fore the occurrence of swelling and other conditions liable to render the diagnosis difficult. Prognosis — The prognosis, as far as it relates to reduc- tion is, in recent dislocations, favorable. In old dislocations it is verv unfavorable as will be seen further on. More or DISLOCATIONS 309 less (Usability with disordered sensibility remains after dis- location in almost all cases. Tlie danger to life attending dislocation is, as a rule, slight, and differs in accordance with the character of the injury and of the joint involved. In recent cases, dislocation of a ball-and-socket joint is more diflicult to overcome than of a hinge -joint. Reduction, how- ever, can be effected in an enarthrodial joint with greater, ease after a lapse of time than in the ginglymoid variety. In females, old persons, and children, reduction is more readily accomplished than in adult males, owing to their slight or impaired muscular development. Treatment — The treatment of dislocations consists in the restoration to the normal position of the separated articular surfaces, their retention in place by suitable dressings* until the injured structures are repaired, the application of sucli remedies as will allay inflammatory action which may occur, and the employment of such measures as will restore the normal functions of the joint. Reduction of the dislocation may be effected by means of manipulation or the application of force. In effecting re- duction by manipulation the patient should, as a rule, oc- cupy the recumbent position, and should be placed under the influence of an anaesthetic. The administration of an anres- thetic may not be necessary if the patient is seen immedi- ately after the receipt of the injury, when the absence of strong muscular action and the condition of shock present, may facilitate the reduction of the dislocation. The patient being completely under the influence of the anaesthetic, with the muscles in a state of relaxation, the surgeon should make a careful examination so as to ascertain the position of the displaced bone, the site, if possible, of the rupture in the ligamentous structures through which it has escaped, 310 DISLOCATIONS. and the structure offering obstruction to its return, whether a tendon of a muscle or a bony process in relation with the joint, or the tightly drawn edges of the rent in the ligament. He should also endeavor to determine the course taken by the bone at the time of the displacement, in order to direct his manipulative efforts, so as to accomplish its return with the least resistance. The manipulations should consist of extension, counter- extension, and pressure, with, if required, the movements belonging to the articulation, as abduction, adduction, flex- ion, and rotation. The movements necessary to be made having been determined upon they should be executed with deliberation and in a systematic manner. If, in their exe- cution, reduction is not effected, an examination should be made to ascertain the cause of obstruction, and, if possible, tliis should be overcome by manipulations performed in other directions. In this manner a bone maybe relieved from a fixed position and the luxation, which had before resisted all efforts, reduced. Aimless movements should not be made, as they have a tendency to increase the difficulties in effecting re- duction by further displacement of the bone and to cause laceration of the tissues. Reduction by force is accomplished through the instru- mentality of certain appliances by means of which it is most effectually applied. In this method counter-extension is effected by the efforts of an assistant who grasps the part, or by strong counter-extending bands. Extension is made by the surgeon in the direction of the long axis of the limb by grasping it with the hands or through the median of the clove hitch (Fig. 161), or Indian basket, or other contrivance which enables him to accomplish trac- tion with better advantage. DISLOCATIONS. Ficr. 161. 311 If greater mechanical power is desired it can be obtained by the use of tlie compound pulleys (Fig. 162), the rope windlass, the dislocation tourniquet, or Jarvis's adjuster. In the application of the compound pulleys the patient should be in the recumbent position, and a soft, Avet napkin or towel long enough to go around the limb twice should be applied. Over this the noose or clove hitch, made from some strong and soft material folded in the form of the cra- vat, should be placed and one hook of the pulleys fastened to it. The other hook should be secured to a staple screwed into the door jamb or other convenient place. The ccrd should then be gradually tiglitened, great care being taken to apply the traction so as to avoid the infliction of injury to the soft structures, or to produce fracture of the bone. 312 LUSLOCATIOXS. Fi-. 162. With the appliances above mentioned great force can be exerted, and they should, therefore, be employed with the utmost caution. That they have done injury, even in the hands of skilful surgeons, is unquestioned, and it is desirable that their use should be entirely dispensed with. The success which has attended the employment of manipulation in effecting re- duction of recent and also of old dislocations justifies the belief that their application is not necessary in any form. Continuous extension, exerted by rubber bands or by Aveights, has been successful, in a number of instances, in re- ducing luxations which have resisted other methods. Subcutaneous division of muscles, tendons, ligaments, and fibrous bands, which have offered unyielding obstruction to the return of the dislocated bone, has been practised by Dif- fenbach and others. The operation is attended with danger to vessels and nerves in relation with the articulation, and is liable to give rise to inflammatory conditions. I have seen a fatal result follow its employment by a most skilful surgeon. DISLOCATIONS. 313 The evidence that reduction of a dislocation has been effected is found in a decrease of the pain, the removal of the accompanying deformity, with more or less complete restoration of the functions of the limb. In some instances, the return of the bone is accompanied by a distinct snap, which is heard by those present. In other cases, owing to the relaxed condition of the parts under the influence of the anaesthetic, the bone returns to its place without this sound. The treatment after reduction consists in combating in- flammation, if present, by appropriate remedies, and in the application of dressings to retain the bone in place ; these should remain in position for different periods of time, ac- cording to the character of the dislocation. At the expiration of ten days to two weeks passive mo- tion, with friction, should be instituted to prevent anchy- losis and restore the functions of the joint. Complicated Dislocations As stated above, various con- ditions complicate dislocation, and among them fracture of the displaced bone and the compound character of the dis- location are of the greatest importance, and require special directions as to the treatment to be adopted. In cases where it is possible, the fracture should be first reduced and the fragments retained in apposition by appropriate dressings. A primary roller should be applied to the limb, and the frac- ture supported by tlie application of a number of well-padded narrow splints, which should be secured in place by a second roller. Under the influence of an anaesthetic, reduction of the dislocation should now be effected by careful manipula- tion or force, the limb being grasped over the splints, and if possible, above the seat of fracture. Dressings should be applied after reduction, to prevent the recurrence of dis- placement. If the seat of fracture is so near the joint as to 27 314 DISLOCATIONS. prevent proper immobilization of the fragments prior to ef- forts at reduction of the dislocation, these should be made first, the surgeoii endeavoring by pressure upon the displaced bone to reduce it. Dressings should then be applied, which will have the combined effect of retaining the displaced bone and fragments of the fracture in place. Compound dislocations occur as the result of external vio- lence applied over the joints, or the forcible extrusion of the dislocated bone through the structures. In the former, the wound is made from without inv\^ard, and in the latter, from within outward. The causes of the injury are blows, pro- ducing usually the dislocation from without inward, and falls, in which the application of the indirect force protrudes the bone through the tissues. The articulations most liable to suffer from this form of injury are the elbow, knee, and ankle, all of the ginglymoid or hinge variety. The symptoms are so plain as not to require special de- scription. The diagnosis is not difficult, owing to the ease with which the parts can be examined by inspection, and, if necessary, explored with the finger. Tiie treatment of these injuries demands the most careful consideration. The great responsibility of decision in these cases with regard to the question of removal of the limb or of an attempt to save it, rests upon the surgeon, and he must act promptly. The presence of tlie following conditions are usually regarded as sufficient to justify the surgeon to resort to immediate amputation : Extensive contusion and lacera- tion of the soft tissues with free exposure of a large joint, great comminution of the luxated bone, rupture of large arteries or nerves, and finally, the advanced age of the pa- tient, the existence of ill-health or dissipated habits. Am- DISLOCATIONS. 315 putation as a secondary operation may be required later wlien after an attempt to save the limb has been made, gangrene or exhaustive suppuration has supervened. Still further, amputation may be performed with propriety, where great deformity, impairing markedly the function of a limb, fol- lows conservative treatment. Primary excision may be performed with advantage in- stead of amputation, where some of the conditions above stated exist, especially in those involving the shoulder- joint. It may be performed secondarily in cases in which necrosis has attacked the bones of the joints. When, after careful consideration of all the conditions present, it is decided to make an effort to save the limb, the following plan of treatment should be pursued. Tiie parts should be thoroughly cleansed with a one to forty solu- tion of carbolic acid, or one to two thousand solution of corro- sive sublimate, using for tiiis purpose the fountain syringe. If comminution of the bone exists, all loose fragments should be carefully removed with the forceps or fingers of the surgeon. When the displaced bone protrudes through the wound it should be returned by manipulation. Extension with pressure upon the extremity may be able to effect this. If it is firmly grasped by the edges of the rent in the tissues they should be separated by means of retractors, and if this is not sufficient the opening may be cautiously en- larged by incision with the probe-pointed bistoury. It may be necessary in some cases to divide certain muscles or ten- dons, the tension of which cannot be overcome by manipu- lation, and also to remove with the saw or cutting pliers the end of the displaced bone which interferes with reduction ; this last operation should be left, however, as a dernier res- sort, the objections obtaining against this procedure being the 316 DISLOCATIONS. same as in compound fracture. With regard to the removal of the uninjured articular surfaces, Prof. Agnew states that in his experience " it is the safest course to cut away the displaced ends of the articulating bones." The late Prof. Gross was, on the contrary, very emphatic in his declaration " that retrenchment should be performed in cases only where the end of the bone is sharp, angular, or denuded of peri- osteum, and such a step should be taken only after the most thorough conviction of its imperative necessity. He could hardly conceive of a case where it would be necessary to re- move the end of a dislocated bone, simply because it pro- trudes at a wound." The displaced bone having been reduced and the ligaments carefully adjusted so as not to rest betw^een the articulating surfaces, drainage-tubes should be introduced to secure com- plete removal of the wound fluids and the edges of the wound accurately approximated by silver sutures or adhesive plas- ter. The corrosive sublimate dressings should be now applied and retained in place by bandages. If the injury occurs in the upper extremity, immobilization should be effected by appro- priate splints, such as those described in connectioii with compound fractures involving the articulations. In com- pound dislocations involving the joints of the lower extrem- ity, the patient should occupy the bed, and antiseptic dress- ings should be applied with the fracture-box, bracketed splint, or plaster bandage, with fenestrum over the wound, to secure perfect rest and quiet. In the event of an inability to employ antiseptic dressings, the treatment may be con- ducted by irrigation of the parts or the application of com- presses wet in the laudanum and lead-water solution. The inflammation which supervenes should be treated by the ad- ministration of appropriate constitutional remedies, and when DISLOCATIONS. 317 suppuration occurs, by means of stimulants and tonics. It is of the utmost importance that perfect drainage of the wound should be accomplished in order to prevent the evil results liable to follow the inflammatory action. Old Dislocations Under the head of patliological char- acters, the changes which take place in the joint and sur- rounding structures in unreduced luxations of long standing were fully discussed. Considering these conditions, an im- portant question relates to the period of time at which the surgeon may, with propriety, institute efforts at reduction, and the manner in which the treatment should be conducted. Wiiile it may be impossible to fix any period arbitrarily in which reduction may be effected for the articulations in gene- ral, the rule laid down by Sir Astley Cooper may be accepted as a safe guide. It was his opinion that the limit of time in which it would be prudent to attempt reduction of the shoul- der-joint was three montlis after the receipt of the injury, and two months in cases of dislocation of the hip-joint. Cases are recorded in which dislocation of both shoulder- and hip-joints have been reduced at much longer periods after injury than those given above, as for instance, several cases of the shoulder-joint, by Dr. N. R. Smith and others, at periods varying from seven to ten and a half months, and a number of the hip-joint by Drs. Travers, Blackman, and others, from five to nine months. These cases are excep- tional, and occurred, no doubt, in persons of advanced age, or in those in whom the ligamentous and other tissues were in a very lax and elongated condition. Some years since, I was called upon to reduce a dislocation of the shoulder- joint of twenty-four months' standing, in a female of advanced years, in whom the tissues were so lax that it was quite easy to produce a recurrence of the displacement. In the gingly- 27* 318 ' DISLOCATIONS. moid form of articulations the period at which reduction may be accomplished, is still more limited, not extending usually beyond three or four weeks. The dangers which attend efforts at reduction in cases of long standing have been alluded to, and relate to the injury liable to be inflicted upon the structures about the joint, con- solidated by inflammatory deposits. Tiiose most important are the vascular and nervous trunks, which are involved in the mass of tissue and become thickened and contracted. No efforts at reduction should be attempted without first informing the patient of the dangers which attend the opera- tion. If it is deemed prudent to attempt reduction, prelimi- nary treatment, extending over a period of two weeks, should be instituted, the purpose of which is, by intelligently con- ducted movements to break up adhesions formed, and to overcome, to a certain extent, the rigid character of the structures involved. These movements may be assisted by manipulations and frictions with the hand, using at the same time soap liniment or some unctuous agent to soften and re- lax the tissues. At first, it is desirable to execute these movements but once in the twenty-four hours. Later tliey may be performed twice in the day. Purgatives and minute doses of mercury may be advantageously administered to avert inflammation and to assist in promoting absorption of plastic deposits. When the preliminary treatment is terminated the patient should be placed under the influence of an ansesthetic, and the attempt at reduction made with great care. The efforts should be conducted in such manner as to elongate the struc- tures so that the articular surface of the displaced bone may be placed upon a level with that of the opposing bone. The extension to accomplish this must be made slowly and de- DISLOCATIONS. 319 Uberately; by tl)is manoeuvre alone the bone may be replaced, if not, other manipulations should be associated with it, with a view to return the bone through the opening in the liga- ment, which, it is natural to infer, will be much contracted in size, and the edges thickened and rigid. Violent and forci- ble efforts should be avoided, as they may result in the lace- ration of a bloodvessel, or nerve, or fracture of the bone. If the effort at reduction fails, the joint should, for the time being, be placed at rest, and evaporating lotions applied to control the inflammatory action liable to follow the manipu- lations performed. On its subsidence in a few days, another attempt may be made, the same precautions being taken. If the attempts made are without avail, and the functions of the joint are so impaired as to render the arm useless, or the pain, produced by the pressure of the displaced bone upon the nerves, unendurable, an operation for the establish- ment of a false joint by subcutaneous section of the bone, should be made in the manner as first suggested, and per- formed by the author in 1875, upon a patient at that time under his care. Excision of the end of the displaced bone may be per- formed in lieu of subcutaneous section, if the circumstances of the case make it desirable, although it is believed all that is needful can be accomplished by the latter with the great advantage of avoiding the dangers attendant upon the former. Rupture of the large artery or vein will be indicated by the sudden effusion of blood into the tissues surrounding the joint, and in case of the artery, cessation of the pulsation in the distal branches. The treatment of arterial rupture consists in making prompt pressure over the course of the vessel and the appli- cation of a ligature, as soon as possible, to the artery above 320 DISLOCATIONS. the seat of rupture. Hemorrliage from a lacerated vein may- be controlled by pressure, and the absorption of the extra- vasated blood promoted by a firmly applied bandage. If, in the attempts at reduction, the bone should be fractured, the lesion should be treated as in fracture occurring under other conditions. Special Dislocations Head and Face. Lower Jaw — Temporo-maxillary Articulation — Double Artiirodia. — This articulation is formed by the glenoid fossa of the temporal bone and the condyle of the lower jaw, and is surrounded by capsular, external, and in- ternal lateral ligaments, with an accessory ligament, the stylo-maxillary. It has two synovial sacs, separated by an inter-articular fibro-cartilage. It is bounded in front by the erainentia articularis, externally by middle root of zygoma, and behind by the vaginal process of the temporal bone. The movements of the joint are gliding in character, with slight rotation. The muscles in relation with the joint are the external and internal pterygoid, temporal, and masseter. Dislocations of the joint may be complete, incomplete, uni- lateral, and bilateral. Rupture of the capsular ligament occurs only in the complete form. Causes — Dislocation may be produced by external vio- lence applied over the joint, causing unilateral displacement. It is more frequently the result of muscular action, when both condyles are dislodged, escaping, in the complete vari- ety, through a rent in the capsular ligament into the zygo- matic fossa (Fig. 163). In the incomplete dislocation they rest upon the eminentia articularis, the capsular ligament being stretched, and, as a DISLOCATIONS. 321 rule, not torn. The effect of muscular action, in producing luxation, is seen wlien the mouth is widely opened, the de- pression of the jaw causing the condyles to advance forwards upon the eminentia articularis. After reaching a certain point, spasmodic action of the fibres of the temporal and masseter muscles occurs, and the processes are thrown into the zygomatic fossa. Depression of the jaw, sufficient to produce dislocation, takes place in yawning, inordinate laugh- ter, the forcible introduction of a foreign body into the mouth, as an apple or billiard ball, or the separation of the jaws for the purpose of the extraction of teeth. I have been informed of a case occurring in this State, in which disloca- tion happened to a woman, who was, at the time, engaged in scolding her husband, the case resembling that reported by Dr. Dorsey. A case came under my observation, some years since, of a lady who suffered very often from luxation of the jaw in the act of singing, or in making any effort which required wide separation of the jaws. Her husband 322 DISLOCATIONS. was instructed in the method of reduction of the dislocation, and performed the operation for her relief. Dislocation may also occur as the result of indirect force, as in falls or blows upon tlie chin, the jaw being at the time depressed. Symptoms. — The symptoms of dislocation of the inferior maxilla are well marked. Pain, in some cases, is quite se- vere, due to the stretching of the ligaments and muscles in- volved in the luxation. Loss of function, deformity, and immobility are prominent symptoms. In the complete va- riety, the wide separation "=' ' of the jaws interferes with the functions of articula- tion, mastication, and de- glutition. The constant pressure of the rami upon the parotid glands excites them toincreased discharge of fluid, and the impaired action of the buccinator muscles permits the free escape of the saliva from the mouth. The depres- sion and projection of the jaw produce marked de- formity and give a very unpleasant, expression to the face (Fig. 164). The position of the condyle in the zygomatic fossa, combined with the muscular action, fixes the bone and renders it immovable. In unilateral displacement the symptoms are not so well defined, loss of function, de- formity, and immobility appearing in a modified degree. In the condition described originally by Sir Astley Cooper as DISLOCATIONS. 323 subluxation of the jaw, the condyles glide beyond the posi- tion of the articular fibro-cartilages and become fixed upon the eminentia aiticularis. The symptoms which attend this condition are immobility of the jaw with slight separation of the teeth. Diagnosis Owing to the prominent character of the symptoms attending dislocations of the lower jaw, the diag- nosis is not difficult to be made, especially if an examination of the parts occurs soon after the accident. In the normal condition the condyle can be readily felt in its position, and its movement distinguished. When dislocation is present, a depression marks the former prominence, and the displaced condyles can be discovered in the zygomatic fossa. This ex- amination is facilitated by carrying a finger into the mouth, when counter-pressure on the outside being made, both processes, coronoid and condyloid, can be felt in their ab- normal positions. Luxation is to be distinguished from frac- ture of the neck of the condyle by the immobility of the jaw? the absence of crepitus and the abnormal position of the condyle in the zygomatic fossa. In unilateral dislocations the jaw is turned to the side opposite the joint affected, and an examination of the mouth shows a want of articulation of the teeth, especially of the anterior. In fracture of the condyloid neck, the jaw is turned toward the side injured, and the bone is movable. In a majority of instances, the history of the case will assist materially in determining the nature of the lesion. Prognosis — The prognosis is favorable, reduction being effected usually without difficulty and the functions of the articulation being unimpaired. Difficulty is sometimes ex- perienced in accomplishing reduction in cases of long stand- ing, although replacement has been effected at the expiration 324 DISLOCATIONS, of three and four months subsequent to the occurrence of the dislocation. In luxations which remain unreduced, the symptoms gradually disappear, the bone and surrounding liofamentous and muscular structures accommodatinor them- o o selves to the new conditions, so that the deformity and disa- bility are largely, though not entirely, removed. Treatment. — The manipulations necessary to obtain re- duction consist in drawing the jaw slightly forward, so as to relieve the condyle from its fixed position, elevation of the chin, effecting, by the same movement, depression of the angles, and pushing the bone backward, the condyle, slipping over the eminentia articularis, into its place. This last movement is usually accomplished by the action of the temporal and masseter muscles, which, when the pro- cess is placed upon the eminentia articularis, suddenly con- tract and throw it into the glenoid fossa. The surgeon may perform these manipulations in the fol- lowing manner. The patient being seated upon a low chair, with the head well supported by an assistant, is, if necessary, placed under the influence of an anaesthetic. The surgeon having wrapped the thumbs with thick compresses for pro- tection, stands in front of the patient and introduces them into the mouth, carrying them back to a position between the three molar teeth, and grasps the body of the jaw around the base with tlie remaining fingers of each hand, extending them backward to the angle (Fig. 165). Having obtained a firm hold of the jaw, it is drawn slightly forward, the chin is elevated, the angles depressed, and condyles pushed back into place or permitted to be drawn back by the muscular action. If the muscles are not too much relaxed by the an- aesthetic, the condyles return to their position in the glenoid fossa with an audible snap. Tiie thumbs of the surgeon DISLOCATIONS. 325 should be quickly removed from between the teeth as soon as he recognizes the beginning of the movement of replace- ment, lest they be caught and injured by the powerful con- traction of the muscles. Fiff. 165. Reduction maybe also effected by the introduction of wedges of soft pine wood, between the molar teeth, which, being used as levers, depress the angles of the jaw and permit the con- dyles to return to place. Corks, secured by pieces of cord, may be used to accomplish the same purpose. The method of M. Nelaton consisted in placing the thumbs on the nape of the neck, the surgeon standing behind the patient, and making pressure on the coronoid processes, through which manipulation the jaw is pushed forward and the angles de- pressed, so that the condyles can pass over the articular emi- nence. The late Prof. Gross succeeded in reducing bilateral dislocations, which had resisted other plans of treatment, 28 326 DISLOCATIONS. by replacing one condyle at a time, in this manner overcom- ing the muscular tension which existed and defeated previous attempts at reduction. A fall upon the buttocks, or backward down a flight of stairs, has been known to effect reduction in cases of com- plete dislocation of the jaw. As methods of treatment, however, they are not to be commended. Unilateral luxation is reduced in the same manner as those of the bilateral variety. Sub-luxations are easily relieved by drawing the jaw forward and downward. Subcutaneous sections of the temporal, masseter, and external pterygoid muscles may be performed to assist in accomplishing reduction in cases of old luxations which resist the ordinary methods. After replacement of the displaced condyles, Rhea Bar- ton's bandage should be applied for the purpose of keeping the articulation at i-est for ten days to two weeks, the patient meanwhile feeding upon liquid diet. Patients of feeble constitutions sometimes suffer from an elongated and relaxed condition of the ligaments of the temporo-maxillary articulation, which permit the condyles to slip back suddenly fi'om their position upon the articular eminences, during movements of the jaw, giving rise, in this way, to a crackling noise. Relief is afforded in these cases by the administration of tonics, as iron and quinine, and the repeated application of small blisters over the position of the articulation. Dislocation is liable to occur in these cases, and care should be taken to guard against its occurrence in depression of the jaw, as in the act of yawning. Instances of congenital dislocation have, been reported in connection with this articulation. Vertebral Articulations — Amphi-Arthrodial. — The vertebral column is a strong, fiexuous column, com- DISLOCATIONS. 327 posed of separate segments of bone fastened together by the anterior and posterior common ligaments, with inter-verte- bral disks of fibro-cartilage between the bodies, ligamenta subflava between the laminae, capsular around the articula- tions and inter-transverse, inter-spinous and supra-spinous between the processes. Tiie peculiar form of articulation be- tween the atlas and occipital bone, and atlas and axis, where- by a greater latitude of movement is permitted, changes some- what the arrangement of the ligaments and character of the articulation, making the former a double arthrodia and the latter a lateral ginglymoid with a double arthrodia between the articular surfaces. The ligaments of the vertebral col- umn are very strong, and bind tlie different vertebrae to- gether in such manner as to render their separation impossi- ble without the application of the greatest violence. The portion of the column most liable to suffer from luxation is the cervical, owing to its greater range of movement. Dis- location, not associated with fracture, is extremely rare in the dorsal region, and it is believed that simple dislocation of the lumbar vertebros never occurs. Dislocation of the vertebra? may be complete and incomplete — unilateral or bi- lateral — and the direction of the displacement may be for- ward or backward. In complete luxations, the anterior and posterior common ligaments with the inter- vertebral substances are torn. The anterior common ligament usually escapes rupture, being detached for some distance above and below ; the cord may be contused or completely severed and extravasation of blood may occur in the canal. The lodg- ment of the cord in the vertebral canal, and the great liabil- ity to the application of pressure upon it by slight encroach- ments upon the calibre of the canal, render displacements of the vertebrae very grave accidents. 328 DISLOCATIONS. Causes The causes of dislocation of the vertebrae are, as a rule, the direct application of violence to the portion in- volved, the rest of the column being fixed, as in falls, crushes -from falling walls or banks of earth, or in railroad accidents, where the body, in a state of extreme flexion or extension, is caught between timbers and firmly held. In the cervical region^ especially in the atlo-axoid articulation, dislocation sometimes occurs as the result of muscular action. At this articulation luxation may occur in various ways. It may result after fracture of the odontoid process or rupture of the transverse ligament. In some instances, when the atlas and axis are widely separated, as may be accomplished by the very reprehensible practice of lifting children up by grasping the sides of the head with the hands, the odontoid process slips from behind the transverse ligament and a luxation occurs, causing, sometimes, instant death. Violent and extreme rotation of the head upon the neck may cause rupture of the capsular ligaments of both articulations and displacement of the atlas obliquely across the axis, a move- ment which has been practised by executioners upon crimi- nals undergoing the sentence of death. Rupture of the liga- ments of one articulation may occur, producing much less displacement. Luxations at the occipito-atloid articulation occur as the result of force directly applied, producing extreme flexion of the head and neck upon the chest. In the articulations be- low the atlo-axoid, displacements may be produced by force applied with the neck in extreme flexion or in the straight position, the vertebra above being displaced anteriorly while that below remains fixed. Owing to the very immovable character of the articula- tions of the dorsal region of the column, luxation, uncom- DISLOCATIONS. 329 plicated with fracture, rarely occurs, especially in the upper tliree-tburths. In the lower fourth, between the ninth ver- tebm and first lumbar, where a greater amount of mobility exists, simple dislocations take place more frequently and are caused by the application of direct violence, producing extreme flexion of the column at this point. Luxations of the lumbar vertebrae would occur, if at all, as a result of the force applied in the same manner. In dislocations of the various regions of the vertebral column, the displacement of the vertebra? may be forward, backward, or lateral. Symptoms. — The symptoms vary in the different regions of the column and in accordance with the character of the injury. Pain is usually a very marked symptom, and is caused by pressure exerted by the displaced bone, as well as the tension to which the structures are subjected. In a case of luxation between the fourth and fifth cervical vertebra) accompanied by fracture, reported by Dr. S. W. Gross, the pain was severe and continued until the death of the patient, nearly two and a half months after the accident. The contusion of the parts accompanying the accident is liable to produce pain, which would be increased on move- ment. Loss of function is very distinct, the patient being unable to perform the movements of flexion, extension, or ro- tation. In luxations involving the cervical region deformity and immobility can be recognized, the head being flexed or extended as the displacement is backward or forward. In the dorsal or lumbar regions these symptoms are less distinct. Paralysis is a symptom common to both fracture and dislo- cation, and is, therefore, not distinctive. It varies in accord- ance with the degree of pressure, and the point at which the pressure is exerted. If the point of pressure is above the origin of the phrenic nerve, immediate death may occur by 28* 330 DISLOCATIONS. reason of the interference with the respiratory function of the diaphragm. Pressure in the dorsal and lumbar regions is followed by paralysis involving sometimes the external muscles of respiration, the bladder, rectum, and lower ex- tremities. Diagnosis In dislocations occurring in the cervical re- gion, the symptoms are sometimes sufficiently distinct to free the diagnosis from great difficulty. In other portions of the column they are ordinarily so obscure as to prevent the for- mation of a positive opinion as to the exact nature of the lesion present. The symptoms of pain, loss of function, and deformity accompany fractures of the vertebrae as well as dislocations, and are, therefore, not distinctive. Immobility is difficult to distinguish in any region of the column, with the excep- tion, possibly, of the cervical. The detection of a sulcus or depression over the site of the luxation may assist in deter- mining the nature of the accident ; it exists, however, in fractures, and I have observed the condition in cases of con- tusion of the spine, in which the speedy recovery of the patient left no doubt as to the nature of the injury. In dislo- cation of the upper cervical vertebrae, inspection of the pos- terior wall of the pharynx may assist in detecting the displacement. In dislocations, the occurrence of paralysis is usually very prompt, while in fractures it may take place at once, as the result of pressure produced by the fragments, or later from pressure exerted by clots or inflammatory de- posits. Pressure by clots of blood is not so liable to occur in dislocations as in fractures. Prognosis. — The prognosis in luxations of the vertebrae is extremely unfavorable, deatli occurring in a majority of cases immediately or within a short time following the re- DISLOCATIONS. 331 oeipt of the injury. AVlien a fatal result does not occur im- mediately, the patient may succumb finally to the exhaustion produced by pain, and, possibly, the suppuration occurring from large bed sores. In some cases the function of respira- tion is seriously involved, by reason of pressure upon the cord in the cervical and lower dorsal regions, which gradu- ally increases, producing a fatal result. Paralysis, more or less complete in character, is liable to follow dislocations of the vertebrie and complicate the case. Instances are recorded of recovery after dislocation, in which the disability has not been very great, and there are still other cases in which re- duction has been effected and permanent recovery estab- lished. Treatment — The great danger of precipitating a fatal ter- mination by sudden compression of the cord in the efforts to effect reduction has contributed largely to the adoption of the expectant plan of treatment in dislocations of the ver- tebrie. The successful results which have attended the ef- forts at reduction in cases of luxation in the cervical region, have encouraged surgeons in the opinion that in certain in- stances in which the nature of the displacement is well- defined, and the symptoms urgent, attempts should be made to accomplish reduction in cases involving this region. In all cases it should be understood that a fatal result may ac- company the effort, a result which is otherw^ise inevitable. If it is decided to attempt reduction, a very careful exami- nation of the parts should be made to obtain, as near as pos- sible, an exact knowledge of the nature of the luxation. The manipulations necessary to obtain reduction should be carefully considered, and should be made with the utmost caution and precision. The patient should be placed under the influence of an anaesthetic, so as to secure complete re- •332 DISLOCATIONS. laxation of the muscular system, and overcome all resistance. Extension should be slowly and steadily made in the line of the vertebral column, the head being firmly grasped by tlie hands of the surgeon, placed beneath the occiput and base of the lower jaw\ Counter-extension should be made from the shoulders, which are securely fastened to the table, upon which the patient rests by folded sheets crossed in front and behind, or they may be held firmly by two assistants grasp- ing the summits. The operator being on a level with the shoulders may place his feet on the summits and in this man- ner make counter-extension while extension is being made with his hands. In anterior displacements the head should be drawn cautiously backw^ard so as to unlock the parts, then upward and finally forward, in this manner placing the ver- tebrae in sucli position that a return to place will occur. In posterior luxations the manipulations should be the reverse. Pressure and counter-pressure may be employed in combina- tion with extension and may prove of great assistance. Some- times pressure may be practised successfully by introducing the finger through the mouth into the pharynx, and in this way pushing the displaced bone into place, whilst extension is maintained. In late^-al luxations rotation should be made at the same time w^ith extension. In dislocation of the vertebrae in the dorsal or lumbar re- gion, accompanied by paralysis, the patient should be placed, if possible, upon a w^ater bed, a cheap form of which can be prepared as described on page 130; if this cannot be pro- cured, he should rest upon a firm mattress, and great care should be exercised to prevent the formation of bed sores. Careful attention should be given to the bladder, the cathe- ter being used at least twice in the day, to evacuate its con- tents. The bow^els should be relieved at stated times by ene- DISLOCATIONS. 333 mata, if necessary. Wlien involiintary escape of the urine or feces occurs, measures should be taken to protect tlie bed by use of the urinal and masses of oakum, in which the feces may be received. A condition designated as sub-luxation of the vertebrae is described as occurring as the result of violence, inflicted over the region involved, most frequently the dorsal, or of force transmitted through a fall upon the buttocks. The effect of the violence is to cause a ru[)ture of the ligaments and sepa- ration of the spinous processes. Severe concussion usually accompanies the injury with, sometimes, symptoms of com- pression of the cord and partial paralysis. The treatment consists in rest in the recumbent position upon a firm mat- tress, with the administration of remedies internally, and, if needed, local applications to allay inflammatory action. Hyoid Bone In youth, the cornua of this bone are con- nected to the body by cartilaginous surfaces and held together by ligaments fonning an articulation. In middle life, con- solidation usually occurs between the body and greater cor- nua, and in old age all of the segments become united, form- ing a single bone. Dislocation of the greater cornua can only occur in early life, and instances recorded as having taken place after that period, have been associated probably with abnormal conditions in the articulation, as in one of the cases reported by Dr. Gibb, of London. Causes Luxation of the cornua of the hyoid bone may be the result of external violence, as that applied to the neck by the hand, or of muscular action, the body of the bone being fixed, while the muscles inserted into the upper bor- der of the cornua act with undue violence. Symptoms — The symptoms attending dislocation of the cornua of the bone are not very distinct. In one of the 334 DISLOCATIONS. cases reported by Dr. Gibb, the patient perceived, at the time of the occurrence of the displacement, a sudden click over the region of the articulation, and experienced the sen- sation of something sticking in the throat. Diagnosis The absence of any well-defined symptoms renders the diagnosis difficult. Luxation may be suspected if the symptoms are present which occurred in the case above alluded to. The differential diagnosis between fracture and dislocation is difficult to make. Prognosis. — In dislocations, the result of external vio- lence, the injury to the larynx may be so severe as to render the prognosis very doubtful. In simple luxations, or in those due to muscular action, the termination is usually favorable. The tendency to the recurrence of displacement is observed to exist in some cases. Treatment Keduction is accomplished by extending the head upon the neck, so as to render the muscles inserted into the lower border of the hyoid bone tense, and then relaxing those inserted into the upper border by depressing the jaw. This movement, conjoined with pressure, is effective in ob- taining reduction. • Ribs and Costal Cartilages — Costo-vertebral Articulations. — The articulation of the head of the ribs with the bodies of the vertebrae and the neck and tubercle with the transverse processes, constitute a series of angular gingly- moid joints in the former, with arthrodial articulations in the latter. Tiie anterior costo-vertebral or stellate, wi1:'h the cap- sular and interarticular ligaments bind the heads of the ribs securely to the contiguous margins of the bodies of the verte- brae, while the anterior, middle, and middle costo-transverse, witii tlie capsular, fasten tlie neck and tubercle equally secure to the transverse processes. This double attachment of the DISLOCATIONS. 335 extremity of the rib to the vertebra renders the articulations very strong, and this fact, combined with the protected posi- tion occupied by tliem, makes simple dislocation at this point almost an impossibility. Tn nine cases of costo-vertebral luxations collected by Mr. Poland and quoted by Prof. Agnew, six were uncomplicated and three accompanied by fracture or other injury. In one case under the care of Prof. Agnew fracture accompanied the dislocation. CosTO-cnONDKAL JUNCTION The junction of the carti- lage with the rib cannot be properly described as an articula- tion ; the cartilages are simply continuous with the osseous structures of the ribs, beino; received in cup-shaped depres- sions on the end of the rib and covered by an expansion of the periosteal membrane. Dislocation, or rather separation at this junction, is extremely rare, although a number of cases have been observed and recorded. The case related by Sir Charles Bell is most remarkable, in which all of the ribs were separated from their cartilages as the result of violent compression of the thorax. Chondro-sternal Articulations These articula- tions are arthrodial, and are united by anterior, posterior, and capsular ligaments with synovial membranes between all ex- cept the first ; the second and third have two each while the remaining have one each. A dislocation occurring at these articulations, although rare, occurs more frequently than those at the costo-vertebral joints. The late Prof. Gross reports having seen several cases of the kind. Chondral Articulations. — The articulations occur- ing between the cartilages of the sixth, seventh, eighth, and ninth ribs are also arthrodial, and are enveloped by thin cap- sular ligaments lined by synovial membranes, and strenghened externally and internally by ligamentous fibres. A few in- stances of luxation of these joints have been reported. 33G DISLOCATIONS. Causes The cause of dislocation of the ribs and costal cartilages is external violence, applied directly or indirectly. Direct force, as in falls, blows, or crushes in railroad acci- dents may produce luxation at either of the joints. Indirect violence, as in severe compression of the thorax, tlie body being caught between opposing objects, is liable to cause separation at the costo-chondral or costo-sternal articulations. The force applied in either way must be very severe in character to cause separation at joints so firmly united and protected, and is frequently productive of serious complica- tions in injury to the organs contained within the thorax. Symptoms In costo-vertebral luxations there are no symptoms which can be regarded as distinctive. Pain may be present as in all severe injuries, and pain experienced during the acts of respiration may be the result of muscular contusion or fracture. Symptoms somewhat rnore promi- nent attend chondral luxations — as pain, deformity, preter- natural mobility, and, in some instances, dyspnoea. Crepitus is sometimes lieard over the position of the articulation. Diagnosis — To determine the exact nature of the dis- placement in costo-vertebral dislocation is regarded as im- possible, on account of the absence of well defined symptoms, and the position of the parts which interferes with a satisfac- tory examination. The facility witli which the parts can be examined in chondral dislocations and the more prominent character of the symptoms, render the diagnosis less difficult. Prognosis — In all forms of dislocations involving the ribs or cartilages, the prognosis is unfavorable, owing to the severe violence accompanying the injury. Costo-vertebral luxations are, as a rule, followed by fatal results, whilst those of the cartilages, if the complications a,re not too serious, may result in recovery. DISLOCATIONS. 337 Treatment. — Efforts at reduction may be made in disloca- tion of the cartilages by extending the trunk, and making pressure over the displaced cartilage. Drawing back the shoulders may assist in the attempt. The inhalation of ether will contribute to success in reduction by the expan- sion of the walls of the chest caused by the deep inspiration taken by the patient. In all varieties of luxation a broad bandage should be firmly applied about the chest to afford support, and limit the extent of the respiratory movements. The conditions resulting from the contusion and other injuries of the parts should be treated upon general principles, the indications being to control by appropriate remedies the inflammatory action liable to supervene. In costo-vertebral luxations the parts should be supported by compresses and a broad bandage, as in fractures, and accompanying complica- tions treated as above indicated. Sternum and Ensiform Cartilage The sternum consists of three pieces, manubrium, gladiolus, and ensiform process or cartilage, united by articulations of the arthrodial variety, w^hich are covered by expansions of the anterior and posterior costo-stenial ligaments. Authorities differ as to the character of the articulation existing between the different portions of the bone. According to Maisonneuve they are fibrous in character in about twenty-five per cent. of cases, and arthrodial in the remaining seventy-five per cent. Dislocation occurs most frequently between the manubrium and gladiolus, rarely between the gladiolus and ensiform process. A number of cases of dislocation between the manubrium and gladiolus have been collected and ana- lyzed by Malgaigne, Mr. Poland, of London, and Dr. Brinton, of this city. Ten by Malgaigne, of which number five died ; fourteen by Poland with six deaths, five recoveries, and 29 338 DISLOCATIONS. three in which the result is unknown ; tliirteen by Brinton with seven deaths and six recoveries. Two cases of luxa- tion of the ensiforin process have been recorded by Malji^aigne. Cause Tiie cause is great violence applied directly, as by a blow, or indirectly by extreme flexion of the body, as in a crush by the debris of a falling wall. Symptoms. — The most prominent symptom is deformity, which is readily seen on examination of the bone. Disloca- tions of the ensiform cartilage are accompanied by pain in the stomach, dypsnoea, and obstinate vomiting. In luxation of the manubrium the gladiolus is the portion displaced, and passes behind or in front of the manubrium. It takes the former position when the force is applied directly, and the latter when the separation is the result of extreme flexion of the body. Pain, dyspnoea, and crepitus heard during respi- ration, are also present in most cases. Diagnosis The displacement of the bone is detected on inspection, and its position may be determined by examina- tion. It is to be distinguished from fracture by fixing the position of the articulation and ascertaining the relation of the point, at which displacement occurs, to it. Prognosis — The complications which so frequently attend dislocation of the sternum render the prognosis unfavorable. In simple cases it may be regarded as favorable, although, in many instances, reduction cannot be effected. Treatment Notwithstanding the unsuccessful results which have accompanied efforts at reduction, tliey should be undertaken in all cases. The patient should be placed on his back, bent over a number of hard cushions or pillows, so as to extend the body and make the thorax very convex anteriorly. While in this position, pressure should be made over the displaced bone, so as to force it downward and DISLOCATIONS. 339 backward. When urgent symptoms are present, caused by pressure of the dislocated bone, a small elevator may be introduced subcutaneously into the bone, for the purpose of lifting it into position. In dislocation of the ensiform process reduction may some- times be etfected by pressing the finger beneatli it and raising it into place. In one of tlie cases reported by Malgaigne, a small incision was made into the abdominal cavity, by the side of the cartilage, and it was then elevated into position with a hook. Whether reduction is effected or not, a broad bandage should be applied around the chest in all varieties of dislocations, and measures should be taken to treat the complications present. Upper Extremity. Dislocations of the upper extremity may be divided into those of the shoulder, including the clavicle and scapula, humerus, radius and ulna, carpus, metacarpus, and phalanges. Shoulder The shoulder is formed by the clavicle and scapula united at the acromio-clavicular articulation. Clavicle. — The clavicle is placed between the manubrium of the sternum and acromion process of the scapula, attached to the former by the ligaments of the sterno-clavicular articu- lation, and to the latter by those of the acromio-clavicular. Dislocations may occur at either joint, or, in rare instances, at both simultaneously. Sterno-clavicular Articulation This articulation is arthroidal in character, and is formed by the sternal end of the clavicle, the u{)per and lateral surfaces of the first piece of the sternum, and the cartilage of the first rib. The liga- ments of the joint are the anterior and posterior sterno- 340 DISLOCATIONS. clavicular, interclavicular, costo-clavicular or rhomboid, and interarticular fibro-cartilage. This joint bears a very im- portant relation to the shoulder, being the centre of its movements, and admits of motion upward, downward, for- ward, backward, as well as that of circumduction. The end of the clavicle and interarticular fibro-cartilage glide upon the articular surface of the sternum. Dislocations at this articu- lation are much less frequent in occurrence than at the acromio-clavicular joint, the explanation being found, pro- bably, in the protected position it occupies, and the immu- nity it enjoys by reason of the manner in which it receives the application of force. Males suffer from the accident more frequently than females. The displacement of the end of the clavicle maybe in i\\% forward, backward, ov upward direction, and may be complete or incomplete. Causes In the production of luxation of the sternal end of the clavicle the force may be applied directly or indirectly, causing the forward, backward, or upward displacement. Dislocation ybr«^;arc? is the result, usually, of force applied to the shoulder when it is drawn backward, as may occur in falls. The end of the bone is driven outward and through the rupture of the ligaments forward upon the front of the sternum, the interarticular ligament generally accompany- ing it. The backward displacement may be caused by violence applied directly over the sternal extremity, by which it is forced from its position backward, as when it is the result of blows over the part. Force applied to the shoulder when it is drawn forward is transmitted to the articulation in such manner as to drive the end through the posterior ligaments backward, and then forward to a position somewhat behind the sternum. DISLOCATIONS. 341 Luxation upward results usually from violence applied to the top of the shoulder, causing a depression of the scapula downward and inward, and pushing the sternal extremity upward through the ligaments upon the interclavicular notch. Symptoms The symptoms vary in accordance with the character of the displacement. In all varieties, pain, loss of function, and deformity are present. In the/orw-'arc? dislocation, pain is usually not very marked; it is increased on making attempts to move the arm, the function of which is interfered with by reason of the luxa- tion. Deformity is very prominent, and is caused by the displaced end of the clavicle on the anterior surface of the sternum, a deep sulcus at the position of the joint, produced by the separation of the articular surfaces, and a depression of the shoulder. The sternal origin of the sterno-cleido- mastoid muscle is drawn tense and rendered very promi- nent, and the head of the patient is turned toward the affected side. The backivard dislocation presents, in addition to those mentioned above, as belonging to the forward luxation, symptoms which are characteristic of the injury. The head of the bone is lodged behind the sternum, leaving a depres- sion in the situation of the joint. Generally the pressure exerted by the dislocated bone upon the trachea, oesophagus, and bloodvessels in this region of the neck is sufficient to cause considerable dyspnoea, dysphagia, and cerebral con- gestion. The loss of function is very marked, the move- ments of the arm being completely lost. The pain is fre- quently very distressing. In the upward dislocation the displaced bone occupies a position upon the top of the sternum, obliterating partially the interclavicular notch. The shoulder is depressed and 29* 342 DISLOCATIONS. carried forward, approacliing nearer to the median line of the body than is normal. The space between the bone and cartilage of the first rib is notably increased with a vacuity at the site of the joint. Loss of function is not so marked as in the other forms of luxation, the movements of the arm being somewhat less restricted. The sternal origin of the sterno-cleido-mastoid muscles is stretched over the end of the displaced bone and rendered tense. Diagnosis A careful inspection of the parts, with a study of the symptoms presented, will enable the surgeon to make the diagnosis w^ithout difficulty. With the finger, the border of the bone can be traced, and the position of its dis- placed extremity fixed whether in front, above, or behind the sternum. Prognosis. — The difficulty of maintaining the displaced bone in accurate position after reduction until repair occurs, by means of any dressing or apparatus yet devised, makes the prognosis as to restoration of the parts to the normal position, unfavorable. Fortunately, the function of the shoulder and arm are not greatly affected, for their move- ments of the former are in time, to a great degree, re-estab- lished. The deformity remains. Treatment Owing to the peculiar formation of the ar- ticular surface of the sternum, its shallow character, and the manner in which the end of the clavicle is received into it, great difficulty is experienced in retaining the displaced bone in place until the rupture of the ligamentous tissues is sufficiently repaired. The displacement of the interarticu- lar cartilage frequently complicates the condition and inter- feres with proper adjustment of the articular surfaces. In the forward dislocation reduction may be effected by drawing the shoulders forcibly backwards, tlie knee of an DISLOCATIONS. 343 assistant being placed between the scapulae of tlie patient, seated on a stool or chair, while the displaced bone is pressed into position by the surgeon. Another method consists in placing one hand closed into the axilla, while with the other the elbow is grasped, the arm pushed upward against the acromio-clavicular articulation, and the shoulder carried up- ward, outward, and backward ; the forearm is then brought across the chest, the fingers resting upon the opposite clavicle. This movement may be assisted by manipulation, the dis- placed extremity being pushed slightly upward and back- ward. Desault's apparatus (Fig. 67) should be now applied to hold the parts in position, a large pad being placed over the articulation to afford pressure and support. In place of this dressing. Fox's apparatus for fractured clavicle (Fig. 107), Yelpeau's bandage (Fig. 66), or the plaster dressing (Fig. 113), may be employed. Frequent inspection of the parts should be made to see that the reduction is maintained, and the dressings should remain in position from ten to twelve weeks. The displacement of the bone in the dislocation hachwara may be overcome by the same manipulation as that practised in effecting reduction in the forward luxation. The method in which the knee is placed between the scapulae will probably be most effective. Assistance may be rendered by drawing the arm away from the body at right angles. Recurrence of the displacement may be prevented by the application of the posterior figure-of-8 bandage, a long, thick, compress be- ing placed between the scapulae. A splint, extending from one shoulder to the other, may be placed over the compress, and the figure-of-8 bandage then applied, as employed by Mr. De Morgan. In an exceptional case of backward dislocation, which re- 344 DISLOCATIONS. sists all efforts at reduction, and in which the pressure ex- erted by the displaced bone upon the structures of the neck causes grave symptoms, it may be necessary to resort to tiie operation of excision of the luxated extremity, as performed by Mr. Davie, of Bungay, in a case wiiere the dislocation was caused by deformity of the spine. In this variety of luxation, the clavicle was forced from its articulation by the gradual advancement forward and depression of the shoul- der. The pressure upon the trachea and oesophagus caused great dyspnoea and serious difficulty in deglutition. Reduc- tion being impossible by reason of the deformity of the ver- tebral column and pathological changes which had occurred in the articulation, excision was performed with the result of relieving the condition at once. Reduction in the upward variety of dislocation is accom- plished by drawing the shoulder upward and outward, while the displaced end of the clavicle is pressed into the articular cavity. Retention may be obtained by the application of Desault's or Fox's apparatus, a pad being firmly secured over the articulation by adhesive strips or bandages ; a plas- ter jacket may be advantageously employed. Great diffi- culty is experienced in retaining the luxated bone in posi- tion, and defective repair usually follows treatment. Acromio-Clavicular Articulation This joint is formed between the outer flattened extremity of the clavicle and the upper edge of the acromion process of the scapula, likewise flattened — the articulatino- surfaces on each beinor small oval facets ; that on the clavicle is directed obliquely downward and inward. The ligaments which serve" to unite the clavicle to the acromion and coracoid processes are the superior and inferior acromio-clavicular, the coraco-clavicular (conoid and trapezoid), and interarticular fibro-cartilage. DISLOCATIONS. 345 The ligaments are very strong and fasten tlie clavicle firmly to the scapula. The form of the articulation permits of a gliding movement of the clavicle on the acromion process and a rotation of the scapula upon the clavicle forward and back- ward. Dislocations of the clavicle may occur in three directions — upward above the acromion process, downward and back- ward beneath it, and downward and forward beneath the coracoid process. Of these different varieties, the first oc- curs most frequently, owing to the direction of the articular surface upon the clavicle. These displacements may be complete or incomplete. In the complete upward disloca- tion, all, or part of the fibres of the coraco-clavicular liga- ments may be torn as well as those of the acromio-clavicular. Causes Severe external violence, applied directly or indirectly, is required to produce luxation at this joint. Direct force may be received upon either the clavicle or scapula, and indirect force may be transmitted from the sternum through tlie clavicle to the articulation, or from the elbow through the humerus to it. The violence necessary to produce the luxation is usually so great as to inflict injury upon the surrounding structures, causing severe contusions. Symptoms. — The most characteristic symptom of the dif- erent forms of dislocation occurring at this articulation is de- formity, varying in accordance Avith the position taken by the displaced bone. Loss of function, affecting the arm, is more marked in the upward and backward than in the forward displacement. Pain, discoloration, with more or less swell- ing, accompany all varieties of the luxation. In the upward dislocation, a small, hard tumor is seen and felt over the acromion process, which disappears on ele- vation of the arm and returns when the limb is depressed. 346 DISLOCATIONS. The head is turned towards the injured shoulder, and the arm rests against the body, the patient being unable to carry the hand to the mouth. The dowmcard luxation is characterized by a very marked prominence of the acromion process, and at the same time an inward projection toward the sternum. The disa- bility of the arm is shown in the inability of the patient to execute voluntary movements with it. \w\\\it forward dislocation, the position of the clavicle be- neath the coracoid process renders" both this process and the acromion very prominent, and at the same time the sternal end of the clavicle is tilted up — the scapula is inclined downward and forward ; the movements of the arm are iVee, except in the upward and inward direction. Diagnosis. — The symptoms in each variety of dislocation are so distinct that no difficulty is encountered in making the diagnosis. When inspection does not reveal the position of the displaced bone, tlie finger can be passed over its border, tracing it to the abnormal position occupied. Ex- amination througli the axillary space will assist in discerning the displaced bone in the dislocation forward, under the coracoid process. Prognosis Owing to the peculiar formation of the acromio-clavicular articulation and the almost complete laceration of the ligaments in dislocation, the prognosis as to permanent restoration of the displaced bone is unfavor- able ; as stated by the late Prof. Gross, it is fortunately a matter simply of deformity and not of utility, as the functions of the parts involved are in a great measure gradually restored. Treatment. — The reduction in the different forms of acro- mio-clavicular luxation is to be effected in the same manner DISLOCATIONS. 3-17 as in those of" tlie sterno-claviciilar articulation. In the vpuuird dislocation the displaced bone can be readily re- turned to its normal position by drawing the shoulders up- ward and backward, the movement being accomplished by placing the knee between the scapula? and grasping the shoulders with the hands, while the patient is seated upon a chair. Retention may be obtained by placing a piece of sheet-lead, enveloped in the folds of a thick compress, over the articulation, and securing it in place, as well as fixing the position of the arm by the application of the spica ban- dage of the shoulder (Fig. 52), or Desault's or Velpeau's bandage. Additional support may be given to the lead compress by passing a broad strap over it, and then carry- ing this under the elbow and securing it by another strap around the chest. The tourniquet of Petit may be applied in the same manner as suggested by Laugier. The downward luxation may be reduced in the manner described above, the elbow being carried across the chest to relax the muscles acting upon the shoulder. The displaced bone may be retained in place by dressings, which will keep the shoulder outward and upward by affording support to the arm as Velpeau's bandage. Reduction of the forward dislocation is obtained by an assistant wiio flexes the arm, and, having drawn it to the side of the body, forces it upward, outward, and backward, the surgeon meanwhile taking hold of the clavicle, dis- lodges it from its position beneath the coracoid process, and returns it to its place. In view of the difficulties encountered in securing satis- factory results after sterno-clavicular and acromio-clavicular dislocations by the dressings employed, the late Prof. Gross suggested the introduction subcutaneously of silver wire 348 DISLOCATIONS. sutures, for the purpose of uniting the articular extremities, permitting them to remain, if not permanently, until firm reunion is established. Successful cases have been reported in which this plan of treatment has been adopted. A number of instances of double dislocation of the clavicle have been reported, the result of falls upon the upper and back part of the shoulders. Reduction may be effected by drawing the shoulders back and pressing the luxated ends into position with the fingers. Compresses should be placed over the affected articulations and held by posterior figure- of-8 and spica bandages of the shoulders. Desault's or Velpeau's bandages may be also employed. Scapula Systematic writers describe the displacement arising from the separation or elongation of the fibres of the latissimus dorsi muscle at their point of attachment to the inferior angle of the scapula as dislocation of the scapula. As no articulation exists at this point, it seems scarcely proper to classify it with luxations of this bone. The dis- placement occurs most frequently in girls and boys of feeble constitution. The angle being freed from its attachment, rides over the border of the muscles and forms a marked prominence in the dorsal region. Detachment of the mus- cular fibres may result from violence, as in a fall or by a blow over the part. Efforts should be made by manipu- lation to replace the angle beneath the muscle, and then to secure it by a compress and broad bandage carried around the chest, the arm being supported in the Velpeau position. Where the displacement occurs in anaemic children, tonics should be administered, and measures should be adopt- ed to improve the general health ; a broad bandage should be worn about the chest, or suitable braces to throw the shoulders back. dislocations. 349 Humerus — Shoulder-Joint — Enarthrodial or Ball and Sockkt Articulation Tlie bones entering into the formation of tliis joint are the scapula, which receives the laro-e orlobidar head of the humerus into the shallow glenoid cavity occupying its head. The ligaments of the joint are the capsular, a large, loose fibrous mem- brane which entirely envelops the articulation, the coraco- humeral, a reinforcing ligament, a broad band extending from the coracoid process across the capsular ligament to the greater tuberosity, and the glenoid, a fibrous band attached around the margin of the glenoid cavity to deepen it. The shallow glenoid fossa, with the globular head of the humerus, forming a large articulating surface, inclosed in the ample capsular ligament, permits extensive movements in this joint — movement in the forward and backward direction, abduction, adduction, circumduction, and rotation. The construction of the joint, while it allows so much free- dom in movement, exposes it to the ready occurrence of dislocation, and as a result, this accident affects this articula- tion more frequently than any other of the body. Luxation takes place oftener in males than in females, owing to the modes of life of the former. Dislocations of this joint rarely occur before fifteen or after sixty years of age. Varieties of Dislocation — The various forms of dislocation described in connection with the shoulder-joint, may be, with propriety, reduced to four. The displacement takes place in three directions, and produces the downward, sub- glenoid or axillary ; the forward, siibcoracoid, thoracic or subclavicular, and the backward, subspinous dislocation. In the subglenoid or axillary luxation, the head of the humerus is placed in the axilla, below the margin of the 30 350 DISLOCATIONS. glenoid cavity (Fig. 166), in the suhcoracoid, it occupies a position a little below and to the inner side of the coracoid ))rocess (Fig. 167) ; in the stih clavicular or thoracic, below Fig. 166. the clavicle, at the junction of the anterior, with the external surface of the chest (Fig. 168) ; in the sub- spinous, on the dorsum of the scapula, below the spine (Fig. 169). Of the various forms the subcoracoid occurs most frequently. Instances of anomalous dislocations have been, from time to time, recorded as the supracoracoid, in which the head of the humerus has been placed above the coracoid process, as in cases reported by Malgaigne and Mr. Holmes ; the subscapular, where the bone occupied the sub- DISLOCATIONS. 351 scapular fossa, in the case described by Dr. Willard Parker. The late Professor Gross had in his cabinet a specimen illus- trating what may be designated as the supraclavicular variety, the displaced head of the bone being "lodged under Fior. 1G8. cover of, and partly above the clavicle." An extremely rare form of luxation has been described by Larrey, from a prepa- ration, in which the displaced bone had penetrated the cavity of the chest through the third intercostal space. In the complete form of dislocation, the head of the bone escapes through a rent in the capsular ligament, more or less extensive, in accordance with the force applied in producing the luxation. The soft structures surrounding the joint are also frequently lacerated and contused. In persons suffering from constitutional debility or paralysis, the ligamentous and muscular structures surrounding the joint maybe so relaxed as to permit luxation without laceration of the capsule. 352 DISLOCATIONS. Causes. — Dislocations of the shoulder-joint may be caused by external violence or muscular action. External violence may be applied directly upon the anterior, superior, or pos- terior surface of the articulation, forcing the head of the bone backward, doivmvard, ov forward, producing displace- ment in these directions. Force applied indirectly, as in falls upon the hand or elbow, may produce displacement in the same directions, the arm being at the time drawn back- ward, extended, or drawn forw^ard. The effect of muscular action in causing luxation has been observed in the violent and spasmodic contractions occurring in epilectic convul- sions ; also in extreme extension of the arm, the head of the bone being in a favorable position to be acted upon by sudden contraction of the muscles. Professor Gross quotes a ease reported by Dr. Garrison, of Illinois, in which luxa- tion occurred in a fit of sneezing. Symptoms While the usual symptoms of dislocation, pain, loss of function, deformity, and immobility characterize all luxations of the joint, each have certain symptoms which distinguish them. In the subglenoid or axillary variety the complete removal of the head of the bone from the glenoid cavity and its posi- tion in the axilla, renders the acromion process very promi- nent, flattens the shoulder, leaves a depression below the process, which can be distinctly felt, and increases the height of the axillary space. Through the action of the deltoid and biceps muscles, the elbow is projected from the body and the arm is flexed. The limb is lengthened. Pres- sure upon the nerves and bloodvessels of the axilla causes numbness in the forearm and hand, and impairment in the force of the arterial pulse. The capsular ligament is torn at its inferior part, and the displaced bone lies between the long DISLOCATIONS. 353 head of the triceps and subscapular muscles, in this position rendering unduly tense the deltoid, supra-spinatus, and both heads of the biceps. The patient is unable to place the hand of the injured arm on the sound shoulder. The symptoms of the subcoracoid dislocation are similar to those of the subglenoid. The position of the head of the bone beneath the coracoid process gives prominence to the acromion process, and leaves a depression beneath it into which the fingers can be placed (Fig. 170). The head of the Fig. 170. displaced bone can be felt in its abnormal position, and the functions of the arm are markedly impaired. The arm is projected backward beyond the middle line of the side of the body, the elbow abducted and the forearm flexed on the arm. The patient cannot grasp the shoulder of the sound side with the hand of the luxated arm. Tlie limb is but little increased in length, if at all, shortening being sometimes present. The vessels and nerves of the axillary space some- times escape pressure, or, at least, less compression is exerted 30* 354 DISLOCATIONS. upon them than in the subglenoid dislocation. As a rule, the compression is very great, and the pain and numbness in the arm and fingers are very marked. In the subclavicular or thoracic luxation the head of the humerus rests upon the anterior lateral surface of the chest, between the second and third ribs, and beneath the pecto- ralis major and minor muscles. The symptoms are the same as those of the subcoracoid variety increased somewhat in degree. The great displacement forward of the bone renders the deltoid muscle very tense, and gives marked prominence to the acromion process. The elbow is projected to a greater distance from the side of the body, and is directed further backward. Severe compression may be made upon the vasculo-nervous cord of the axilla, and, as a result, the pain may be very great. Tiie fixed position of the limb produces great impairment of function. The head of the bone may be seen and felt in its position beneath the lower border of the clavicle. The arm in this variety of dislocation is shortened. The symptoms of the subspinous form of dislocation are very characteristic. The displacement backward of the head of the bone stretches the clavicular fibres of the deltoid, and gives decided prominence to the acromion and coracoid processes. The bone is placed in its abnormal position, upon the neck of tlie scapula, beneath the border and inferior surface of the spine, just behind the angle of the acromion process. The limb is advanced beyond the line of the body, and crosses the chest in an oblique direction ; it is much shortened, and the forearm is rotated inwards, placing the hand in a state of pronation. The arm is fixed in its abnormal position, and any attempt to move it subjects the patient to pain. In this variety the patient can place the DISLOCATIONS. 355 hand of the injured limb on the opposite shoulder, a move- ment which cannot be accomplished in any of the three forms of dislocation above described. The head of the bone can be felt beneath the spine of the scapula. The rent in the capsular ligament is usually very extensive, and the muscles are lacerated and contused, producing ecchymosis and swelling. It will be observed that the prominent symptoms of the various forms of dislocation of the shoulder-joint relate to the configuration of the shoulder, affected as it is by the different displacements of the humerus, the position of the arm and elbow with regard to the body, the function of tiie limb, especially as far as relates to the ability of the patient to place the hand upon the opposite shoulder, and compres- sion of the vessels and nerves by the displaced bone. Diagnosis In making the diagnosis in dislocations of the shoulder-joint, it is necessary to distinguish the various forms, one from the other, and also from certain conditions which simulate them. A careful study of the characteristic features of each dislocation will enable the surgeon to recog- nize them in his examination of the part. They may be tabulated as follows : — 356 DISLOCATIONS. Subglenoid. Shoulder, very much flattened, Acromioa process markedly promiuent. Depressiou indicating position of glenoid fossa very distinct. Elbow projected from side in the line of axis of body. Functions greatly im- paired. Futient unable to place hand of dislocated arm on opposite shoulder. Limb lengthened, usu- ally flexed, and forearm supinated. Displaced head of hu- merus felt in the axilla. Pain and numbness in arm and fingers due to compression of axillary nerves. 1. subcoracoid. 2 Subclavicular. Slightly. Very much more pro- minent in subclavicular than in subcoracoid or other forms. Posterior portion dis- tinct. Projected from side of body and directed back- ward, more in subclavi- cular than in subcora- coid variety. Impairment of function greater in subclavicular than in subcoracoid form. The same disability ex- ists in these varieties of dislocation. Limb shortened, twist- ed and forearm partially flexed. Displaced head of hu- merus felt in axilla higher up and anteriorly. Increased pain and numbness in arm and fin- gers, due to compression of axillary nerves. Subspinous. Slightly. Prominent. Anterior portion dis- tinct. In contact with body, directed forward beyond line of axis of body, rest- ing obliquely across tbe chest. Great impairment of function. Patient can place hand of injured limb on sound shoulder. Limb much shortened, forearm flexed and pi"o- nated. Axilla free ; displaced head of humerus felt be- neath spine of scapula. No compression of ax- illary nerves, and ab- sence of pain and numb- ness in arm and fingers ; pain in shoulder. The injuries, the symptoms of which may simulate dislo- cation, and which are to be distinguished from it, are contu- sions and fractures involving the upper extremity of the humerus, the neck of the scapula, or the acromion process. In these cases it is essential that the patient should be ex- amined under the influence of an anaesthetic. The free and unrestricted movements of the limb will distinguish contu- sions, Avhile the presence of mobility, crepitus, and easy DISLOCATIONS. 3i)7 removal of the displacement and its prompt recurrence on withdrawal of the support, will enable tlie surgeon to recog- nize the existence of fracture. In all forms of shoulder- joint dislocations, unless the swelling is very great, the head of the humerus can be felt in its abnormal situation ; if it is grasped, and the arm rotated, the hand of the surgeon will readily recognize the movement. Prognosis. — In recent and uncomplicated dislocations of the shoulder-joint the prognosis is iavorable, the reduction being easily effected, and restoration of the functions of tiie joint being re-established, as a rule, in a short time. In some instances a stiffness of the joint, with imi)aired function, ensues, which requires some time to fully remove. Atrophy of the deltoid muscle occasionally occurs as a result of the injury inflicted upon the parts at the time of the accident. Dislocation of the shoulder-joint may be complicated by fracture of the humerus, neck of the scapula, or acromion process. In these cases reduction may be very difficult to accomplish and the functions of the limb greatly impaired. In old and neglected dislocations the prognosis is very un- favorable, owing to the difficulties and dangers which attend efforts at their reduction. Treatment. — Tiie reduction in shoulder-joint dislocations may be conducted by two methods, manipulation and exten- sion and counter-extension. By manipulation^ the injured limb is moved in such di- rections as to overcome the tension of the muscles, which, by their contraction, hold the bone in its displaced position and prevent its return to the articulating cavity. In employing manipulation it is essential that the surgeon should first carefully examine the parts and ascertain which muscles are involved. Having determined this point, the limb should 358 DISLOCATIONS. be placed in the position which will cause their relaxation and release the bone, wiiile their subsequent individual or combined normal action will assist in restoring it to its place. In the various forms of shoulder-joint luxations, the differ- ent muscles, which act upon the upper extremity of the humerus, are involved in accordance with the character of the displacement. In the downward dislocation, subglenoid, the deltoid and supra-spinatus muscles are rendered abnormally tense, and fix the head of the bone in its displaced position against the lower border of the glenoid fossa. The lonoj tendon of the biceps muscle is, as can be readily seen on examination Fig. 171. of the articulation, abnormally stretched in all forms of scapulo-humeral dislocations. In effecting reduction by manipulation in this variety, it is necessary to relax the tendon of the biceps, the deltoid, and supra-spinatus, by DISLOCATIONS. 359 flexing tlie forearm and elevating the limb to a position along the side of tiie head and then supinating the forearm. In this position the head of the humerus can be felt in tlie axilla, and should be supported by the fingers of the surgeon, the thumb resting on the top of the shoulder. (Fig. 171.) The limb should now be depressed to the side of the body, the head of the bone being lifted into the socket as the arm is brought to a right angle with tlie chest. In the forward dislocation, subcoracoid and subclavicular, the infraspinatus and teres minor muscles are concerned witli the long tendon of the biceps^ the deltoid, and supra- spinntus in holding the head of the bone in its abnormal situation. The manipulation necessary to secure reduction is the same as that practised in the subglenoid variety with the addition of external rotation after elevation of the arm, in order to relax the supra- and infra-spinati and teres minor muscles. The posterior dislocation, subspinous, places upon the stretch the clavicular fibres of the deltoid, the supraspina- ius, the teres major, pectoralis major, and subscapularis muscles. The relaxation of these muscles is accomplished, and reduction is effected, by elevating the limb to its fullest extent, rotating it inward to relieve the tension of the sub- scapularis, and pushing the head of the bone forward into the glenoid cavity as the arm is carried down to the side of the body. Prof. H. PI. Smith introduced, some years since, the fol- lowing method of reduction by manipulation. Forward and backward displacements were converted into the downward or subglenoid form as a preliminary step. The forward being changed to the downward luxation by simply elevating the elbow and carrying it to the head of the patient, the arm 360 DISLOCATIONS. being kept in the line of the body. The backward disloca- tion was converted into the downward by elevating the elbow and carrying it forwards. The head of the bone being in the axilla, the following manipulations were executed to return it to the socket : First, elevation of the elbow and arm to the highest point, and flexion of forearm at right angles with the arm to relax supraspinatus muscle. Second, using the forearm as a lever, rotation of the head of the bone upward and forward, as far as possible, is made, to relax the infraspinatus, the palm of the hand being directed upward ; depression of the elbow to the side, carrying it toward the body, and keeping the forearm so that the palm is still directed upward. Lastly, quick and gentle rotation of the head of the humerus upward and outward by carrying the palm downward and across the patient's body. Reduction by extension and counter -extension may be ac- complished by various methods. A very effective and simple Fig. 172. DISLOCATIONS. 3G1 plan is tliat known as Sir Astley Cooper's, in which extension is made by tlie surgeon grasping the arm of the patient, counter-extension being made by placing the foot in the axilla. The patient is placed in the recumbent position upon a low bed, table, or on the floor. Extending bands, made with a towel or sheet, are fastened to the arm above the elbow and the limb flexed at a right angle. A towel is placed in tiie axilla to protect it, and the surgeon, sitting upon the bed with one foot upon the floor, places the other, divested of the shoe, against the compress in the axilla. Steady and continuous traction is now made by means of the extending bands, which, if necessary, may be passed around the shoulders of the surgeon, the limb being gradu- ally carried forward across the body. (Fig. 172.) Reduction may be also effected by placing the knee in the axilla, the patient beinfr seated in a chair and the foot of the surgeon resting upon it or a stool placed near by. The arm is grasped with one hand, while the other is placed on the top of the shoulder, and the limb is bent over the knee, the head of the bone being, by this movement, raised into its socket. (Fig. 173.) Another plan in which reduction is effected by extension and counter-extension is that usually described as La Mothe's. According to this method the patient is placed in the re- cumbent position upon a table, and the surgeon, standing at his head, grasps the arm above the elbow with one hand, while the other is placed upon the top of the shoulder, so as to make counter-extension. (Fig. 174.) Extension being made, the bone will usually return to its place. Increased power may be gained by putting the foot on the top of the shoulder, and assistance will be rendered by rotating the limb and carrying it from the body while extension is made. 31 DISLOCATIONS. Fi?. 173. Fig- 174. DISLOCATIONS 3(53 Tlie (lis[)laced bone may be reduced by making extension and counter-extension, by placing tlie foot on the posterior fold of the axilla, so as to steady tlie scapula, and making traction with the arm at right angles to the body. The effort is completed by bringing the arm to the side of the body so as to direct the bone into the articulating cavity. Tiiis plan of extension is somewhat modified in the method of Dr. Logan, of New Orleans, the surgeon gras[)ing the shoulder between the feet and traction being made with the arm at right angles to the body. In executing this raa- n-cuvre, the heel of one foot is placed in the axilla, against the ribs, so as to press somewhat obliquely, and the base of the great toe of the other foot rests against the acromion process. In both of the methods, in which the extension is made at right angles to the body, the movement is best accomplished when the patient is in the recumbent position on the floor. The method of Dr. Nathan Smith in making extension and counter-extension with the arm at riglit angles to the body is seen in Fig. 175. The sound arm being carried from the body at right angles, a counter-extending band, made from a folded sheet, is placed around the chest, the ends passing in front and behind the chest and arm, and is secured at the wrist by a circular band. The extending band is fastened by figure-of 8 turns to the wrist and hand of the injured arm, while a third band passing over the top of the shoulder is secured to the chair. Tiie surgeon, with the foot upon the chair, places the knee in the axilla and as exten- sion and counter-extension are made, lifts the bone into place. If reduction cannot be obtained by the methods above de- scribed an effort may be made to accomplish it by means of the compound pulleys. They should be employed with 3U DISLOCATIONS. Fig. 175. great care lest serious injury be inflicted upon the structures of the joint. They may be applied in the manner repre- sented in Fig. 176, the patient being seated in a chair, and counter-extension being made by a band with an opening in it through which the injured arm is passed. It is desirable, in all cases of luxation of this joint, to make efforts at reduction, while the patient is under the in- fluence of an anaesthetic, so as to secure complete relaxation DISLOCATION'S. 365 of the muscles involved in the dislocation and avoid resist- ance on the part of the patient. Fiff. 176. After reduction, the arm should be supported in the Vel- peau or Desault bandage for a period of ten days or two weeks and then for a similar period carried in a sling. Rigidity of the parts may be removed by frictions with stimulating lini- ments and careful passive movements. In obstinate cases the rigid tendons and muscles may be divided subcutaneously. If much contusion has been received at the time of the ac- cident, the pain and swelling may be relieved by enveloping the parts in compresses wet in a solution of laudanum and lead-water. Paralysis and atrophy of the deltoid muscle may be treated 31* 3G6 DISLOCATIONS. by the application of electricity, the cold douche, frictions, and counter-irritation, vesication being sometimes of great service. The treatment in cases of dislocation complicated with fracture of the humerus consists in the application of tempo- rary dressings for the fracture, in order that the limb may be used in the manipulations necessary to effect reduction. After reduction of the luxation, permanent fracture dress- ings should be applied. When the dislocation is accompa- nied by fracture of the anatomical neck of the humerus, efforts may be made to restore the displaced bone by pres- sure — these are usually unavailing. Luxation, with frac- ture of the neck of the scapula, is attended with great em- barrassment in effecting reduction, owing to the mobility of the head of the scapula on which the glenoid fossa is placed and the difficulty of rendering it immovable. Fracture of the acromion process of the scapula does not complicate disloca- tion very seriously. Compound dislocations of the shoulder-joint are rare in occurrence. The displaced bone should be returned, if uninjured, and tlie injury treated as directed in the general discussion of compound dislocations on page 314. Emphysema, suddenly developed in connection with dis- location, sometimes occurs and is due to wounding of the chest by the displaced bone. The swelling, beginning beneath the pectoralis major muscle, spreads rapidly to the axilla and surrounding parts. Compression, firmly made with bandages, applied to the arm and chest, is usually sufficient to control the condition. Rupture or laceration of the axillary artery or vein is an accident which sometimes attends dislocation of the shoulder- joint. In case of complete rupture, producing extensive in- DISLOCATIONS. 3G7 filtration of blood into the tissues, prompt ligation of both ends of the torn artery is the proper treatment. Where laceration of the inner coats of the artery occur forming dif- fused aneurism, ligation of the subclavian artery should be performed. In one case, reported by Berard, in which pul- sation of the radical artery ceased after subcoracoid lux- ation, gangrene attacked several of the fingers and death subsequently occurred. Laceration of the axillary vein should be treated by pressure with compresses and a roller firmly applied. Double dislocations of the shoulder-joint, which occur rarely, are the result of falls, the patient extending both hands to avoid injury. The displacement may be the same in both joints or may vary. Fracture of the scapula, clavicle, or humerus frequently accompanies this form of luxation. The late Prof. Gross observed two cases of simultaneous disloca- tion, one occurring in his own practice, both having taken place during an attack of epileptic convulsions. Dr. Nathan Smith reported a case occurring in an attack of puerperal convulsions. The treatment of double luxations is to be con- ducted in the same manner as that in single displacements. Old Dislocations — The pathological changes which take place in old unreduced dislocations have been freely discus- sed on page 317. The question of interference in these cases is a very important one, and requires serious consideration on the part of the surgeon. "While there are a number of instances on record in which successful efforts at reduction have been made at the expiration of several months, there are also records of cases in which very serious accidents and fatal results have followed efforts at reduction at much less period of time, and hence there can be no general rule laid down for guidance in these cases. The conditions which 308 DISLOCATIONS. would call for interference on the part of the surgeon relate to the character of the new articulation formed, as far as usefulness, of the limb is concerned, and the existence of pain. If it is found upon examination that the movement of the limb is free, and not restricted to any great extent, it may be inferred that such changes in the surrounding struc- tures have occurred, in the formation of a new joint, as to make it hazardous to interfere. The same may be said if there is the history of severe inflammation following the re- ceipt of the injury as tlie result of which the structures are consolidated by plastic deposits. If great pain is present, as the result of pressure by the displaced bone upon the axillary nerves, then an attempt at reduction is justifiable if the con- ditions of the parts are favorable. Otherwise, the operation for the formation of a false joint by subcutaneous section of the neck of the humerus, performed by the author, with prompt relief, in a case of unreduced subcoracoid dislocation of the shoulder of fourteen months' duration, should be made. This case was fully reported in a paper read before the College of Physicians of Philadelphia, and published in volume third, 1877, of its Transactions. Excision of the head of the bone may be performed if all other means of re- lief fail. If attempts at reduction are to be undertaken, the preliminary treatment should be carried out as directed in the discussion of the subject of old dislocations on page 317. The safest plan of extension to be practised is that made with the arm at right angles to the body, or timt in which the arm is held alongside of the body. The great tension to which the arteries, veins, and nerves, matted together by in- flammatory products, are subjected, in the method of exten- sion by elevation of the arm along the side of the head renders this plan very dangerous. In the attempt at reduc- DISLOCATIONS. 369 tion of a dislocation of six weeks' standing by this plan, Prof. Agnew ruptured the axillary vein in a woman sixty years old, who recovered under the use of sorbefacient lotions and firm bandaging. Dr. Willard, of this city, has col- lected and analyzed nineteen cases of rupture of the axillary artery following efforts at reduction in old dislocations of the shoulder-joint. Of these, twelve died, six recovered, and in one the result was unknown. In three of these cases the axillary artery was ligated without benefit ; in four the sub- clavian, with two successful results. Rupture of both artery and vein occurred in three cases, two of which terminated fatally — the result in the other was not stated. As stated above, ligation of the artery should be performed in all cases of rupture. Contusion, rather than laceration, of the axillary 7ierves is liable to follow efforts at reduction in old disloca- tions of this joint. Impaired function, with pain and swell- ing of the limb, occurs. When rupture of any of the principal nerves takes place, paralysis of the parts supplied by the nerve follows the accident. In these cases, the arm should be confined in Desault's or Velpeau's dressing until repair of the injury has occurred, massage and friction being then instituted to assist in restoring the impaired function. Fractures of the humerus occurring in connection with attempts at reduction should be treated upon general prin- ciples. Mr. Tee van, of London, has reported a case of fracture of the ribs following pressure in the axilla during efforts at reduction. The inflammation which follows the separation of the ad- hesions in old dislocations is sometimes of a very severe character, and may result in the formation of a diffused ab- scess, endangering the life of the patient. 370 DISLOCATIONS. Cases have been reported in which death has followed as the result of shock. Considering the dangers which attend efforts at reduction in old dislocations of the shoulder-joint, the following propo- sitions may be stated for guidance in their employment. 1. In view of the varying conditions which attend old luxations of the shoulder-joint in different individuals, the rule applied by Sir Astley Cooper, fixing three months, after the receipt of the injury, as the limit beyond which any efforts at reduction should be regarded as injudicious, except in persons of very lax fibre or advanced age, may be ac- cepted as a guide. 2. Interference should be avoided in those cases in which free movements of the limb indicate the formation of a new joint, and the establishment of such relations of the sur- rounding structures to it by inflammatory action as to ren- der manipulative efforts dangerous. 3. The occurrence of severe inflammation after the re- ceipt of the injury, indicaHng, as a result, the consolidation of the structures by plastic deposits, and the formation of extensive adhesions between the displaced bone and the structures, may be accepted as a contra-indication to the adoption of efforts at reduction. 4. Interference should be avoided in those cases in which the function of the limb is not very greatly impaired, and in which some doubt may exist as to the re-establishment of more perfect movements after reduction. In connection with this proposition, the question of the risks assumed in making the attempts at reduction should be considered. 0. Interference is justifiable in cases in which there is great impairment of function or constant and excessive pain due to pressure of the displaced head of the humerus upon DISLOCATIONS. 371 the brachial plexus of nerves. In siicli cases, the formation of a false joint, by subcutaneous section through the surgical neck of the bone, or excision of the head of the bone, is the proper method of treatment to be pursued. 6. In all cases in which efforts at reduction are under- taken, preliminary treatment should be instituted to place the patient and the parts in the best condition. The diffi- culties and dangers attending the procedure should be clearly explained to the patient, in order that the surgeon, in the proper performance of his duty, may not be held re- sponsible for accidents beyond his control. Congenital Dislocations — Instances of congenital disloca- tions of the shoulder-joint have been recorded and carefully studied by Mr. R. W. Smith in his work on Fractures, Gail- lard, as quoted by Malgaigne, Gu^rin, Nelaton, and others. Two varieties, the suhcoracoid and subacromial^ have been described. Among the symptoms presented in these cases is atrophy of the arm, with normal development of the fore- arm. The other symptoms are the same as those accom- panying ordinary traumatic dislocations. The changes present in the articulation in these cases, consequent upon defective development, render their treatment usually unsuc- cessful. When attempted, it should be conducted according to the methods employed in luxations generally. Dislocation of the shoulder-joint occurs sometimes as the result of traction made upon the arm during parturition. Prof. Agnew states " it is not improbable that such may have been the origin of some of the cases recorded as con- genital dislocations." Dislocation of the tendon of the biceps muscle is reported as having occurred independent of luxation of the humerus. In connection with dislocation of the humerus it may be 372 DISLOCATIONS. wrenched from its position in the bicipital groove, lacerated or completely ruptured. As an independent lesion the symptoms which attend it are very obscure. The absence of the displacement of the head of the humerus from the glenoid cavity, with more or less prominence of the head of the humerus, pain in the region of the bicipital groove, and in- ability to flex the forearm upon the arm, may be regarded as symptoms of the lesion. In certain cases it may be pos- sible to feel the displaced tendon. The treatment consists in flexing the arm at right angles and making efforts to press tlie tendon back into its groove with the fingers. The arm placed at a right angle should be carried in a sling or supported in the Desault dressing. Local applications should be made to combat the inflammation which generally supervenes, and which may produce anchylosis of the shoulder- joint. Radius and Ulna — Elbow-Joint — Ginglymoid Ar- ticulation The bones entering into the formation of this joint are the humerus, radius, and ulna, firmly united by the anterior, posterior, external and internal lateral liga- ments, together forming a loose capsule which envelops the articulation and incloses an extensive synovial membrane. Being a true ginglymoid or hinge-joint, its movements are limited to flexion and extension, through the articulation of the trochlear surface of the humerus with the greater sisr- moid cavity of the ulna. The articulation of the cup-shaped depression on the head of the radius with the radial tuber- osity of the humerus permits the movement of rotation of the radius on the ulna. The radius, therefore, has a double movement of gliding in flexion and extension of the arm and rotation in the movement of supination and pronation of the forearm. DISLOCATIONS. 373 The muscles in rehition with the articulation are the biceps and bracliialis anticus in front, the triceps and an- coneus behind, the supinator longus and brevis, with the common tendon of origin of the extensor muscles of the forearm externally, and the common tendon of origin of the flexor muscles internally. Those which are chiefly concerned in the displacements, which occur in dislocations of the joint, are the triceps, biceps, brachialis anticus, and supinators. The brachial artery and median nerve occupy important re- lations in front of the joint, with the musculo-spiral nerve externally and the ulnar in the groove upon the back of the inner condyle of the humerus. Dislocations of the elbow-joint occur most frequently in early life. Hospital statistics showing that the majority take place under fifteen years of age, the average, in a number, being about twenty years. The accident is rare after forty- five years — as with luxations of the shoulder-joint it occurs more frequently in males than in females. Dislocations of the articulation may be divided into those of the humerus, radius and ulna^ of the humerus and ulna, and of the humerus and both radius and ulna, commonly described as dislocation of the elbow-joint. Humerus, Radius and Ulnar — Superior Radio- ulnar Articulation — Lateral Ginglymoid — This joint is formed by the inner side of the circumference of the head of the radius, and lesser sigmoid cavity of the ulna in wliich it rotates. The radius is held in place by the orbicular ligament which surrounds its neck, and the joint is lined by an expansion of the synovial membrane of the elbow-joint. The movement of the articulation is confined to rotation of the head of the radius, within the orbicular ligament. The proximity of tliis articulation to that of the elbow and the 32 374 DISLOCATIONS. relation held by the radius to both, makes it important that their construction and movements should be studied in con- junction. The explanation of the great difficulties which attend reduction in dislocations of the elbow-joint, after the lapse of a short period of time, may be found, I believe, in the relation assumed by the structures entering into the formation of both articulations, on account of the indepen- dent movement of the radius. In the complete forms of dislocation of the humerus, radius, and ulna, the anterior, external lateral, and posterior liga- ments, with the orbicular, are torn and the radius is separated from the lesser sigmoid cavity of the ulna and from the radial head of the humerus, and placed m front of, behind, or ex- ternal to the external condyle of the humerus, forming a dislocation yb^'tt'arc?, backward, and outward. Causes The cause of radio -ulnar -linmeral dislocations is external violence, applied either directly or indirectly. It is applied most frequently in the indirect manner, as in falls upon the hand, the forearm being at the time in a state of extreme pronation. In the /or^^wrc? luxation the displacement may occur as the result of blows or kicks upon the posterior surface of the upper extremity of the radius, of severe wrenches or twists of the forearm, or of falls upon the hand. Bachivard dislocation may be produced by direct force applied to the anterior surface of the head of the radius, by extreme forcible pronation of the hand, or by falls upon the hand, the forearm being in a state of pronation and carried away from the body. Fracture of the condyle of the humerus frequently accompanies this form of luxation. The outward dislocation, in the complete variety, is the result of extreme violence indirectly applied, through falls DISLOCATIONS. 375 upon the band. In order to place the head of the radius upon the external surface of the condyle, the ulna retaining its position, a laceration of the oblique and interosseous liga- ments must occur. The violence necessary to accomplish this would be liable to produce, at the same time, fracture of the ulna or humerus and, as well, inflict great injury upon the soft structures. Si/nipfoms. — The symptoms of tlie various forms of dis- placement are usually characteristic, the different positions assumed by the head of the radius giving a distinctive char- acter to the deformity. The pain is caused rather by the injury inflicted upon the soft structures at the time of the accident, than by the implication of any of the large nerves in relation with the joint or the muscular tension due to the displacement. The function of the joint is abridged, not totally lost in any form. In the foru'a?'d dislocation, the position of the head of the bone upon the anterior surface of the condyle (Fig. 177) Fie:. 177. shortens the radial side and rotates it outward. Flexion of the forearm at a right angle is prevented by the brachialis muscle which holds the radius in contact with the anterior 37r> DISLOCATIONS. surface of the humerus, thus interfering with its further dis- placement upward. Extension cannot be completely obtained owing to the position of the head of the radius, which can be felt rotating beneath the finger, when efforts at supina- tion and pronation are made. The biceps and supinator brevis muscles are relaxed and the forearm is usually parti- ally flexed, and in a position of slight pronation or midway between supination and pronation. The lesser sigmoid cav- ity of the ulna, made vacant by the displacement of the bone, can be felt as a depression below the external condyle of the humerus. In the hacJcward luxation, the loss of function is very marked, the limb being semi-flexed, and in a fixed state of pronation. The movements of extension, flexion, and supi- nation cannot be executed without the employment of much force. The biceps muscle is tense, its tendon being felt be- neath the skin. The depression caused by the unoccupied Fig. 178. sigmoid cavity cannot usually be distinctly outlined, owing to the position of the bone. The displaced head of the ra- dius can be felt in its fixed position on the posterior surface of the condyle (Fig. 178), by the side of the olecranon pro- cess. The fingers are usually somewhat bent. DISLOCATIONS. 377 The outward luxation is characterized, in the complete variety, by marked deformity, caused by the position of the head of the radius upon the outer surface of the external condyle. The function of the limb is very much impaired, flexion and extension being restricted, and the movement of supination abolished or executed with great difficulty. The arm is placed midway between pronation and supination, with marked prominence of the radial border of the forearm. Diagnosis The symptoms in the different varieties of dislocation of the humerus and radius are sufficiently dis- tinctive to render the diagnosis easy after careful examina- tion and study. The prominence afforded by the displaced bone, in the different positions occupied, will enable the sur- geon to distinguish it. If the movements of pronation and supination are executed, the rotation of the head can be readily felt. ■^ Prognosis The difficulty of effecting reduction and reten- tion in the forward dislocation makes the prognosis in this variety doubtful. In unreduced luxations the functions of the joint are not materially impaired, the movements of ex- tension, pronation, and supination being well performed while that of flexion gradually improves. In the backward and outward luxations the prognosis may be regarded as favorable. Treatment Reduction may be effected in the forward luxation by flexing the arm to increase the relaxation of the biceps muscle and then making extension from the hand, counter-extension being accomplished by an assistant who grasps the arm. Whilst extension is being made, the sur- geon should press the head of the radius downward and out- ward, the forearm being placed at the same time in a state of supination. 32* 378 DISLOCATIONS. The hachward and outward dislocation may be reduced by the same method. After reduction, the arm should be placed, in iki^ forward variety, at a right angle, and held in this position by either an anterior or posterior angular splint. A compress may be placed over the joint to assist in pre- venting displacement, and a bandage applied to hold the compress and splint in position. The dressings should not be disturbed under ten days or two weeks' time. Support should be given to the joint for two months, as that time is required for complete repair. The splint applied in the hachward displacement should be at an obtuse angle or near- ly straight, so as to prevent recurrence of the luxation. When the reparative process has progressed sufficiently, at the expiration usually of ten days or two weeks, passive mo- tion should be carefully instituted to avert anchylosis. Great difficulty frequently occurs in effiicting reduction in these dislocations, and after the lapse of a few days it some- times is found impossible to accomplish replacement of the bone, especially in the forward variety. Careful attention should be given to the application of tiie retentive dressings as there exists a great tendency to the recurrence of dis- placement. In persons of ansemic condition, in whom there is a relaxed state of the nniscular and ligamentous tissues, subluxation at the superior radio-ulnar articulation frequently exists. It occurs in children of a strumous habit and in females oftener than in males. Tiie functions of the limb are not seriously affected. Tlie treatment consists in general con- stitutional remedies to restore tone to the system and the local application of counter-irritants, small blisters frequently repeated, being of great service. HuMEKUS AND Ulna. — The separation of the ulna from DISLOCATIONS. 379 the hiinierus occurs very infrequently. The disphicenieut is usually backivard, the coronoid process resting in the ole- cranon fossa of the humerus or behind the internal condyle (Fig. 179). In this displacement the orbicular, as well as the oblique ligament and interosseous membrane will be ruptured. In the complete variety the coronoid process is usually fractured. Fisr. 179. Causes The dislocation is the result of severe violence applied indirectly, as in falls upon the inner and upper part of the hand, the force being transmitted in the line of the ulna while the arm is in such position of flexion as to favor the separation of the bone from the trochlear surface of the humerus. Symptoms — The symptoms are very characteristic, the forearm and hand being flexed and the limbs presenting a twisted appearance. The function of the arm is very much impaired, both flexion and extension, especially the latter, being restricted and painful. The olecranon process can be distinctly felt in its abnormal position. If fracture of the coronoid process has occurred, the displacement backward and upward of the olecranon process will be greater and as a result the deformity will be increased. The head of the radius is usually slightly displaced from its articulating surface. Diagnosis The prominence formed by the displaced 380 DISLOCATION: olecranon process is so distinctive of this dislocation that little or no difficulty should be experienced in arriving at a correct conclusion with regard to the nature of the injury. Associated with the prominent projection of the process, is the twisted appearance of the limb which is characteristic of the luxation. Prognosis. — The prognosis in dislocation of the ulna is favorable, both with regard to reduction and the restoration of the function of the limb. Treatment — The return of the displaced bone to its place may be readily accomplished by placing the knee in the bend of the elbow and making extension by grasping the hand and wrist or forearm. If difficulty is experienced, pressure may be made on the process to assist in effiicting reduction. The arm should be secured to an anterior or posterior angular splint, of slight angle, by bandages, and maintained in this position for two weeks. If fracture of the coronoid process is associated with the dislocation, the arm should be placed in a posterior rectangular case, made of felt or tin. and a compress placed over the position of the coronoid process, the whole being held in place by a roller. Radius and Ulxa — Elbo^v Joint The dislocation of both bones of the forearm at the elbow-joint is usually desig- Fi-. ISO. DISLOCATIONS. 381 Fig. 181. nated dislocation of the elbow. The displiicenient may occur in the backward, forivnrd, outward and inward direction. In the backward dislocation, both bones of the forearm leave the articulating surfaces of the humerus and take a position posterior to the lower extremity of the bone, the coro- noid process of the ulna occupy- ing the olecranon fossa and the head of the radius resting in contact with the posterior sur- face of the external condyle. (Fig. 180). In the forward luxation, which, as an uncomplicated lesion, is extremely rare, the position of the bones of the forearm is rever>ed, tliu head of the radius being placed in front of the external condyle and the olecranon process over the coronoid fossa. In the incomplete variety, the upper surface of the olecranon pro- cess is placed over the coronoid fossa, the radius having no point of contact. (Fig. 181.) The /«^era/ displacements of the bones of the forearm are, as a rule, incomplete, the articulating surfaces being rarely entirely separated. In the outward dislocation the head of the radius slips beyond the border of the external condyle, dragging the ole- cranon process with it, but not separating it completely from the trochlear surface. (Fig. 182.) The olecranon process, in the inward luxation, leaves the trochlear surface and embraces the internal condyle, while 382 DISLOCATIONS. the head of the radius rests in contact with the lower border of the trochlear surface. (Fig. 183.) Causes The dislocations of the elbow-joint, in the vari- ous directions described, are caused by severe violence ap- Fiff. 182. plied directly or indirectly. The effect of the application of direct violence is seen in falls upon the point of the elbow, the arm being in a state of extreme flexion ; as the result of the impact of force, the. forward variety of displacement may be produced. Lateral displacements either outward or inward may oc- cur also as the result of direct violence, as when the arm is DISLOCATIONS. 383 caught in the spokes of a wheel in motion, or by a rapidly- revolving belt attached to machinery. Falls from a height upon the hand, the arm being at the time in a position favorable to permit separation of the articulating surfaces of the bones of the elbow-joint, may produce the backward dis- location. Symptoms. — The symptoms in the various forms of dislo- cation of the elbow-joint are very prominent. They are characterized usually by great pain, increased upon efforts at movement, marked deformity and immobility. Loss of function is also present, the movements of the limb being very much abridged, if not entirely annulled. The position of the displaced bones in each variety of dislocation affords a distinguishing symptom by which it may be recognized. Fiff. 184. In the luxation backward the anterior and lateral liga- ments are ruptured and the brachialis muscle, with the ten- 384 DISLOCATIONS. don of the biceps, made tense as they pass over the end of the humerus. The triceps muscle may be readily grasped at its point of insertion into the olecranon process, and it is either tense or relaxed, according to the position of the arm, whether flexed or extended. (Fig. 180.) Tlie median and ulnar nerves may be subjected to pressure between the pos- terior and lower surface of the end of the humerus and the bones of the forearm. Great swelling usually attends the injury and contributes to the deformity, which is usually very great. The distance between the wrist and elbow- joints is diminished on the anterior surface, and the arm is twisted and flexed, the forearm being either in a state of slight pronation or in that midway between supination and pronation. (Fig. 184.) The function of the arm is much impaired, flexion and extension being materially restricted and much pain being caused on making attempts to effect movement. If the part is examined before much swelling has supervened the displaced olecranon process can be read- ily felt in its position behind the humerus where it forms a marked prominence. A projection somewhat more promi- nent, can be outlined on the anterior surface of the forearm, caused by the lower extremity of the humerus. The comi^lete forivard dislocation is accompanied by rup- ture of all of the ligaments of the joint, with more or less contusion and laceration of the surrounding soft structures. The triceps muscle is rendered unduly tense and in close contact with the end of the humerus, while the biceps and trachealis anticus are much relaxed. The distance between the wrist and elbow-joint is decreased on the posterior sur- face, the forearm being slightly flexed. The olecranon process and head of the radius can be felt in front of the lower end of the humerus — the latter can be distinguished DISLOCATION'S. 38o by the movement imparted to it on making rotation of the forearm. Posteriorily, the end of the humerus with the smooth articular surfaces, condyles, and olecranon fossa may be outlined. Extension of the forearm can be effected without much effort. When the dislocation is incomplete, lengthening, instead of shortening, of the forearm is pre- sent, with flexion. In the incomplete oiitivard lateral dislocation, which is the usual form, the head of the radius does not entirely separate itself from the articular surface of the humerus. The ulna also remains in partial contact with the trochlear surface. In the complete variety the radius is carried be- yond the external condyle, Avhile the ulna surmounts it. As a result of this lateral displacement of the bones of the forearm, the elbow is increased remarkably in breadth and the muscles taking origin from the external and internal condyles are made very tense. The undue tension of the pronator radii teres produces forced pronation of the forearm. The action of the muscles upon the displaced bones, to- gether with their abnormal positions, produce a twisted condition of the limb. The inward lateral luxation is also characterized by great deformity of the iimb, especially noted upon the ulnar side, and, as in the outward displacement, there is a great increase in the breadth of the articulation. The forearm is maintained in a state of supination by the action of the supinator brevis and longus muscles, which are rendered tense, especially the former. In the complete variety of the dislocation the displaced olecranon yn'ocess of the ulna may be felt on the inside of the joint, while on the outer aspect the external condyle forms a very prominent projection. 33 386 DISLOCATIONS. Diagnosis. — While the symptons accompanying the va- rious forms of displacement of the elbow-joint are usually well marked and sufficiently distinctive, it requires, in many instances, the most careful examination and study to deter- mine the exact character of the dislocation. Owing to the severe violence required to produce these injuries, contusions and lacerations of the soft structures occur, and as a result, great swelling rapidly supervenes. This condition interferes very much with a satisfactory examination of the parts and obscures the symptoms present. Fracture of the humerus above the condyles, of the olecranon process of the ulna or the neck of the radius may resemble posterior dislocation of the bones of the forearm, but can be distinguished from it by careful examination and comparison of the symptoms. Frac- ture of the humerus is characterized by the following symp- toms : Position of the olecranon process normal, on a line with the condyles of the humerus ; mobility of arm and forearm, flexion, extension, pronation, and supination preserved; crepi- tus obtained on bringing the fragmentsin contact and making rotation ; no shortening of the forearm ; ei\d of upper fragment, forming prominence on anterior surface, rough and flattened ; flexion of the arm diminishes prominence of posterior pro- jection. In the backward dislocation of the radius and ulna the position of the olecranon process is above the line of the condyles — the movements of the limb restricted, fore- arm fixed, crepitus absent, anterior surface of forearm short- ened, lower end of humerus smooth, preserting articular surfaces, flexion of arm increases prominenc^^ of posterior projection. In fracture of the olecranon process, the de- tached portion can be felt in its elevated position, and the depression caused by separation of the fragments can be easily recognized. In fracture of the neck of the radius, DISLOCATIONS. 387 there is an absence of deformity on the posterior surface of the articuhition, and crepitus can be elicited on rotation of the bone. Prognosis, — The injury inflicted upon the parts at the time of the production of the dislocation, as well as the great difficulties experienced in effecting reduction in one variety, the backward luxation, renders the prognosis doubt- ful. In the backward dislocation it is sometimes found im- possible to effect reduction at the expiration of so short a period as the second or third week. Several instances are recorded, however, in which it has been accomplished after the lapse of six months. Severe inflammation, suppuration, and gangrene have followed long-continued attempts made at reduction. In one instance, rupture of the brachial artery occurred, necessitating amputation at the elbow-joint to save the patient's life. In another case, death followed the acci- dent. Treatment — Reduction, in the different forms of dislocation of tiie elbow, may be effected by extension and counter-exten- sion, with the arm in either the flexed or straight position. In the backward dislocation, the method of Sir Astley Cooper may be employed, which consisted in seating the patient in a chair, while the surgeon, standing in front, placed the knee in the bend of the elbow, the foot resting upon the chair. The surgeon, grasping the forearm, makes extension, at the same time bending the elbow round the knee and pressing with it upon the inner surface of the joint so as to afford counter-extension and leverage. By the lat- ter, the coronoid process is lifted out of the olecranon fossa, the efforts at extension being usually successful in restoring the bones to place. (Fig. 185.) This method was modified by the late Prof. Gross, who 388 DISLOCATIONS. Ficr. 185. obtained more power by placing the heel in the bend of the elbow, made extension by grasping the forearm, and assisted reduction by bending the forearm over the chest. To afford still greater power, bands may be se- cured to the forearm and then placed over the shoul- ders of the surgeon. In effecting reduction by this plan the patient is placed in the recumbent position. Reduction has also been accomplished by bending the arm round a bed-post while extension is made. Pressure made firmly upon the displaced olecra- non process by the thumbs of the surgeon while ex- tension and counter-exten- sion is effected by assistants, who grasp the arm and forearm, will sometimes aid in obtaining replacement. In cases which resist reduction witli the arm in the flexed position, the coronoid process may be unlocked from its posi- tion in the olecranon fossa by forcibly extending the limb beyond the straight line and then accomplishing reduction by extension and counter-extension. This plan is very effectual in old dislocations. If still greater power is required in making extension the compound pulleys, which may be fastened to the forearm by appropriate bands, may be employed. Counter-extension DISLOCATIONS. 389 IS obtained by bands attached to the arm and secured to the bed-post or confiiled to the care of strong assistants. Great care should be exercised in making traction lest injury be inflicted upon the structures of the joint. The patient should be in the recumbent posture and under the influence of an antesthetic. When all other means ftiil in effecting reduction, subcuta- neous division of the tendon of the triceps muscle or subcu- taneous section of the olecranon process may be performed with orreat advantage. Subcutaneous division of resisting structures in close proximity to the important vessels and nerves in relation with the joint is attended with very great danger and may result in very serious consequences. Reduction in the, forward and lateral dislocations may be accomplished by the same methods as those employed in the backward displacement, that is, extension and counter-exten- sion in the flexed or straight position, combined if necessary with pressure. The return of the bones to tlieir normal positions is accom- panied by a characteristic sound, and the functions of the joint are restored. The re-establishnient of complete flexion and extension, and of the normal relations of the olecranon process to the condyles of the humerus, will always indicate successful reduction of the dislocation. Tlie treatment after reduction consists in the local appli- cation of remedies to control inflammatory action, and the adaptation of an angular splint, with compresses over the joint to prevent the recurrence of displacement. At the end of a week or ten days, the inflammation having sufficiently subsided, passive movements may be carefully instituted. 33* S90 DISLOCATIONS. Compound dislocations of the elbow are rare, and are the result of extraordinary violence. They may be treated either by replacement of the displaced bones and closure of the wound, partial or complete resection of the bones, or amputation. The age, habits, and the state of the general health of the patient, with the nature and extent of the injury, will guide the surgeon in making a decision as to the best plan of treat- ment to be adopted. If the patient is young and in good health and the injury slight, an effort may be made to conduct treatment by replacing the bones, closing the wound, and applying antiseptic dressings. If the injury is more ex- tensive, partial resection of the bones may be performed and the joint treated by the strictest antiseptic methods. In those cases in which injury has been inflicted upon the bloodvessels and nerves of the joint, with extensive lacera- tions of the muscular structures, amputation should be per- formed. Several cases of a peculiar form of dislocation have been reported, in which a simultaneous luxation of the ulna and radius occurs in opposite directions, the former being thrown behind and the latter in front of the humerus. It is the result of severe violence applied, when the forearm is flexed and twisted forcibly upon its axis. The nature of the in- jury is recognized by the increase in the antero-posterior diameter of the articulation, with a decrease in the trans- verse measurement ; also by the presence of a prominence both upon the anterior and posterior surfaces of the joint, caused by the head of the radius and olecranon process of the ulna. The deformity is very striking, the forearm and hand being both twisted inwardly and slightly bent. Replacement of the dislocated bones may be accomplished by extension and counter-extension with flexion, made in DISLOCATIONS. 391 tlie usual way. The ulna is first returned to place and then the radius by extension, combined with pressure upon its head. Radius and Ulna — Inferior Radio-Ulnar Artic- ulation — Lateral Ginglymoid This articulation is formed by the lower end of the ulna, the rounded articular eminence of which is received into the sigmoid cavity on the inner side of the lower end of the radius. The bones are held together by the anterior and posterior radio-ulnar ligaments attaching the margins of the sigmoid cavity to the anterior and posterior surfaces of the ulna, with the tri- angular interarticular fibro-cartilage, binding the surfaces of the lower ends of both bones. The synovial membrane of the articulation extends between the articular surfaces of the ulna and radius and the lower end of the ulna and the interarticular fibro-cartilage. It has been called, from its extreme laxity, the membrana sacclformis. The move- ment of the articulation is limited to rotation of the radius around the head of the ulna, forward and backward, pro- ducing pronation and supination. Dislocation of the articulation occurs in two directions, yb?'- ward and backward. In the former, the anterior radio-ulnar ligament witli the synovial membrane and interarticular fibro-cartilage are ruptured, the cartilage being torn from its attachment to the radius, and sometimes displaced with the head of the ulna, which rests on the anterior surface of the radius. In the latter, the posterior radio-ulnar ligaments with the synovial membrane and fibro-cartilage are lacerated, the latter being displaced with the ulna, which is lodged upon the posterior surface of the radius. Of the two varieties, the backward luxation occurs most frequently. As inde- pendent lesions, dislocations of this articulation are very rare ; 392 DISLOCATIONS. they occur frequently in the partial form as complications of fracture of the lower end of the radius. Causes The cause of dislocation of this joint is the ap- plication of violence in such manner as to produce very forcible supination or pronation of the hand, as in twists or wrenches. In ih^ forivard luxation forcible supination of the hand is required to dislodge the bone from its articulating cavity, and place it upon the anterior surface of the radius. In the hackivard displacement, force applied in producing extreme pronation of the hand is necessary in order to sepa- rate the articular surfaces and place the ulna upon the pos- terior surface of the radius. Symptoms — The symptoms vary in accordance with the nature of the dislocation. In both varieties loss of function and deformity are marked. The chief symptoms of the forward dislocation are the position of the forearm and hand in fixed supination with flexion of the fingers and the presence, on the anterior surface of tlie forearm, just above the carpus, of a marked prominence due to tlie displaced head of the ulna. In the backward luxation the symptoms are reversed. The forearm and hand are in a state of pronation, and im- movably fixed, with slight flexion of the fingers. A promi- nence exists upon the posterior surface of the wrist at its outer border, formed by the head of the ulna, which is di- rected obliquely across the radius. A depression may be felt above tlie position of the cuneiform bone, and the styloid process and fifth metacarpal bone are not in line, as in the normal relations. The breadth of the lower end of the forearm is diminished, and the tense tendon of the extensor DISLOCATIONS. 393 carpi ulnaris can be distinctly felt in its course from the ulna to the fifth metacarpal bone. jyiagnosis If examination of the parts is made before the occurrence of much swelling, the nature of the disloca- tion can be readily determined. Difficulty may be experi- enced in ascertaining the exact character of the displacement, when the relation of the parts are altered by accompanying fracture. Prognosis — In uncomplicated dislocations the prognosis is favorable. Repair of the lacei-ated ligaments takes place slowly, and care should be exercised in order to avoid re- moving the retentive dressings too early. Treatment Reduction may be effected in the forward displacement by flexing the forearm upon the arm, extend- ing, and then forcibly pronating the hand, while pressure is made over the head of the ulna to assist in returning it to its articulating cavity. In the backward dislocation, after flexion of the arm, ex- tension of the hand should be made, combined with forcible supination. The after-treatment should be conducted by the applica- tion of compresses over the articulation, in front and behind, secured in place by a firm roller, and a Bond's splint, or two well-padded straight splints, placed on the anterior and pos- terior surfaces of the forearm, and secured likewise by a roller. Partial dislocation of this articulation is sometimes ob- served in persons of feeble constitutions, or in otliers after severe injury to the joint, or as a result of a fracture of the lower end of the radius in which the treatment has been defective. The hand remains in the position of abduction, owino; to the relaxed and elon";ated condition of the liga- 394 DISLOCATIONS. ments. Very little can be done in obtaining complete re- lief. The repeated application of small blisters over the joint might be etfective in overcoming the condition. Sup- port, by means of a firm band or a strap made of soft ma- terial, should be given to the joint. Cakpus — Wrist-Joint — Partial Enarthrodial Ar- ticulation — This articulation is formed by the lower end of the radius, with the triangular interarticular fibro-cartil- age above, and the scaphoid, semilunar and cuneiform bones below. A transversely elliptical concave surface is pre- sented by the under surface of the radius and fibro- cartilage, into which the convex surfaces of the bones of the carpus is icceived. The ligaments which fasten the parts together are the anterior, posterior, internal, and external lateral. A large ^synovial membrane lines the articular surfaces and is reflected on the inner surfaces of the ligaments. The arti- culation has all of tlie movements of an enarthrodial or ball- and-socket joint, except rotation, namely, flexion, exten- sion, abduction, adduction, and circumduction. The joint is very strong and well protected by the arrangement of the articulating surfaces of the bones and the fibro-cartilage, with the tendons passing in front and behind, and by the styloid processes which project on each side. Dislocation of the carpus is an exceedingly rare accident, so much so that its existence as an independent traumatic lesion was denied by Dupuytren. Later observations have shown that its occurrence is possible, and a number of cases have been made the subject of clinical study. I have had under my care two cases of luxation of the carpus, both of the posterior variety, occurring in boys, as the result of falls upon the hand, which were reported to the Philadelphia Academy of Surgery in March, 1881. DISLOCATIONS. 395 The dislocations Fig- 186. which occur are the backward2i.T\di forward : in the former, the car- pus is placed upon the posterior surface of the radius and ulna, the pos- terior and lateral lig- aments having been ruptured (Fig. 18G). In the latter, the car- pus takes a position upon the anterior sur- face of the forearm (Fig. 187), the anterior and portions of the lat- eral lio^aments havinoj been lacerated. Lateral dislocation can only occur when accompanied by fracture of one of the styloid processes, and then in the incomplete form. Fig. 187. Causes Dislocations of the carpus are, as a rule, the re- sult of falls upon the hand when it is either in the flexed or extended position. 396 DISLOCATIONS. The backward luxation is caused by falls upon the back of the hand, producing very sudden and forcible flexion. In the forward displacement the force is received upon the palm of the hand, causing sudden and forcible exten- sion. Symptoms — The symptoms of displacement are very characteristic — loss of function and deformity are marked. In the hachward variety a projection exists upon the posterior surface of the lower part of the forearm, with another upon the anterior surface of the carpus, increasing very greatly the an- ■^^o- ■^°°' tero-posterior diameter of the joint. The hand and fingers are flexed and only slightly movable. The forearm is shortened on its posterior aspect (Fig. 188). In i\\Q forward dislocation the antero-posterior diameter is increased, as in the backward luxation, the carpus, however, lying upon the anterior, instead of the posterior, surface of the forearm. The hand Fig- 189. is markedly extended, with strong flexion of the fingers, and the forearm is shortened on its anterior aspect (Fig 189). Diagnosis, — In most cases, before swelling to any extent has supervened, the out- lines of the displaced carpus can be readily traced, and the DISLOCATIONS. 397 concave surface of the radius, with the styloid processes of both bones, distinguished. The condition of flexion or extension of the hand and fingers will also assist in determining the position of the displaced carpus. The differential diagnosis between dislocation of the car- pus and fracture of the lower extremity of the radius is made by a careful examination of the parts and a study of the symptoms. Dislocations are characterized by greater deformity, immobility, absence of lateral displacements, and crepitus. Reduction, when effected, is permanent. Prognosis — The prognosis in dislocations of the carpus is favorable, reduction being usually easily accomplished, and the functions of the joint, in a short time, fully restored. Treatment Reduction is effected by grasping the hand and making extension, the movements of extension and flexion of the hand, with abduction and adduction being executed at the same time and in accordance with the direction of the displacement, so as to facilitate replacement. Pressure exerted upon the displaced carpus will also assist in returning it to place. After reduction, the joint should be enveloped in compresses saturated with a lotion of laud- anum and lead-water, and the forearm kept upon a well- padded anterior splint, held in position by a roller. At the expiration of eight to ten days passive motion should be care- fully instituted. The treatment of coynpound dislocation of the carpus should be conducted upon general principles. An effort should be made to save, if possible, the hand, the displaced bones being returned or excision being performed if neces- sary, the wound closed, and antiseptic dressings applied. Perfect drainage of the wound should be accomplished. 34 398 DISLOCATIONS. Where great injury has been inflicted upon the structures of the joint, lacerating the bloodvessels and nerves, amputation should be performed. A number of instances of congenital dislocation have been recorded as occurring in this articulation, the displacements being in the backward or forward direction. In these cases, treatment is of little avail, owing to the degenerative changes which have taken place in the structures. Carpus — Carpal Articulations — -Arthrodia and Enarthrodial Articulations. — The articulations of the carpus are divided into those of the first row of carpal bones, those of the second row, and those of the two rows with each other, the first row being connected by two dorsal, two pal- mar, and two interosseous ligaments ; the second by three dorsal, three palmar, and two interosseous ; while the two rows of bones are united by dorsal, palmar, internal, and external lateral ligaments. Tlie articulations of the first and second row are arthrodial, while that of the two rows with each other is compound, being enarthrodial in the middle, between the OS magnum and scaphoid and semilunar bones, and ar- throdial on the sides, between the scaphoid and trapezium and trapezoid, on the outside, and cuneiform and unciform on the inside. (Fig. 190.) The movements betw'een the bones of each row are very limited, those between the two rows are more distinct, but chiefly limited to flexion and extension, while that between different bones of the two rows is more extensive, in accordance wnth the character of the articulations above described. Two synovial membranes are placed between the bones of the carpus and, by their expan- sions, cover apposing surfaces. Uncomplicated dislocation of the carpal bones is a very rare occurrence. The bones most frequently displaced are the os magnum^ semilunar^ ciinei- DISLOCATIONS. 399 fonii, and pisiform. A few cases of" dislocation of an entire row have been recorded — a notable one by Maisonneuve. As Fig- 190. a rule the dislocation occurs in the posterior direction, the bone being placed upon the dorsum, in the complete variety ; two cases are reported, one by Prof. Chisolm, of Baltimore, in which anterior displacement occurred. Causes — Dislocation of the carpal bones takes place as the result of falls upon the hand when it is in a state of forced flexion, or in the forcible contraction of the hand and fingers in grasping the sheet or towel during the pains of labor. 400 DISLOCATIONS. Mr. Cooper records the case of a patient in Guy's Hospital who could produce dislocation of the os magnum at pleasure. Symptoms — The principal symptom, in dislocation of the carpal bones, is the deformity which is caused by the pro- jection of the bone from its normal position. In luxation of the os magnum the tumor exists at the base of the third metacarpal bone, which increases in prominence, in flexion of the wrist, and diminishes in extension. A cor- responding depression may be felt on the palmar surface of the hand. When dislocation of the semilunar bone occurs, it produces a swelling upon the dorsal or palmar surface corresponding to its position in the first row of carpal bones. In the case of Prof. Chisolm the displacement was anterior and the swelling was just above the last fold of the palmar surface of the wrist on a line with the radius. On the dorsal surface the tumor would be just below the border of the radius on a line with the metacarpal bone of the middle finger. Dislocation of the cuneiform bone is exceedingly rare — the symptoms attending its displacement are similar to those of the other carpal bones. The swelling on the dorsal surface would be to the ulnar side of the wrist, and on a line with the fifth metacarpal bone. In luxation of the pisiform bone it is elevated by the action of the flexor carpi ulnaris muscle which is inserted into it. Its displacement is due to the inordinate contraction of the muscle as in lifting a heavy weight. The position of the dis- placed bone can be detected on the anterior surface of the ulnar side of the forearm. Diagnosis. — The swelling which follows dislocation of the carpal bones may be suflicient in some cases to prevent recognition of the bone displaced. Ordinarily the bone will DISLOCATIONS. 401 maintain its relation with the metacarpal bones so as to fix its position. Sometimes the shape of the bone may be traced. Prognosis. — The prognosis in simple dislocation is favor- able, restoration and retention being usually easily accom- plished. It is sometimes found difficult to retain the pisiform bone in place owing to the action of the flexor carpiulnaris muscle which has its insertion into it. Treatment. — As the dislocations of the carpal bones are usually incomplete their reduction should be accomplished without much difficulty. It sometimes occurs that the swelling which accompanies the accident renders it difficult to return the displaced bone, and the efforts of the surgeon may be, for a time, unavailing. In effecting reduction of the OS magnum, semilunar, or cuneiform bones the hand should be extended and pressure should be made on the bone in such a direction as to return it to its place. It may be necessary to employ continuous pressure by means of the tourniquet or other appliances. The manipulations should be made with care and in a gentle manner. If inflammation is present, local applications should be made to abate it ; after reduction the forearm and hand should be supported by an anterior and posterior straight splint, a compress having been placed over the luxated bone. A roller should be applied to secure the dressings in position. At the end of two weeks the splints may be removed, and passive movement of the wrist- joint carefully made in order to prevent anchylosis. The splints should then be re-applied and worn for two weeks longer until repair of the ligaments is accomplished. Replacement of the pisiform bone may be effected by flexing the hand upon the forearm and pushing the bone down into place. Efforts should be made to fix it in its re- stored position by strips of adiiesive plaster and a bandage, 34* 402 DISLOCATIONS. the hand being maintained in a flexed condition, over a light anterior splint having an obtuse angle at the position of the wrist-joint. In compound dislocations of the carpal bones it will be found necessary, as a rule, to remove the displaced bone. Metacarpus — Carpo-metacarpal Articulation of THE Fingers — Arthrodia The metacarpal articulations of the fingers are formed by the trapezium, trapezoid, os mag- num, and unciform of the second row of carpal bones, and the bases of the second, third, fourth, and fifth metacarpal bones, fastened together by dorsal, palmar, and interosseous liga- ments. The synovial membrane is placed between the sur- faces of the bones of the articulation and also between the bases of the adjacent metacarpal bones, being a continuation of that between the two rows of carpal bones. The move- ment of the articulations are limited to slight gliding of the surfaces upon each other ; the movements of the fifth meta- carpal joint are greater than those of the others. Carpo- metacarpal Articulation of the Thumb — Enarthrodia. — This joint is formed by the trapezium and base of the first metacarpal bone, and is inclosed by a capsular ligament and lined by a synovial membrane. The movements of the joint are flexion, extension, abduction, adduction, and circumduction. Dislocations of the metacarpal hones of the fingers are extremely rare occurrences. One instance of forward luxation of all of the metacarpal bones, taken from a cast in the Museum of the University College, London, is given by Mr. Erichsen. Prof. Hamilton records three cases of back- ward displacement, in one of which the metacarpal bones of all of the fingers, and in the remaining, the metacarpal bones of the index and middle fingers were dislocated. DISLOCATIONS. 403 Dislocations of the metacarpal hone of the tlnimh occur rarely in the complete and incomplete form. Causes Dislocation of the carpo-metacarpalarticulatioiis of the fingers may be caused by direct violence, as in blows upon the back of the hand producing ybrit'^rc? displacements; or by indirect force, as in blows given with the fist or falls upon the closed hand, giving rise to hachward luxations. Luxation of the metacarpal hone of the thumh is caused by force applied to the posterior surface producing extreme flexion or upon the distal end. The direction of displace- ment may be hachward or forward, the latter occurring very rarely. Symptoms The symptoms of dislocation of the meta- carpal hones of the fingers are chiefly confined to the deformity caused by the displaced bone either upon the dorsal or palmar surface in accordance with a hachward or foricard dislocation. Pain and loss of function are not very marked. The limited mobility of the joint is not materially affected. The symptoms attending luxation of the metacarpal hone of the thumh are more prominent. In the hachward lux- ation loss of function is present with marked deformity, caused above, by the proximal extremity of the metacarpal bone and below, by the trapezium. The position of the thumb varies, being either straight or somewhat flexed with slight adduction of the metacarpal bone. In X\\q foricard dislo- cation the symptoms are less distinct — the displacement being usually incomplete. Diag7iosis. — If examination is made before the occur- rence of swelling when the displaced bone can be felt, the nature of the dislocation may be readily determined. A number of instances are recorded in which a failure to recog- 404 DISLOCATIONS. nize the conditions was made, the dislocations remaining unreduced. Prognosis More or less disability remains for a short time after reduction in metacarpal dislocations. In those which remain unreduced there is marked deformity with great impairment of function. Treatment — Reduction is effected by making extension from the fingers, counter-extension being made from the wrist and pressure being exerted upon the bone to force it into place. In dislocation of the metacarpal bone of the thumb it may be necessary to attach the noose, the prepara- tion of which is shown in Figs. 76, 77, and its application, in Fig. 191, or Indian puzzle (Fig. 197) in order to exert greater Fiff. 191. force. After reduction the hand should be placed upon an anterior splint with compresses over the articulation and a roller to secure both in place. The metacarpal bone of the thumb may be readily retained in place by a plaster bandage applied in the form of the spica of the thumb. Phalanges — Metacarpo - phalangeal Articula- tions — Partial Enarthrodial Articulations — These articulations are formed between the heads, or digital ex- tremities of the metacarpal bones and the bases of the first phalanges, tlie rounded surface of the former being received into the shallow cavities in the ends of the latter. The DISLOCATIONS. 405 bones are connected by an anterior and two lateral liga- ments, a synovial membrane lining the joint. The move- ments of these articulations are flexion, extension, abduction, adduction, and circumduction. Phalanges — Phalangeal Articulations — Gingly- MOiD Joints. — These articulations exist between the first and second, and second and third phalanges, the flattened late- ral condyles of the heads being received into corresponding shallow cavities on the bases of the contiguous bones. The phalanges are united by an anterior and two lateral ligaments, the posterior ligament being supplied by the extensor ten- dons as in the metacarpo-phalangeal articulations. The movements of the joints are limited to flexion and extension ; a slight degree of rotation may be obtained by manipulation. Dislocations of the thumb and fingers at the metacarpo-phal- angeal and phalangeal 2iVi\Q,u[^i\oxis occur either in the hack- ivard OT fortcard direction. The latter luxation takes place infrequently, very few instances having been recorded. In backward dislocation of the thiimh at the metacarpo- phalangeal articulation the anterior and lateral ligaments Fig. 192. are extensively ruptured, and the head of the first phalanx rests upon the posterior and inner surface of the metacarpal bone. (Fig. 192.) 406 DISLOCATIONS. At the time of dislocation, the head of the metacarpal bone is forced through the anterior ligament, passing between the superficial and deep portion of the flexor brevis poUicis, the tendon of the flexor longus pollicis, which occupies the interval between the two portions, usually being pushed to the inner or outer side. From this description of the posi- tion assumed by the displaced bone and its relations to the surrounding structures it is evident that, so long as the points of insertion of the short flexor into the first phalanx are intact, it will be difficult to pull the phalanx dow7i and over the head of the metacarpal bone. The contraction of the fibres of this muscle has a tendency, not only to draw the base of the phalanx up, but also to hold it in close con- tact with the posterior surface of the metacarpal bone. The position of the tendon of the long flexor of the thumb and its relation, after the laceration of the tissues, to the dis- placed bone are also to be considered. It is possible for it, at the time of the dislocation, to slip over the head of the metacarpal bone and to grasp it with great power, and by its position and the eff'ect it exerts upon the bone, afford an ob- struction difficult to be overcome in the efforts at reduction. It is to be borne in mind that the first phalanx is the mov- able bone, and in reduction the resistance of the muscles at- tached to it are to be overcome. The explanation of the difficulty encountered in effecting reduction in these cases is to be found therefore in the action of the flexor brevis polli- cis, and in some instances the peculiar relations assumed to the metacarpal bone by the tendon of the flexor longus pollicis. In dislocation hachward of the fingers at the metacarpo- phalangeal articulation, the lateral ligaments are ruptured, the anterior being usually intact. The dislocation occurs most frequently in the articulation of the index and little DISLOCATIONS. 407 fingers on account of the greater mobility of the joints and their more exposed positions. Tlie i)Osition of the phahinges in forward dislocation is sliown in Fig. 193. An instance Fiff. 193. of the forward dislocation of all of the fingers at the meta- carpo-phalangeal articulations has been reported by M. Serre, of Paris. Causes. — The cause of luxation at the metacarpo-phalan- geal and phalangeal joints is violence, directly and indirectly applied. In the tJiumh, falls upon the posterior surface of the last phalanx, producing extreme flexion, may cause hachicard luxation. The forward dislocation may be pro- duced by making forced extension of the thumb. In the fingers, falls upon the last phalanges or the impact of great force, as when a base or cricket ball, impelled with great momentum, strikes the ends, slightly flexed or extended. Syn,pioms. — The symptoms of dislocation of the thumb or fingers are usually very prominent. Deformity con- stitutes the chief symptom and is easily recognized. Impair- ment of function, in some forms of luxation, is quite marked. Pain, due to the displacement, is usually slight. In the backward metacarpo-{)halangeal dislocation of the thumb the deformity is characteristic, the thumb being short- ened and turned inward, while flexion of the last phalanx is produced by contraction of the flexor longus pollicis. Two projections exist on the surfaces, caused by the head of the 408 DISLOCATIONS. metacarpal bone anteriorly, and the base of the first phalanx, posteriorly. In the /ori^'a7*c? dislocation the position of the displaced bone is reversed, and the thumb is either straight, or the last phalanx is but slightly flexed. Dislocations of the fingers at the metacarpo-phalangeal or phalangeal articulations are easily recognized by the symp- toms they present. Diagnosis, — The facility with which the parts can be ex- amined renders the detection of the luxation quite easy. Prognosis The great difficulties which are sometimes experienced in effecting reduction of the dislocation occur- ring at the metacarpo-phalangeal articulation of the thumb, and the injury inflicted upon the parts in the violent efforts made, render the prognosis doubtful. In the other luxations of the thumb and in all of those of the fingers, reduction is easily accomplished, and the restoration of the function soon takes place. Treatment Reduction is effected by extension and counter-extension, the latter being obtained by grasping the Fiff. 194. hand, while the former is made by grasping the finger between the thumb and fingers of the surgeon. In reducing DISLOCATIONS. 400 the displacement tlie finger should be placed in a position of forcible extension, and, as traction is made, the phalanx should be pressed forward into place. (Fig. 194.) If more force is required than can be secured by the fingers of the surgeon, appliances devised to retain firm hold of the finger Fiff. 195. may be employed, as the lever-tractor of Dr. Levis (Fio-. 195), traction forceps of Charriere (Fig. 196), the double Fig. 196. noose or clove hitch (Fig. 191), or the Indian puzzle (Fig. 197). In the reduction of dislocation of the thumb at the meta- carpo-phalangeal articulation, special manipulations are neces- sary on account of the relations assumed by the bones and the flexor brevis, and in some cases the tendon of the flexor longus pollicis muscle. Various methods have, from time to time, been suggested and practised with varying success. Extension and counter-extension made with great force have failed usually to accomplish reduction. Manipulations, 35 410 DISLOCATIONS. having for their object the relaxation of the flexor muscles, and through this, the release of the imprisoned metacarpal bone, have been more successful. FiR. 197. The method of Dr. Batchelder, of New York, consists in grasping the metacarpal bone of the luxated thumb between the thumb and finger of one hand and forcing it as far as possible into the palm of the hand for the purpose of relaxing the flexor brevis pollicis muscle. The thumb of one hand should now be placed against the base of the displaced phalanx, while with the other hand tiie dislocated thumb should be grasped. Forced flexion and extension should now be made while pressure is exerted upon the base of the phalanx, forcing it downward toward the articular end of the metacarpal bone. When, by these combined efforts, the base of the phalanx is brought down on a line with the articu- lating surface of the metacarpal bone, forcible flexion should be made while pressure is still exerted from behind. If not successful in returning the bone to its place by this move- ment, the thumb should be forcibly extended and pressure still be made on the base of the phalanx, the thumb of the surgeon maintaining its position acts as a fulcrum, and the bone is pressed into place. Prof. Crosby's method consists in placing the phalanx at a right angle with the metacarpal bone (Fig. 198) and DISLOCATIONS. 411 Fis. 198. pressing the base forward into place. In order to accom- plisli this he places the hand of the patient on his knee, elevates the phalanx to a point slightly beyond the perpendicular, and grasps the base between his thumbs placed behind, and his index fingers in front. With this hold of the base of the bone great pressure can be exerted, forcing the base of the phalanx downward and forward until it glides over the head of the meta- carpal bone. In cases in which all other methods fail subcuta- neous section of the tendons of the flexor brevis muscle may be performed with great advantage. Great care should be exercised in making forcible efforts at reduction. Very serious consequences have followed violent and injudicious attempts, sucli as erysipelas and gangrene. In one instance the thumb was torn off during forcible and long-continued efforts. Reduction in the forward luxation may be accomplished by making extension followed by forcible flexion. If this plan is not successful, the phalanx may be placed in a posi- tion of forced extension and traction then employed. Compound dislocations of the thumb and fingers should be treated in the same manner as those occurring in con- nection with other joints. Tetanus frequently follows the accident when much laceration of the soft parts has taken place. 412 dislocatioxs. Pelvis. Sacruisi and Ilium — Amphtarthrodial Articula- tion This joint is formed by the lateral surfaces of the sacrum and ilium connected by the anterior and posterior sacro-iliac ligaments. During early life, occasionally in the adult, and in the female during pregnancy, the articulation is lined by a delicate synovial membrane. The movements of this articulation are very limited, occurring, to but a very slight degree, in any direction. Sacrum and Coccyx — Amphiarthrodial Joint This articulation resembles those of the vertebra?, being formed between the oval concave surface on the apex of the sacrum and the oval surface on the base of the coccyx. The ligaments are the anterior and posterior sacro- coccygeal and the interarticular fibro-cartilage. A synovial membrane is found to exist usually during pregnancy. The movements of the articulation are limited to gliding in the forward and backward direction. "\^"hen much motion exists the cavity is lined by a synovial membrane. PuBEs — Amphiarthrodial Articulation This joint is formed by the apposition of the two oval surfaces on the inner extremities of the pubes, held together by the anterior, posterior, and superior pubic with the sub-pubic ligaments and interarticular fibro-cartilage. The movements of this articulation, which occur in but a very limited degree in any direction, are much increased during pregnancy, owing to changes which take place at that time between the surfaces of the plates of the interarticular fibro-cartilage. An inter- mediate fibrous elastic tissue connects the two plates, except at the upper and back part of the articulation, where it is absent, and the surfaces of the fibro-cartilaginous plates are DISLOCATIONS. 413 lined by synovial membrane. In some instances, the elastic tissue is entirely absent, permitting the synovial cavity to extend the entire length of the cartilages, and giving, as a result, greater latitude of movement to the articulation. Dislocations, usually incomplete in form, may occur at any of the articulations above mentioned. They are generally associated with fracture or injury to the bloodvessels and viscera of the pelvis. In sacro-iliac dislocations the dis- placement of the ilium is upward and backward. In the sacro-coccygeal luxation it may be either in i\\Q forward or backward direction, while in separation of the pubes the bone of either side may be displaced in the forward or back- ward direction. Where the separation of the articulating surfaces is extensive the ligaments are ruptured ; usually they escape laceration, but are subjected to great tension. Causes. — Great violence applied directly is necessary to cause separation at the sacro-iliac and pubic articulations, as crushes by heavy masses of earth, rockj or coal, between the drawheads of railway cars, or between a wall and a wagon in motion. It may be also produced by violent kicks or blows directly over the parts. A case is reported by Dr. Thomas Harris, of this city, in wdiich partial dislocation of both sacro-iliac and pubic articulations occurred in a woman as the result of a blow, by her husband, with the fist, de- livered upon tlie sacrum. During pregnancy, in some in- stances, the ligamentous structures of the pubic joint become relaxed and softened, so as to permit dislocation, in the incomplete form, upon the application of slight force. In- stances are recorded in which separation, with but slight displacement, has occurred during parturition. Sacro-coccygeal dislocations may occur from the appli cation of force applied externally, as in kicks or falls upon 35* 414 DISLOCATIONS. the buttocks, or internally, by the pressure exerted by the child's head in its passage through the pelvis, during par- turition. Symptoms The symptoms of unilateral dislocation of the sacro-iliac junction, in which the displacement back- ward is extensive, are usually well marked. Pain, loss of function, and deformity, are very prominent. The pain is very severe, and prevents recumbency upon the back. The limb of the affected side is shortened, and its function is greatly impaired by reason of injury to the sacral nerves. Deformity is caused by the projection upward and backward of the posterior border and crest of the ilium, and the tuber- osity of the ischium occupies a higher position than that on the sound side. Severe contusion of the soft parts usually accompanies the injury, and the patient is unable to pass his urine. In pubic dislocations, due to traumatism, the symptoms relate principally to the condition of the pelvic organs, which are usually seriously involved. In extensive separa- tion of the articulating surfaces the deformity is well marked. Pain is sometimes very pronounced and increased on move- ment. The symptoms of sacro-coccygeal luxations are similar, in some respects, to those of the sacro-iliac junction. Pain is very marked and constant, and is increased on defecation. Tenesmus is present, with retention of urine. The displace- ment, whether in the backward or forward direction, may be recognized on inspection. If the former exists, a prominence will be felt over the region of the articulation ; and if the latter, a depression can be outlined with the fino-er. In some instances a late- DISLOCATIONS. 415 ml displacement may occur, as in the case reported by Dr. Roeser. Diagnosis. — A careful examination of the parts is usu- ally necessary to detect the displacements occurring in dif- ferent forms of pelvic dislocations. Occasionally the swell- ing, which rapidly supervenes, obscures the symptoms and increases the difficulty in making a diagnosis. In disloca- tions of the coccyx, the nature of the injury can be detected by introducing the finger into the rectum and making, in this way, an exploration of the parts. Prognosis The violent injury inflicted upon the con- tents of the pelvic cavity and surrounding structures in dis- location of the pelvic articulations renders the prognosis un- favorable. More or less disability, with pain, remains after the occurrence of the injury. The sacro-coccygeal articu- lation becomes the seat, sometimes, of a very painful and persistent neuralgic affection. In some cases reduction of the dislocations in the various joints cannot be effected, and the deformity is not removed. Treatment — In sacro-iliac and puhic dislocations, reduc- tion is accomplished by pressure and counter-pressure made on opposite sides of the pelvis. In luxations of the coccyx, pressure can be exerted by introducing the finger of one hand into the rectum, and bringing it in contact with the bone, while counter-pressure is made with the fingers of the other hand placed on the outside. After reduction, the pel- vis should be surrounded by a broad bandage, firmly applied, and the patient should rest in bed for ten days, two weeks, or longer, if necessary. Careful attention should be given to the functions of the rectum and bladder. Defecation is usually painful and is accomplished with effort, and should be assisted by enemata, in order to prevent recurrence of 416 DISLOCATIONS. tlie displacement. The catheter should be used twice or thrice a day to relieve the bladder. Pain should be re- lieved by anodynes, and inflammation should be treated by the local application of sorbefacients and fomentations, as well as by the internal administration of appropriate reme- dies. It may be necessary, in some cases, to wear a ban- dage for some time to afford support to the parts. Lower Extremity. Dislocations of the lower extremity may be divided into those of the femur, patella, tibia, fibula, tarsus, metatarsus, and phalanges. Femur — Hip-joint (Coxo-femoral) — Enarthro- DiAL OR Ball-and-Socket Joint — This articulation is formed by the femur and os innomatum, the large globular head of the former being received into the deep, cup-shaped cavity, the acetabulum, situated upon the external surface of the latter, near its middle. The ligaments of the joint are 4he capsular, a strong ligamentous capsule inclosing the articulation ; the ilio-femoral or Y ligament, a reinforcing band taking origin, above, from the anterior inferior spine of the ilium and being inserted, below, into the anterior inter-trochanteric line, crossing the joint obliquely from above, downward, and inward ; the ligamentum teres, a tri- angular fibrous band, attached by its base to the margins of the notch at the bottom of the acetabulum, its fibres uniting with those of the transverse ligament, and by its apex to the ovoid depression, situated a little behind and below the centre of the head of the femur ; the cotyloid ligament, a fibro-cartilaginous rim fastened to the border of the acetab- ulum, and the transverse ligament which crosses the cotyloid DISLOCATIONS. 417 notch, and converts it into a foramen. A large synovial membrane covers the interior of the joint. A number of muscles are in relation with the articulation, some of which take part in the displacements occurring in connection with dislocations of the joint. The movements of the articulation are very extensive and occur in all directions, as extension, flexion, abduction, adduction, circumduction, and rotation. Owing to the very secure manner in which the head of the femur is lodged in the acetabular cavity by reason of its depth, the large contact of articulating surfaces, the ar- rangement of the strong ligaments of the articulation, and the protection afforded by the powerful muscles in relation with the joint, complete dislocation is accomplished only, as a rule, after the application of extreme and sudden vio- lence. In the complete separation of the articular surfaces extensive laceration of the ligamentous and muscular struc- tures occurs. Of the ligaments, the capsular and ligamentum teres are ruptured, the former usually in that portion not pro- tected by the ilio-femoral or Y ligament. In dislocations, the result of extraordinary violence, producing the rarer forms of displacement, the ilio-femoral ligament is also torn. The muscles in immediate relations with joints, and those at- tached to the trochanter major especially, are liable to be ruptured. The larger muscles, and those whose insertions are more remote from the head, on this account affording them more play, escape laceration. With the exception of the great sciatic nerve, the large vascular and nerve trunks are not involved in hip-joint luxations. In some instances, severe contusions of the soft parts accompany the acci- dent. A number of instances of spontaneous dislocation of the hip-joint have been recorded, in which the displacement 418 DISLOCATIONS. is always incomplete and unattended by rupture of the cap- sular ligament. Dislocations of the hip-joint occur next in frequency to those of the shoulder-joint and second in the list of luxations of the different joints of the body. Of 491 cases collected by Malgaigne, 321 occurred in the shoulder and 34 in the hip. According to the statistics of the Pennsylvania Hos- pital, as reported by Prof. Agnew, 89 cases of hip-joint lux- ations occurred in 912 cases of dislocations admitted into the Hospital. The same causes which determine the occurrence of other injuries in males and females exist in hip-joint dis- locations, males suffering always in very much Lrger pro- portion than females. Age has also an important influence. Of the 89 cases taken from the records of the Pennsylvania Hospital 78 were males and 11 females; 39 occurred between the ages of fifteen and twenty-five years, 26 between twenty-five and thirty, 12 between thirty-five and forty-five, 6 between forty-five and fifty-five, 5 between fifty-five and sixty-five, and 1 between sixty-five and seventy-five. According to the table of Prof. Agnew, given above, luxation of the joint is most frequent ^between fifteen and twenty-five years of age. Prof. Gross states that dislocation often occurs between the ages of twenty and twenty-five, but is most frequent from the thirtieth to the forty-fifth year. Two cases of hip-joint dislo- cation are reported as occurring in children at the age of six months, and five cases, from the records of the Pennsylvania Hospital, between seventy-five and eighty-five years of age. The absence of muscular power in the very young and its loss, with a condition of fragility of the bones, conducing to DISLOCATIONS. 419 fractures, in the old, contribute to the infrequent occurrence of dislocations at tliese periods of life. The results of the investigations of Mr. Henry Morris of London, published in 1877 in the Medico-Ghirurgical Trans- actions, have shown that abduction of the limb is the position most favorable to the occurrence of dislocations of the hip- joint, the head of the femur being largely displaced from the acetabulum while the limb is abducted. The conclu- sions, arrived at by Mr. Morris, have been confirmed by him by experiments made upon the cadaver, as well as by clinical observations. They are not, however, accepted by others who have made special study of the subject. Varieties of Displacement. — Dislocation of the head of the femur may take place in four different directions : back- ward and upward, upon the dorsum of the ilium, iliac dis- location ; backward and upward, into the great sacro- sciatic or ischiatic foramen, sciatic ov ischiatic ; forward and downward, into the obturator or thyroid foramen, obtu- rator or thyroid; forward and upward on the pubes, pubic. Variations, to slight degree, in the positions assumed by the head of the femur in the four principal forms described may occur ; practically they exert but little or no influence. Of the chief forms above mentioned, dislocation upon the dorsum ilii occurs most frequently, next, that into the ischiatic foramen, then, tlie thyroid variety, and finally, the pubic, which occurs quite rarely. The relative frequency is shown in the cases collected by Prof. Hamilton, who gives, out of lOJ^ instances, oo iliac, 28 ischiatic, 13 thyroid, and 8 pubic. The same order of occurrence appears in the table prepared by Mr. Bryant from the records in Guy's Hospital. A number of instances of simultaneous dislocations of the hip-joint have been reported ; in some, the luxation was in 420 DISLOCATIONS. the same direction and position ; in others, they have varied, one being an iliac dislocation and the other a thy- roid. The frequent occurrence of the posterior displacement is to be explained in the manner, in which, and the direction, from which, the vulnerating force is applied, as well as the attitude of the limb at the time of the impact of the force. In most instances, the violence is applied from the front, upon the foot or knee, the limb being at the time advanced causing flexion of the thigh upon the pelvis and in a state of abduction and internal rotation. Under such conditions, the force would be conveyed through the bone upon its head in such direction as to project it backward and upward upon the dorsum of the ilium. Force applied in the same way, with the femur still more flexed, would be liable to produce dislocation backward and downward into the sciatic foramen. Causes — As stated above, extreme and sudden violence is necessary to dislodge the head of the femar from the ace- tabulum. This may be applied directly or indirectly, in the latter manner more frequently than in the former ; as in falls upon the knee or foot, by crushes by heavy weights upon the back, the tliighs being flexed and Avidely separated, or twists of the pelvis, while the lower extremity is fixed. In the iliac dislocations, the causes are usually falls upon the knee or foot, the limb being advanced, the thigh flexed, abducted, and rotated internally. In the ischiatic luxation the causes are the same as those concerned in the production of the iliac variety. When ischiatic displacement occurs, however, the thighs are at a greater degree of flexion, exceeding that of a right angle, the limb abducted, and rotated strongly internally. DISLOCATIONS. 421 Thi/roid dislocations are caused by falls upon tlie knee or foot, the limb being markedly abducted and drawn back- ward, and rotiiled outward. They may also occur as the result of the impact of great force upon the hip, while the body is bent forward, the limb being abducted and re- tracted. Pubic luxations occur as the result of force applied in the same manner as in thyroid dislocations, the limb being abducted and retracted. Heavy weights upon the shoulders which fix the trunk, assist in the production of this form of displacement. It may also occur when the thighs are firmly held and the trunk is bent forcibly backward. A notable case is reported by Mr. Ure, of London, in which this form of dislocation occurred in a swimmer, while vigorously " striking out" in the act of swimming. The position of the limb, in the various dislocations above mentioned, has been de.^ Fi-. 228. 478 LIGATURE OF ARTERIES. position, also, the edge may be turned upward or downward (Fig. 228). Incisions The incisions which are employed may be STRAIGHT, CURVILINEAR, OR ANGULAR, and may be made from without inward or from within outward. The straight incision (Fig. 229) is that most commonly used, and may be made in a vertical, oblique, or transverse direction. The curvilinear incision (Fig. 230) is used where it is Fiff. 229. Fi^. 230. Fi^. 231. — I \ ^ L V H desirable to conform to the shape of the part involved, or where large space is required for the purposes of the ope- ration. Two curvilinear incisions meeting at tlieir extremi- ties form the elliptical (Fig. 230). The angular incision (Fig. 231) is composed of two or more straight incisions placed at different angles — as the rijjht anojle forminji; the letter L, or the acute ano-le forming; the letter V, etc. In making incisions from without inward, the integument should be put upon the stretch ; by this plan the incision is made with precision, and the integument is preserved. In order to make the incision from within outward, a fold of the integument should be held up and its base transfixed by the knife, which should cut its way out. This method is employed where great caution is required in dividing tne superficial tissues. The knife should be held lightly yet firmly, and the movements necessary to carry it through the tissues should, as a rule, be made w^th the fingers, and LIGATURE OF ARTERIES. 479 not at the wrist or elbow-joint. Very long incisions may require a sweeping movement made with the entire arm. In cutting from without inward, tlie edge of the knife should be held lightly in contact with the surface, not pressed into the tissues. " Dexterity, grace, and elegance," in using the knife, can be acquired only by practice and careful study. Closure of Wounds. — In order to retain the edges of wounds in close apposition, so that union may take place, the introduction of sutures is necessary. The Sutures. — The material used may be silk or linen, animal tissue or metal. The metallic suture may be made of silver, iron, or lead-wire. The suture may be fastened by a square knot, or, as in the metallic suture, by twisting the ends or clamping shot upon them. AYhen the metallic suture is used in a cavity, as the mouth or vagina, the cut ends can be covered by clamping a shot on them, so as to prevent them from penetrating the tissues, and thus causing pain. The knots or twisted ends should always be placed on the side of the incision, and not over it. The principal forms of sutures employed are the inter- rupted, the CONTINUED, the TWISTED, and the quilled. The interrupted, continued^ and quilled sutures are made by the insertion of a needle armed with a thread made of silk, linen, or wire. In the interrupted suture (Figs. 232, 23.3) the needle is carried through the edge of the wound from without inward, at a proper distance from the border, across the wound, and pushed from within outward at exactly the same point on the opposite side. The thread is then cut, and another suture introduced either above or below. They may be superficial or deep (Fig. 234). 480 LIGATURE OF ARTERIES. The continued suture (Fig. 235) is made by passing the needle diagonally from one side of the wound to the other. In this suture, the thread is not cut until a sufficient num- Fig. 232. Fig. 233. 2g 'I; Fi<-. 234. Fig. 235. Fig. 236. mm ^^\ LIGATURE OF ARTERIKS. 481 ber of sutures have been introduced to hold the edges in apposition. The qtiiUed suture (Fig. 236) is formed by passing through the lips of the wound a needle armed vvitli a Fig. 237. Ficr. 238. double thread. The ends of the thread are tied over pieces of quill, bougie, or light wood, placed parallel to the edge of the incision. This suture, as well as the beaded suture (Fig. 237), is employed in approximating the edges of deep wounds. The hoisted suture (Fig. 238) is made by introduc- ing a pin made of steel, commonly called the hare- lip pin, through the edges of the wound, and carrying a thread round it in an elliptical manner, so as to hold it in place. The pin is passed through the deeper parts of the wound, approximating tliem, while the thread brings the superficial portions in contact. Needles. — The needles employed to pass the threads in forming sutures may be either straight or curved, round, 41 482 LIGATURE OF ARTERIES. Fig. 239. the tiss triangular,ordou. ble-edged (Fig. 239). They may be mounted on handles (Fig. 240), and maybe cannulated (Fig. 241), and pro- vided with spe- cial appliances for facilitating the passage of thread or wire. In using needles with handles they should be passed through the Lies, then threaded and withdrawn. Fig. 240. J.H.GEMRIB. OPERATIONS UPON THE LIVING AND DEAD SUBJECTS. As the knowledge of the surgeon is to be acquired in operations performed upon the dead subject, it is important LIGATURE OF ARTERIES. 483 for liim to understand tliat a marked difference exists with regard to the character of the tissues and the manner in which they separate under the edge of the knife in the living and the dead subjects. This difference should be carefully noted, so tliat wlien he undertakes operations upon the living subject he may avoid errors. In the living subject tlie soft tissues possess a great amount of elasticity and power of contractility. The former property resides to a marked degree in the common integu- ment, and thus adapts it in an admirable manner to the purposes of a common covering of the body. In the muscu- lar structures tl)e power of contractility is very great, varying, of course, in proportion to the size and amount of tissue involved. In the dead subject these conditions are entirely absent ; it is true that in the recently dead subject a small amount may exist, but it may, however, be regarded as practically wanting. In the subject which has been injected with such an agent as chloride of zinc, and kept for a period of time in a solution of salt, elasticity and contractility of the tis- sues ai-e not only absent, but there exists, in fact, as a result of this method of preservation, an induration which is altogether unnatural, and which impairs to a great degree the value of the subject for anatomical or surgical purposes. Tlie color and api)earance of the tissues as well as the tex- ture are altered, so that these cannot be taken as guides in recognizing different structures. In the living subject a very slight exertion will carry a sharp knife easily and smoothly through the tissues — almost, it may be said, to glide through without any effort on the part of the operator. In the dead subject, on the contrary, an effort is required to pass the knife through the structures, and in a subject 484 LIGATURE OF ARTERIES. prepared as above described, some force is necessary to divide them. The resistance offered by the tissues of the dead subject is well shown in the effort to introduce the catheter in the cadaver. Sometimes it is impossible to accomplish it, and even when done it has required so much force as to inflict injury upon the parts. The information derived from the operation is therefore of little practical value, since in the living subject the instrument is simply guided through the canal, passing almost by its own weight. The surgeon will find, therefore, in passing from operations upon the dead to those upon the living subject, that unless he exercises great caution he will overestimate the resistance of the tissues and fail to make his incisions as contemplated. INSTRUMENTS USED IN THE LIGATURE OF ARTERIES. Fig. 242. Instruments. — The instruments required to perform operations for the application of ligatures to arteries, are : — 1. A hnife Thar known as the scalpel, an instrument having a sharp point and a broad body or belly (Fig. 242). 2. A pair of dissecting forceps (Fig. 243) to seize and hold the tissues, as may be neces- sary, in their division. The forceps should be held between the thumb and index and middle fingers. 3. A grooved director A blunt-pointed director, from four and a half to five inches in length, with a groove upon its upper sur- face (Fig. 244). It is used to introduce beneath lavers of tissue before dividing them, LIGATLRE OF AKTERIES. 485 anFrom the opening in the adductor magnus mus- cle, obliquely downward and outward to the lower border of the popliteus muscle, traversing the middle of the popliteal space. Surface markings. — Borders of the muscles which form the boundaries of the popliteal space. General relations. — -In fro7it.-^ Above, the inner side of the femur; in the middle, the posterior ligament of the joint ; and, below, the popliteal fascia. Behi?id.^—The popliteal vein, layer of fat, internal pop- liteal nerve, fascia lata (deep fascia), superficial fascia, and skin. Inside. — Semimembranosus and inner head of the gastro- cnemius muscles. Outside. — -Biceps and outer head of the gastrocnemius muscles. Guides -Above, the border of the semimembranosus muscle ; below, the heads of the gastrocnemius muscle. Structures to be avoided External saphenous vein, popliteal vein, and internal popliteal nerve, with their branches. Operation. — In upper third. — -The patient being placed in the prone position, with the limb extended, an incision three inches in length should be made along the posterior margin of the semimembranosus muscle, dividing the skin. The superficial and deep fascias are next divided carefully on the director, bringing into view the border of the semi- THE POPLITEAL ARTERY. Fig. 279. membranosus muscle, which sliould be drawn inward, ing the internal popliteal nerve lying to the outside. rating carefully the layer of fat, which is usually between the nerve and the vein and artery, the latter is sought for beneath tlie vein, and somewhat to its inner side. Detaching cau- tiously the artery from the vein, the ligature needle is passed from without inward (Fig. 279). In the lower thirds between the heads of the gastrocnemius mus- cle An incision, three inches in length, should be made in the middle line, or slightly to the out- side of this line beginning opposite 1. The popliteal artery. 2. The skin. 3. The superficial fascia. 4. The fascia lata (deep fascia). 5. The internal popliteal nerve. 6. The biceps muscle. 7. The popliteal vein. expos- Se pa- found the bend of the knee-joint, dividing the skin. The super- ficial and deep fasciae should be divided on the director, care being taken to avoid the external or short saphenous vein, which perforates the deep fascia in the lower part of the popliteal space to join the ven^e comites. Superficial branches of the internal popliteal nerve are also to be avoided in dividing the fasciae. After the division of the deep fascia, the nerve, vein, and artery are found, placed in the order 556 LIGATURE OF ARTERIES. Fio^. 280. The Anterior Tibial Artery. named from without inward, between the heads of the gastro- enemus muscle. Flexing the leg, so as to relax the heads of the gastrocnemius, the nerve and vein are cautiously sepa- rated from the artery, and the ligature nee- dle is passed from without inward. The Anterior Tibial Artery — Surgical Anat- omy. — At the lower border of the pop- 7. Patella. 2 External malleolus. 3. Deep fascia. 4. Tibialis anticas mus- cle. 5. Extensor longns digi- torum muscle. 6. Peroneus longus and brevis • muscles cut across. 7. Border of fibula. S. Extensor proprius pol- licis muscle. 9. Flexor longus pollicis. 10. Anterior tibial artery. 11. 11. Veuse comites. 12. Anterior tibial nerve. 13. Dorsalis pedis artery. 14. The peroneal artery. THE ANTERIOR TIBIAL ARTERY. 557 liteus muscle the anterior tibial artery is given off from tlie popliteal, and, passing between the two heads of the tibialis posticus muscle and then between the tibia and fibula in the interspace above the upper margin of the interosseus mem- brane, it reaches the anterior surface of the leg, and lies upon the interosseous membrane (Fig. 280). In the upper part of its course it is connected to the interosseous mem- brane by delicate bands of fibrous tissue, which pass over it; and below, it lies upon the anterior surface of the tibia and the anterior ligament of the ankle-joint, passing beneath the anterior annular ligament. As it descends it changes its relations to the muscles, by reason of the direction the tibi- alis amicus and the extensor proprius pollicis take to their points of insertion, lying above, between the tibialis anticus and extensor longus digitorum, in the middle portion of the leg between the tibialis anticus and extensor proprius polli- cis, and in the lower part between the tendon of the extensor proprius pollicis and the inner tendon of the extensor longus digitorum. Its course may be indicated by a line drawn from the inner side of the head of the fibula to a point mid- way between the two malleoli. The anterior tibial nerve lies to the outer side of the ves- sel in its entire extent. In the middle it is in very close relation, getting somewhat upon its anterior surface. Yente comites are placed upon either side of the artery, and should be separated before passing the ligature. Course — From the lower border of the popliteus muscle, forward through the interspace between the tibia and fibula above the upper border of the interosseous membrane, and downward on the anterior surface of the membrane to a point midway between the malleoli. 47* 558 LIGATURE OF ARTERIES. Surface markings Crest of the tibia and tibialis antlcus muscle. General relations. — In front — Skin, superficial and deep fasciae, tibialis anticus, extensor longus digitorum, and ex- tensor proprius pollicis muscles, anterior tibial nerve, and anterior annular ligament. Behind. — Interosseus membrane, tibia, and anterior liga- ment of the ankle-joint. Inside. — Tibialis anticus and extensor proprius pollicis muscles. Outside. — Anterior tibial nerve, extensor longus digi- torum and extensor proprius pollicis muscles. Guides Tibialis anticus, tendons of the extensor longus digitorum and extensor proprius pollicis. Structures to he avoided. — Anterior tibial nerve and venae comites. Operation. — In the upper third. — Turning the limb in- ward and extending it, an incision four inches in length is made over the course of the artery through the skin, mid- way between the crest oi" the tibia and the outer border of the fibula. The superficial and deep fasciae are divided next on the director, and the septum between the tibialis anticus and extensor longus digitorum is sought for. This may be recognized as the first intermuscular space from within out- ward, and by a white line at the lower part of the wound. The different muscles should also be brought into action by moving the foot, which will assist in distinguishing the line of separation. Flexing the foot, so as to relax the muscles, they are separated with the handle of the knife or finger, and the artery brought into view as it lies on the interosse- ous membrane, embraced between the venae comites, with the anterior tibial nerve to the outside. Separating the THE ANTEKIOR TIBIAL ARTERY. 559 Fis. 281. veins from the artery, the ligature needle is passed from without inward. In the middle third At this point the artery is reached by an incision, three inches in length, over the course of the vessel, somewhat nearer to the crest of the tibia than above, dividing the skin. The fasciae are divided, and the artery is found on the tibia, between the tibialis anticus and the extensor proprius pollicis muscles, with the nerve lying over it. Separating the nerve from the artery, the ligature needle is passed from witiiout in- ward (Fig. 281). In ligaturing the artery at this point, care should be taken to avoid mak- ing the incision too far from the crest of the tibia. It is to be remembered that the artery at this point approaches the tibia. In the lower third An inci- sion three inches in length, dividing the skin, is made along the external border of the tibi- alis anticus muscle to the upper 1. Extensor proprius pollicis and extensor longus digitorum muscles. 2. Tibialis anticus rnuscle. 'H. Venae comites. 4. Artery. margin of the anterior angular ligament, which passes obliquely across tlie limb from above downward, from tiie external to the internal malleolus. The superficial and deep fasciae are divided carefully on the director, and the artery sought for as it lies between the tendons of the tibialis anti- 560 LIGATURE OF ARTERIES. cus and extensor proprius pollicis, with the nerve to the outside. If not found in this position, it may be sought for beneath the tendon of the extensor proprius pollicis, or between this tendon and that of the extensor longus dim- torum. The ligature needle is passed from without inward, the venae comites having been separated from the artery. At this point of its course the artery is superficial, and deep dissections should be avoided in seekinsf it. Fis. 282. ii'l The Dorsalis Pedis Artery Surgical Anatomy- — The dorsalis pedis artery is the continuation of the ante- rior tibial, beginning at the point midway between the malleoli, and passing down the foot, near to the tibial bor- der, to the first interosseous space. It is superficial in its entire extent, lying upon the bones of the tarsus, crossing the astragalus, scaphoid, middle cuneiform and a slight portion of the internal cunei- forms, with the internal branch of the anterior tibial nerve to the out- side. At its lower part, the inner tendon of the extensor brevis digi- torum crosses it (Fig. 282). Course From the bend of the ankle forward and downward to the first interosseous space. A line 1. Anterior aanular ligament of the tarsus. 2. Tendon of the extensor proprius pollicis muscle. 3. Tendons of the extensor longus digitorum muscle. 4. Extensor hvevis digitorum muscle. 5. Dorsalis pedis artery. Dorsalis Pedis Artery, 6. Anterior tibial nerve. THE DORSALIS PEDIS ARTERY. 5G1 drawn from a point midway between tlie two malleoli to the space between the first and second metatarsal bones, indi- cates its course. Surface marking Extensor proprius poUicis muscle. General relations In front Skin, superficial and deep fasciae, inner tendon of extensor brevis digitorum muscle. Behind Astragalus, scaphoid, middle and internal cuneiform bones and their ligaments. Inside. — Extensor proprius pollicis muscle. Outside Extensor longus digitorum muscle and anterior tibial nerve. Guides Tendon of the extensor proprius pollicis muscle and inner tendon of the extensor brevis digitorum. Structures to he avoided Anterior tibial nerve and vena? comites. Operation An incision, two inches in length, not extending below the upper point of the first interosseous space, is made along the outer border of the ex- tensor proprius pollicis muscle, di- viding the skin. The superficial and deep fasciae are divided on the director, and the artery exposed, lying between the tendon of the extensor proprius pollicis muscle and the inner border of the exten- sor brevis muscle, with the nerve to 1. Inner tendon of the extensor brevis digitorum muscle. 2. Venae comites. 3. Tendon of the extensor proprius pollicis muscle. 4. Dorsalis pedis artery. Fig. 283. 562 LIGATURE OF ARTERIES. Fig. 284. the outside. The lig- ature needle is passed from without inward, avoiding the venae co- mites (Fig. 283). The Posterior Tibial Artery Surgical Anatomy. — The posterior tibial artery is the larger of the terminal branches of the popliteal ; aris- ing at the lower border of the popliteus mus- cle,- it passes obliquely, from without inward, down on the posterior surface of the leg to the space midway be- 1. Patella, 2. Internal malleolus. 3. Internal surface of the tibia. 4. Deep fascia. o. Soleus muscle drawn aside. 6. Tendo Achillis. 7. Tibialis posticus. 8. Flexor longus digitorum muscle. 9. Gastrocnemius muscle. 10. Posterior tibial artery. 11. Venae comites. 12. Posterior tibial nerve. 13. 13. Internal or long saphe- nous vein. The Posterior Tibial Artery. THE POSTERIOR TIBIAL ARTERY. 563 tween the internal malleolus and the tuberosity of the os calcis, where it terminates as the inteinal and external plantar arteries (Fig. 284). A line drawn from the middle of the popliteal space to a point behind the internal malleo- lus, will represent the direction it takes. In the upper part of its course it lies upon the tibialis posticus muscle, beneath the gastrocnemius and soleus muscles, covered by the inter- muscular fascia, which separates it from the soleus. As it descends it becomes superficial, and in the lower third passes along the inner border of the tendo Achillis, a short distance from its point of origin. The posterior tibial nerve occupies a position to the inside, then it crosses the artery, and passes on the outside in the remainder of its course. Venas comites accompany it in its entire extent. As it passes round the heel, it lies between the tendons of the flexor longus digitorum and flexor longus pollicis, embraced between the vense comites, with the nerve to the outside. Course. — Obliquely downward and inward from the lower border of the popliteus muscle to a point midway between the internal malleolus and the point of the heel. Surface markings.- — Inner border of the tibia and the tendo Achillis. General relations. — -In front. — -Tibia, tibialis posticus and flexor longus digitorum muscles, ankle-joint. Behind. — Soleus and gastrocnemius muscles, deep and superficial fascise, skin. Inside. — Upper third Origin of soleus muscle; above, to slight extent, posterior tibial nerve. Outside — Lower two-thirds — Posterior tibial nerve. Guides. — Above. — Intermuscular fascia, which separates the superficial and deep layers of muscles. Below. — Tendo Achillis. 5G4 LIGATURE OF ARTERIES. dividing the skin. Fig. 285. Structures to he avoided Internal saphenous vein, pos- terior tibial nerve, and venae comites. Operation. — In the upper third. — Placing the limb on the outer side, with the leg flexed and the foot extended, so as to relax the muscles of tlie calf, an incision four inches in length is made along the inner border of the tibia. The superficial fascia should be divided on the director, care being taken to avoid the internal saphenous vein which passes up the leg in this region between its layers. The deep fascia being divided, the mar- gin of the gastrocnemius is exposed, which should be drawn aside, and the attachment of the soleus to the tibia divided on the director. Seeking the intermuscular septum which binds the artery to the posterior surface of the tibialis posticus, it should be divided cau- tiously, and the artery exposed. Increase the flexion of the leg so as to relax to the fullest extent the muscles of the calf, then sepa- rate the vena3 comites from the artery, and pass the ligature from without inward, avoiding the pos- terior tibial nerve (Fig. 285). The posterior tibial artery can be exposed in the upper portion by an incision on the posterior surface of the leg through tlie superficial muscles. This method is not advised, owing to the great amount of injury inflicted on 1. Solens muscle. 2. Venre comites. 3. Arterv. THE POSTERIOR TIBIAL ARTERY. 565 the structures, although drainage can be better effected than in the metliod of operation above described. In these opemtions the relations of the intermuscular septum to the artery should be remembered. The septum is a pearly white membrane which covers the artery, and which can be seen distinctly, and recognized by its color and the transverse direction of its fibres. It separates the superficial and deep muscles, and beneath it the artery is placed with its veins and the posterior tibial nerve. In dividing tlie attachment of the soleus muscle to the tibia, care should be taken to avoid severing at the same time the origin of the flexor longus digitorum. If this precaution is neglected, the substance of the muscle will be invaded and the artery missed. Its position should be remembered as being on the posterior surface of the tibialis posticus muscle, covered by the intermuscular septum. In the middle third. — The limb being in the same posi- tion as for the ligature in the upper third, an incision three inches in length midway between the inner border of the tibia and inner edge of the tendo Achillis should be made, dividing the skin. Fixing the position of the internal saphenous vein, the superficial and deep fascia? should be divided on the director, avoiding it. Seek the edge of the tendo Achillis, and divide the layers of fascia connected with it. The artery, surrounded more or less by fat, will be found along the inner edge of the flexor longus digitorum, accompanied by its veins, with the nerve to the outside. The ligature should be passed from without inward, avoiding the nerve. In the lower third. — An incision two inches in length is made along the inner border of the tibia, and three-quarters of an inch posterior to it, dividing the skin. The sheath of 48 obb LK^^ATUEE OF AETEEIE?. the artery, with its venae comites. will be found imbedded in fat, which is peenliar to this region. Separating the veins from the artery, the ligature should be passed from without inward, to avoid the posterior tibial nerve, which lies to the outside. In this operation care should be taken to avoid opening the sheaths of the tendons which are placed on the posterior surface of the tibia Fig. 286. (Fig. 286). At the anUe. — A semi- lunar incision two and one- half inches in length should be made midway between the internal malleolus and the heel, dividing the skin. The strong and dense fascia (the internal annular liga- ment) covering the vessels and nerves, which is now exposed, and which is closely adherent to the sheaths of the tendons, should be divided cautiously on the director. The sheath of the vessels should be opened, the vence comites separated from the artery, and the ligature passed from below upward, avoiding the posterior tibial nerve. 1. Skin and fasciae. 2. Posterior tibial nerre. -3. Tense comiies. II. Posterior libial artery. The Peroneal Artery — Suegical Axatomt — The peroneal artery arises from the posterior tibial and passes down the posterior suiface of the leg along the outer or tibular side, terminating in branches on the back and outer THE PERONEAL ARTERY. 567 side of the aukle. A line drawn from the posterior part of the head of the fibula to the external border of the tendo Achillis at the malleolus will indicate its course. Course — From point of origin from the posterior tibial artery an inch below the lower border of the popliteus mus- cle, obliquely outward to the fibula, descending along its inner border to the ankle (Fig. 280, 14). Surface marking The fibula. General relations In front Tibialis posticus and flexor longus pollicis muscles. Behind. — Soleus and flexor longus pollicis muscles, fascia, and skin. Outside. — Fibula. Guide Flexor longus pollicis muscle. Structures to he avoided. — The peroneal nerve. Operation — An incision three inches in length, parallel with, but behind, the external border of the fibula, should be made, dividing the skin. The attachment of the soleus muscle to the fibula must be divided, if necessary, and the muscle drawn inward. The origin of the flexor longus pollicis is to be detached, and the artery wiU be found to the inner side, lying beneath a strong aponeurosis on the anterior surface of this muscle, which must be divided. The ligature should be passed so as to avoid the peroneal nerve. PART VI. AMPUTATIONS Amputations are operations which are performed for the purpose of removing a limb or a part of a limb from the body. The point of separation may be either in the con- tinuity of the limb, through the bone, or at the articulation, between two or more bones. Conditions demanding Amputation Amputation is, as a rule, required in those cases in which the condition of the part, whether as the result of injury or disease, is such as to jeopardize the life of the patient or involve a more extensive loss of the limb, by the adoption of a more conservative plan of treatment. In every case of very serious injury or disease involving a limb, the best judgment of the surgeon, based upon his knowledge and experience, should be exercised in arriving at a decision. It is, frequently, a very doubtful point to decide whether a patient will sustain better the attendant shock of an amputation and the subsequent demand upon his reparative powers, than the risks of inflammatory conditions and the longer drain upon his system, by an effort to save the limb. It is further to be considered that, in some instances, a limb may be saved with its functions so impaired and the deformity so great as to render it a useless and obstructive appendage. The question of the occupation AMPUTATIONS. 569 of the individual as well as his status in life should enter somewhat into the decision. To a working man, an arti- ficial appliance even if of rudest construction, will be of more service than the natural limb preserved in a deformed and useless condition. The conditions which call for amputation include injuries and diseases of the soft structures, of the hones and joints, malformations, deformities, aneurisms, and gangrene. The injuries of the soft tissues which may require amputa- tion embrace extensive lacerations and contusions involving bloodvessels and nerves, the results of the application of force, or gunshot wounds. Tlie diseases whicli may necessitate re- moval of the part or limb are generally of a malignant character. iS on-malignant growths, when of large size, may demand am- putation by reason of the pressure exerted. Wlien amputa- tion is performed for malignant tumors, the section should be made some distance from the seat of the disease. Tiie injuries of the bones which require amputation are associated usually with those of serious injuries of the soft tissues, as compound and comminuted fractures, the result of railroad crushes or severe gunshot wound. Where it is necessary to transport a patient some distance, as in military campaigns, it may be, in many instances, more prudent to amputate the injured limb than submit the patient to the dangers resulting from the motion and jarring incident to transportation over rough roads. Extensive necrosis, osteomyelitis, and malignant tumors of the bone, as well as ulcers, malignant and specific, of the soft tissues which in- volve the bone secondarily, demand amputation. Compound dislocations are sometimes of such gravity, by reason of complications, as to require amputation, especially those of the knee-joint. In diseases of the joints, amputa- 48* 570 AMPUTATIONS. tion is not often required, excision beinjj^ usually successful in the removal of the diseased tissue. Malformations^ which are causes of disability, require in some cases amputation. Supernumerary fingers or toes may be removed without danger at an early period of life. Deformities^ which are at the same time sources of disability and which cannot be relieved by excision or section of ten- dons, demand amputation. Aileurisms sometimes require amputation, as in cases of secondary hemorrhage, following ligature of the vessel per- formed for its relief, or rupture of the aneurismal sac. Rapture, caused in the efforts at reducing old luxations or complete division of the main artery of a limb, the result of gunshot wound, call frequently for the removal of the limb. Gangrene, consequent upon injury, demands amputation, performed preferably after the formation of the line of de- marcation. In traumatic conditions amputation may be j;erformed either in the primary, intermediary, or secondary period. The primary stage is that included between the receipt of the injury and the supervention of inflammation. This period may be limited usually to twenty-four or thirty hours, varying in different cases. Amputation should be performed in this stage as soon as reaction is established, which con- dition is indicated by a re-establishment of the circulation and a restoration of warmth and color to the surface. This is the most favorable period in which amputation can be performed and should be the time chosen if possible by the sm'geon for the performance of the operation. The intermediary stage embraces the period between the ac- cession of inflammation and the establishment of suppuration. Amputation should be performed in this stage only when INSTRUMENTS. 571 it cannot be avoided, as may happen in accidents in which the patient may not obtain the services of the surgeon until the primary stage has elapsed, and the conditions are such as to demand immediate interference. The secondary period is that in which the inflammation has passed to the stage of suppuration, the acute symptoms having measurably subsided. While this stage offers better prospects of success than the intermediary, it is still an un- favorable one, owing to the state of exhaustion which exists after the subsidence of the active inflammation. In this stage, tonics and good diet will improve the patient's condi- tion and place him in a more favorable state for operative interference. Patients are frequently permitted to pass into this stage on account of the opposition of the patient or of his friends to the performance of amputation when the primary stage is present. INSTRUMENTS USED IN AMPUTATIONS. The instruments and appliances required in performing these operations are knives, saws, bone-nippers, dissecting forceps, artery forceps, tenaculum, ligatures, sutures, suture- needles, scissors, retractors, and tourniquet. 1. Knives. — These consist of amputating knives, large and small, the catlin, bistoury, and scalpel. The amputating knives may vary in length from seven to twelve inches; in width, from three-eighths to three-quarters. They should have thick backs, the principal cutting edge extending the whole length of the blade, and the edge upon the back not longer than an inch and a half. They should be mounted in strong and roughened handles (Figs. 287 288, 289). 572 AMPUTATIONS. The catUn or douhle-edged knife (Fig. 290) is used, and forms part of the operating cases ; it is employed to divide the interosseous membranes and intervening tissues in am- Figs. 294. 293. 292. 291. 290. 289. 288. 287. INSTRUMKNTS. i)7:] putations of the forearm and leg. It can be dispensed with, the bistoury or scalpel accomplishing this portion of the operation equally well. It should not be used to make flaps by transfixion, as the borders are liable to be cut in a jagged manner by the double cutting edge of the instrument. r. 295. Fig. 297. The bistoury should have a narrow, sharp-pointed blade three inches in length, with a strong back to it (Fig. 291). 574 AMPUTATIONS. The scalpel should have a strong blade three inches in length, with a broad body and a sharp point (Fig. 292). 2. Saws. — These may be of two kinds. The one for larger bones should be ten inches long by two and a half wide; strong, with heavy back, and teeth not too widely set (Fig. 295). For the bones of the hand, a small saw, called tlie metacarpal saw, is employed (Fig. 296). A small saw, with a movable back, is used for the foot (Fig. 294). 3. Bo7ie-nippers or cutting pliers are used for dividing the bone in amputation of phalanges or cutting off rough edges left by the saw. The blades should be short and sharp, and the handles long and strong (Fig. 297). 4. Artery Forceps are used to seize the divided vessels. The blades should be toothed, so as to hold firmly, and ex- Fig. 298. Fig. 299. panded a short distance above the point, in order that the ligature may slip over easily, and not include the point in the knot. They should fasten with a spring or c^tch (Figs. 298, 299). INSTRUMENTS. 575 5. The Tenaculum. — A sharp, slightly curved hook (Fig. 300). This is used to penetrate the coats of the vessel and hold it while the ligature is applied, or to pick up a mass of tissue when it is not possible to isolate the artery. 6. Ligatures, sutures, suture needles, and scissors have already been described (pp. 479-486). Fig. 300. 7. Retractors — These are formed from pieces of strong muslin, six to eight inches wide and of proper length to embrace the limb, one end being torn into two or three tails. Tliey are applied around the bone to retract the Fig. 301. Fig. 302. soft structures, and prevent injury to them by the saw, and also to protect them from tlie bone dust (Figs. 301, 302). 576 AMPUTATIONS. In securing the flaps in apposition bv sutures, that first introduced should be in the centre, and should be carried in a direction so as to pass first through the most dependent flap. The remaining sutures should be applied on either side of the first, alternately, so as to support the flaps equably and prevent dragging. Care should be taken to avoid the introduction of too many sutures — a suflftcient number only to bring the edges in accurate apposition should be used. If the subcutaneous tissue protrudes between the edges of the flaps as they are drawn together, it should be turned in and the cut surfaces placed evenly in contact, folding in of the edges being carefully prevented. Adhesive strips, compress, and roller are required in the living subjects to complete the dressing. Methods of Controlling Hemorrhage In per- forming amputations in the living subjects, it is necessary to adopt means for controlling hemorrhage after section of the bloodvessels. For this purpose the tourniquet, an instru- ment devised by Morel in 1674, and subsequently modified by Petit, has been employed (Figs. 303, 304). Within a few years. Prof. Esmarch, of Germany, has introduced an apparatus for bloodless operations, which consists of tliree yards of red elastic and four feet of rubber tubing, with hook and chain. The elastic bandage measures two and a half inches in width, and is applied to the limb by spiral turns, beginning at the distal point and terminating a short dis- tance above the point where section is to be made. The rubber tubing, which is three-eighths of an inch in width, is then applied by two or more turns just above the border of the last turn of the bandage, and fastened securely by the hook and chain (Fig. 305). On removal of the bandage, METHODS OF CONTROLLING HE3I0RRHAGE. 577 the limb presents a blanched appearance, and on section the vessels and tissues are found free from blood. In the place Fig. 303. of the red elastic, an ordinary rubber band of the same length and width can be employed. To avoid a possible injury to the nerves of the part by undue pressure on the part of the rubber tubing, the author suggested, and employed some years since, a rubber band, measuring one and a half inch in width, as a substitute for the tubing. It was found to answer the purpose of making pressure equally as well as the tubing, and to avoid injury to the nerve structures (Fig. 306). 40 578 AMPUTATIONS. Fig. 304. Fis. 305. When it is not thought needful to apply the tourniquet or bloodless apparatus the hemorrliage may be controlled by 306. digital pressure as shown in Figs. 307, 308. In cases of hemorrhage following injuries or gunshot wounds an im- METHOD* OF CONTROLLING HEMORRHAGE. 579 Fiff. 307. Fijr. 308. provised tourniquet may be employed, made as represented in Figs. 309, 310. Yis. 310. The instruments which are required in performing am- 580 AMPUTATIONS. Fig. 311. putations are arranged in a convenient manner in the amputating-case (Fig. 311). METHODS OF AMPUTATION. There are two principal methods of amputation ; the circular and the flap. The oval may be regarded as a variety of the circular, and the rectangular of the flap method. The Circular Method This operation may be de- scribed as consisting of three staores. The first stage includes the division of the skin and superficial fascia ; the second, that of the muscles and other structures to the bone ; and the third, section of the bone. THE CIRCULAR METHOD. 581 In performing the operation, tlie opei'ator stands so as to enable him to grasp the proximal part and retract the super- ficial tissues with the left hand ; then, stooping so as to place his face on a level with the limb, he carries the amputating knife, held lightly in the right hand, around to the opposite side of the limb until the blade is perpendicular to the floor, pressing the heel firmly into the tissues (Fig. 312). He Fijr. 312. then makes a circular cut around the limb, rising as he makes it, so as to complete the entire incision with one motion. Separating the skin and fascia by careful dissection (Fig. 313), to the extent of two or two and a half inches, the cuff or fold thus formed is turned back, and the knife is carried about the limb just below its border in the same manner as above described, dividing the muscles and other structures to the bone. A circular sweep is now made around the bone, dividing the periosteum, which, with the muscular structures, is dissected up to the extent of an inch 49* 682 AMPUTATIONS. or more. The retractor is now applied, the tails being directed upward, and crossed in such manner that they, with the body of the retractor, completely cover the cut surfaces. The tissues being firmly pressed back, tlie saw, held vertically, is applied to the highest point exposed Fig. 313. Fig. 314. (Fig. 314), and drawn from heel to point, steadied carefully by the thumb-nail of the left hand, and the bone divided by short, light, and even strokes. If two bones are to be sawn, the saw should be used so that the smaller and most movable shall be divided first. The vessels are now to be ligatured, spicula of bone (if any exist) removed by the bone nippers, the projecting ends of nerves and tendons retrenched, and the edges of the fold of skin brought into apposition transversely, and fastened together by means of sutures. THE CIRCULAR METHOD. 583 In applying ligatures to the arteries after amputation, the divided end is to be seized with the artery forceps (Fig. Fiff. 31 315) or transfixed by the tenaculum, and drawn out (Fig. 316) from the tissues so as to isolate it — any structures Fig. 316. which adhere to the artery can be pushed back by the handle of the knife, or carefully removed by dissection. 584 AMPUTATIONS. Great care should be taken to avoid the inclusion of the nerve in the ligature, else the most serious consequences may ensue, such as secondary hemorrhage or tetanus. It is important that the end should be cut across straight, and not obliquely, and that the ligature should be applied a sufficient distance from the divided end to insure complete occlusion of the vessel. One end of the ligature should be cut off close, and the other brought out between the flaps at the nearest point to the surface. The most important vessel may be indicated by a knot tied in the ligature, or the two ends may be allowed to remain, and be then knotted. It is important that the ligature should be applied securely to the artery, and to accomplish this the reef-knot should always be used. To tie this knot successfully the following Fi^. 317. method is given by Mr. Heath. The ligature is to be held in the palm of the right hand between the thumb and index finger, the end is then to be thrown around the forceps closely and caught with the left hand ; the right hand is now brought under the end in the left, when that end is to THE CIRCULAR MKTIIOD. 58o be crossed over the right thumb and inserted between tlie third and fourtli fingers of the right hand (Fig. 317), the Fig. 318. left hand at the same moment seizes the outer end, and thus an interchange is effected, and the ends of tlie threads are drawn out (Fig. 318). The index fingers or thumbs can be 586 AMPUTATIONS. Fig. 320. used to draw this knot tight (Fig. 319). The knot is com- pleted by another tie, the same manoeuvre being effected, taking care to begin with the opposite hand to that which began before. Where the cut end of the artery is short and deeply im- bedded in the tissues the ligature may be applied by transfixing the tissues with a handled needle, armed with a ligature which is deposited as is shown in Fig. 320. The double liga- ture should be cut and each half tied and tiien a turn should be made around the entire vessel. The method of applying haemostatic for- ceps after amputation is shown in Fig. 321. He- morrhage may be controlled in some instances by torsion (Fig. 322), or by the in- troduction of acupressure pins, of which different me- thods are employed (Fig. 323). As the ligatures are lia- ble to become adherent to the dressings, it is a good plan to fasten them to the surface by short pieces of adhesive plaster, so as to THE CIRCULAR METHOD. Fig. 321. 587 prevent them from being pulled upon when the dressings are removed. The projecting ends of the nerves should be removed, in order to prevent them from being held between the flaps, 588 AMPUTATIONS. Fig. 322. and thus, after union has occurred, liable to be submitted to pressure. The tendons should be cut off close, as their pre- sence interferes with the healing process. Ficr. 323. Several points are to be noted by the surgeon In perform- ing the circular operation. When the circular cut around the limb is made, care should be taken that the point of the knife does not strike the face as it turns. It happens some- THE CIRCULAR METHOD. 589 times that tlie incisions are not made successfully because tlie knife is drawn around the part, the heel alone being kept in contact with the surface. The knife should be drawn gradually from heel to point as it passes around the limb, finishing the cut with the point. The amount of pressure to be employed varies somewhat with the condition of the part and of the knife, whether sharp or dull. Practice alone will enable the operator to acquire proper knowledge upon this point. Before making the second incision, it is directed that the cuff of skin and fascia, which has been formed, should be turned up. In some cases, owing to the conical shape of the limb, this may be difficult to accomplish. When it is found difficult to turn this back, it should be slit open at one side. In making the second incision, the assistant should hold back the cuff, so as to avoid its section as the knife is car- ried around the limb. The periosteum is directed to be dissected up to some distance ; this is desirable, in order to secure good repair in the divided end of the bone and prevent exfoliation. In sawing the bone the saw should be held vertically, so as to divide it from side to side, and thus avoid a liability to fracture or splintering. Proper care should always be taken in supporting the portion to be removed during this part of the operation. The manner in which the limb is held and supported is of great importance, as splintering and fracture occur fre- quently from want of proper knowledge upon this point. The limb should be covered with a towel or bandage, so that a firm grasp can be taken ; and, while it is firmly sup- ported, without being raised up or down, it should be drawn 50 590 AMPUTATIONS. away with moderate force from the body in the line of its long axis. This action will cause a separation of the ends, and prevent binding of the saw, while steady support com- bined with it, will remove the weight of the limb. The circular method of amputation can be employed at any part of the limb ; it is preferably used where there are two bones or an absence of muscular structures, as in the lower portions of the forearm and leg. The Modified Circular Method This name is given to an operation which consists in forming two short Fig. 324. flaps of skin and superficial fascia by cutting from without inward, and dividing the muscles by a circular incision (Fig. THE FLAP METHOD. 591 324). It may be employed in cases where tliere is a redundancy of muscular tissues. The Flap-Method Amputation by the flap method consists in the division of the tissues so as to form one or more flaps, with which the end of the bone is covered. Tliese flaps may be made by cutting from without inward to the bone, or from ivithin outivard, the knife transfixing the tissues, and cutting from the bone to the surface. In some instances, one flap is made in the first way, and the other in the second. The flaps may vary in number from one to two or more, according to the circumstances of each case. The length also varies according to the size of the limb. A safe rule to adopt is to make them equal in length to three-quarters the diameter of the limb at the point of section of the bone. Tliey may be made antero-posteriorly, laterally, or obliquely, and may include all of the structures to tlie bone, or may be made of skin and fascia alone, the muscles and other structures being divided circularly. They may be cut of equal lengtli, or one may be longer than the otlier, according to the amount of muscular tissue in the part involved. They are, as a rule, convex in shape, terminating in a point more or less oblique. Care should be taken to avoid making them too oblique ; and it should be remembered that it is always better to have an abundance of tissue rather than too small an amount. In the one case the redundant tissue can be retrenched ; in the other it may be found difficult to supply the deficiency. If, in any case, the flaps are found to be too short, and there is danger of protrusion of the bone, the bone should then be sawn througli at a higher point. In performing the operation by transfixion the operator stands so as to grasp the proximal part of the limb firmly 592 AMPUTATIONS. with the left hand. Raising the tissues so as to see that the flaps to be made will be, as nearly as possible, of equal size, the point of the amputating knife is entered on the side, midway between the upper and lower borders of the limb, and pushed inward until it strikes the middle of the bone. The handle of the knife is then depressed until the point is carried over the bone, and then elevated, returning the blade to the horizontal position, in order to bring the point out exactly opposite to the point of entrance. The knife, still in the horizontal position, and in close contact with the bone, is carried downward with a sawing motion to a sufficient distance, and then turning its edge to about an angle of 45°, it is carried upward and outward until the tissues are divided. In cutting outward, the handle of the knife should be gradually turned in the hand, so that when the edge leaves the tissues it will look directly upward. In this way, a pointed flap Fig. 325. will be avoided. Turn- ing back the flap, the knife is re-entered at the same point as before, car- ried under the bone by movements similar to those used in making the first flap, the point brought out as before (Fig. 325), and the flap cut in the same way as the first. The flaps are now held back by the retractor, and the remainins tissues and TlIK FLAT AIKTIIOD. 593 periosteum divided by a circular cut of the knife. The periosteum is dissected back to a sufficient extent, and the bone sawn. Tiie arteries are ligatured, nerves and tendons retrenched, and sutures introduced, as described in the cir- cular method. In transfixing the tissues in this operation in the arm and thigh, it is important that the principal artery should not be pierced by the point of the knife in making the first flap, as a punctured wound or a longitudinal slit will be made in the vessel which may cause serious trouble, the operator being compelled to dissect back to a sound portion of the artery in order to apply the ligature. If the position of the main artery is well ascertained before the incisions are commenced, the point of the knife can be passed so as to avoid it. An effort should always be made to leave it in the flap which is made last thus deferring its division to the later stages of the operation. In the arm and thigh, where the superficial fascia is usu- ally abundant and the skin is very elastic and moves readily over the subjacent muscular tissues, care must be taken, in cutting from within outward, to retract the skin firmly, so that when the section is completed the muscles and skin will be divided on the same line. If this important injunction is unheeded, the operator will find a projecting mass of mus- cular tissues without sufficient skin to cover them. This mass should be retrenched, otherwise, if an attempt is made to pull the skin forcibly over it and then apply sutures, these will cut through, owing to the undue tension. It may be advisable, in some instances, when cutting from within outward, to turn the knife so as to divide the muscles at a higher point than the skin, thus reducing the muscular mass in the flap and giving a longer skin flap. 50* 594 AMPUTATIONS. In forming antero-posterior flaps by transfixion, tlie anterior flap should be made first. In the lateral flap operation, the outer flap should be cut first. As a rule, the principal artery should be contained in the flap formed last. An effort should be made, in cutting the flaps in the living subject, to form them with regard to shape and size, so as to obtain a stump to which an artificial appliance can be adapted with comfort to the individual, the line of the cica- trix being so placed as to be free from pressure. In the flap method, the flaps may also be made by cutting from without inward. When this plan of forming them is adopted, the amputating knife or, if preferred, a large scalpel, should be entered on one side, at the point fixed upon for section of the bone, and carried over the front of the limb, making a curvilinear incision downward to the extent nec- essary to give proper length to the flap, bringing it out at a point just opposite to that of entrance. With this incision, the skin and superficial fascia, or the entire structures to the bone, are divided. The posterfor flap may be formed in the same way, or by translixion. The Oval Method (Scoutetten's method) This method, as stated above, may be regarded as a modification of tlie circular. It may be employed when amputation is performed in the continuity of a limb, but it is more fre- quently adopted in disarticulations or amputations through the joints. The incision is made by introducing the knife a few lines above the point of section of the bone or above the joint, carrying it downward in a vertical line for a short distance, and then sweeping it about the limb in an oblique direction, dividing all the structures to the bone, and re- THE llECTANGULAR FLAP METHOD. 595 turning to the point of entrance. It may also be made by two incisions in the sliape of the letter v reversed, these being made first and tlien united by a transverse cut. The Rectangular Flap Method (Teale's method). — Tins is a moditication of the double flap, and consists in forming two rectangular flaps, a long and a short one. The length and breadth of the long flap should be equal to one- Fiff. 326. Fig. 327. Fiff. 328. Aa//" (preferably one-third) the circumference of the limb at the point of section of the bone, and the short flap, which should contain the vessels, should measure one-eighth the cir- cumference, or one-fourth the length of the long flap. The 596 AMPUTATIONS. lines of incision should be traced out upon the part (Fig. 326), and in cutting the flaps tlie knife should be carried to the bone, including all of the structures. The flaps should be dissected up, and the bone divided as in the otlier methods, care being taken to remove all rough points and spicula (Fig. 327). The long flap is then drawn over the end of the bone, and attached by sutures to the short one at the end and sides. Tlie apposed edges of the long flap sliould also be secured by sutures (Fig. 328). The different methods of amputation described above may be employed witli advantage in different parts of the limb. When thus employed they are found to serve well the pur- pose of a covering to the divided bone. Certain objections have been urged against the circular and flap methods to which reference may be made. The time required in the circular method to fashion the flap is objected to, and is of little consequence so long as the patient is under the influ- ence of an anaesthetic. The separation of the flap from the deep fascia causes the division of a number of nutrient vessels, and leaves it dependent entirely upon those at tlie point of reflection, which may not be sufficient to supply nutrition in long flaps and in those in which mucli contusion of the parts has occurred. It is desirable in order to facilitate tlie turning over of the flap and to prevent too much tension at the time to incise it. The advantages of this method are the absence of danger of bone protrusion, of the formation of a conical stump, of the occurrence of secondary hemorrhage, by reason of the straight incision of the arteries, and of deep- seated suppuration. The principal objections to the flap method are the oblique incision of the arteries, the occurrence of neuralgia on account of the pressure exerted, and the delay in union THE AFTER-TREATMENT. 597 owing to the large cut surfaces. The large muscular cushion left after the flap operation, and which is claimed as an advantage, gradually undergoes atrophy, leaving in its place a mass of connective tissue. The great objections to the rectangular flap is the large surface divided and the amount of bone removed. The special methods of operation upon the foot and at the various articulations are modifications of the principal varieties ada[)ted in each case to the configuration of the part. After treatment. — Hemorrhage having been controlled and the flaps adjusted by sutures, and, if necessary, supported by adhesive strips, the dressings should be applied. Much stress was laid formerly on the importance of allowing the wound to remain unclosed or pai'tially closed until all appre- hension of heraori-hage had passed away and the surface had become glazed with a layer of lymph. The edges were then approximated and the stump was dressed with the dry or wet dressings. The introduction of the antiseptic methods of wound treatment has effected a change, in the opinion of surgeons, with regard to the necessity of delay in applying the perma- nent dressings after amputation and in the character of dress- ings employed. The use of antiseptic agents at the time of the operation, the thorough drainage of the wound by the introduction of drainage tubes, whereby the wound fluids are immediately removed and disinfected in the dressings, with the accurate apposition of the cut surfaces by the employment of the various forms of sutures of coaptation, approximation, and relaxation, remove to a great extent the causes which give rise to unfavorable conditions during the progress of the after-treatment. While it is important that all oozing of blood should cease and that all clots should be carefully removed 598 A:\iprTATioxs. before closure of the wound, it is known that under the anti- septic methods the small quantity of blood not removed by the drainage tubes may undergo a process by which it becomes a pabulum for the cells of tiie newly organized tissue. The occurrence of these favorable conditions under antiseptic methods should not, however, relax the vigilance of the surgeon in all efforts to obtain complete control of the hemorrhage following operation by the careful application ot ligatures or other means before closure of the wound. TVhen the antiseptic dressings are employed the vessels sliould be ligatured by carbolized animal or silk ligatures, the former of which should be cut close and the latter cut in the same manner or brought out between the flaps at the nearest points. The surfaces of the flaps should be thoroughly douched with the carbolized or sublimated solu- tion, a drainage tube should be introduced at the bottom of the wound between the flaps, one end being brought out at each angle and secured by a loop of silk ligature cut off close. The flaps should now be approximated and held in contact by an assistant, while the metallic sutures are introduced. Carbolated or sublimated solutions should now be thrown through the drainage tube to douche the interior of the wound. If deemed necessary, strips of adhe- sive plaster may be employed to afford support to the flaps, and the carbolated or sublimated ^^-- ■^^^* dressings applied as directed in tlie cha})ter on Surgical Dress- ings. Over the dressing a band- age should be applied, beginning above and passing down to the end of the stump, which should be covered by recurrent and circular turns. Tiie stump should be placed upon an inclined plane tbrnied of pillows, and pro- THE AFTEII-TRKAT.MKNT. 509 tectcd from pressure of tlie bedclothes by a frame (Fig. 329). Redressing should not be made before the expira- tion of four to six days, the temperature record being the guide for the surgeon in this respect. If the temperature remains uniform or with slight variation the dressings should not be disturbed until the fifth to the sixth day, at which period the process of repair is well advanced. After this the dressings should be renewed in accordance with the amount of suppuration, if that has occurred, or the necessity for the removal of sutures or ligatures. Both should be gradually removed, the former when they have ceased to afford support to the edges or are cutting through the tissues, and the latter from time to time as they show on slight traction a disposition to separate. The ligature upon the main artery should be allowed to remain for a longer period than the smaller branches, and traction should be made very cautiously lest it be detached prematurely and fat^l hemorrhage occur. Treatment by '• pneumatic aspiration" or by the " open method" may be employed if deemed advisable. The former mode of treatment, devised by Maisonneuve, is designed to exclude the air from the stump, the flaps of which are held together simply by adhesive strips, and consists '• in surround- ing the stump with a closely-fitting hood of vulcanized rubber, to the centre of the free extremity of which is attached a tube of similar material, from two to three feet in length, the opposite end of which is fitted, by means of a metallic canula, in a rubber plug secured in a gallon glass jar. A second metallic tube pierces the rubber plug, and is con- nected with a vulcanized tube of convenient length attached to a brass exhausting pump. A few strokes of the piston, morning and evening, suffice to draw the discharges from GOO AMPUTATIONS. the Stump into the jar, where, in the absence of air, they accumulate without the danger of decomposition." The '* open method" of dressing dispenses with sutures, adhesive strips, and bandages during the first week of treat- ment. It is necessary that the flaps, in the amputations treated by this plan, should be entirely cutaneous, and, on account of the great shrinkage which occurs, proportionally large. In the method, as practised by the late Dr. James Wood, of ]Sew York, ''the wound is douched immediately after the operation with a moderately strong solution of carbolic acid and then filled with balsam of Peru, the drain- age being accomplished by the interposition of a pledget of oakum soaked in the balsam. If the stump becomes hot or painful from overaction the dressing is removed, otherwise it is allowed to remain undisturbed for twenty-four hours. After this the wound is douched twice daily with a weak solution of carbolic acid, and the balsam and oakum applied as in the first instance. At the end of the sixth or eighth day, w^hen suppuration has nearly ceased, the flaps are moulded into shape and gradually approximated with adhe- sive strips." This method of treatment, as stated by the late Prof. Gross, is not liable to be followed, as the ordinary close dressing, by erysipelas, abscesses, pyaemia, septicaemia, or suppurative fever. Affections of the Stump These may be primary or secondary, and local or local and constitutional in their origin. The primary conditions include hemorrhage, muscular spasm, pain, inflammation of a high grade, osteomyelitis, and protrusion of the bone due to the retraction of the muscles. Primary hemorrhage may occur from a few hours after the dressing to the fourth or fifth day. AFFECTIONS OF THE STUMT. GOl Hemorrliage of slight character is liable to follow in every case of amputation and to stain the dressings more or less. This form of hemorrhage does not require any special atten- tion. "When, however, the dressings are soaked with blood of a red or dark color they should be immediately removed and attention should be given to the source of the bleeding. Primary hemorrhage may occur from an artery which did not bleed at the time of the dressings and to whicli a liga- ture was not applied ; from an artery cut obliquely and, as a result, imperfectly ligatured ; from a vessel in a state of dis- ease or from one imbedded in inflamed tissues ; and it may also take place from the vessels of the Haversian canals. Etforts should be made to arrest the hemorrhage by elevation of the stump, the application of cold and digital compression of the main artery, combined with compression of the stump by a firmly applied bandage. If these measures do not succeed the flaps should be separated to sufficient extent to secure the bleeding vessel with a ligature. Hemorrhage from the divided bone may be arrested by pressure made with a com- press of lint to which a thread is tied, applied directly to the part, or the bleeding points may be plugged with pieces of catgut ligature, beeswax, or a plug of soft wood, sufficiently long to project beyond the edges of the flaps, and which may be withdrawn in a few days. The application of caustics should not be made lest necrosis be induced. Spasms of the muscles are very liable to occur after ampu- tation especially in nervous subjects and should be allayed by the hypodermic injection of morphia. The spasms are frequently accompanied by excessive pain, which should be relieved promptly by morphia. Erysipelatous inflammation, a frequent complication of am- putations under the old form of dressings employed, is not 51 602 AMPUTATIONS. liable to occur under antiseptic methods. In case of its occurrence it should be treated by constitutional and local remedies. If excessive suppuration occurs the pus should be conducted from the wound by drainage-tubes and fre- quent douching of warm antiseptic lotions should be made. Gangrene^ liable to occur in debilitated subjects and in badly ventilated and crowded hospitals, should be treated by the internal administration of stimulants and tonics and by the local application of counter-irritants in the earlier stages, and with poultices in the later stages to facilitate the removal of the slouorhs. Thorough drainao;e of the wound should be maintained, and antiseptic solutions should be freely em- ployed. Osteomyelitis may result from injury to the bone at the time of the accident or when the bone is divided by the saw in the amputation. It sometimes accompanies erysipelas and pyaemia, and is a very grave complication. It should be treated by the free use of antiseptic solutions thrown into the wound, and complete drainage to remove the wound secretions. Constitutional agents should be also employed to maintain the strength of the patient. When death of the bone occurs its removal should be delayed until the condition of the patient is sufficiently improved to enable him to with- stand the shock of the operation. Protrusion of the hone occurs as the result of inordinate retraction of the muscles, especially after amputations of the thigh, where the powerful muscles of the region are divided. The application of a firm bandage beginning above and passing downward to the end of the stump will frequently prevent retraction of the muscles. Extension by means of Aveights and pulley may also be employed as in fracture of the thigh. Subcutaneous section of the muscles may also AFFECTIONS OF THE STUMP. G03 be practised if other means fail. Section of the bone at a higher point may be performed after dissection of the tissues, or re-amputation may be required to provide a satisfactory stump. The principal secondary affections of the stump are secondary hemorrhage, necrosis of tlie bone, and neuralgia. Secondary hemorrhage may occur from the eighth day to the second or third week, and may be the result of premature separation of the ligature due to organic disease of tlie arterial walls or of sloughing caused by gangrene. It may be arrested by digital compression of the main artery of the limb, or by the introduction of an acupressure needle. If these measures are not successful, ligature of the main artery should be performed some distance above the stump. Hemoi-rhage sometimes occurs in connection with necrosis of the bone, and is arrested upon removal of the sequestrum. Necrosis of the bone may occur from injury inflicted at the time of the accident or operation, as the result of exces- sive inflammation and suppuration, or of interference with the proper blood supply causing defective nutrition. No efforts should be made to remove the sequestrum until it is completely detached, at which period it may be accomplished by careful dissection of the soft tissues. Violence should be avoided in extracting the sequestrum lest serious hemor- rhage be provoked. Neuralgia, due to peripheral or central conditions, occurs as an affection of the stump in persons of a nervous organi- zation, and more frequently in women than in men. The peripheral form may be the result of the pressure exerted upon the nerves of the stump by the cicatrix in the flap or by a bulbous enlargement of the ends of the divided nerves. Ordinarily the nerve ends undergo enlargement, G04 AMPUTATIONS, and give rise to no unplea??ant condition. When they assume the proportions of a wahiut, or even larger, forming a neuro- matous tumor, as sometimes happens, they become exqui- sitely painful. Internal medication is usually of little avail, especially in the severer forms, nothing short of excision or, if they are multiple, amputation, affording permanent relief. In addition to the secondary affections above mentioned, there are a number of sufficient importance to claim atten- tion, as caries of the bone ; choreaic spasms of the muscles of the stump ; the formation of a bursa upon the end of the stump caused by the pressure of an improperly constructed and adapted artificial limb ; a conical formation of the stump due to insufficient flap, retraction or sloughing of the flaps; fibroid, fatty, or malignant degeneration of the tissues of the stump caused by pressure of an artificial limb, or the recur- rence of malignant disease ; ulceration of the integumental covering of the stump, due to contracted flap or inflammation of the cicatrix ; eczema of the stump, the result of irritation in the cicatrix ; contraction of the tendons occurring chiefly in those of the biceps, semitendinosis and semimembranosis muscles of the thigh, and the tendo Achillis of the leg, the result usually of not maintaining proper extension during the after-treatment. Varicose enlargement of the arteries ot .the stump is a rare afl'ection, due to organic disease of the arterial walls. In most of the affections above enumerated, in the severer forms, excision or reamputation is required. In eczema of the stump internal remedies with local appli- cations are indicated, such as vaseline, with camphor and chloral to allay the itching, or carbolated zinc ointment. Subcutaneous division of the tendons should be performed in cases of contraction, and extension applied by weights and pulley. SYNCIIKONOUS AMPUTATIONS. G05 Sf/uchi'0)WKS Amputations In railway accidents, espe- cially where persons are crushed beneath the wheels of" a train, two or more of the extremities are frequently involved in the injury, and require removal simultaneously. (Fig. Fi-. 330. 330.) Where two of the extremities are removed it is desi"-- nated double synchronous amputation ; three, triple syn- chronous amputation. Of the former a number of operations have been [jerlbrmed, some of them successfully. 51* 606 AMPUTATIONS. Fiff. 331. Dr. James McCann, of Pittsburg, Pennsylvania, reports, in a paper read before the American Surgical Association, and published in volume 2d of its Transactions, 29 cases of double synchronous amputations performed in the Western Pennsylvania Hospital, of which 14 recovered, showing a moi-tality of 51 per cent. In the same paper he records a case of triple synchronous amputation performed successfully by Dr. W. B. Low man, of Johns- town, Pa., upon a boy aged 9 years (Fig. 331 ). Dr. J. G. Koehler, of Schuylkill Haven, Pa., performed successfully a similar operation in 1847 upon a boy aged 13. A similar success- ful operation was per- formed by Professor Stone, of New Orleans. In 1879 Professor Jo! in Ashhurst performed successfully a double synchronous amputa- tion on a boy thirteen years of age. In 1882 the author performed a double synchronous amputation upon a child aged eight, removing the left limb at the hip- joint, and tlie right in RE-AMPUTATIONS. GOT tlie lower tliird of tlie femur, the result of a crush by the wheels of a railway train. The patient died in a few hours after from shock. In these cases it is deemed advisable to remove the limbs at once and then ligature tlie vessels in each stump, the hemorrhage in each limb being controlled by competent assistants or the abdominal tourniquet. Re-amputations Under the heading of secondary affec- tions of tlie stump a number of conditions were referred to in which re-amputation was demanded. The operation should not be performed until the patient's health is such as to enable him to withstand the shock of the operation and care should be taken to guard against any undue loss of blood. The operation should be performed in the same manner as the primary amputation. In chronic diseases of the bone of the stump, it is sometimes difficult to determine with regard to the propriety of disarticulation in the place of amputa- tion in the continuity of the bone. The question must be decided in each case according to the extent of bone involved and the proximity to the articulation. Iiitra-iiterine Amputation — Instances have been recorded of amputation of the limbs of \.\\q foetus in utero. One, two, or all of the limbs may be removed, the separation being either partial or com[)lete. It is the generally received opinion that the amputation is produced by a band of false membrane which surrounds the limb, and by its contraction gradually severs the tissues. Constitutional effects. — Amputations are frequently fol- lowed by grave constitutional effects which greatly compli- cate the results, such as shock, surgical fever, pycBmia, and tetanus. These conditions should be treated upon general principles, the last two resulting, as a rule, fatally under any plan. Precautions should be taken to avoid exposure of 608 AMPUTATIONS. the patient to the direct currents of cold air, wliich is liable to induce tetanus. The author was called to see in consul- tation a case, some years since, of tt tanus following amputa- tion at the elbow-joint. Death ensued, and an examination showed that the condition had been caused by ligature of the median nerve. The mortality after amputations is influenced by various conditions — as the age, habits, occupation, and general health of the patient ; the cause of the operation, whether per- formed for an injury or disease, the nature, extent, and situa- tion of the operation, the hygienic conditions which surrounds the patient ; tl)e proximity of the amputation to the trunk — whether a primary, intermediary, or secondary operation ; the conduct of the after-treatment — all of these conditions influence largely the results of amputations. The statistics gathered from all sources, civil, military, private, and hospi- tal, show that the mortality of amputations performed after injuries is greater than tiiose in disease. Primary opera- tions are, as a rule, less fatal than secondary, and amputa- tions of the lower show a larger mortality than those of the upper extremity. The moi'tality in amputations of the supe- rior extremity for gunshot injuries is shown by the tables of Prof. S. W. Gross to be 27.42 per cent., and of tlie inferior extremity 55.76 per cent. The principal points to be observed in performing ampu- tations may be embraced in a few general statements : — I. The patient or subject should be placed in the recum- 'bent position ; the operator should take a position which will permit him to control his movements without restraint. The table should be firm and high, so as to prevent motion and unnecessary fatigue to the operator in bending over it. RULES TO BE OliSERVED. 609 II. Tlie assistants sliould perform tlie duties assigned them with promptness ; no delay on tlieir part should attend the delivery of the instruments as they are required, the supply of sponges in proper condition, the supply and the proper application of the ligatures. Perfect quietude should be maintained, and no conversation should be indulged in except that which relates to the performance of the operation in hand. The office of tlie assistant who ad- ministers the anjBsthetic agent is a most responsible one ; his entire attention should be given to the duty assigned him. He should carefully watch the state of aniesthesia in which the patient is placed, as manifested by the circulation, respiration, and other symptoms. He should endeavor to maintain a uniform effect upon the patient of the agent used ; under no circumstances should he leave the patient or take part in any of the other duties of the operation. III. The proximal part should be grasped firmly, and the integument drawn upward so that sufficient length will be given to this portion of the flap. Care should always be taken to cut the flaps of sufficient length. Redundant tissues should be retrenched. Flaps cut too short require section of the bone at a higher point. lY. As a general rule, as little of the bone as possible should be sacriflced. In amptations for the removal of dis- eased structures, it is important to cut through the bone at a point sufficiently beyond the disease to insure healthy flaps. In injuries, on the contrary, all of the soft structures re- maining should be utilized in forming the flaps, and as much of the bone saved as possible. V. The periosteum should be dissected up to the extent of an inch or more, so as to assist in the reparative process which occurs about tlie end of the bone. VI. The bloodvessels requiring ligature should bo com- 610 AMPUTATIONS. pletely isolated before the ligatures are applied. Great care should be taken to avoid the inclusion of the nerve in the ligature. The projecting ends of the nerves and tendons should always be cut off. VII. In approximating the edges of the flaps, the sutures should be introduced to such depth as is necessary to afford proper support. In removing the sutures, they should be cut with the .scissors at the side, just beyond the edge of the wound, and withdrawn, the borders of the wound being supported by the thumb and index finger of tlie free hand. If wire sutures are used, they should be divided in the same manner, or untwisted, the cut, or free, ends being bent back so as to straighten them, and the suture removed by gentle, even traction ; usually more force is required to remove the wire suture, and, therefore, care should be taken to support carefully the edges of the wound. SPECIAL AMPUTATIONS. THE LOWER EXTREMITY. Amputation of the Foot Surgical Anatomy — The foot is tiie terminal part of the lower extremity, and consists of three portions, the tarsus, metatarsus, and pha- langes (Fig. 332). Bones The Tarsus is composed of seven irregular bones, the OS caicis, astragalus, cuboid on the outside, scaphoid on the inside, internal, middle, and external cuneiform bones, placed between the cuboid and the inner border of the foot. The Metatarsus consists of five bones, numbered from within outward, and classified as long bones. The Phalanges are fourteen in number, two for the great toe and three for the remaining toes, and are enumerated AMPUTATION OF THE FOOT. on from the metatarsus. Tliese are also classified as long bones. Ligaments Tlie bones of the tarsus are attaohed to each other by strong doi*sal, plantar, and interosseous liga- ments, with intervening synovial mem- branes. The articulations between the various bones of the tarsus are of the diarthrodial form, embracing the ar- throdia and the enarthrosis. The metatarsal bones are united to the last row of tarsal bones and to each other by dorsal, plantar, and interosseous ligaments. Tiiey are connected with the first phalanges by an anterior plantar and two lateral ligaments. The phalanges are bound together by plantar and lateral ligaments. Sy- novial membranes line the joints. Muscles. — The upper or dorsal sur- face of the foot is covered by the ten- dons of the extensor muscles, which take origin on the anterior surface of the leg, and by the fleshy bellies of the ex- tensor brevis digitorum. The plantar surface or sole of the foot is well protected by the dense plantar fascia and the thick, fleshy masses formed by the flexor brevis digitorum and muscles of the great and little toes. The spaces between the metatarsal bones are occupied by dorsal and plantar interossei muscles. Articulations. — As amputation is performed at the various articulations of the foot, it is important to study the nature 1-5. Metatarsal bones. 6. Tibia. 7. Fibula. S. Astragalus. 9. Os calcis. 10. Scapboid. 11. Cuboid. 12. Internal cuneiform. 1.3. Middle cuneiform. 14. External cuneiform. 1.5-15. Pbalantres. 012 AMPUTATIONS. and position of these very carefully. The articulation of the phalanges with each other and with the metatarsus is quite regular, and does not differ materially from that observed in the hand. Between the metatarsus and the second row of bones of the tarsus, the line of articulation is irregular, owing to the projection backward of the head of the second metatarsal bone, and its interlocking with the three cuneiform bones (Fig. 332). The mortise formed by the three cuneiform bones has the following measurements ; the internal wall is one-third of an inch deep, and has a di- rection obliquely backward and outward ; the external wall is one-sixth of an inch deep, and its direction is obliquely backward and inward ; the posterior wall measures about one-half of an inch in width, and is transverse. This posi- tion of the head of the second metatarsal bone should be particularly borne in mind in the attempts to effect disar- ticulation. The position of the articulation on the outside is indicated by a point just behind the tuberosity of the fifth metatarsal bone. On the inside it lies one inch in front of the tuberosity of the scaphoid. The next line of articulation is a partial one existing be- tw^een the heads of the three cuneiform bones and the base of the scaphoid, limited on the outside by the body of the cuboid. In disarticulation through the tarsus, this articula- tion is sometimes opened by mistake. The error can be detected at once by observing the three articulating facets on the base of the scaphoid. The line of articulation between the astragalus and sca- phoid and the os calcis and cuboid is, in its nature, com- pound, being convex anteriorly between the astragalus and scaphoid, and concavo-convex anteriorly between the os calcis and cuboid. On the outside, a point midway between AMPUTATION OF THE TOKS. (313 the external malleolus and the tuberosity of the fifth meta- tarsal bone, indicates the position of the articulation, while a point just back of the tuberosity of the scaphoid fixes the position on the inside. Bloodvessels — Tlie arteries which supply the foot are the dorsalis pedis, on the dorsal surface, and the plantar arteries on the plantar surface, with their venre comites. On a level nearly with the line of articulation, between the tarsus and metatarsus, the arteries form arches across the surfaces of the foot, from which are given off branches which terminate in two digital branches on each surface of the toes. Nerves. — The nervous supply to the foot is derived from the anterior tibial and musculo-cutaneous on the dorsal sur- face, and the plantar nerves on the sole of the foot. Digital branches are given off, which follow the course of the arteries. Amputation of the Toes. — MetJiods At the phalan- geal articulations, or in the continuity of the phalanges, by the circular or flap methods. At the metatarso-phalangeal articulations, by the oval method. Operation Throiiglt the articulation. — Single flap method Tiie toe being firmly grasped and flexed, a trans- verse incision is made wath a small narrow-bladed knife, cutting directly into the joint on the dorsal surface, over the most distinct fold which has been taken as a guide to the joint. The lateral ligaments are now to be divided, and the blade of the knife is introduced behind the head of the phalanx to be removed. The toe being extended, the knife is car- ried downward and forward toward the end in close contact with the bone, making a flap of the requisite length to cover the end of the bone. The digital arteries are, if necessary, 52 614 AMPUTATIONS. ligatured, the nerves and tendons retrenched, and the flap brought up over the end of the bone, and held in apposition by means of sutures. Circular method — Amputation may be performed by this method through the articulation by making an incision three or four lines below, dividing the skin. Dissecting this up to the joint, the ligaments are divided and dis- articulation effected. The cuff of skin is approximated in the transverse direction. Amputation in the Continuity of the Bones Either the circular or flap method may be employed in performing this operation. The incision being made and the flaps formed, as above described, the bone is divided with the small saw or cutting pliers. The flaps are held in apposition by sutures, applied as in the other forms. Amputation through the Metatarso- phalan- geal Articulation By the Oval method. OrERATiON The toe being flexed, the incision is made on the dorsal surface one-quarter of an inch above the joint, and carried obliquely down to the commissure, then across the plantar surface to the opposite side, the toe being extended, and thence obliquely upward to the point of departure. The extensor tendon, the lateral ligaments, and flexor tendons are to be divided in the order named, effecting disarticulation. The vessels are ligatured, the tendons and nerves retrenched, and the edges of the wound approximated in a linear direction. In this operation the head of the metatarsal bone may be removed, if deemed necessary. Amputation of the Great Toe — By the Oval method. Operations 1. This operation is performed by an incision beginning on the dorsum of the foot one-quarter of AMPUTATION OF THE GRKAT TOE. 615 an inch above tlie joint, and then carrying it obliquely down- ward and for^Yard on the outer side of the toe to the com- missure of the toes, then under the toe to the outer side, and terminating at the point of departure. Fiff. 333. Fig. 334. 1, 2, 3, 4. Line of incision for removing first metatarsal bone with great toe. The flap is dissected up to the joint, the extensor ten- dons, lateral ligaments, and the flexor tendons are divided, completing disarticulation (Fig. 333). The arteries are liga- tured, the tendons retrenched, and the flaps approximated in a linear direction. In this operation the expanded extremity of the first metatarsal bone may be removed by the saw, the section being made obliquely through the bone from within outward, or the entire bone maybe dissected out, the incision being carried up to the tarso-metatarsal articulation (Fig. 334). 2. The great toe may also be removed by making a straight incision on the inner surface of the foot, beginning one-half of an inch above the joint, and carrying it down- ward to the middle of the first phalanx. From the termina- tion of this incision, a sliglitly curved incision is made on the dorsal surface to the commissure of the toes, and then one is made in a similar way on the plantar surface, joining the one first made. These flaps are dissected up to the joint, 616 AMPUTATIONS. disarticulation effected, and sutures applied so as to bring the edges together in a transverse direction. In performing these operations, care should always be taken to secure ample flaps to cover the large surface which the head of the first metatarsal bone presents. Amputation of the Little Toe By the Oval method. Operation — This toe can be removed by incisions made in the same manner as those employed to effect disarticula- tion of the great toe. Amputation of all of the Toes. — By the Flap method. Operation. — Fix the positions of the articulations (Fig. 332), and make a semilunar incision a short distance in front of them, carrying it from one side to the other (Fig. 335). A short flap is then dissected up, the joints exposed, and opened by dividing the extensor tendons and lateral Fiff. 335. Y\cr. 336. ligaments. The knife is passed behind the phalanges (Fig. 336), and the flap, of requisite length, is made from the plantar surface (Fig. 337). The vessels are ligatured, the AMPUTATION OF THE METATARSAL BONES G17 Fiff. 337. Fiff. 338. tendons retrenched, and the plantar flap is drawn up over the ends of the metatarsal bones, and secured by suture to tlie dorsal flap. Fig. 338 shows the stump after this opera- tion. Amputation in the Continuity of the Metatar- sal Bones. — By the Flap method. Operation Amputation through the metatarsal bones is performed by making a semilunar incision on the dorsum of the foot, a short distance below the point of section of the bones, dividing all of the tissues to the bones. Dissect up the integuments to a slight extent, and form a plantar flap by transfixion, introducing the knife, carrying it, in close contact with the bones, to the commissure of the toes. The flaps are retracted by a six-tailed retractor, four of the tails being passed through the four interosseous spaces, and the bones divided by the metacarpal saw. The vessels are liga- tured, the tendons on the dorsal and plantar surfaces re- trenched, and the plantar flap placed over the divided ends of the bones and secured to the dorsal flap by sutures. 52* 618 AMPUTATIONS. Amputation at the Tarso-metatarsal Articu- lation. — By the Flap method (Lisfranc's operation). Bones. — The bones entering into the formation of the articulation are the internal, middle, and external cuneiform, articulating in order with the first, second, and third meta- tarsal bones, cuboid articulating with fourth and fifth meta- tarsal bones. Ligaments. — The ligaments are the dorsal, plantar, and interrosseous. Line of the articulation — A line drawn from a point behind the tuberosity of the fifth metatarsal bone across the Fig. 839. Fiff. 340. dorsum of the foot, to a point one inch in front of the tuber- osity of the scaphoid bone. Operation — Grasping the foot firmly, a curvilinear AT TiiK tarso-:metatarsal articulation. 619 incision, dividing tlie skin and fascice, should be made, with a strong scalpel, over the dorsum of tlie foot between tlie points above given, passing a short distance below the line of the articulation (Fig. 339). The skin and fascias should be dissected up to a slight extent, and another incision, across the foot, on a level with the edge of the retracted skin, should be made, dividing the remaining structures down to the bones. The dorsal ligaments should now be divided from the fifth to the second metatarsal bone, then the dorsal ligament connecting the first metatarsal bone to the internal cuneiform, and lastly, the dorsal ligament be- tween the second metatarsal bone and the middle cuneiform, bearing in mind that the line of the articulation between the second cuneiform bone and the second metatarsal bone is one-third of an inch above the others (Fig. 340). The knife, being held at an angle of 45° to the axis of the foot, Fig. 341. with the edge turned upward, should now be introduced be- tween the first and second metatarsal bones, and carried up with its point by this movement to a right angle, dividin 620 AMPUTATIONS. the ligament which binds the head of the second metatarsal bone to the outer surface of the first cuneiform bone (Fig. 341.) Complete division being effected by giving the knife a rocking motion, it is withdrawn and applied in the same Fiff. 342. Fig. 343. Fig. 344. manner between the second and third metatarsal bones, and the head of the second metatarsal bone separated from the inner surface of the third cuneiform bone. De- pressing the foot firmly, the joint is opened and the remaining attach- ments can be divided. The plantar ligaments and the tendons of the peronei muscles should now be divided. An amputating knife is then introduced beneath the heads of the metatarsal bones (Fig. 342), and a flap made from the sole of the foot by carrying the knife forward AT THE tarso-:metatarsal articulation. 621 in close contact ^\\ih tlie surfaces of the bones, care being taken to avoid the sesamoid bones of the great toe. The flap sliould be terminated at the roots of the toes by a broadly convex border (Fig. 3-13). The dorsalis pedis in the ujiper, and the two plantar arteries in the lower flap are divided, and may require the application of a ligature. The tendons being retrenched, the plantar flap is brought up over the exposed surfaces of the bones of the tarsus, and united to the upper flap by sutures. In Fig. 344 the stump after amputation by this method is shown. Amputation at the Tarso-metatarsal Articu- lation (Hey's operation.) This operation is a modification of that just described, and differs from it in the method of forming the flaps and in the section of the internal cuneiform bone. Operation A transverse incision, dividing the struc- tures to the bone, is made across the foot, extending from the tuberosity of the fifth metatarsal bone to a point mid- way between the head of the first metatarsal bone and the tuberosity of the scaphoid. From the extremities of this incision, lateral incisions are made to the toes, and are con- nected by an incision across the sole of the foot, disarticulating the toes. A flap from the sole of the foot is dissected back to the articulation, and disarticulation of the second, third, fourth, and fifth metatarsal bones effected by dividing the dorsal, plantar, and interosseous ligaments. The separation is now completed by dividing with the saw the projecting portion of the internal cuneiform bone. The remaining steps of the operation are performed in the same manner as described in Lisfranc's operation. 022 AMPUTATIONS. Section of the second metatarsal, instead of the internal cuneiform bone, has been practised in amputation at the tarso-metatarsal articulation. Also, disarticulation of the first metatarsal bone, and section of the remainder on a level with the internal cuneiform. Amputation at the Medio -tarsal Articulation. — By the flap method (Chopart's operation). Bones The bones entering into the formation of the articulation, on the inside, are the astragalus behind with the scaphoid in front ; outside, os calcis behind, with the cuboid in front (Fig. 345). Fig. 345. Fiff. 346. 1. Astragalus. 2. Os calcis. 3. Cuboid. 4. Scaphoid. Ligaments Dorsal — superior astragalo-scaphoid, supe- rior calcaneo-scaphoid, superior calcaneo-cuboid, and inter- nal calcaneo-cuboid or interosseous. t*lantar — inferior calcaneo-scaphoid, long and short calcaneo-cuboid. Line of articulation A line drawn across the dorsum of the foot from a point one-half to three-quarters of an inch AT TIIK MEDIO-TAKSAL ARTICULATION. 623 behind the head of the fiftli metatarsal bone to a point one inch in front of the internal malleolus, or immediately behind the tubercle on the scaphoid bone. This line will be three-quarters of an inch in front of the ankle-joint. Operation Grasping the foot with the left hand so that the thumb and index finger shall rest at the points given on the inner and outer side of the foot, indicating the position of the articulation, the knife, a strong scalpel, should be carried across the dorsum of the foot, making a short, slightly convex flap (Fig. 346). Dissecting up the integuments to a slight extent, a second incision should be made on a level with the retracted flap, dividing the remain- in": structures down to the bones. Fixing the line of the articulation, the dorsal and interosseous ligaments are divided, exposing the joint fully. Dividing the plantar Fi?. 347. Fig. 348. ligaments, an amputating knife is placed beneath the bones (Fig. 347), and a flap of suflicient length made from the sole of the foot (Fig. 348). The arteries which are divided 624 AMPUTATIONS. Fig. 349. in this operation are the dorsalis pedis in the dorsal flap, and the plantar arteries in the plantar flap. The tendons are retrenched, and the plantar is attached to the dorsal flap by means of sutures. In this operation attention is directed to the importance of making the lateral incisions low down upon either side, so as to pass the knife readily under the bones, and of giving an oval shape to the border of the plantar flap. In seeking the line of the articulation, it is desirable to avoid o-ettincr too far back, so as to reach the line between the astragalus and os cal- cis, and equally desirable to avoid advancing so far forward as to get between the scaphoid and cuneiform bones. The convex and rounded articu- latincr surface of the astrasjalus is to be distinguished from the articulating sur- face of the scaphoid, which shows three distinct impressions, which receive the articulating surfaces of the three cuneiform bones. The stump after union has occurred is shown in Fig. 349. By the flap method. (Tripier's operation.) — Commencing at the outer edge of the tendo Achillis, on a level with the external malleolus, an incision through the integument is to be made in a direction at first downward and forward, and afterwards forward, passing two fingers' breadth below the malleolus, and then approaching by a finger's breadth the upper part of the base of the fifth metatarsal bone (Fig. 350). From this point the incision is to be carried upward, forward, and inward, so as to reach the inner margin of the tendon of the extensor proprius pollicis, just behind the first AT THE MEDIO-TAUSAL ARTICULATION. C25 tarso-metatarsal articulation. The knife slioulcl now be made to cut downward and forward, so as to enter the sole of the foot a finger's breadth in front of the dorsal incision. The incision is then to be carried with a gentle forward curve, outward and backward, until it can be made continuous with the first portion of that below the outer malleolus (Fig. 351). The divided integument having undergone some degree of Fis. 350. retraction the dorsal and plantar structures are to be divided half an inch behind the superficial incision ; the soft parts are then to be separated from the bones, extreme care being taken to preserve uninjured the vessels contained on the inner part of the plantar flap. At this stage, the cuboid and scaphoid sliould be disarticulated from the os calcis and astragalus, the periosteum then divided and separated from the under surface and posterior extremity of the os calcis up to the level of the sustentaculum tali where the bone is to be sawn through in a direction from behind and within, 53 6-26 AMPUTATIONS. forward and outward, so as to leave a surface which will be at right angles with the axis of the tibia when the limb assumes the position for walking or standing (Fig. 352). Fig. 352. Fig. 353. All sharp bone edges and angles should be rounded off. The posterior tibial nerve is to be retrenched to avoid danger of neuroma, and the wound dressed so as to secure moderate flexion of the ankle-joint during repair (Fig. 353). Amputation at the Tibio-tarsal Articulation By thejiap method (Syme's operation). Bones. — The bones entering into the formation of the ar- ticulation are the lower extremity of the tibia on the inside, terminating in the internal malleolus, and the lower extrem- ity of the fibula on the outside, terminating in the external malleolus, embracing the broad trochlear surface of the as- tragalus, and forming a true ginglymoid joint free from lateral motion. Ligaments The ligaments of the articulation are the anterior, the internal lateral or deltoid, and the external lateral, consisting of three fasciculi. The transverse Hofa- AT THE TIBTO-TARSAL ARTICULATIOX. 027 ment of the tibia and fibula supply the place of a posterior ligament to the joint. Lines of incision. — First. — From the centre of the outer malleolus, downward and across the sole of the heel, in a straight line ; then upward to a point on the same level of the opposite side, a slight distance below and behind the extremity of the inner malleolus (Figs. 354, 355). Second. — An incision across the instep, connecting the points of the first incision. Operation — The leg being supported, and the foot placed at right angles to the leg, an incision should be made with tlie scalpel from the outer Fig. 354. malleolus to a point on the same level of the oppo- site side, a slight distance below and behind the extre- mity of the inner malleolus, across the heel, dividing the structures to the bone, in the line indicated. The anterior in- cision across the instep should be next made, and the posterior flap dissected from the surface of the os calcis, the knife being kept in close con- Fig. 355. 628 AMPUTATIONS. contact with the bone, so as to avoid wounding the blood- vessels and transfixing the flap (Fig. 356.) This can be accomplished by placing the fingers of the left hand upon the heel, the thumb resting upon the edge of the integument, and keeping the knife between the thumb-nail and the sur- Fig. 356. face of the bone, at the same time pressing back the tissues as they are detached. The tendo Achillis, when exposed, should be divided, and disarticulation effected by cutting into the joint on the dorsum, and the sides of the foot at the margin of the anterior flap. The tissues are dissected up- ward so as to expose the malleoli fully, the knife carried around so as to divide the periosteum, and the saw applied, removing a thin slice of the tibia with the two malleoli. The arteries divided in this operation and requiring liga- ture are the dorsalis pedis on the dorsal surface, and the two plantar. The tendons having been retrenched, the posterior AT THE TIBIO-TARSAL ARTICULATION. G29 is to be placed in apposition with the Fig. 357. anterior flap and secured by sutures, and an opening made in the posterior flap to secure drainage. In performing this operation, the surgeon should bear in mind the im- portance of keeping the knife close to the bone in dissecting off the posterior flap, in order to avoid wounding the vessels which nourish the tissues, and also to avoid puncturing the flap, which, where it is in contact with the tendo Achillis, is very thin and closely adher- ent. The character of stump formed after this operation is shown in Fig. 357. Amputation at the Tibio-tarsal Articulation (Pirogoff's operation). This operation is a modification of Syme's method, and consists in leaving the posterior portion of the os calcis in the heel flap, and placing it in apposition with the surfaces of the tibia and flbula, the articulating surfaces of which have been removed. Operation. — The incisions, in this operation, are made in the same manner as in »Syme's operation, the lines of sec- tion through the integument (b) and the bones (a, c) being shown in Fig. 358. The articulation is opened from the front, and the lateral ligaments divided, thus disarticulating the head of the astragalus. A small narrow -bladed saw, or a saw such as is used in excisions, is placed obliquely upon the OS calcis behind the astragalus, exactly upon the lesser process of the bone, or sustentaculum tali, and section of the 53* 630 AMPUTATIONS. bone is made following the line indicated («) in Fig. 358. Tlie malleoli are next exposed and removed by the saw, the Fig. 358. tendons are retrenched, and the posterior flap containing the segment of the os calcis is now brought up and attached Fiff. 359. AMPUTATIONS OF THE LEG 631 to the anterior flap, placing the bony sur- faces in apposition. The direction given to the line of sec- tion of the OS calcis in this operation is a matter of importance, in order that the bones may be brought accurately into ap- position. Care should be taken to avoid making the section too oblique and also in beginning the section too near the astra- galus. Fig. 360 represents the stump formed after this method of amputation. Amputations of the Leg. — Surgical Anatomy. — The leg is that portion of the lower extremity which extends from the thigh to the foot, and may be divided into the upper, middle, and lower third. Bones. — The bones which enter into its formation are tlie Patella, the Tibia, and the Fibula. The Patella is a large sesamoid bone placed in front of the knee-joint. Its purpose is to protect the front of the joint and to increase the leverage of the extensor quadriceps femoris muscle. The Tihia is a large prismoidal-shaped bone placed on the inside of the leg, entering by an expanded upper ex- tremity into the formation of the knee-joint, and below into the ankle-joint by its lower extremity, the internal malleolus. It presents on its anterior surface a sharp crest which lies subcutaneous in its entire extent. The Fibula is a long slender bone occupying a position on the outside of the leg, articulating by its upper extremity with the tibia, and below terminating in the outer malleolus, which forms part of the ankle-joint. 632 AMPUTATIONS. Ligaments — The tibia and fibula are united by the inter- osseous ligament, and are connected to the astragalus below by the ligaments already described (page 626). Muscles — On the inner side of the anterior surface the tibia is placed, its crest being subcutaneous. In the middle and on the outer or fibular side of this surface the tibialis anticus, extensor proprius poUicis, extensor longus digito- rum, and peroneus tertius muscles are situated. Two layers of muscles occupy the posterior surface ; the gastrocnemius, soleus, and plantaris muscles being superficial and forming the '^ calf." The deep layer consists of the popliteus, flexor longus pollicis, flexor longus digitorum, and tibialis posticus. On the fibular surface the peroneus longus and brevis are placed. Bloodvessels The anterior and posterior tibial and the peroneal arteries pass down on the anterior and posterior surface of the leg, the anterior tibial lying on the anterior surface of the interosseous ligament until it reaches the lower part of the leg, while the posterior tibial and peroneal arteries rest upon the posterior surface of the posterior tibial muscle. Nerves The anterior tibial and musculo-cutaneous nerves are distributed to the anterior surface of the leg, while the posterior tibial and peroneal supply the posterior and outer surface (Fig. 361). Amputation may be performed in either the lower, mid- dle, or upper third of the leg, and by the circular, oval, rectangular, single or double flap methods. The circular and rectangular methods are best adapted for the lower third, the modified circular or flap methods are preferable in the middle and upper third. Amputation of the leg should never be performed above the tubercle of the tibai AMPUTATIONS OF THE LEG — LOWER THIRD. 633 or the points of insertion of the biceps, semi-tendinosus, and semi-membranosus muscles, which are necessary in control- ling the movements of the stump. The point of election, or the most desirable point for removal of the leg, is from two to two and a half inches below the tuberosity of the tibia. Fiff. 361. 1. Tibialis posticus mus- cle. 2. Tibialis anticus muscle, i Flexor longus digito- rum. 4. Extensor longas digito- rum. 6. Internal saphenous vein. 6. Anterior tibial vessels and nerve. 7. Tendon of the plautaris muscle. 8. Peroneous longus mus- cle. 9. Posterior tibial vessels and nerves. 10. Flexor longus pollicis. 11. External saphenous vein and nerve. 12. Soleus muscle with fi- brous intersection. 13. Peroneal vessels, 14. Gastrocnemius muscle. 15. Communicans peronei nerve. Section of the Right Leg in the upper third, showing structure. Operation — In the loiver third Three to three and one-half inches above the ankle-joint. By the circular method — The limb being supported by an assistant, the proximal part is grasped by the left hand of the operator, the skin firmly retracted, and the ampu- tating knife is carried around the limb, making a circular 634 AMPUTATIONS. incision (Fig. 3G2, a), dividing the skin and superficial fascia in the manner already described (page 581). The cuff of skin and ^^' ' fascia is dissected up to the extent of one and one-half to two inches and turn- ed back. Guard- ing carefully the margin of the re- tracted cuff, a cir- cular incision is made around the limb at this point, dividing the mus- cles and other struc- tures to the bones. Tliese, with the pe- riosteum, are dis- sected back to the extent of an inch or more, and the interosseous membrane divided with the catlin or a large scalpel. A three-tailed retractor is now applied, the middle tail being passed through the inter- osseous space from below upward and the tissues firmly re- tracted. The saw, held in a vertical position, should be applied to both bones, drawing it from heel to point and dividing them by short, even strokes, care being taken that the fibula, which is the smaller and most movable bone, should be divided first. The anterior and posterior tibial and peroneal arteries are divided and require ligature. The anterior tibial artery AMPUTATIONS OF THE LEG — LOWER THIRD. 635 at this point lies in front of the tibia. The posterior tibial and peroneal arteries should be sought for in the interspace between the soleus muscle beliind, and the tibialis posticus muscle in front, the former lying somewhat behind the tibia, and the latter along the inner border of the fibula. The vessels having been ligatured, the tendons and nerves re- trenched, the cufF is drawn down and the edges approxi- mated by sutures in the transverse or vertical direction. In amputations of the leg it is desirable to remove the sharp point formed by the crest of the tibia after section. This should be done with the saw or bone pliers, cutting obliquely from above downward. In the lower third. By the rectangular method (Teale's operation). Operatiox. — The lines of incision having been traced out on the limb, the knife is introdced on one side at the point of intended section of the bones and carried downward to a distance equal in length to one-half or one-third the circumference of the limb, dividing all of the structures to the bone (Fig. 326). A similar incision is made on the opposite side, and the two are united by one made trans- versely across the anterior surface of the leg. The flap, containing the skin and muscular structures, is now dissected up, care being taken to avoid wounding the anterior tibial artery at the base of the flap. The posterior flap, equal in length to one-eighth the circumference of the limb, or one- fourth the length of the anterior flap, is made by a circular incision down to the bone. This flap is dissected up to the requisite extent, the interosseous membrane is divided, the retractor applied, and the bones sawn (Fig. 327). The vessels having been ligatured, the tendons and nerves re- 636 AMPUTATIONS. trenched, the long flap is turned over the ends of the bones and attached to the short flap by sutures (Fig. 328). In the middle and tipper third. By the double-flap method Antero-posterior. Operation. — The limb being supported, the operator grasps the proximal part (placing the thumb and index finger at the points on the outer and inner surfaces of the leg, so as to indicate the breadth of the flap, as well as the point of section of the bone), retracts the skin, and makes a semilunar incision, either with the scalpel or small ampu- tating knife, across the front of the leg from the inner edge of the tibia to the outer edge of the fibula, dividing skin and superficial fascia. This flap, which should be one-fourth the length of the posterior and cutaneous in character, is dis- sected up to the requisite extent, and, the leg being flexed slightly, the amputating knife is entered at the external angle of the first incision and made to transfix the structures on the posterior part of the leg, emerging at a point corres- ponding on the opposite side of the leg (Fig. 363). In Fig. 363. passing the knife, care sliould be taken to avoid carrying its point betiveen the bones. This is likely to occur, unless the operator bears in mind that the edge of the fibula is on a plane posterior to that of the tibia, and, therefore, the handle of the knife should be elevated in order to depress the point as it passes behind the bone. The knife, having AMPUTATION AT THE KNEE-JOINT. 037 transHxed the tissues, is carried downward in close contact with the surface of the bones, forming a flap of at least four inches in lengtli. The flaps are now drawn back, the re- maining structures and interosseous membrane divided, the retractor applied, and the bones sawn. The anterior and posterior tibial and peroneal arteries will require ligature — possibly some of the larger muscular branches. Sometimes difficulty is experienced in sur- rounding the anterior tibial artery with a ligature, owing to its retraction above the section of the interosseous mem- brane upon which it lies. Extension of the limb will frequently cause it to project, so that it can be seized and ligatured. The vessels having been ligatured, and the tendons and nerves retrenched, the flaps are approximated by sutures. By the lateral double-flap method Long external and short internal flap (Sedillot's operation). Operation. — The limb being flexed and the foot ex- tended, the skin is elevated over the point of intended sec- tion, and the amputating knife is introduced midway between the crest of the tibia and the fibula, and, passing external to the latter, is brought out in the calf of the leg (Fig. '6^2, c). Cai-rying it downward in close contact with tlie external surface of the bone, a long external flap is formed. A transverse incision, slightly convex forward, divides the tissues on the inside of the leg. Dissecting up this flap to the requisite extent, the interosseous membrane is divided, the retractor applied, and the bones sawn as described in the other operations. Amputation at the Knee-joint Surgical An- atomy Tiie knee is a ginglymoid or hinge-joint, composed 54 638 AMPUTATIONS. of three bones, the condyles of the femur above, the patella in front, and the upper extremity of the tibia below. The bones are united by fourteen ligaments, anterior, lateral, posterior, and internal, the more important of which are — The anterior or ligamentum patellce, a portion of the ten- don of the extensor quadriceps femoris, measuring three inches in leno-th, and extendinoj from the lower border of the patella to the point of insertion in the tuberosity of the tibia. The lateral ligaments are the internal, and the long and short external. The posterior, or the ligamentum posticum Winslowii, covers over the entire posterior portion of the joint, and is formed of dense fibrous tissue. Of the ligaments within the joint, the two crucial, anterior and posterior, and the two semilunar Jibro-cartilages, the internal and external, are the most important in the surgical point of view. The crucial ligaments are strong interosseous bands at- tached, below, to the spine of the tibia, and, above, to the outer and inner condyles of the femur, crossing each other as they pass from below upward, the anterior being attached to the front of the spine of the tibia and the inner surface of the outer condyle, and the posterior to the back of the spine and the outer surface of the inner condyle. The semilunar fibro-cartilages are two crescentic lamellae attached to the borders of the head of the tibia, and serve to deepen the surface for articulation with the condyles of the femur. The tendons of the powerful muscles of the thigh, with some of the muscles of the leg, surround and protect it, AMPUTATION AT THE KNEE-.TOTNT. G39 Fig. 364. while important bloodvessels and nerves have intimate rela- tions with the joint (Fig. 3G4). The condyles of the femur are two large eminences, into which the lower extremity divides. The external condyle is the more prominent anteriorly, and broader, while the internal is most prominent internally, and narrower. It is to be remembered that they are not on the same level, the internal being nearly one-half of an inch lower than the external. The tuberosity on the outer surface of the external condyle is less prominent than that on the internal. The line of the articulation may be described as extending inter- nally from a point three-quarters of an inch above the tuberosity of the tibia, across the lower border of the patella, -^ '^^^ patella. 4. The crucial ligaments. and terminating externally three- quarters of an inch below the prominence of the condyle of the femur. Amputation through the knee-joint may be performed by either the flap, circular, or oval methods. Of the flap methods, that by the long anterior and short posterior is preferred. Amputation hy the long anterior and short posterior Jiap method, retaining the Patella. Operation — The knee being flexed, an incision is made, with the scalpel or small amputating knife, from a point on a line with the condyle, near to the border of the popliteal space, across the front of the leg, two and one-half inches below the tubercle of the tibia, to a point corresponding on Vertical Section of the Knee-joint. 1. The femur. 2. The tibia. 640 AMPUTATIONS. Fig. 365. the opposite side. Dissecting up this flap, tlie ligamentiim patellae and the lateral ligaments are divided, opening the joint. The crucial liga- ments are next divided, and any remaining portions of the lateral ligaments, thus completely exposing the joint. The amputating knife is now placed behind the head of the tibia, and a short posterior flap is made by cutting downward, keep- ing the knife in close con- tact with the bone, care being taken to avoid the head of the fibula. The popliteal artery will require ligature, and possibly several of its branches (Fig. 365). It lies in close contact with the posterior surface of the posterior ligament of the joint, and should be sought ibr in this position. The tendons and nerves are retrenched, and the anterior flap drawn down over the condyles of the femur, and attached to the posterior by sutures. The importance of keeping near to the margins of the popliteal space is to be borne in mind, in order that a flap of sufficient size may be secured to cover the large articulat- ino- surfaces of the condyles of the femur. The Popliteal Artery and its Branches in relation with the Kuee-joiut. 1. Femur. 2, 3. Condyles of femur. 4. Popliteal artery. 5, 6, 7. Superior articular b- aches. S, 9. Inferior articular Lranche.s. 10, 11. Sural branches. AMPUTATION AT THE KNEE-JOINT. G41 By the short anterior and long posterior flap — Tliis method of amputation may also be employed, in which case the patella is removed, and also the condyles of the femur, the long flap being taken from the muscles forming the calf of the leg (Figs. 3GG, 3G7). Ficr. 3(j6. Fi. Acromion proces?s. 4. Infi-a-sp'.nous fossa. o. Head of humerus conned ed to i^leni.id cavity of .scapula bycapsiilar iiicari-ent. AMPUTATION AT TIIK SHOULDEU-JOINT. G91 Guides to the articuhttion. — Tlie acromion process forms u prominent projection above the joint which can be easily recognized. It is phiced nearly half of an inch above the glenoid cavity and projects :»n inch beyond it. The cora- Fig. 419. 10. Clavicle. Acromion process. Supra-spinatus muscle. Trapezius muscle. Intra-spinatus muscle. Teres miuor muscle. Teres major muscle. Latissimus dorsi muscle. Coraco-bracliialis and short head of the biceps muscle. Tendon of the subscapn- laris muscle, blended with the capsulai- ligament. Pectoralis major muscle. Deltoid rauFcle. Axillary vessels aud nerves. /3 9 Section thi-ough Right Shoulder showing structure. ■joint, eoid process is situated within and lower down, and more nearly in contact with the articulation. Amputation at the shoulder-joint may be performed by either the oval, single, or double flap method. By the oval method (Larrey's opeiation). Operation Elevating the shoulder of the patient and projecting it beyond the edge of the table, a vertical incision, three inches in length, beginning at the apex of the acromion process, is carried downward in the long axis of the arm, dividing the tissues to the bone. From the centre of this incision two oblique incisions are made, one on the anterior and the other on the posterior surface of the arm, extending respectively to the anterior and posterior borders of the ax- 092 AMPUTATIONS. ilia (Fig. 420). The flaps thus formed are dissected up so as to uncover the joint. The arm is now rotated outward, and the insertion of the subscapular muscle into the lesser tuberosity divided. The capsular ligament and the long tendon of the biceps muscle are next divided and the arm is rotated inward in order to separate the insertions of the Ym. 420. 421. ], 2, 3, -1. Wound after Larrey's operation. 5. Glenoid cavity and remains of cap-ular ligament. Axillary vessels. supra-spinatus, infra-spinatus, and teres minor muscles into the greater tuberosity. Disarticulation is completed by di- viding the remaining portions of the capsular ligament, and the amputating knife is placed behind the bone, and the two oblique incisions are joined by a transverse incision, which divides the structures containing the axillary artery (Fig. 421). The artery should be seized as soon as divided, and AMPUTATION AT THE SITOrLDER-.TOTNT. G93 ligaturecl. The anterior and posterior circumflex arteries, with, possibly, otlier articular branches, will require ligature. The edges of the wound are approximated, so as to form, when union has occurred, a linear cicatrix. By the oval method (Spence's operation). — An incision three inches in length, is made on the inside of the arm, from a point just external to the coracoid process downward, passing in the line of separation between the deltoid and clavicular portion of the pectoralis major dividing these as well as the tendon of insertion of the latter muscle ; from the lower end of the vertical incision the knife is carried, in a slightly curvilinear direction, outward, dividing the fibres of the deltoid muscle, to the posterior border of the axilla. A third incision is now made, from the junction of the first and second, on the inner surface of the arm, dividing the skin and fascia only to join the incision made on the outer surface. The flap on the outer surface can now be raised, exposing the articulation ; the capsular ligament, with the long tendon of the biceps and the points of inser- tion of the supra-spinatus, infra-spinatus, and teres minor into the greater tuberosity and that of the subscapularis into the lesser tuberosity, should be divided, disarticulation ef- fected, and the anterior and posterior incisions joined by section of the tissues containing the axillary artery. The vessels should be ligatured in the same manner as in the Larrey mr^thod. The advantages claimed for this method of operation are a better formed stump, the division of smaller articular branches, and the ease with which the joint is exposed. By the single Jlap method (Dupuytren's operation). — In this operation the flap, which is formed from the deltoid muscle, may be made either by transfixion or by cutting 694 AMPUTATIONS. from without inward. In the fortner, tlie knife is entered about an inch in front of the acromion process, carried directly across the joint, and brought out at the posterior fold of the axilla. It is then carried downward in close con- tact with the bone, and a broad flap of sufficient lengtli (three to four inches) is made. This flap is raised, and dis- articulation effected by dividing the ligamentous and mus- cular structures attached to the head of the bone by a semi- circular incision, the head being drawn away from the glenoid cavity. The knife is now passed behind the bone and carried to the lower margins of the first incision, and the intervening tissues are divided on a level with the in- ferior attachments of the pectoralis mnjor and latissimus dorsi muscles. In the latter, the incision is commenced near the anterior border of the deltoid muscle on a level with the articulation, descending in a curved direction to within two-thirds of an inch of the insertion of the muscle and, ascending on the posterior surface, terminates at the same level as the point of origin (Fig. 422). This flap is dissected up, disarticulation effected, and the amputating knife passed behind the bone, and the inferior incision made from within outward. The arteries are ligatured and the incisions united by sutures. By the double flap method (Lisfranc's operation) In this method the amputating knife is entered at the outer side of the posterior border of the axilla, in front of the tendons of the latissimus dorsi and teres major muscles ; passing obliquely upward in close contact with the joint, the handle is elevated and the point is brought out in front and below the clavicle in the triangular space formed by the acromion and coracoid processes and the clavicle (Fig. 423). The arm being drawn from the body, and the deltoid AMPUTATION AT THE SHOULDER-JOINT. 695 muscle raised from the bone, the knite is carried downward in close contact with the bone, forming a posterior semi- circular flap three inches in length. Disarticulation is effected, and the knife passed behind the bone, and the Fiff. 423. Fig. 422, anterior flap, of the same length as the posterior, is made by carrying it downward and forward, dividing the structures which contain the axillary artery (Fig. 424). The arteries are ligatured and the flaps approximated by sutures. In amputation of the forearm or at the elbow the arterial circulation may be controlled by digital compression of the brachial artery in the middle of the arm, or by the appli- 696 AMPUTATIONS. cation of the tourniquet over a compress at the same part. Esmarch's bandage may be used as in the lower extremity. Fiff. 424. In. amputation of the arm or at the shoulder-joint, the subclavian artery may be compressed against the first rib by the handle of a key well padded. The hemorrhage may also be controlled by carrying the narrow band of the Esmarch apparatus around the axilla close to the body. PART VII. EXCISION OF BONES ANB JOINTS. The tprms Excision^ Exsection, iind Resection may be applied without distinction to operations having for their object the removal of the articular extremities of bones, or of bones in part or whole. The operation has been performed from an early period of time in those cases in which the local character of the injury or disease did not demand removal of the limb or part of it by amputation. The general adoption by surgeons of the operation in proper cases has without question contributed largely to the preservation of both life and limb. The table of statistics compiled by Heyfelder, of St. Petersburg, and published in 1861, shows that in 1280 cases of excisions of bones, 932 recovered, 266 died, and 82 failed, giving a percentage of deaths amounting to 36.04. Of 961 excisions of joints 684 recovered, 186 died, 91 failed, giving a percentage of deaths of 36.78. The table prepared by Prof. S. W. Gross of excision of tlie shaft of bones for gunshot injuries in 1657 cases gives the percentage of deaths at 23.47. In 3596 cases of gun- shot injuries of the joints in which excision was performed the percentage of deaths, as reported by Prof. Gurlt, of Berlin, was 33.92. The mortality, in nearly 6000 cases of amputations is shown by Mr. Lane to be 3G.92 per cent. An examination of the tables, the results in which are 59 698 EXCISION OF BONES AND JOINTS. quoted above, shows that of the bones, the greatest mortality followed excision of those of the face, and of the joints, the hip gave the highest mortality, and the ankle, the lowest. The conditions which indicate the employment of excision, as an operative measure, may be traumatic or pathological. Shaft or Body of the Bones — The traumatic conditions occun-ing in the shaft or body of the bones are — Protrusion of the fragments, to such extent, in compound fractures as to prevent reduction, in which excision of por- tions of the protruding ends may be required. Comminution of the bone in fracture or gunshot wounds may require the removal of the portions comminuted and deprived of periosteum. The pathological conditions are chiefly those due to caries or necrosis in which excision is necessary in order to stop suppurative action and permit repair to occur. In ununited fractures excision may be practised as a method of treatment. It may also be performed for the relief of de- formity after union in fracture or where it may be desirable to straighten a bone in rachitis. Articular Extremities. — The traumatic conditions occur- ring in the articular extremities of bones which demand excision are quite numerous. Fractures involving the joints are frequently of such nature as to necessitate the removal of the fragment or frag- ments in relation with the joint. In compound dislocations it may be necessary to excise the displaced articular end in order to effect reduction. Excision of the head of the bone may be indicated in old unreduced dislocations in which great pain is experienced from pressure upon nerves. The chief pathological condition which demands exci- PROCESS OF REPAIR AFTER EXCISION. 699 sion is chronic inflammation of tlie joints in which all of the structures are involved, with erosion of tlie articular surfaces and very great suppuration, producing severe constitutional disturbance. Excision may also be performed to relieve the great de- formity which sometimes attends anchylosis of a joint, or in certain forms of club-foot, irremediable by other means. ' Cnntra-indications The conditions which contra-indi- cate the performance of excision are, extensive involvement of the articular surfaces, which, if removed, would leave the limb useless, the existence of malignant disease, the presence o^ acute inflammation, structural disease of the lungs or kid- neys, symptoms of osteo-myelitis, and rapid extension of the articular disease indicating a constitutional vice. In addition it may be stated that excision may be performed with safety to relieve conditions involving the articulations of the upper extremity, which would contra-indicate interference in the hip and knee-joint. The age of the patient is also to be considered; the tendency to recovery exists to a very marked extent in the young, and in these excision should not be resorted to at too early a period of the disease. Old age Is a contra-indication, owing generally to the feeble character of the reparative processes. Process of Repair after Excision After excision of the articular surfaces of bones, or of a portion of a bone, if the surfaces are kept in apposition, an immobile osseous union will occur as in fractures. If the cut surfaces are more widely separated and if motion is maintained, the ends will be attached by a dense fibrous band, forming a false joint. This condition is favorable in excisions performed upon the joints of the upper extremity in which it is desirable to pre- serve tlie prehensile function of the limb. In these joints 700 EXCISION OF BONES AND JOINTS. the usefulness of the limb is preserved best when the con- necting fibrous band is short. In the articulations of the lower extremity osseous union is preferable as, with this, the function of the limb as a support is better accomplished. In the excision of an entire bone, or of a portion of a bone in its continuity, it is of the greatest importance that the periosteum should be preserved. In excisions performed for the relief of pathological conditions the removal of the periosteum may be accomplished without great difficulty, as it is, in these cases, thickened and the process of bone forma- tion has commenced in its inner osteo-genetic layer. In excisions performed for traumatic conditions the periosteum is in the normal condition, and in the adult firmly adherent to the bone. To remove it in such cases without laceration r'equires careful dissection, so that its bone-producing func- tion may not be destroyed. In eight cases of excision of the lower jaw performed by me for pliosphorus necrosis re- production of bone has occurred in each case to such extent as to furnish an excellent basis for an artificial denture. Of these eight excisions, one included the entire bone, one three-fourths of the bone, and the remaining, one-half. The importance of retaining a portion of the epiphysis of long bones in persons under twenty years of age, at which time the growth of the bone in length is completed and con- solidation occurs between the diaphysis and epiphysis, is very great. Removal of the entire epiphysis in a child will result in an arrest of growth in the length of the bone. In performing excisions, the following instruments are required : — Scalpel (Fig. 425) and dissecting forceps (Fig. 243), retractors (Fig. 246), sharp and probe-pointed bistouries witii strong blades and handles, bone director (Fig. 426), INSTRUMENTS REQUIRED FOR EXCISION. 701 periosteal elevators (Figs. 427, 428), shield of wood or sole leather to place between the bone and soft tissues during section of the bone, saws of different kinds — that of Mr. Fig. 425. Fi-. 426. Fig. 427. Fi-. 428. Butcher is especially designed for the purpose, having a narrow reversable blade ; the semi-circular saw of Mr. Hey, a small metacarpal saw (Figs. 429, 430, 431, 296), and a chain saw with handles or fastened to a frame (Figs. 432, ;)9* '02 EXCISION OF BONES AND JOINTS. 433). To seize and obtain firm hold of the bone during dis- section a number of strong forceps with various curves will 429. Fi-. 430. Fig. 431. be required (Fig. 434, 435). Cutting pliers, straight and curved, are also needed to cut away spicula of bone and to divide small bones (Figs. 297, 436, 437, 438, 439). Chisels, scrapers, and gouges of various forms, with a metal mallet, will be required to scrape away and gouge out diseased bone INCISIONS TO HE EMPLOYKD. 703 (F'igs. 440, 441, 442, 443). A tourniquet may be placed over the main artery to control capillary bleeding during Fig. 432. the operation. An Esmarch bandage applied to the limb secures a bloodless field of operation. Large bloodvessels are not usually divided in operations of excision, as the dis- section of the soft tissues is generally made at points re- moved from their position. A syringe to wash out the wound should be provided. In performing excisions, as in other operations, proper prepa- rations should be made beforehand. The instruments, dressings, and all articles needed during the operation should be arranged and placed in convenient places ; the assistants, usually four or five, should be instructed in their duties. As a rule, the patient should occupy the recumbent position. The incisions made in reaching the part of bone to be excised vary according to the situation of the joint or bone. A straigiit or slightly curved incision may be employed in the excision of any joint or bone. The H and square in- 704 EXCISION OK BONES AND JOINTS. cisions are objectionable on account of the angles formed, which are difficult to approximate accurately and maintain Fig. 433. Fiff. 434. Fiff. 435. SECTION OF THE BONE. 705 ID proper apposition, whereby tlie process of healing is de- layed. AVhen it is necessary to include diseased tissue in the Fis:. 436. Fig. 437. Fiff. 438. incision the elliptical form may be employed. Care should be taken to avoid retrenchment of the flaps, as sufficient shrinking usually occurs to adapt them to the parts. The section of the bone is made after it has been com- pletely exposed by the incision and denuded of its perios- teum which, as stated above, is a difficult and tedious oper- ation in accidents and acute conditions, but much less so in those of a chronic character. When the chain saw is used tlie bone need not be lifted from its place, the cliain being readily slipped beneath it by an eyed probe armed with a 706 EXCISION OF BONES AND JOINTS. thread; the leather shield to protect the parts and receive the bone dust may also be pushed beneath the bone. If thestraiglit Fiff. 439. Fig. 440. Fi^. 441. saw is employed, the bone should be raised from the wound, and supported upon a soft wooden shield while section is made. In operations done upon the forearm and leg care should be taken that the bones are divided on the same level, other- wise the limb may be forced to one side and its functions greatly impaired. After section, the end of the bone and the medullary canal should be carefully examined to see that they are free from disease. In joint excisions, the line of SECTION OF THE IJONE. 707 section should always be outside of the insertion of the liga- ments, as experience has shown that inflammation is very Ficr. 442. Fig. 443. f^ liable to occur if any portion of the ligaments is left. In every instance the section should be made through healthy bone, otherwise a speedy return of the disease will ensue. If the periosteum is found detached from the surface, the uncovered portion of the bone should be excised, as exfoli- ation is liable to follow in such cases. The saw should be used in dividing the bone in preference to the cutting pliers, as this instrument produces contusion of the parts, with more or less irregular edges. 708 EXCISION OF BOXES AND JOINTS. After removal of the bone, hemorrhage, if present, should be controlled by the application of pressure or by douching the wound with hot water ; if necessary ligatures may be employed. The wound should then be thoroughly cleansed by injections of warm antiseptic lotions and the periosteum carefully replaced. When all of the bone dust and spicula have been removed, drainage tubes should be introduced so as to secure complete drainage of the wound cavity and the edges brought together by interrupted sutures. Antiseptic dressings should be applied, and the limb should be band- aged and placed upon a splint which is so arranged as to permit examination and dressing of the wound without dis- turbance of the limb. After excisions upon the articula- tions of the upper extremity passive movements should con- stitute part of the treatment, as it is of great importance that movement of the joints be established. In operations upon those of the lower extremity this is not requisite, as osseous union, in proper position, is desirable in order to afford sup- port. The adoption of the antiseptic methods of treatment will to a great extent, if not entirely, prevent the occurrence of excessive suppuration, pyaemia, erysipelas, and septicaemia, which under other plans increased greatly the dangers of excisions. Morphia, by the mouth or preferably by hypodermic inr jection, should be given to allay the muscular spasm which is prone to follow the operation and disturb the process of repair. Should suppuration ensue, stimulants, with tonics and good diet should be given. Prolonged suppuration, with the formation of sinuses, indicates generally the recur- rence of disease of the bone which may be relieved by a second operation, providing that this will not cause the loss of too much bone. In this event amputation should be per^r formed. STKOIAL EXCISIONS SKULL. 709 SPECIAL EXCISIONS SKULL. Cranium Surgical Anatomy — The bones of the head, or cranium, are so articulated as to form a cavity in which is lodged the brain and its membranes. Tlie articu- hitions are of the synarthrodia! or immovable variety, and bind the different bones firmly together. The external sur- face of the vertex and sides of the cranium are covered by the integument, which is thick in this portion and studded with hair follicles ; by the superficial fascia, a firm, dense membrane intimately adherent to the integument, and to the occipito-frontalis muscle and its aponeurosis, and by the occi- pito-frontalis muscle which, with its tendon, extends from the occiput to the eyebrow, covering one side of the entire vertex, the muscular portions extending from an inch and a half to two inches, the frontal portions being the longer. On the sides, the temporal muscles occupy the temporal fossa? covered by the strong and dense fascia which is at- tached to the temporal ridge. Covering the surfaces of the bones is the pericranium, a delicate periosteal membrane. The arterial supply to the scalp on the top and sides is furnished by the anterior and posterior temporal and occi- pital arteries. The nerves are derived from branches of the supra-orbital, temporal, auricularis magnus, and occipitalis major and minor. The flat bones forming the vertex consist of two compact layers, with the spongy or diploic tissue between. The external table is strong and dense, while the internal or the vitreous is very brittle. The diploic tissue contains a number of sinuses or venous channels which ramify in tortuous directions throughout the structure, being composed of the fiontal, anterior and posterior temporal, and occipital. The internal surface of the cranijd bones is lined 710 EXCISION OF BONES AND JOINTS. by the dura mater, the fibrous membrane of the brain, whieli forms tlie internal periosteum. The dura mater contains the meningeal arteries and their branches, and the superior longitudinal and lateral sinuses, two large venous channels having important surgical relations. The superior sinus occupies the attached margin of the falx cerebri, beginning at the crista galli and passing backward, terminates at the internal occipital protuberance in the lateral sinuses. In its course, it grooves the inner surface of the frontal bone, tlie apposing margins of the two parietal, and the superior por- tion of the crucial ridge of the occipital bone. The lateral sinuses begin at the torcular Herophili, a slight distance to the side of the internal occipital protuberance, and are lodged in the attached margin of the tentorium cerebelli. As they pass to their termination in the jugular foramina, they rest upon the inner surface of the occipital bone, the posterior inferior angle of the parietal, the mastoid portion of the temporal, and the upper surface of the jugular process of the occipital. The position of these important vascular channels should be borne in mind in all operations upon the vertex and the mastoid portion of the lateral region. The thickness of the cranial walls differs at different points, being thickest at the protuberance of the occipital bone and thinnest in the temporal region and roofs of the orbits. The cranial bones of different individuals vary greatly in this respect. In some they are very thin, fracturing under the application of the slightest force. In others, especially in negroes, the bones are sometimes found to be very thick, measuring frequently one-quarter to one-half of an inch at all points. The conditions which demand excision of portions of the cranial walls are necrosis, morbid growths, intracranial THE CRANIU^I. 711 collections of blood or pus, the removal of foreign bodies, as bullets or fragments of knife blades, the relief of epilepsy or insanity due to bone pressure, and fractures causing depres- sion of the bone, with symptoms of brain compression, or injury to the brain by rough edges or spicula of bone, 'in necrosis and morbid growths, the disease may be limited to the external plates, and relief may be afforded by removal of this portion of the bone alone. In operations for the removal of intracranial collections of blood or pus, or of pressure by bone, either recent or chronic, the opening into the cavity is made through both plates of bone by the tre- phine, or where a compound fracture exists the bone may be elevated and excised with the pliers. The question with regard to the employment of the trephine in cranial injuries is one of great importance, and its discussion has recently taken a wide range. It may be stated in general that excision of the cranial bones is indicated and should be performed in the adult in all instances of injury which are accompanied by depression of the bone and symptoms of compression; in compound fractures with symptoms of compression, with or without depression; it may be proper in similar cases, with depres- sion and without symptoms of compression ; in compound comminuted fractures with depression ; in punctured frac- tures; in compound fractures, in which inflammatory symp- toms develop, which may be due to spicula of bone pressing upon the brain. In the child, owing to the comparative thinness of the cranial walls and the accompanying elasticity by reason of which depression may occur without fracture and without the occurrence of marked brain pressure, the use of the trephine is rarely required. Under the process of growth and development the brain may accommodate itself to the altered shape of the cranial wall. In all cases, where 12 EXCISION OF BONES AND JOINTS. it is possible, the forceps and elevator, with the pliers, should be employed in preference to the trephine. The gravity of the operation does not exist in the effect upon the bone, but in that exerted upon the important and sensitive organ and structures within the cavity surrounded by them. Section of the external and internal plates with the intervening diploic structures may be regarded as an operation of no greater gravity than that of the compact and cancellated tissue of a long bone. The primary and second- ary effects exerted upon the brain and its membranes by the cranial injuries which are amenable to relief by the operation upon the bones, give to it an importance not possessed by any otlier. Fis;. 444. Ficr. 445. The instruments required for the performance of excision of the cranial bones consists of a scalpel (Fig. 242), dissect- ing, arteiy (Figs. 434, 435), and bone ibrceps (Fig. 435), a tenticulum, trephines, cylindrical and conical in shape, and TIIK OKANirM. 713 of (liri'erent diameters (Fi^ns. 444, 445, 440), a probe witli ji flat end, a brush to remove the bone dust from the teetli of the trephine (Fi^. 447), an ehivator (Fig. 448), a lenti- cular (Fig. 449), a Hey's saw (F'ig. 450), a Holsen chisel (Fig. 451), ligatures, sutures, and needles. The crucial Fill. 446. Ficr. 44S. Fiir. 449. Fiir 450. Ficr. 451. Fi-. 44: incision has been usually employed in the section of tlie scalp, but it is not as advantageous as that semilunar or horse-shoe shaped in form. Operation Tiie patient having been placed in the re- cumbent position with the head elevated, an anaesthetic is administered and tiie liair removed by the razor for some 00* 714 EXCISION OF BONES AND JOINTS. Fig. 452. distance around the wound. If the patient is unconscious by reason of the compression exerted by depressed bone or other cause, the anaesthetic may be withhekl. If a wound of the scalp exists, it may be enlarged in the necessary directions, or a horse-shoe shaped incision may be made carrying the knife to the bone and reflecting the flap thus form- ed (Fig. 452). Bleeding from the divided vessels of the scalp may be controlled temporarily by the hj^mostatic forceps and usually permanently, without dif- ficulty by the sutures employed in closing the wound, in this manner dispensing with liga- tures. If a depression of the bone exists tlie trephine should be applied over the border of the depression, tlie pin of the instrument being pushed down into the sound bone. A circular incision of the pericranium should be made before application of the instrument. The trepliine having been fixed in position by the pin, it should be revolved by a movement of supination and pronation of the hand until a slight groove is made by the teeth, when the pin should be retracted and held firmly in this position by the screw (Fig. 445). The instrument should be re-applied and the section of the bone cautiously proceeded with. The bone dust should be removed from the teeth of the trephine by the brush or a wet sponge and the groove in the bone cleaned by the flat end of the probe. Section of the diploe will be indicated by the flowing of blood into the wound ; from this point great care should be exercised during section of the THE CKANIUM. 715 tliiniier internal table. The button of the bone should be grasped by the forceps and gently moved in order to ascer- tain when it is entirely iree. It may be removed in the open- ing of the trephine or picked out with the forceps. After removal of the section of bone, the wound is gently cleansed, the flap replaced, and secured by silver wire sutures, sufficient intervals being left for the escape of the wound fluids. The wound should be dressed antiseptically, and the treatment of the patient conducted so as to avoid the occurrence of inflammation. In compound and comminuted fractures, the fragments of bone may be removed with the bone forceps and elevator, the use of the trephine being dispensed with. This plan should always be adopted when practicable. In a case of compound comminuted fracture of the frontal and parietal bones, under my care some years since, I removed, in this manner, twenty-four fragments of bone, varying in size, the largest fragment being the size of a silver dollar, and detached from the internal table. In a number of instances of compound and comminuted fractures of the cranium, I have succeeded in effecting removal of the fragments and elevation of the depressed bone with the forceps and eleva- tor. If possible to avoid it, the trephine should not be applied over the course of the longitudinal or lateral sinuses, or their point of union at the occipital protuberance ; over the frontal sinuses, or the anterior inferior angle of the parietal bone, at wdiich point the middle meningeal artery enters the cranial cavity. When the condition demands operation at these points care should be taken to avoid wounding these important vessels. Hemorrhage from a sinus may be con- trolled by pressure with a compress of lint for a few hours, or, if necessary, a double lateral ligature may be applied. 716 EXCISION OF BONES AND JOINTS. Fiff. 453. In using the trephine, the operator should avoid making too much pressure, lest by reason of a thin cranial wall or almost complete section of the bone, great injury be inflicted upon the brain, or its membranes by the forcible passage of the end of the instrument into the cranial cavity. The coni- cal-shaped trephine is for this reason the safer instrument to use. It is also important to bear in mind that, for the pur- pose of elevating depressed bone, a small trephine, one- half of an inch in diameter, is sufficient. Great care is to be exercised with regard to the use of the pin attached to the instrument, which, if not retracted and secured in place, may perforate the bone before section is complete. A modi- fication of the trephine has been devised by Dr. Hopkins, of this city, in which the pin rests upon a spring, and, as the teeth penetrate the bone, it is pushed up into the interior of the crown (Fig. 453). The wounding of the dura mater is to be carefully avoided, as such a procedure greatly complicates the operation ; if the operation is per- formed to evacuate pus or blood lying beneatli this membrane it should then be incised in order to afford escape for the fluid. Eepair after excision of the cra- nial wall takes place by fibrous tis- sue, and the part must be protected by the adaptation, externally, of a metal plate. In rare instances, a thin layer of bone is re- produced. MAT.AR nOXK — TTPPF.n JAW. 717 FACK. Malar Bone. — Surgical Anatomy. — Themalar bone, one of the double bones of the face, is situated at the upper and outer part of the face, and enters into the formation of the orbit and zygomatic and temporal fossae. It articulates with tlie frontal, sphenoid, and temporal bones of the cra- nium, and the superior maxilla of the face. Its position is quite superficial, and its relations, except to the sphenoidal fissure, are not very important. Several small arterial and nervous branches traverse canals in its substance. It may be the seat of necrosis, or participate in gunshot and other fractures of the bones of the face requiring exci- sion. It is frequently removed in part or entire in operations of excision of tix; upper jaw. The bone may be exposed by a curved incision carried from the external angle of the frontal bone to the maxillary process. Opekatiox. — When excision of the bone is required as an independent operation, it may be exposed by the incision given above, the periosteum reflected, and the frontal, zygo- matic, and maxillary processes divided with the pliers, and the bone grasped with the forceps and dislodged. In gun- shot fractures the fragments which are detached may be re- moved with the forceps. After excision the wound should be closed by suture, dressings applied and retained in posi- tion by roller. Upper Ja"W Surgical Anatomy The participa- tion of the upper jaw in the formation of three important cavities, the mouth, nose, and eye, associated with the ex- istence of a cavity within its interior, the maxillary sinus. 718 EXCISION OF BONES AND JOINTS. renders the surgical relations of the bone of great import- ance in connection with the various diseases, benign and malignant, with which it is liable to be attacked. Its articu- lation with two bones of the cranium and seven of the face increases the importance of its surgical relations when it be- comes the subject of operation. It articulates by its nasal process with the nasal bone and frontal; by the inner margin of its superior or orbital surface, with the lachrymal, eth- moid, and palate ; by the inferior turbinated crest with the inferior turbinated bone ; by the palate process with the pal- ate, vomer and fellow of the opposite side ; and by the malar process with the malar bone. In its complete removal, these articulations are all severed, either by disruption or section with the saw, and the mouth is deprived of nearly one-half of its roof, the nose of its outer wall and a part of its floor, and the orbit of its floor, leaving a large cavity which exposes nearly the anterior half of the base of the cranium. The infra-orbital artery and superior maxillary nerve are divided in complete excision of the bone. The morbid conditions demanding excision of the bone are tumors of a recurrent or malignant form involving the entire structure, originating either in the antrum or in the substance of the bone. Fibroid tumors, which are frequently limited in their growth to the external surface of the bone, can be readily removed from the surface, and therefore do not demand dis- articulation of the bone. Sometimes they produce, by pres- sure, absorption of the osseous tissue, and force their way into the cavities of the antrum, nose, or orbit, requiring in such cases excision of a greater part of the bone. Enchondromata^ originating either from the external sur- face or the interior of the antrum, likewise cause absor{)tion TIIK UPPER JAW. 719 by pressure and involve in their removal the greater portions of the bone. Osseous tumors existing in their simplest form, as an hy- pertrophy of the whole or a part of the jaw, or as the result of the transformation of pre-existing growths, compels the excision of those parts involved. Sarcomatous tumors require extirpation of the entire jaw, or free excision in those of the less malignant character. Carcinoma of the jaw, of whatever form, demands the re- moval of the entire bone. A difference of opinion exists with regard to the propriety of operative interference in car- cinomatous affections of the upper jaw. The difficulty, in advanced cases, of obtaining complete removal of the dis- eased tissue and the speedy recurrence of the growth in the majority of cases after operation, suggest grave doubts as to the benefits to be derived from an operation, in itself, of a serious character. In the early stages, the growth may occupy an area so circumscribed as to permit of its entire removal, the patient gaining, if not complete relief, at least an immunity of longer duration than when the disease is attacked after its full development. Secondary operations should not be performed, as it is impossible to reach, after recurrence, the limits of the disease. Operation — The patient should be placed in the semi- recumbent position upon a firm table and an anaesthetic ad- ministered. The instruments required for the operation are scalpel, dissecting forceps, cutting pliers of various angles (Figs. 297, 437), strong forceps, among them the lion-jawed forceps (Figs. 454, 455), the metacarpal, Hey's or Adams's saw (Fig. 456), chisels, gouges, and retractors. Sponge- holders should be provided, in order that sponges may be carried into the mouth and pharynx to remove the blood and prevent its passage into the larynx. 720 EXCISION OP BONES AND JOINTS. Lines of Incision Incisions in various directions have been employed for the purpose of exposing the upper jaw at the time of removal. The chief object in the selection of any line of incision is to obtain sufficient exposure of the parts Fis. 454. Fiff. 455. Fio-. 456. in order to avoid embarrassment to the operator during the ditferent steps of the operation. A consideration of some importance is to avoid division of the facial artery and nerve at such points as to give rise to Iree hemorrliage at the time THE UPPER JAW. 721 Fk. 45: of the operation, and subsequently to extended paralysis ol* the muscles of the face. It is a matter of some importance also to avoid section of the duct of the parotid gland (Steno's duct), which, if made, may result in the formation of a sali- vary fistula. The incision, at first employed, began at the ancrle of the mouth, and was carried in a curved direction across the cheek, to the malar bone or external angle of the fron- tal bone (Fig. 4o7, 1). To this incision has been added another, which is carried tVom the point of termination of the first beneath the inferior border of the orbit to the side of the nose. By these incisions large branches of the facial artery and nerve are divi- ded. In order to avoid section of these large branches, Sir William Fergusson suggested and employ- ed a line of incision, wLich began ^-" at the middle of the upper lip, and was carried to the column^e nasi and round the ala of the nose to the inner angle of the eye and from this point beneath the inferior border of the orbit to external angle of the frontal bone (Fig. 457, 2). This incision divides the artery and nerve where their branches are smallest and the flap formed is extensive enough to uncover the entire surface of the jaw. The only objection to be offered to this line is the formation of angles, the edges of which are difficult to approximate accurately and in the union of which the repara- tive process is slow. To overcome this objection I have employed a curved incision which begins near the angle of the mouth, passes along the ala of the nose to near the inner 61 722 EXCISION OF BONES AND JOINTS. angle of the eye, and then curves out to the external angle of the frontal bone (Fig. 458). Operation — Having raade the incision the operation is continued by rapidly dissecting the flap from the sur- face and entrusting it to the care of an assistant who grasps the bleeding points and compresses them by the fingers, meanwhile making pressure on the facial artery as it passes over the border of the lower jaw in front of the anterior inferior angle of the masse- ter muscle. The portion of the flap attached to the nasal process is now to be detached, and, if neces- sary, the points of attachment of the cartilage of the nose to the nasal spine. As the hard palate is divided alongside of the line of articulation of the two bones the detachment of the nasal cartilage may be omitted. The middle in- cisor tooth of the side operated upon is now extracted, and an incision is made from the alveolus backward to the posterior border of the horizontal portion of the palate bone, dividing the tissues on the roof of the mouth, and the soft palate is then detached from the palatine border. The nasal process is now divided by the cutting pliers or metacarpal saw, the section being made obliquely upward so as to terminate at the lower border of the lachry- mal groove. The articulation between the malar process of the jaw and the malar bone is likewise divided by the pliers or saw, and the separation of the bones from each other is accomplished by section of the hard palate with the meta- carpal saw, the blade being entered into the cavity of the THE UrPER JAAV. 723 no»e for that purpose (Fig. 459). The bone is now seized with the lion-jawed forceps (Fig. 454), forcibly depressed and abducted and adducted so as to separate the suture be- tween the pterygoid process of the sphenoid bone and palate bone, and also the articulations within the orbit, the tissues occupying the floor of the orbit having been detached with care and pushed up with the handle of the knife. As soon as the bone is removed sponges, which have been prepared anti- septically, should be pressed into the wound with some force Fig. 459. in order to check the bleeding, which is usually controlled by this means. If this is not sufficient, hot water may be employed to stop the general oozing, and animal or carbo- lized silk ligatures should be applied to the arteries requiring them. The hemorrhage having ceased, the cavity should be cleansed and packed with 77-^ per cent, iodoform gauze and the fla[)S re{)laced and sutured with silver wire, the incision in 724 EXCISION OF BONKS AND JOINTS. the lip being secured by a harelip pin and carbolized silk ligature, and the line of incision covered with iodoform gauze and retained in place by adhesive strips or a bandage. Union takes place very promptly between the edges of the incision, and the sutures may be removed in part or in whole on the fourth day. The cavity left by the removal of the jaw is partially closed by a formation of fibrous tissue ; where the operation has been performed for the removal of malignant growths, the return of the disease in the part is to be expected sooner or later. In non-malignant affections, limited to the anterior surface or to the alveolar process, par- tial excisions of the upper jaw may be performed without ex- ternal incision of the over- ■^^S" "^^^^ ly^"o tissues or with those of limited extent, from the lip to the ala of tlie nose or beyond to the inner angle of the eye (Fig. 460). More or less diffi- culty attends the attempt to remove, through the mouth, morbid growths in- volving the u[)per jaw,and the surgeon is unable to obtain such view of the parts as to be confident of tiie entire extirpation of tlie disease. In cases of necrosis, in wliicli detach- ment of the dead bone has occurred, its removal can be readily accomplished through the mouth without external incision. In many instances the orbital plate of the upper jaw is not involved, and may be THE UPPER JAW. 725 allowed to remain in position by malting a section of the bone with the saw, just beneath the lower border of the orbit. The application of ligatures is rarely needed in this opera- tion, providing care has been exercised to make the incisions bevond the limits of the morbid m-owths involving the bone. Tiie larger arterial branches of the deeper parts are suffi- ciently removed from the seat of operation to escape injury, except in an unusual involvement of the parts in the morbid growth. Tiie preliminary application of a ligature to the common carotid artery can scarcely be required in any case. The prognosis in excisions of the superior maxilla is ex- ceedingly favorable. Heyfelder's tables give 26 deaths in 112 complete excisions, 36 in 187 partial excisions, and 5 in 12 excisions of both bones. Prof. S. D. Gross performed the operation upwards of twenty times without a single loss. Of eight excisions performed by the author, one, a case of large medullary carcinoma, terminated fatally two weeks after the operation, x^o difficulty in controlling the liemor- Fio:. 461. Fiff. 4(52. rhage occurred in any of the cases, and in but one w^as it necessary to apply any ligatures. Figs. 461, 462 show the appearance presented in a sarcoma of the upper jaw of the 61* 726 EXCISION OF BONES AND JOINTS. spindle-celled variety in a girl eleven years old, and the re- sult subsequent to the operation of excision of the entire jaw. Lo"wer Javr Surgical Anatomy. — The lower jaw is the largest bone of the face, and consists of a body or cen- tral portion, two rami and two processes, the coronoid and condyloid, t.he latter, forming with the glenoid fossa of the temporal bone, the temporo-maxillary articulation. A number of muscles, fourteen in all, are attached to it at various points and are concerned in its elevation and de- pression, as well as in the movements of the tongue, lower lip, and pharynx. The inferior dental artery and nerve occupy the inferior dental canal within its interior, and the facial artery crosses its lower border at the anterior inferior angle of the masseter muscle. The parotid gland has an important relation to the ramus, the outer surface and pos- terior border of which it covers. The submaxillary and sublingual glands are placed in fossoe on its inner surface. Excision, partial and complete, of the lower jaw is re- quired for morbid conditions similar to those attacking the upper jaw. Tumors, occupying the external surface of the bone and limited in their attachment to the external plate, may be removed by dissection and elevation of the growth with the external plate. In cases of necrosis and other conditions, where the periosteum is not involved in tlie dis- ease, it should be detached and allowed to remain. Operation — The patient may be seated in a suitable chair with a rest for the head, or be placed upon the table in a semi-recumbent position and an anaesthetic should be given. The line of incision which exposes the jaw to the best advantage, and conceals the cicatrix formed, should begin slightly in front of the lobe of the ear and be con- tinned over the ansle to the base and along the base to tlie TFIE LO\VER JAW. 727 sympliysis ami thence upward to tlie border of the lip or tlirouixh the entire lip. In excision of the entire jaw the incision should be carried to the lobe of the ear of the oppo- site side. In partial excisions but a portion of the incision is required. In necrosis, and affections limited to the alveolar border, excision can be performed through the mouth and without external incision. The incision along the base will necessitate division of the facial artery, which may be secured, before section, by a hairlip pin introduced beneath the vessel and a ligature applied over it in the manner of the twisted suture. The bone having been exposed by the dissection of the overlying tissues with the masseter muscle, it should be divided by the chain saw, which should be car- ried beneath it by a threaded needle at such point as is required. The muscles attached to the inner surface of the base and angle, with the periosteum, if deemed advisable, should be detached with a probe-pointed bistoury or with the periosteal elevator, care being taken in excision of the entire jaw to secure the fr^ennm of the tongue with n Hiatiire before separation from the bone, in order to prevent its re- traction, which might result in closure of the glottis and suffocation (Fig. 463).. Separa- tion of the temporal muscle, from the coro- noid process and of the condyloid process from the glenoid fossa at the point of articula- tion is one of tlie most difficult steps of the ope- ration. The intimate Fi^. 463. 728 EXCISION OF BONES AND JOINTS. relation of the internal maxillary artery to the condyle, pass- ing, as it does, on the innersideoftheneck of this process, ren- ders it liable to injury unless the knife is used with great cau- tion. Although the vessel is further removed from thecoronoid process, lying to the inner side and behind, it may be wounded in the unguarded use of the knife. For the purpose of division of the tendon of the temporal muscle and capsular ligaments of the joint, the probe-pointed bistoury — that used in hernia is preferable — should be applied, cutting the tendon from without inward and the ligament upon the outer side alone. This partial section is usually sufficient to permit the bone to be detached by seizing the body and forcibly twisting it outward. In excision of the lower jaw through the mouth the tissues lying in front of the anterior border of the ramus Fij?. 464. Fis. 465. may be cautiously divided with the probe-pointed bistoury, the incision being made upward until the base of the coro- noid process is reached, and then section of the tendon and THE LOWER JAW. 729 ligaments may be made, if necessary, by carrying the knife across on the outside of the bone. Tiie hite Prof. Gross etFected, with great ease and safety, the separation of these parts by an elevator which combined the principles of a knife and lever (Figs. 4G4, 4G5). The blunt edge of this instrument is insinuated beneath the soft structures, peeling them off, and the processes are detached by priz- ing them out of place. The same precautions should be taken in excision of the lower jaw as in the upper with re- gard to a careful dissection of the structures so as to effect entire removal ; the avoidance of incisions into the morbid growtli, in order to prevent hemorrhage, and the preservation of the periosteum wherever it can be done with safety. The preservation of the periosteum is very important in opera- tions upon the lower jaw, as new bone formation occurs when tliis membrane is not removed, which provides a suitable basis for an artificial denture. Especially is this to be ob- Fio:. 466. Fiff. 467. served in operations for necrosis of the bone in which the new bone is readily reproduced. In a number of instances of excision of the lower jaw, partial and complete, performed by tlie author for necrosis, the reproduction of bone has been 730 EXCISION OF BONES AND JOINTS. Fig. 468. STERNUM AND ENSIFOKM CARTILAGE. 731 ^o complete as to prevent deformity by preserving the shape of the jaw and supplying a firm support for artificial appli- ances. This is seen in Figs. 466 and 467, representing the conditions in a case of phosphorus necrosis in which one-half of the lower jaw was excised. In operations upon both the upper and lower jaws Bon- will's surgical engine, with properly adapted burrs and saws, may be employed with advantage (Fig. 468). TRUNK. Sternum and Ensiform Cartilage. — Surgical Anatomy. — The sternum, with the costal cartilages, forms a portion of the anterior wall of the thorax. It consists of delicate cancellated tissue covered by a compact layer in front and behind. A number of muscles are attached to it, chiefly by aponeurotic points of origin. Its anterior surface is subcutaneous, being covered by the skin, fasci?e, and aponeurosis of the two pectoralis major muscles. Its pos- terior surface has an important relation with the anterior mediastinum, forming its anterior wall, with the pleurse on the sides and the pericardium behind. In this space, the internal mammary vessels of the left side are placed with a quantity of loose areolar tissue, in w^hich inflammation, leading to suppuration and the formation of post-sternal abscesses, sometimes occurs. In operations upon the sternum, the proximity of the pericardium should be borne in mind, and care should be exercised in the use of cutting instru- ments upon the posterior surface. The conditions requiring excision, which are, as a rule, partial in character, are caries and necrosis, abscess in the anterior mediastinum, gunshot injuries, with lodgement of 732 EXCISION OF BONES AND JOINTS. foreign bodies in the substance of the bone or in the medias- tinum. In rare instances, where harmful pressure is exerted by the displaced fragment or portion in fractures or dislocations excision may be necessary. In extensive comminution of the bone by shot wounds, the pericardium may be exposed on removal of the fragments. It is always desirable to make the operations subperiosteal as far as possible, in order that a support may be afforded by new bone formation. Operation A longitudinal line of incision is usually sufficient to expose the bone for any operation. A crucial or semilunar may be employed, if deemed advisable. The diseased bone may be removed by the gouge, cutting pliers, Hey's saw, or the trephine. A drainage tube should be introduced, especially if the wound is large, and antiseptic dressings applied. It is very important to afford an easy outlet to the wound fluids lest they should dissect up the tissues posteriorly and enter the mediastinal space. Rib and Costal Cartilages Surgical Anatomy. — The ribs, twelve in number on each side, form the chief part of the walls of the thoracic cavity. From the second to the twelfth they are placed obliquely, the costal extremity being lower than the vertebral. The spaces between them are filled up by the intercostal muscles. In structure the ribs consist of cancellated tissue covered by a thin external compact layer. They have important relations with the pleura, being separated from it on the inner surface by a delicate areolar tissue. On the outside they are covered by the integument, fasciae, and muscular layers. The inter- costal vessels lie in a groove on the inferior border. Tlie conditions which may require excision of the ribs and RIBS AND COSTAL CARTILAGES. 733 their cartilages are caries, necrosis, comminuted fractures, collections of pus in the pleural cavity, and morbid growths. A number of ribs may sometimes be involved, requiring operation. It is seldom that the entire bone demands removal. Line of incision. — In cases of caries and necrosis the incision may be made in the long axis of the rib following its curve. Where more than one rib is involved a semi- lunar or crucial incision may be required to expose the bones. For the removal of tumors connected with the ribs an elliptical incision should be made. When resection is per- formed to evacuate pus from the pleural cavity, a straiglit or semilunar incision will fully expose the part. Operation The patient should be placed in the recum- bent position, turned slightly upon the sound side, and an ana3S- thetic should be administered. When the operation is per- formed for caries or necrosis, the incision should be made directly to the bone, dividing the periosteum, which, in these cases, is much thickened by inflammation. This membrane should be separated from the bone by the elevator, which should be kept in close contact with the bone to avoid wound- ing the pleura or intercostal vessels, and the caries removed by chisel or gouge, or in case of necrosis, the rib divided either by the chain saw, which may be passed around it, by the meta- carpal saw, a shield being passed beneath it to protect the adjacent tissues, or with the pliers. After section, the rib should be lifted from its position, drawn out, the periosteum detached from its posterior surface, and the bone again di- vided by the saw or pliers. In excision of the ribs for morbid orrowths o;reat care should be exercised in separating the posterior attachments, which are, as a rule, intimately adherent to the pleura, and 02 734 EXCISION OF BONES AND JOINTS. perforation of which may occur. Hemorrhage from the intercostal arteries may require application of the ligature, carried around the rib, if necessary. Drainage having been provided for, the wound should be closed by suture, dressings applied and retained in place by adhesive strips or broad bandages carried around the chest. Pelvic Bones. — Surgical Anatomy The pelvis is that portion of the trunk interposed between the lower extremity of the vertebral column, to which it affords sup- port, and the lower extremities, upon which it rests. It is formed of four bones, the two ossa innominata, the sacrum, and the coccyx. Externally it is covered by the integu- ment, fascise, and layers of thick muscles which are attached to its surface, borders, and prominences ; within it is lined by fascia and partially by muscles and the peritoneum. The conditions which demand excision of the pelvic bones are necrosis, morbid growths, compound comminuted frac- tures and, in the coccyx, a condition of neuralgia following, in some cases, fracture or dislocation of the bone. The li7ie of incision may be straight or curved according to the position of the growth or dead bone. If sinuses exists these may be enlarged in any direction and the bone extracted through the opening. Operation — The patient should be placed upon the side or in the semi-prone position and the incision made, in cases of necrosis, directly to the bone, dividing the periosteum, which should then be separated by the elevator. Tumors occupying the surface of the bone may be exposed by an elliptical incision and the growth removed by the chisel or gouge. In compound comminuted fractures, the fragments uprEU extre:\iity — sitoulpek. 735 which have no periostea,! attachment may be removed through the external wound. Coccyx Coccygectomy, excision of the coccyx, may be required in cases of coccygodynia, or painful neuralgic affection of the coccyx, and in necrosis. The bone may be exposed by an incision carried in the middle line from the sacro-coccv"real junction two inches downward toward the anus. The periosteum should be carefully detached with the periosteotome or elevator, the index finger of the left hand being kept meanwhile in the rectum to guard against wound- ing the bowel. It will be found frequently quite difficult to effect separation of the bone without breaking it up into small fragments, and in this way accomplishing extraction. In two of the three excisions of this bone which I have per- formed, I experienced this difficulty ; in the remaining opera- tion, for necrosis, the bone was easily lifted from its position. A drainai]re tube should be introduced extendino^ the entire length of the wound and emerging at the upper and lower angle, in order to secure perfect drainage and douching of the cavity. The wound, as in excisions of other portions of the pelvis, should be closed by suture and the dressings retained by adhesive strips or a broad bandage. UPPER EXTREMITY SHOULDER. Clavicle Surgical Anatomy The clavicle is placed between the sternum and scapula, articulating by its inner extremity with the manubrium of the sternum and car- tilage of the first rib, and by its outer end with the acromion process of the scapula. It receives the attachments of the sterno-cleido-mastoid, sterno-hyoid, pectoralis major, sub- clavius, trapezius, and deltoid muscles. It lias most import- 736 EXCISION OF BONES AND JOINTS. ant surgical relations, by the posterior surface of its inner two-thirds, with large arterial and venous trunks, nerves, and the right lymphatic and thoracic ducts. Posterior to the sterno-clavicular articulation on the right side, the bifurca- tion of the innominate artery into the common carotid and subclavian occurs, with the junction of the internal jugular and subclavian veins, which, with numerous smaller arteries and veins, form a vascular network which greatly complicate any operations in this region. On the left side, the common carotid and subclavian arteries, with the internal jugular and subclavian veins and smaller arteries and veins, give to this region also important surgical relations. The anterior sur- face of the bone is nearly subcutaneous in its entire extent, being covered in addition by the platysma muscle only. The conditions which demand excision of the bone are caries, necrosis, pathological displacements of the articular extremities, and morbid growths. The incision necessary to effect excision may be made in the long axis of the bone, which will permit it to be exposed sufficiently for opei-ation in cases of caries, necrosis, or ex- cision of either of the articular extremities. When the bone is the seat of a morbid growtii, an elliptical incision may be employed. Operation The patient should be placed in the recum- bent position, with the shoulder of the affected side elevated and drawn outward. In caries or necrosis, an incision should be made over the anterior border, dividing the tissues to the bone. These with the periosteum should be separated with the elevator, and in caries, the diseased bone scraped or gouged out with the chisel. In partial excision for necrosis the bone can be divided with the chain saw, metacarpal saw, or pliers, and the dead portion removed (Fig. 4G9j. When CLAVICLE. 737 tlie entire bone is to be removeil, disartieuljition should be eflected at the acromio-chivicidar junction, the coraco-chivi- cuhir ligaments severed, the bone lifted from its position, and the posterior attachments carefully separated, until the sterno- Fls. 469. clavicular articulation is reached. The ligaments of this articulation should be carefully divided with a probe-pointed bistoury and the bone released. The hemorrliage which fol- lows the removal of the bone is usually slight, and may be easily controlled by pressure and douching with hot water. Excision of the clavicle for morbid growths' is frequently a very serious operation, owing to the intimate relations assumed by the growths to the structures lying posterior to the bone. A very careful dissection is necessary to avoid inflictino- injury upon the subclavian vein, lymphatic or thoracic duct, and possibly the phrenic nerve. Great care should be taken to prevent the entrance of air into the large G2* 738 EXCISION OF BONES AND JOINTS. veins which may be divided ; a double ligature should be ap- plied before section or compression made by hcemostatic for- ceps. All appliances for checking and controlling hemorrhage should be at hand, and the handle, in preference to the blade, of the knife should be employed in separating the growth from its attachments. After removal of the bone, drainage should be provided for, the wound closed by interrupted sutures, antiseptic dressings applied and retained in position by the Velpeau bandage. In removal of the bone for necrosis, reproduction takes place, the entire bone having been reproduced in instances reported. Where excision is performed for morbid growths, this does not occur. The functions of the arm are very little if any impaired after removal of the bone. Scapula Surgical Anatomy — The scapula occu- pies the posterior and lateral aspects of the thorax between the first and eighth ribs, and is held in position by muscles which attach it to the vertebral column and occipital bone, as well as to tlie walls of the tiiorax, the clavicle, and humerus. These muscles are attached to its anterior and posterior surfaces, its borders, the spine, and both pro- cesses. It articulates by the acromion process witli the chivicle, and by its head witli the humerus. The vascular supply to the bone is derived from the supra- scapular artery, which crosses the supra-scapular ligament and is distributed to the supra-spinous fossa and acromial process — the posterior scapular, a branch of the transversalis colli, distributed to the posterior border of the bone and the subscapular, which supplies the subscapular fossa and sends off a branch, the dorsalis scapulae, to the infra-spinous fossa. Excision of a portion, or of the entire scapula, may be SCAPULA. 739 required for caries, necrosis, gunshot wounds, and morbid growths. The hitter, very frequently of a malignant char- acter, involve the entire bone, assuming collossal proportions, and demanding, in some instances, for their extirpation, re- moval of the entire upper extremity. The lines of incision vary according to the character and extent of the operation. In excision of the acromion pro- cess or spine for caries or necrosis, a straight incision over the part will suffice to expose it and permit of its removal. When the entire bone is necrosed, a subperiosteal operation may be performed, the bone being exposed by two incisions, one extending the whole length of the posterior border and the other along the spine, beginning at the acromion process and terminating at the base, where it joins the posterior in- cision. In the removal of the bone, when the seat of large morbid growths, a f" -slipped incision may be employed, tlie horizontal portion extending along the upper border of the growth, the vertical crossing it and terminating at the lower border. Operation The patient, placed in the recumbent posi- tion, is turned upon the sound side and the body inclined forward. In cases of caries or necrosis involving the spine with the acromion process, the parts can be exposed by an incision carried from the acromio-clavicular junction backward over the spine to its base. The skin, fasciae, and points of attachment of the trapezius and deltoid muscles with the periosteum should be carefully separated from the surface of the bone, and the gouge or chisel employed to remove the caries. If the spine is necrosed and the acromio-clavicular articulation is intact, the ligaments of the joint wdth the coraco-acromial should be severed and the d^ad portion re- moved, or if the acromial end of the clavicle is implicated, 740 EXCISION OF BONES AND JOINTS. it should be released by dissection and divided with the pliers or saw. When the entire bone is involved in necrosis subperiosteal resection should be performed by making two incisions as above described — one along the posterior border and another over the spine from the acromion process to the base, joining the first. These flaps should be reflected, and the overlying tissues and periosteum raised at this point with the elevator from the supra- and infra-spinous fosste, and then the posterior border from the superior to the infe- rior angle, released. The bone should now be gently raised, and the subscapular muscle wath the periosteum detached from the subscapular fossa freeing at the same time the supe- rior and inferior borders. The bone should now be drawn upward and outward, and, if the disease permits it, the neck divided with the pliers leaving the glenoid fossa and coracoid process — otherwise, the ligaments of the shoulder-joint should be divided as well as the structures attached to the coracoid process, and the entire bone removed. If the bone has been allowed to remain until completely detached by the necrotic action, the muscular attachments can be removed with the periosteum. When the scapula is the seat of a large morbid growth, the T-shaped incision should be employed to expose the tumor, from the surface of which the tissues should be care- fully dissected. If the integument is involved in the growth, an elliptical incision, over the surface or about the base of the tumor, directed obliquely from the point of the shoulder to the vertebral column, should be made. As the mass is carefully dissected from its position the various muscular attachments should be divided as they are reached. If the disease does not extend beyond the neck of the bone, this with the acro- mio-clavicular articulation should be severed. When the SCAPULA. 741 outer end of tlie clavicle and the shoulder- joint are involved, the incision should be carried over the clavicle and in front and behind the shoulder-joint to the anterior and posterior borders of the axilla, the bone divided at a point beyond the disease and the arm removed with the growth. In perform- ing this operation, the greatest caution should be exercised when the region of the shoulder-joint is approached, and it becomes necessary to sever the vessels of the axilla in re- moving the arm. The dissection should be made from below upward, the tumor be turned up toward the neck and the axillary artery, if possible, isolated and surrounded with a ligature. The arteries distributed to the scapula should be ligatured as they are divided, or compressed with the haemos- tatic forceps until completion of the operation. In this ope- ration, as in that n^)on the clavicle, precaution should be taken against the entrance of air into the divided veins. Hemorrhaore having been controlled, drainaoje tubes should be inserted, if necessary, the wound closed by interrupted sutures, and antiseptic dressings applied and confined in position by a broad roller or spica bandage of the shoulder. The arm should be supported at a right angle in a sling. After removal of the scapula the functions of the arm are not very greatly impaired. Of the various movements that of abduction is alone destroyed. The mortality following total excision of the scapula is very slight, and the operation is found to be attended with less mortality than that for partial removal. Excision per- formed for malignant growths gives a large mortality and, as a rule, the operation should not be performed. Prof. Gross quotes the report of Prof. Adelraann in which the re- sults in 261 excisions of the scapula are given, 66 of which were total and 195 partial. Of the total excisions, 22 were 742 EXCISION OF BONES AND JOINTS. traumatic, with a mortality of 27.2 per cent., and 43 patha- logical with a death-rate of 19 per cent., the lesion in one being unknown. Of the 195 partial operations, 153 were traumatic, with a mortality of 26.3 per cent, and 19.5 per cent, in those performed for disease. Humerus. — Shoulder-joint Surgical Anat- omy The shoulder-joint is formed by the reception of the head of the humerus into the glenoid fossa on the head of the scapula. The capsular ligament, re-inforced by the coraco-humeral, incloses the joint through which passes the long tendon of the biceps muscle from its point of origin, the upper border of the glenoid fossa, covered by a reflec- tion of the synovial membrane. The deltoid muscle sur- rounds the joint in the greater part of its extent, covering it on the outer side, in front and behind. Behind, the supra- and infra-spinati, with the teres minor muscles, are in intimate relation with the joint as they pass to their points of inser- tion into the greater tuberosity of the humerus. In front and to the inside, the sub-scapularis, the coraco-humeral, and short head of the biceps are in close relation with the joint. The axillary artery and vein, with the nerves of the brachial plexus, pass obliquely along the outer boundary of the axil- lary space. The anterior and posterior circumflex arteries, given off from the third portion of the axillary artery, curve backward and are distributed to the deltoid muscle, the neck and head of the humerus, and the shoulder- joint. The anterior artery gives off a branch which ascends in the bicipital groove to the joint, whilst the posterior winds around the neck of the humerus and by its branches anas- tomoses with the supra-scapular, acromial thoracic, and anterior circumflex arteries. The upper and lower branches lIUMKItUS — SHOULDER-JOINT. 7-13 of the circiiindex nerve, one of the divisions of the posterior cord of the brachial plexus, follow, in general, the distribu- tion of the arterial branches to the joint. Tlie conditions for which excision of the shoulder-joint is performed are caries and necrosis, gunshot injuries, com- pound comminuted fractures, old unreduced dislocations in which severe pain is produced by pressure upon the axil- lary nerves, removal of the head of the bone in intra-cap- sular fracture when necrosis and suppuration have occurred, benign tumors involving the head of the humerus, and chronic rheumatic arthritis. In the majority of instances it is found that the disease is limited to the head of the humerus re- quiring excision of this part alone ; in shot injuries, the head of the scapula, with the coracoid and acromion processes'and the outer end of the clavicle, may be implicated and demand removal. The incisions which have been employed for exposing the joint are various, embracing the straight or longitudinal, curvilinear, U'' H^? T"? L"?^^^^ V'^^^^P^^* Of the different forms, that which inflicts the least injury upon the deltoid muscle and overlying tissues and affords, at the same time, ample exposure of the joint, is the longitudinal, beginning just beneath the extremity of the acromion process and car- ried downward in a straight line to near the point of inser- tion of the deltoid muscle, measuring some five inches in length. Operation — The patient should be placed in the recum- bent position with the shoulder projecting beyond the edge of the table. The knife should be entered below the acromion process, the point being carried to the bone and tlie incision made five inches in length dividing tlie fibres of the deltoid muscle. Tiie tissues being separated from the 744 EXCISION OF BONES AND JOINTS. Fig. 470. bone to a slight extent with the handle of the knife or ele- vator, should be held apart by the retractors and the arm rotated inward so as to permit division of the insertion of the supra- and infra-spi- nati and teres minor muscles into the great- er tuberosity, and then rotated outward in order that the inser- tion of the subscapu- laris muscle into the lesser tuberosity may be severed. The long tendon of the biceps muscles should now be carefully dissected from its position in the bicipital groove and beneath the capsule of the joint, and held out of the way. If not destroyed by disease, the capsule should now be divided and the head of the bone forced through the opening, the arm being carried forward. The leather or wooden shield being placed beneath the projected bone, the saw is applied and care is taken to make the sec- tion beyond the line of the disease (Fig. 470). The bone may be divided with the chain saw, and disarticulation then effected of the diseased portion (Fig. 471). If the glenoid fossa, clavicle, coracoid, or acromion processes are involved, the incision may be extended and the diseased portions removed by the pliers or chain saw. Disease of the glenoid fossa may be removed by the chisel or gouge after excision of the head of the humerus. Subperiosteal resection may be performed by opening the capsule, after the preliminary incision, and with the elevator HUMERUS — SHOULDER-JOINT. 745 detaching the insertions of the muscles into the greater and lesser tuberosities with the periosteum, lifting the tendon of the biceps from the groove, projecting the bone through the opening in the tissues and dividing it with the saw. Tlie divided branches of the circumflex arteries should be ligatured if required, the wound thoroughly cleansed by douching with a warm antiseptic lotion, a drainage tube intro- duced so as to traverse the entire length of the wound (Fig. 472), the ends appearing at the upper and lower angles, and the edges approximated with sutures. Antiseptic dressings should be applied and retained by loose turns of the spica bandage of the slioulder, a pad placed in tlie axilla and the arm supported in a sling or by the third bandage of Desault, the object being to carry the upper extremity upward and bring it in near apposition with the glenoid fossa. The amount of bone to be excised varies in accordance G3 46 EXCISION OF BONES AND JOINTS. FiV. 472. Avitli tlie nature of the disease, it being desirable in all instances to make the section beyond its limits. Experi- ence has shown that from four to five, and, in exceptional instances, seven to eight, inches may be removed and the func- tions of the arm very little, if any, im- paired as a result. Amputation is, as a rule, to be resorted to in preference, where one-half or more of the bone demands removal, as the arm is found to be useless when excision is performed in these cases. In necrosis, however, this rule does not apply, as the bone reproduction is sufficient usually to pre- vent great impairment of function. Repair after Excision — Six to eight weeks are required to accomplish heal- ing, and from three to four months before the reparative process has advanced sufficiently to permit use of the arm. In cases in which the periosteum has been retained bone reproduction occurs, and the functions of the arm are pre- served to a great extent. Where this has not been done the movements of the arm liave not, in some instances, been greatly impaired. The mortality rate after excision of the shoulder-joint for all causes is very sliglit. The tables of Dr. Gurlt give the rate at 34.70 per cent, for gunshot injuries ; the cases analyzed by Dr. S. W. Gross, for similar injuries, 33.51 per cent ; those of Dr. Hodges 23 per cent, in primary operations and 38 per cent, in secondary operations. Excis- ion for disease in 50 cases yields a rate of 16 per cent. The tables of Dr. Culbertson show that the greatest mortality HUMERUS — SHAFT. 747 attends tlie opertition wlien pei-fornied during the inter- mediary ov period of traumatic or inflammatory fever, reach- ing, in these instances, as high as 50 per cent. The mortality rate after excision of this joint exceeds that after amputation, the average in the former being 30 per cent., according to the tables of Culbertson, and 28.5 per cent, in the latter, according to the tables in the Surgeon- General's Report prepared by Dr. Otis. Humerus — Shaft. — Surgical Anatomy — The shaft of tiie humerus is that part included between the upper and lower extremities, cylindrical in the upper half and flattened and prismatic below. The musculo-spiral groove traverses the centre of the extei-nal border and passes across tlie external and posterior surfaces obliquely forward and down- ward. Below the surgical neck of tlie humerus the shaft is covered on the outer side and behind by the deltoid and triceps, and on the front and inner side by the coraco- humeral, biceps, triceps, and brachialis anticus muscles. On the inner side of the arm above, between the coraco- humeral, biceps, and triceps, and below, between the biceps, brachiali anticus, and triceps muscles, the brachial artery, with the median nerve, pass. The ulnar nerve diverges from the median in its course, leaving the brachial artery at the middle of the arm, and from this point it descends to the groove between the internal condyle and olecranon process, resting upon the posterior surface of the former at the elbow. The superior profunda artery and musculo-spiral nerve occupy the musculo-spiral groove and descend on the outer side of the arm, between the brachialis anticus and supinator longus muscles, to the front of the external condyle. 748 EXCISION OF BONES AND JOINTS. Excision of the shaft of the humerus may be required for necrosis, gunshot wounds, and ununited fracture. In gunshot fractures, the experience in military campaigns has shown that more favorable results follow removal of the detached frag- ments alone than when the more formal operation of excision of the ends of the upper and lower fragments is performed. Favorable results have followed excision in cases of pseud- arthrosis, especially when performed under antiseptic me- thods. When performed for necrosis of the shaft, excision gives the most favorable results. The incision employed in removing the shaft should be made on the outer side of the arm, beginning above, in the interspace between the biceps, deltoid, and triceps, and ter- minating below between the biceps and brachialis anticus, following in the entire incision the external border of the biceps. Care should be taken, in the lower part of the inci- sion, to avoid carrying the knife between the brachialis anti- cus and supinator longus muscles, where the bifurcation of the musculo-spiral nerve into the radial and posterior inter- osseous occurs, and which may be wounded. Operation The patient being in the recumbent posi- tion, and the arm supported by assistants or placed upon firm pillows, the incision should be made along the external border of the biceps muscle as indicated above, and the knife carried to the bone dividing the periosteum. This membrane should be carefully elevated, reflected, and tlie diseased bone divided with the chain saw, if necessary, and removed. In gunshot fractures, the detached fragments should alone be removed, those which are partially free being allowed to remain with the hope that they may become consolidated. In ununited fractures, the ends of tlie fragments should be HUMERUS, RADIUS, AND ULNA ELBOW-JOINT. 749 excised to a sliirht extent and, after adjustment, sutured by wire, if necessary. After excision, the hemorrhage, which is usually slight, should be controlled by torsion or ligature, the wound douched with a warm antiseptic solution, the periosteum re- placed, and the edges of the incision approximated by suture. A drainage tube having been introduced, antiseptic dressings should be applied, and the arm placed upon an internal angu- lar splint, secured in position by a roller and supported in a sling. Very favorable results have followed excision of the hu- merus for necrosis, the entire bone having been removed in a number of instances with success. In a few cases the humerus, with the upper portions of the ulna and radius, has been successfully excised. In one remarkable case by Prof. V. Langenbeck, the humerus, radius, and ulna were re- moved at different intervals and a serviceable limb obtained. The retention of the periosteum, in these cases, is followed by bone reproduction to such an extent as to replace the origi- nal structure. Tiie mortality rate following excision in gunshot fracture is more favorable than amputation for the same condition. Humerus, Radius, and Ulna — Elbow-joint Surgical Anatomy. — Tlie elbow-joint is formed by the lower extremity of the humerus, and upper extremities of the radius and ulna, and is surrounded by the triceps muscle behind, brachialis amicus, and tendon of the biceps in front, common origin of the flexor and extensor muscles of the forearm on the inner and outer surfaces. In front, in the bend of the elbow, the brachial artery with its veins, the radial and ulna arteries, and the median and musculo-spiral G3* 750 EXCISION OF BONES AND JOINTS. nerves are placed. These structures are separated from the joint by the brachialis anticus, and su[)inator brevis muscles, upon which they rest. The ulnar nerve lies upon the pos- terior surface of the internal condyle. The vascular supply of the joint is derived from the superior profunda, inferior profunda, and anastomatica magna of the brachial, with the radial recurrent and anterior and posterior ulnar recurrent arteries. Excision of the elbow-joint may be demanded for com- pound comminuted fractures, compound and complicated dislocations, caries, necrosis, and gunshot injuries. Various incisions have been employed to expose the articu- lation, as the H- ^^^ X-sli^P^d incision. That which interferes least with the fibres of the triceps muscle and ex- poses the parts fully, is the longitudinal, wOiich should extend four inches over the posterior surface of the joint. The position of the ulnar nerve upon the back of the inner con- dyle is to be borne in mind in the section of the structures to expose the joint. Operation. — The body of the patient should be inclined toward tlie sound side and the affected arm supported upon firm pillows. The incision shoutd be made over the poster- ior surface of the joint to the extent of four inches as above described, cutting through the fibres of the triceps muscle and its tendon. The tissues, with the periosteum and apon- eurosis of the triceps upon the outer portion of tlie incision, should be raised with the elevator and held by a retractor over the external condyle. Tiie tissues upon the inner side should likewise be raised and placed over the internal condyle, great care being exercised in exposing and lifting the ulnar nerveoutof its position in thegroove upon the posterior surface of the inner condyle. It is covered bya dense fibrous envelope. HUMERUS, RADIUS, AND ULNA— ELBOW-JOINT. 751 which should be carefully opened with the grooved director and the nerve held out of the way by a blunt hook. The parts being exposed, the olecranon process should be divided with the pliers and the lateral ligaments severed with the probe- pointed bistoury. The arm should now be flexed and an effort made to project the bones through the wound, this movement being facilitated by detaching the soft structures ^^^' ' * carefully with the elevator (Fig. 473). The shield being placed beneath the projecting ends, they should be divided by the saw, that portion only removed which is injured, or in a state of disease. It is de- sirable always, when possible, to limit the section to the ar- ticulating surfaces; the coro- noid process of tlie ulna, at the base of which tlie brachialis anticus is attached, and the tubercle of the radius into which the biceps muscle is in- serted should be preserved, retaining by this procedure the important function of flexion. Hemorrhage having been controlled, the wound should be thorouglily washed out, a drainage-tube introduced, the edges approximated by suture, antiseptic dressings applied, and the limb placed either upon an internal angular splint, in a tin or felt trough or a plaster bandage with a metal bracket (Fig. 92), or with an opening arranged so that dress- ings may be applied without disturbing the limb. Comfort 752 EXCISION OF BONES AND JOINTS. may be afforded by suspending the limb in the splint, or the apparatus of Mr. Heath may be employed (Fig. 474). Some difference of opinion has existed among surgeons with regard to the relative dangers of complete and partial Fig. 474. excisions of the elbow-joint, the belief having been enter- tained that the latter were attended with more risk than the former and should not be practised. Experience has shown that partial excisions may be performed with safety in dis- ease, whereas in gunshot injuries and traumatic conditions of recent origin complete excision should be employed. As it is desirable to maintain movement in the joint, the ends of the bones should be kept separated in order to pre- vent bony anchylosis and that a fibrous band of union may form. It is also desirable that the fibrous band shall be as sliort as possible in order to give increased power to the arm. The tables prepared by different authors show tliat excision of the elbow-joint gives the most favorable results, varying from 10.87 to 23.05 per cent.; those for shot injuries, 19 to 23 per cent.; for other injuries, 15 per cent. ; for disease, 10 to 12 per cent. In gunsliot wounds, primary operations are much more favorable than secondary. Radius and Ulna — Shalt — Surgical Anatomy. — The anterior and posterior surfaces of the forearm are cov- T?ADIITS AND ULNA SHAFT. 7r)3 ered by the pronators, flexor, and extensor muscles, and the radial region by the supinator longus and extensors of the thumb. The radial and ulnar arteries pass along the outer and inner borders of the forearm, in a line from the bend of the elbow to the styloid processes. The interosseae arteries run upon the anterior and posterior surface of the interos- soeus membrane. The radial, median, and ulnar nerves lie upon the outer, middle, and inner portions of the anterior surface. Excision of the shafts of the radius and ulna may be re- quired for necrosis, gunshot fracture, ununited fracture, and morbid growths. The bones may be easily exposed by longitudinal incisions, care being taken to avoid injury to the bloodvessels and Fig. 475. Fig. 476. nerves of the part. An incision on the posterior surface of the forearm, along the border of the supinator longus muscle, will reach the radius without interfering witli any important structures (Fig. 475). To expose the ulna the incision 754 EXCISION OF BONES AND JOINTS. should be made on the ulnar side of the forearm between the flexor and extensor carpi ulnaris muscles (Fig. 476). Operation The incisions having been made as above described, the periosteum should be carefully detached and the entire, or a portion of the bone removed as may be re- quired. In caries, the diseased bone may be removed by the chisel or scraper. When but a portion of the bone is to be excised it can be divided by the pliers or chain-saw. The hemorrhage will, as a rule, be slight, and can be readily controlled by torsion or ligature. Drainage should be pro- vided for, the periosteum replaced, the edges brought to- gether by sutures, antiseptic dressings applied, and the arm placed upon an internal angular splint. In excision of the bones of the forearm for necrosis repro- duction of bone occurs to such extent as to afford a useful limb. The repair is not as complete in partial excisions, nor in that of one bone, as in the operation for the removal of the entire bone, and both bones. The results are not, as a rule, very favorable in primary operations for gunshot fractures nor for pseudarthrosis. In a number of excisions for gunshot injuries, consecutive amputation has been demanded. The tables of Dr. S. W. Gross give very favorable results in partial excisions prac- tised for gunshot injuries, the mortality rate being 12.19 per cent. Excision of both bones gave a larger ratio of mor- tality than that of the individual bones. Carpus Wrist-joint Surgical Anatomy The wrist-joint is formed by the lower extremity of the radius and inter-articular fibro-cartilage above, with the scaphoid, semilunar, and cuneiform bones below. The tendons of the flexor and extensor muscles of the thumb, carpus, and fingers CARPUS — WRIST JOIXT. 755 are placed upon tlie anterior and posterior surfaces of tlie joint. The radial and ulnar arteries cross the articulation in passing into the hand to form the superficial and deep palmar arches, the former winding backward around the outer side of the carpus and the latter passing in front to the radial side of the pisiform bone. The posterior carpal branch of the radial, with the anterior and posterior carpal branches of the ulnar, are distributed to the articulation. The articular branches of the ulnar in front, and posterior interosseous nerves behind, supply the joint. The intimate relations to the articulation of the various tendons which pass in front and behind, render excision of the joint very difficult. The position of these structures is to be borne in mind in order to avoid inflicting injury upon them. Excision of the wrist-joint is required in cases of arthritis, necrosis, and gunshot injury. Owing to the peculiar form- ation of the articulation, disease and injury are usually not limited to the bones entering into the formation of the joint proper, but invade the ulna and inter-articular cartilages, as well as all of the carpal bones, and even sometimes attack the bases of the metacarpal bones. Various incisions have been employed to expose tlie joint as the H? L? quadrilateral, and linear incision upon the borders of the articulation. The objection to those which are carried across the surface is the division of the tendons in such a manner as to interfere with their future functions. The linear incisions should be made on the radial and ulnar borders, the former beginning an inch and a half above the styloid process of the radius and terminating half an inch beyond the base of the metacarpal bone of the thumb, care being taken to avoid wounding the radial artery as it passes beneath the extensor tendons of the thumb. The incision 756 EXCISION OF BONES AND JOINTS. on the ulnar border should begin just above the styloid pro- cess of the ulna and extend downward to a point half an inch below the base of the metacarpal bone of the little finger. Operation. — The patient having been placed under the influence of an anaesthetic and the forearm and hand supported, the incisions above described should be made on the radial and ulnar borders of the joint. The tissues on the posterior surface, including the tendons, should be carefully detached from the radius and bones of the carpus, and the radial artery lifted from its position and held out of the way by a blunt hook. The tissues on the anterior surface of the joint should be detached, a straight sharp-pointed bistoury being passed from the ulnar to the radial side in close contact with the bones and carried downward until it strikes the pisiform bone which should be separated from its articulation with the cuneiform. The detachment of the pisiform bone per- mits the insertion of tlie tendon of the flexor carpi ulnaris into the base of the fifth metacarpal bone to remain undis- turbed. The lateral ligaments should now be divided and the ends of the radius and ulna projected through the wounds on the radial and ulnar sides, and removed on the same level by the chain saw or pliers. The carpus can now be forced through tlie wound, and the dorsal ligaments, uniting the two rows of bones, divided with the probe- pointed bistoury and separatc^d with the pliers, removing the upper row entirely or separately with the bone forceps. In the same manner the second row may be detached from the metacarpal bones and with them, if necessary, the bases of these bones. In this operation, the position of the radial and ulnar arteries and the deep palmar arch should be remembered. In the operation known as Mr. Lister's, two incisions are C A KITS. 757 made, and it is peiTormt'd in the following manner, as quoted by Prof. Ashluiist. The radial incision begins about the middle of the dorsal aspect of the radius, on a level with the styloid process, and passes downward and outward toward the inner side of the metacarpo-phalangeal articulation of the thumb, but, on reaching the line of the radial border of the metacarpal bone of the index finger, diverges at an obtuse angle and passes downward longitudinally for half the length of that bone. An ulnar incision begins two inches above the end of the ulna and immediately in front of that bone, passes downward between the flexor carpi ulnaris and the ulna, and terminates at the middle of the palmar aspect of the fifth metacarpal bone. The only tendons necessarily divided by this method are the extensors of the wrist. The trapezium is to be separated from the rest of the carpus by cutting with the bone forceps before the ulnar incision is made, but is not to be removed till a later stage of the operation ; similarly, the pisiform bone is to be separated and leff attached to the flexor carpi ulnaris, while the hook of the unciform bone is also severed and left attached to the annular ligament. The tendons being then raised before and behind the wrist, the anterior ligaments of the joint may be divided and the cutting pliers intro- duced first between the carpus and raJius, and afterward between the carpus and metacarpus. Its connections being thus divided, the whole carpus except the trapezium and pisiform may be pulled out with a pair of strong forceps. The articulating extremities of the radius and ulna can now be made to protrude through the ulnar incision and can be retrenched as much as may be thought desirable, the ulna being sawn obliquely so as to retain the styloid process and thus lessen the tendency to subsequent displacement. The 6i 758 EXCISION OB' BONES AND JOINTS. articulating ends of the metacarpal bones are then protruded and excised, and the operation completed by dissecting out the trapezium, and by removing the articulating surf{\ce of the thumb, and as much of the pisiform and hook-like process of CARPUS. 759 the unciform as may be found necessary. When the opera- tion is completed a drainage tube should be passed through tlie wound, the incisions sutured, antiseptic dressings applied, and the forearm and hand placed upon a Bond's splint with the sides removed, or an anterior palmar splint with a block of wood upon it for tlie hand to grasp, and, if necessary, extension may be maintained by weights and pulley. A plaster bandage with an iron frame for support (Figs. 477, 47