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MINOE SURGERY. 
 
ON 
 
 BANDAGING, 
 
 AXD OTHER 
 
 OPEEATIONS 
 
 MINOR SURGERY. 
 
 F. W. SARGENT, M.D., 
 
 MEJIBER OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; ONE OF THE SURGEONS 
 TO WILLS' HOSPITAL, ETC. ETC. 
 
 NEW EDITION, REVISED AND ENLARGED. 
 
 ONE HUNDRED AND EIGHTY- ONE ILLUSTRATIONS. 
 
 PHILADELPHIA: 
 BLANCHARD AND LEA. 
 
 1856. 
 
"9v 
 
 Entered, according to Act of Congress, in the year 1855, by 
 
 BLANCHARD & LEA, 
 
 in the Clerk's Office of the District Court of the United States in and for the 
 Eastern District of Pennsylvania. 
 
 Printed "by T. K & P. G. Collins. 
 
TO 
 
 GEORGE W. NORRIS, M. D., 
 
 SURGEON TO THE PENNSYLVANIA HOSPITAL, 
 
 AS A TRIBUTE OF RESPECT 
 
 FOR HIS PROFESSIONAL AND PERSONAL CHARACTER, 
 
 AND IN ACKNOWLEDGEMENT 
 
 OF HIS INSTRUCTIONS AND REPEATED KINDNESS, 
 
 \\% ffllttttU 
 IS INSCRIBED 
 
 BY THE AUTHOE. 
 
 1* (v) 
 
PREFACE TO THE NEW EDITION. 
 
 The very kind manner in which the first edition of this 
 little book was received, has stimulated the Author to renewed 
 diligence in adding to it whatever seemed to him calculated 
 to augment its usefulness and its comprehensiveness. He 
 hopes that his efforts will be found successful. 
 
 By an increase in the size of the page, it will be seen that 
 the considerable additions to this edition have been introduced 
 without causing any enlargement of the volume. 
 
 (Yii) 
 
 
PREFACE. 
 
 The object which the Author has had in view in the pre- 
 paration of the following pages, has been, to present to the 
 younger surgeon, and to the student, information relative to 
 the art of bandaging, and to some other points of importance 
 in the practice of surgery. These are subjects which are but 
 slightly alluded to in systematic courses of lectures, or in most 
 of the published treatises on the science ; yet the necessity of 
 a familiar acquaintance with them will be readily acknowledged 
 by every surgeon of experience. 
 
 In the collection of the materials for this volume, the Au- 
 thor has availed himself very freely of the knowledge of 
 others, as exhibited in books, and of his own opportunities in 
 hospitals and in private, of gaining practical acquaintance 
 with the subjects of which he has treated. He trusts that he 
 has not failed in his intention, always to give due credit to 
 all from whom he has taken information. Originality can 
 scarcely be expected, in a work of this kind, excepting, per- 
 haps, in its composition. 
 
 The book is divided into five parts. Of these, the first em- 
 braces a description of the implements, if such a term be ad- 
 missible, with which the ordinary duties of the surgeon are 
 accomplished. 
 
 The second treats of the composition and preparation of 
 Bandages, of their application to the different regions of the 
 
 («) 
 
X PREFACE. 
 
 body, and of the purposes which they are thus made to sub- 
 serve. 
 
 The third is devoted to the consideration of the apparatus 
 of various kinds, used in the treatment of Fractures. In the 
 arrangement of this portion of the volume, the Author has 
 thought it expedient to give pretty full details, showing the 
 indications of treatment in each particular case of Fracture, 
 and thereby rendering more manifest the adaptation of each 
 bandage, splint, or other dressing, to the fulfilment of these 
 requirements. 
 
 The fourth division describes the mechanical means em- 
 ployed in the treatment of dislocations, with the mode of ap- 
 plying them. 
 
 In the fifth part are detailed at length the methods of per- 
 forming such operations as seem strictly to be included in the 
 term "Minor Surgery;" these are the operations for bleed- 
 ing, general and local ; the modes of effecting counter-irrita- 
 tion ; — the methods of arresting haemorrhage ; the closure 
 of wounds ; the introduction of the catheter, and the adminis- 
 tration of injections. A few remarks on the mode of relieving 
 pain during operations, and a short appendix of useful for- 
 mulae, close the volume. 
 
 Philadelphia, May, 1848. 
 
TABLE OF CONTENTS. 
 
 PREFACES Page vii 
 
 PART I. 
 CHAPTER I. 
 
 ON THE INSTRUMENTS USED IN DRESSING 25 
 
 CHAPTER II. 
 
 ON SURGICAL DRESSINGS. 
 
 Lint — Charpie — Cotton — Tow — The Compress — Retractors — The 
 Malta Cross — Sponge-Tent — Setons — Adhesive Plasters — Collodion 
 — Soap Plaster — Mercurial Plaster — The Poultice — The Water 
 Dressing — Spongio-Piline — Lotions — Cerates — Ointments — Lini- 
 ments — The Sponge 29 
 
 CHAPTER III. 
 
 GENERAL RULES FOR DRESSING 49 
 
 CHAPTER IV. 
 
 ON THE USE OF WATER.... 52 
 
 SECTION I. 
 
 IRRIGATION 52 
 
 SECTION II. 
 
 THE DOUCHE 54 
 
 SECTION III. 
 
 BATHING. — WATER AND VAPOUR BATHS 57 
 
 (xi) 
 
 I 
 
Xll CONTENTS. 
 
 SECTION IV. 
 
 ON FUMIGATIONS 
 
 SECTION V. 
 
 ON DISINFECTING AGENTS 
 
 PART II. 
 
 ON BANDAGES AND THEIR APPLICATION 
 
 CHAPTER I. 
 SECTION I. 
 
 THE ROLLER, OR SIMPLE BANDAGE. 
 
 Composition and preparation of the Roller — Different modes of appli- 
 cation — Circular — Spiral and reversed turns — Crossed — Spica and 
 recurrent bandages — Uniting — Dividing — Compressing — Expelling 
 — Retaining and Knotted bandages 
 
 SECTION II. 
 
 COMPOUND BANDAGES. 
 
 The T bandage— The Invaginated-- The Split, or Tailed— The Laced 
 — The Sheath — And the Suspensory bandages 
 
 SECTION III. 
 
 M. MAYOR'S SYSTEM OF BANDAGES 
 
 CHAPTER II. 
 
 REGIONAL BANDAGING. 
 
 SECTION I. 
 BANDAGES FOR THE HEAD AND NECK. 
 
 The Recurrent — The T — The Four-tailed — The Six-tailed bandages 
 — The Fronto-occipital Triangle — The Knotted — The Four-tailed 
 bandage of the Chin— The T-bandage of the Ear— The double T- 
 bandage of the Nose — The sheath of the Nose — Bandages for the 
 Eyes — The Invaginated bandage of the Lip — The Sheath of Pibrac 
 for the Tongue — The Mask for the Face — The Cervical Cravat — 
 The flexor bandage of the Neck — Jorg's flexor of the Neck 77 
 
CONTEXTS. XU1 
 
 SECTION II. 
 
 BANDAGES FOR THE TRUNK. 
 
 The Dorso-thoracic Triangle — Circular bandage — The bandage of Vel- 
 peau — The figure-8 bandage of the shoulders — The Suspensory of 
 the breast — The triangular cap for the breast — The Compressor of 
 the breast — The Straight-jacket — The Body-bandage — The triangu- 
 lar coverings for the Sacrum and Pubis — The triangular bandage 
 for the Groin — The Cruro-inguinal triangle — The Spicas of the 
 Groin — The Cruro-inguinal cravat — The double T-bandage for the 
 Pelvis — Suspensories of the Scrotum — Bandage for the Penis 88 
 
 SECTION III. 
 
 BANDAGES FOR THE UPPER EXTREMITIES. 
 
 The Axillo-clavicular cravats — The figure-8 bandage for the shoulder 
 and axilla — Sling for the fore-arm — Triangular bandages for the 
 wrist and hand — The Spiral for the arm — The Spica for the arm 
 and shoulder — The Spica for the thumb — The Gauntlet — The Demi- 
 gauntlet — The cravat bandage for the hand — The perforated ban- 
 dage for the hand 99 
 
 SECTION IV. 
 
 BANDAGES FOR THE LOVTER EXTREMITY. 
 
 The Cruro-iliac triangle — The bandage of Scultetus — The eighteen- 
 tailed bandage — The invaginated bandages — The figure-8 bandage 
 for the knee — Weiss' elastic knee-cap — Common elastic cap for the 
 knee — Spiral bandages for the lower extremity — Baynton's bandage 
 —The laced stocking— The Gaiter 104 
 
 PART III. 
 
 BANDAGES AND APPARATUS EMPLOYED IN THE TREATMENT OF FRACTURES. 
 
 CHAPTER I. 
 
 GENERAL CONSIDERATIONS. 
 
 Mode of reparation of fracture — Indications of treatment — " The Im- 
 movable Apparatus" of Larrey, Seutin, Yelpeau, Laugier, and 
 Dieffenbach — The " Hyponarthecia" of Sauter and Mayor — Vehicle 
 for transporting injured persons — Mode of exposing the seat of in- 
 jury — Fracture-beds — Clinical frame — The apparatus of Jenks, for 
 raising the patient from the bed 108 
 
 2 
 
XIV CONTENTS, 
 
 CHAPTER II. 
 
 BANDAGES AND DRESSINGS FOR FRACTURES OF THE BONES OF THE HEAD 
 AND TRUNK. 
 
 SECTION I 
 FOR FRACTURES OF THE BONES OF THE SKULL AND FACE. 
 
 Of the bones of the Cranium — Of the Face — The four-tailed bandage 
 of the chin, for fractures of the lower jaw — Gibson's and Barton's 
 bandages for the same , 121 
 
 SECTION II. 
 
 BANDAGES FOR FRACTURES OF THE BONES OF THE TRUNK. V 
 
 For fractures of the Vertebrae — Of the Ribs and Sternum — Treat- 
 ment by compresses and a roller — By lath or pasteboard splints — 
 Fractures of the Sternum — Fractures of the bones of the Pelvis — 
 Treatment of compound fractures : 124 
 
 CHAPTER III. 
 
 APPARATUS AND DRESSINGS FOR FRACTURES OF THE BONES OF THE SHOULDER. 
 
 SECTION I. 
 FOR FRACTURES OF THE CLAVICLE. 
 
 Older methods of treatment — Fox's apparatus — Bandage of Mr. Lons- 
 dale — Of Brown — New plan recommended by M. Guillou 128 
 
 SECTION II. 
 
 FOR FRACTURES OF THE SCAPULA. 
 
 Fractures of the body and inferior angle — ■ Of the coracoid process 
 — Bandage of M. Velpeau — Of the acromion process and neck — 
 Mr. Lonsdale's mode of treatment— Other apparatus— Compound 
 fractures » 133 
 
 CHAPTER IY. 
 SECTION I. 
 
 FOR FRACTURES OF THE HUMERUS. 
 
 Fracture of the shaft of the bone — Ordinary mode of treatment — 
 Mr. Lonsdale's splint — Fractures of the upper extremity of the 
 
CONTENTS. XV 
 
 bone — At the surgical and anatomical neck — Fracture at the 
 condyloid extremity — Sir A. Cooper's method of treatment — Mr. 
 Mayo's splint for compound fractures of this portion of the bone — 
 Treatment of compound fractures of the humerus generally 138 
 
 SECTION II. 
 
 FOR FRACTURES OF THE BOXES OF THE FORE-ARM. 
 
 Fractures of both bones — Ordinary method of treatment — Mr. Lons- 
 dale's plan — The " Ante-brachial Hyponarthecia" of Mayor — 
 Fractures of the radius — Of the head of the bone — Of the shaft — 
 Of the lower portion of the bone — Dupuytren's splint — Oblique 
 fracture of the lower end of the radius — Modes of treatment — 
 Fractures of the ulna — Of the coronoid process — Of the olecranon 
 process — Sir A. Cooper's plan of treatment — Other methods — Com- 
 pound fractures — Partial fractures 148 
 
 SECTION III. 
 
 FOR FRACTURES OF THE BONES OF THE WRIST AND HAND. 
 
 Fracture of the carpal bones — Of the metacarpal bones — Of the pha- 
 
 i — Compound fractures 159 
 
 CHAPTER V. 
 
 APPARATUS AND DRESSINGS FOR FRACTURES OF THE BONES OF THE LOWER 
 
 EXTREMITY. 
 
 SECTION I. 
 
 FOR FRACTURES OF THE OS FEMORIS. 
 
 Treatment in the flexed and straight positions — Treatment of frac- 
 tures of the shaft of the bone — By the method of Pott — Of Sir 
 Charles Bell — Apparatus used at the Middlesex Hospital — Plan 
 of Mr. Amesbury — Splint of Dr. N. R. Smith — Hyponarthecia for 
 fractures of the thigh — Treatment by the straight splints of 
 Desault — Dr. Physick's modification — Splints of Boyer, Liston, 
 Hagedorn, (as modified by Dr. Gibson), and others — Treatment of 
 fractures of the upper part of the femur — "Within the capsular liga- 
 ment — Exterior to this — Fractures of the lower extremity of the 
 bone — Above the condyles — Through these processes — Compound 
 fractures of the thigh 163 
 
XVI CONTENTS. 
 
 SECTION II. 
 
 FOR FRACTURES OF THE PATELLA. 
 
 longitudinal and transverse fractures — Plans of treatment pursued 
 by Sir A. Cooper, by Desault, Gerdy, Amesbury, Lonsdale, and 
 others — Rupture of the tendon, and ligament of the patella — Com- 
 pound fractures of the patella 190 
 
 SECTION III. 
 
 FOR FRACTURES OF THE BONES OF THE LEG. 
 
 Of both bones, treatment by "the Junks" — By the splint of Mr. 
 Neville — By the fracture-box — By the splints of Hutchinson — By 
 the double inclined plane of Mr. Liston — Other methods — Fracture 
 of tibia only — Of the fibula only — "Pott's fracture" — Its treat- 
 ment according to Dupuytren — By the fracture-box — Suspension 
 method of Sauter and Mayor — Compound fractures — The bran- 
 dressing 197 
 
 SECTION IV. 
 
 FOR FRACTURES OF THE BONES OF THE FOOT. 
 
 Of the os calcis — Method of Mr. Lonsdale — Of Druitt — Simple frac- 
 tures of the bones of the foot generally — Compound fractures 208 
 
 PART IV. 
 
 ON THE MECHANICAL MEANS EMPLOYED IN THE TREATMENT OF DISLOCATIONS. 
 
 General observations 208 
 
 CHAPTER I. 
 
 DISLOCATIONS OF THE BONES OF THE HEAD AND TRUNK. 
 
 SECTION I. 
 OF THE LOWER JAW. 
 
 Reduction — Retention by the bandages of Barton or Gibson.... 212 
 
 SECTION II. 
 
 OF THE BONES OF THE TRUNK 213 
 
CONTEXTS. Xvii 
 
 SECTION III. 
 
 OF THE CLAVICLE. 
 
 Reduction — Treatment by the crucial bandage 213 
 
 CHAPTER II. 
 
 DISLOCATION'S OF THE BOXES OF THE UPPER EXTREMITY. 
 
 SECTION I. 
 
 OF THE HUMERI'S. 
 
 Different positions assumed — Reduction by the heel in the axilla, 
 ■with the double roller towel — By relaxing the supra-spinatus and 
 deltoid muscles — By the use of the pulleys, with the knee in the 
 axilla — After treatment 215 
 
 SECTION II. 
 
 OF THE BOXES OF THE ELBOW. 
 
 Varieties of the accident — Restoration — Subsequent treatment 220 
 
 SECTION III. 
 
 OF THE LOWER EXTREMITY OF THE FORE-ARM. 
 
 Varieties — Reduction — Subsequent treatment 221 
 
 SECTION IV. 
 
 OF THE BOXES OF THE HAXD. 
 
 Of the carpal and metacarpal bones —Reduction of the phalanges — 
 
 Reduction by various methods umm ~~221 
 
 CHAPTER III. 
 
 DISLOCATIONS OF THE BOXES OF THE LOWER EXTREMITY. 
 
 SECTION I. 
 
 OF THE HIP JOIXT. 
 
 Varieties— General plan of reduction — Restoration of each variety, 
 with subsequent treatment — Restoration by means of the twisted 
 r °P e ".... 221 
 
 SECTION II. 
 
 OF THE PATELLA. 
 
 Varieties of the accident— Restoration and after-treatment 99Q 
 
XV111 CONTENTS. 
 
 SECTION III. 
 
 OF THE TIBIA AT THE KNEE. 
 
 Varieties — Their mode of treatment 230 
 
 SECTION IV. 
 
 OP THE HEAD OF THE FIBULA. 
 
 Reduction and subsequent treatment... 230 
 
 | SECTIONV. 
 
 OF THE ANKLE. 
 
 Varieties and treatment . 231 
 
 CHAPTER IV. 
 
 
 COMPOUND DISLOCATIONS. 
 
 Mode of treatment 232 
 
 Apparatus for the relief of partial anchylosis 233 
 
 PART V. 
 CHAPTER It 
 
 ON SOME OF THE MINOR SURGICAL OPERATIONS. 
 
 On the making of incisions 235 
 
 CHAPTER II. 
 
 ON BLOODLETTING 241 
 
 SECTION I. 
 
 OPERATIONS FOR GENERAL BLEEDING. 
 
 Phlebotomy at the bend of the arm — Choice of the vein — Prelimi- 
 nary arrangements — Position of the patient — Choice of the arm — 
 Of the lancet — Mode of operating with the thumb-lancet and with 
 the spring-lancet — Difficulties attending the operation, and modes 
 of obviating them — Mode of dressing the wound — Bleeding from 
 
 the hand — From the ankle — From the external jugular vein 241 
 
 Accidents attending phlebotomy 253 
 
 Thrombus — Its causes — Treatment and mode of prevention 277 
 
 Wound of a nerve 254 
 
 Symptoms of the accident — Treatment 254 
 
 Wound of an artery 255 
 
 Mode of recognising the injury — Treatment by compression 255 
 
 Wound of a tendon — Treatment 256 
 
 Arteriotomy .....,., 257 
 
CONTENTS. XIX 
 
 Opening of the temporal artery — Operation of Magistel — Incision of 
 
 one of the branches, as advised by Velpeau 258 
 
 SECTION II. 
 
 ON TOPICAL BLEEDING. 
 
 On Cupping — Dry-cupping — Modes of operating — Wet-cupping — 
 Apparatus required — Mode of lessening the pain attending the 
 
 application of cups 258 
 
 On the application of leeches 261 
 
 Modes of arresting bleeding from leech-bites 263 
 
 Mode of preserving the leech 264 
 
 Scarification as a means of local depletion 265 
 
 CHAPTER III. 
 
 ON THE MODES OF EFFECTING COUNTER-IRRITATION 266 
 
 SECTION I. 
 
 RUBEFACIENTS. 
 
 Hot water — Sand — The oils, &c. — Sinapisms — Mode of their employ- 
 ment — " The spice poultice" — Preparation ... f . 266 
 
 SECTION II. 
 
 VESICANTS. 
 
 Boiling water — Hot metal — Steam — Spanish flies — Mode of employ- 
 ing the cerate — Application of the vesicant — Treatment of the blis- 
 tered surface — Mode of relieving strangury — Cases to which this 
 agent is applicable — Croton oil — Its mode of action and employ- 
 ment — Croton oil plaster — The strong water of ammonia — Mode 
 of employment — Granville's lotions 268 
 
 SECTION III. 
 
 SUPPURATIVE COUNTER-IRRITANTS. 
 
 Mineral acids — The actual cautery, &c. — Tartar emetic — Application 
 of the ointment — Dressing of the surface — Tartar emetic in solu- 
 tion and in plaster — Nitrate of silver — Application and uses — 
 Caustic potassa — Mode of employment — Dressing of the surface — 
 " The Vienna paste" — M. Canquoin's chloride of zinc paste — 
 White oxide of arsenic — The actual cautery — The moxa, prepara- 
 tion and employment — Issues — Their formation — Point of inser- 
 tion — Setons — Composition — Mode of employment — Acupuncture 
 — Operation — Electro-puncture — Uses — Vaccination — Collection 
 and preservation of the vaccine virus — Modes of inserting the 
 matter .- , 273 
 
XX CONTENTS. 
 
 CHAPTER IV. 
 
 METHODS OF ARRESTING HAEMORRHAGE. 
 
 By tlie action of cold — Of astringents and styptics — Matico — By cau- 
 terization, with the actual or potential cautery — By pressure with 
 the hand, or tourniquet — By plugging the wound, or divided ves- 
 sel — By torsion — By the application of the ligature — Mode of 
 arresting epistaxis, and hemorrhage from the rectum 282 
 
 CHAPTER V. 
 
 ON THE DRESSING OF WOUNDS. 
 
 Cleansing of the wound — Arrest of bleeding — Treatment of granu- 
 lating wounds — Modes of securing the apposition of the edges of 
 incised wounds — By adhesive strips of lead-plaster, isinglass-plas- 
 ter, and by means of the solution of gun-cotton — By the inter- 
 rupted suture — By the continued suture — By the quilled suture — 
 By the twisted suture — By the dry suture — By invaguiated and 
 other bandages , 302 
 
 CHAPTER VI. 
 
 ON THE INTRODUCTION OF THE CATHETER. 
 
 Catheterism of the eustachian tube — The instrument and manner of 
 introducing it — Catheterism of the oesophagus — The stomach-tube, 
 and mode of using it — Catheterism of the urethra — Construction of 
 the catheter, male and female, and the various plans for intro- 
 ducing it into the bladder — Mode of obviating difficulties — Mode of 
 securing the catheter in the bladder — Catheterism of the large 
 intestine — Catheterism of the air-passages 312 
 
 CHAPTER VII. 
 
 ON THE ADMINISTRATION OF INJECTIONS. 
 
 Composition of and apparatus for injections — Injections by the rec- 
 tum — Syringes and mode of employment — Preparation of the 
 enema — Suppositories — Injections by the vagina — Injections by 
 the urethra — Injections by the lachrymal duct 327 
 
 CHAPTER VIII. 
 
 ON THE REMOVAL OF FOREIGN BODIES FROM THE NATURAL CANALS AND 
 
 PASSAGES 333 
 
 MEANS OF DIMINISHING PAIN DURING OPERATIONS. 
 
 Administration of opium — Of the vapours of vegetable narcotics, 
 and nitrous oxide gas — Inhalation of sulphuric ether and chloro- 
 form vapours < 346 
 
 APPENDIX OF FORMULA. 
 
 Lotions— Cerates— Ointments— Liniments 350 
 
LIST OF ILLUSTRATIONS. 
 
 FIG. PAGE 
 
 1 Dressing forceps 26 
 
 2 Scalpel 26 
 
 3 Double Catheter 27 
 
 4 Graduated compress, from Cutler 33 
 
 5 Pyramidal " " 33 
 
 6 Malta cross, " , 34 
 
 7 Treatment of epididymitis by compression, from Velpeau 37 
 
 8 Hays' bandage for retaining dressings 41 
 
 9 " " applied to the leg 41 
 
 10 Arch of hoop, from South c 50 
 
 11 Apparatus for irrigation, from Velpeau 53 
 
 12 Portable shower-bath, from Thomson , 56 
 
 13 " bathing-apparatus, from Thomson 59 
 
 14 Vessel for the hip-bath, " 60 
 
 15 Machine for rolling bandages 66 
 
 16 Different applications of the roller, from Cutler 68 
 
 17 Mode of making reversed turns, from Velpeau 69 
 
 18 Crossed bandage of the elbow, from Cutler 70 
 
 19 Recurrent bandage of the head, from Velpeau 78 
 
 20 Four-tailed " " " Cutler 79 
 
 21 Six-tailed " " " Velpeau 80 
 
 22 Four-tailed " of the chin, " Cutler 81 
 
 23 Double T " ofthenose, " " 82 
 
 24 Monocle " from Culver 84 
 
 25 Invaginated " of the lip, from Smith 84 
 
 26 Purse of Pibrac for the tongue, from Velpeau 85 
 
 27 Flexor bandage of the neck, from Velpeau 86 
 
 28 Jorg's apparatus for wry-neck, from Cutler , ... 87 
 
 29 Compressing bandage of the chest, from Velpeau 89 
 
 30 Crossed " " " 90 
 
 31 Compressing " of the abdomen, " 94 
 
 32 Triangular " of the groin, " , , 95 
 
 33 Cruro-inguinal triangle, from Cutler 95 
 
 34-5 Suspensory of the scrotum, from Cutler 97 
 
 36 Suspensory triangle, from Cutler 98 
 
 37 Spica bandage of the shoulder, from Velpeau 101 
 
 38 Gauntlet, from Velpeau ...... 103 
 
 (xsi) 
 
XXU LIST OF ILLUSTRATIONS. 
 
 FIG. PAGE 
 
 39 Demi-gauntlet, from Velpeau 103 
 
 40 Spiral bandage of the leg 106 
 
 41 Pasteboard splint for the chin, from Cutler 122 
 
 42 Gibson's bandage for fracture of the lower jaw, from Gibson 123 
 
 43 Barton's " " " 123 
 
 44 Fox's apparatus for fracture of the clavicle 131 
 
 45 Lonsdale's apparatus for fracture of the clavicle, from Lonsdale 131 
 
 46 Velpeau's bandage for fracture of the shoulder, from Velpeau „ 135 
 
 47 Lonsdale's " " acromion, from Lonsdale 136 
 
 48 Splint for fractures of the humerus, from Lonsdale 140 
 
 49 Fracture of humerus, above the condyles, from Cooper 142 
 
 50 " " through the condyles, from Lonsdale 143 
 
 51 Splints for the treatment of this accident, from Cooper 144 
 
 52 Mayo's splint for compound fractures, from Lonsdale 146 
 
 53 Ante-brachial hyponarthecia, from Cutler 150 
 
 54 Dupuytren's splint for fracture of the radius, from Lonsdale. ........ 151 
 
 55 Oblique fracture of the lower end of the radius, from Fergusson.... 152 
 
 56 Nelaton's splint for radius, from Erichsen 153 
 
 57-8 Bond's " " " American MedicalJournal 154 
 
 59 Hay's " " « " « 155 
 
 60 Treatment of fracture of the olecranon process of the ulna, from 
 
 Cooper 157 
 
 61 Olecrano-metacarpal cravat, from Cutler 158 
 
 62 Splint for fractures of the bones of the hand, from Lonsdale 161 
 
 63 Double inclined plane, from Lonsdale .., 167 
 
 64 The same applied 168 
 
 65 Mr. Amesbury's double inclined plane, from Amesbury 169 
 
 66 The same applied, from Amesbury 170 
 
 67 Dr. N. R. Smith's splint, from H. H. Smith < 172 
 
 68 M'Intyre and Liston's splint, from Fergusson 172 
 
 69 The long splint of Desault 174 
 
 70 Gaiter for extension, 175 
 
 71 Cravat band for extension , 177 
 
 72 Boyers apparatus for fracture of the thigh, from Cutler 181 
 
 73 Liston's splint lt " " Fergusson 181 
 
 74 Kimball and Sanborn's splint, from Miller.. 182 
 
 75 Gibson's Hagedorn's apparatus, from Gibson 183 
 
 76 Treatment of fracture of the great trochanter, from Cooper. 187 
 
 77 Straight splint for compressed feet, from Erichsen...., 189 
 
 78 Treatment of fracture of the patella, from Cooper..... 191 
 
 79 " " " " 192 
 
 80 Lonsdale's apparatus for the same, from Lonsdale... 193 
 
 81 Wood splint, for fracture of the patella, from Fergusson 195 
 
 82 Fracture-box 199 
 
 83 A fractured leg, from Fergusson 199 
 
 84 Fergusson's splint for fractured leg 202 
 
 85 Suspension apparatus, from Fergusson 203 
 
 86 Mr. Liston's splint, double plane, from Fergusson 204 
 
 87 "Pott's fracture" of the fibula, from Lonsdale 205 
 
 88 Dupuytren's treatment of the same, from Lonsdale 206 
 
 89 Mode of treatment of fracture of the os calcis, from Lonsdale 209 
 
 90 " " " " " Druitt 209 
 
 91 Dislocation of the lower jaw, from Druitt... 212 
 
. 
 
 LIST OF ILLUSTRATIONS. XXU1 
 
 FIG. PAGE 
 
 92 Bandage for treatment of dislocation of clavicle, from Druitt 214 
 
 93 Reduction of dislocation of the humerus, from Cooper , 216 
 
 94 " " " " 216 
 
 95 Pulleys and staple, from Fergusson 217 
 
 96 Reduction of dislocation of the humerus, from Cooper 218 
 
 97 " " phalanx, from Fergusson 222 
 
 98 " " " " 222 
 
 99 "The clove-hitch," from Fergusson 223 
 
 100 Reduction of dislocation of the thumb, from Cooper 223 
 
 101 " " femur, " 225 
 
 102 " " " " 226 
 
 103 " " " " 227 
 
 104 " " « " .'. 228 
 
 105 " «f m from Fergusson 228 
 
 105 Apparatus for the relief of partial anchylosis, from Mutter 233 
 
 107 Manner of holding the knife, from Fergusson 236 
 
 108 " " " " 236 
 
 109 " " " " 236 
 
 110 " opening an abscess " 237 
 
 111 " " " " 237 
 
 112 Plan of crucial incision, from Fergusson. 238 
 
 113 " elliptical incisions, from Fergusson 238 
 
 114 " variously shaped incisions, from Fergusson 238 
 
 115 " " " " 238 
 
 116 " " " " 238 
 
 117 " " " " 238 
 
 118 Incision guided by the finger, from Fergusson 239 
 
 119 Tenotomy-knife, from Miller 239 
 
 120 Another pattern, from Erichsen.... 240 
 
 121 Disposition of the veins, &c, at the bend of the arm, from Wilson. 242 
 
 122 " " " " Druitt.. 242 
 
 123 Position of the lancet in bleeding, from Fergusson 248 
 
 124 Bleeding from the jugular vein and temporal artery, from Telpeau. 252 
 
 125 Plan of compressing an artery, from Miller 256 
 
 126 Seton needle, armed, from Fergusson 277 
 
 127 Eyed probe, as a substitute for the above, from Erichsen 277 
 
 128 Forms of the actual cautery irons, from Liston and Mutter 285 
 
 129 Compression of the brachial artery, from Fergusson , 287 
 
 130 " femoral " 287 
 
 131 The tourniquet, from Fergusson 288 
 
 132 " applied to the arm, from Fergusson 289 
 
 133 " « " thigh, " 289 
 
 134 " " " popliteal region, from Fergusson... 289 
 
 135 Field " " " arm, from Liston and Mutter 290 
 
 136 The compressor of Dupuytren applied to the thigh, from Liston and 
 
 Mutter 290 
 
 137 Compressor for middle of thigh, from Erichsen 292 
 
 138 " groin, " 292 
 
 139 Carte's improved circular compressor, from Fergusson 293 
 
 140 Serrated forceps, from Fergusson 294 
 
 141 Plan of making torsion, from Fergusson , 294 
 
 142 The toothed forceps, from Fergusson 295 
 
 143 The tenaculum, from Fergusson , « 296 
 
XXIV LIST OF ILLUSTRATIONS. 
 
 FIG. PAGE 
 
 144 The sailor's knot, from Fergusson 296 
 
 145 The common aneurism-needle, from Fergusson 298 
 
 146 Physick's forceps, from Liston and Mutter 299 
 
 147 Mode of plugging the nostrils, from Liston and Mutter 300 
 
 148 Belloc's instrument for the same, from Liston and Mutter 300 
 
 149 The interrupted suture, from Fergusson , 306 
 
 150 The quilled suture, from Druitt 307 
 
 151 Surgeons' needles, from Fergusson , 307 
 
 152 The hare-lip suture, " 308 
 
 153 Apparatus to aid the hair-lip suture, from Fergusson 308 
 
 154 The invaginated bandage for longitudinal wounds, from Cutler 310 
 
 155 Same applied, from Cutler 310 
 
 156 Invaginated bandage for transverse wounds, from Cutler 311 
 
 157 View of the course of the lachrymal passages, from Lawrence 312 
 
 158 Anel's probe for dilating the lachrymal puncta and canals 313 
 
 159 Probe for dilating the nasal duct, from Lawrence 313 
 
 160 Morgan's probe for the same, from Lawrence 314 
 
 161 Eustachian tube catheter, from Wilde 315 
 
 162 Catheters for the male urethra, from Fergusson * 319 
 
 163 Introduction of the male catheter ., 320 
 
 164 Obstruction to catheterism from enlarged prostate, from Druitt.... 822 
 
 165 Velpeau's mode of securing the catheter in the bladder, from Vel- 
 
 peau . 324 
 
 166 Double catheter and Read's syringe for injecting the bladder, from 
 
 Fergusson * 331 
 
 167 Mr. Wilde's ear speculum 335 
 
 168 Wilde's gorget-like speculum auris. , 335 
 
 169 Forceps and curette, from Wilde's Aural Surgery 336 
 
 170 Curved forceps for the external ear, from Wilde's Aural Surgery... 336 
 
 171 Probang, from Fergusson „ 337 
 
 172 Removal of foreign body by the gullet forceps, from Fergusson 337 
 
 173 Hook for removing foreign bodies from gullet, from Fergusson 338 
 
 174 Bond's hook for removal of bodies from gullet 338 
 
 175 Gullet forceps, from Miller 339 
 
 176 Bond's gullet forceps 339 
 
 177 Civiale's urethra forceps, from Fergusson.... 343 
 
 178 Weiss' metallic urethra dilator, from Fergusson 344 
 
 179 Scoop for removing foreign substances from the rectum, from Fer- 
 
 gusson 345 
 
 180-181 Inhalers, from Pereira.. 348 
 
MINOR SURGERY. 
 
 PART I. 
 
 The means employed by the surgeon in the treatment of 
 the diseases to which he is ordinarily called, should first 
 engage our attention : they are, in a measure, of a mechanical 
 and chemical kind. This part of the volume will therefore be 
 devoted to the consideration : 
 
 First. Of the instruments which it is most necessary to 
 provide for daily use. 
 
 Second. Of the materials employed for surgical dressings, 
 and the mode of applying them, — including the use of water 
 as a local application, and for bathing. 
 
 Third. Of the means of purifying the atmosphere of the 
 patient's apartment. 
 
 CHAPTER I. 
 
 ON THE INSTRUMENTS USED IN DRESSING. 
 
 The instruments which the daily avocations of the surgeon 
 call for are of various kinds. For convenience-sake they are 
 arranged in a " pocket-case. " They may be multiplied 
 according to the fancy of the surgeon ; but those which will 
 be found most useful are, the dressing and dissecting forceps, 
 a pair of scissors, bistouries, scalpels, a thumb-lancet, an 
 abscess lancet, a director, probes, a tenaculum, curved needles, 
 a porte-caustic, a double catheter, and ligatures. 
 
 3 (25) 
 
26 INSTRUMENTS USED IN DRESSING. 
 
 The uses of the dressing forceps are manifest, in the re- 
 moval of oiled dressings, covered, as _ they very often are 
 S acrid and irritating secretions; in the loosening and 
 Ti hdrawal of decayed bone, and other foreign matters, from 
 Onuses deep wounds, and such points as are of difficult access 
 
 o the finge?s alone.' For such purposes the common dissect- 
 iL forceps will frequently answer. But the proper Dressing- 
 
 ffrtp Ts of a more suitable shape, as illustrated by the ac- 
 Smpinying drawing (fig. 1). A still better form is that of 
 
 Fig. 1. 
 
 the French Polypus-forceps, the blades being bent in^ front 
 of the pivot, so that the instrument occupies less space m the 
 ■wound or sinus, when opened than when closed. 
 
 The scissors used by the surgeon may be straight or 
 curved. 
 
 There should be two bistouries in the pocket-case : a 
 sharp-pointed and a probe-pointed. The circumstances m 
 which each will be most advantageously employed, will rea- 
 dily suggest themselves to the operator. 
 
 There is great variety of opinion as to the best form and 
 
 Fig. 2. 
 
 size for the Scalpel Mr. Fergusson prefers one of the shape 
 and dimensions indicated in the annexed drawing (fig. 2), the 
 blade and handle together being about six inches long. With 
 such a scalpel in his pocket-case, one may perform almost any 
 
INSTRUMENTS USED IN DRESSING. 
 
 27 
 
 Fig. 3. 
 
 i 
 
 of the capital operations of surgery, so far as mere cutting is 
 concerned. 
 
 The director and the probes should be of silver, as being 
 flexible, and less liable to be injured by contact with the 
 various fluids with which they will meet, than if made of steel. 
 The probes should be of various sizes, and one should be made 
 with an eye in its flattened extremity, for the purpose of being 
 armed, if occasion require, with a ligature, a skein of silk, or 
 a piece of tape. 
 
 The porte-caustic should be 
 of platinum, as this metal best 
 resists the action of nitrate of 
 silver, which is the caustic ge- 
 nerally carried in the pocket- 
 case. The platinum cup may 
 be fitted to a stem of wood, or 
 it may be so made as to be re- 
 ceived into a silver case ; the 
 latter is the best arrangement. 
 In addition to the lunar caustic, 
 the surgeon will find it conve- 
 nient, oftentimes, to have a 
 crystal of the sulphate of copper 
 in his case. 
 
 The double catheter is made 
 of silver, as is the common male, 
 or female, catheter. It con- 
 sists of three pieces, as repre- 
 sented in the annexed drawing, 
 (see fig. 3.) A, a straight tube, 
 about five inches long, having 
 at its upper extremity two rings 
 firmly soldered to the tube at 
 points opposite to each other ; 
 while the lower extremity has a 
 female screw-thread cut upon it, 
 of half an inch in length : B, 
 a beak, an inch and a half or 
 two inches long, slightly curved, 
 its lower extremity closed and 
 rounded, while the upper end is provided with a male screw, 
 
28 INSTRUMENTS USED IN DRESSING. 
 
 corresponding with the female screw of the staff which is in- 
 tended to receive it. Just above the lower extremity of this 
 beak, two oval or rounded fenestra are cut, one on each 
 side, thus throwing open the cavity : C, another beak, about 
 seven inches. long, having a curve similar to that of the or- 
 dinary male catheter, and its upper and lower extremities 
 adjusted as are those of the shorter beak. By simply 
 screwing the short curved piece to the staff, we have an ele- 
 gant female catheter ; by similarly attaching the long curve, 
 a male catheter. When in the pocket-case, the short' beak 
 should be kept screwed to the staff. 
 
 This instrument is very well made by Mr. Warner of this 
 city, Commerce Street. The tube should be thicker and 
 stronger than that of the ordinary catheter, and care should 
 be used that the joints be accurately fitted. 
 
 The advantages of having so important an instrument as 
 this reduced to a form so portable, need not be insisted upon. 
 
 In addition to the instruments above enumerated, the 
 pocket-case may be made to include a spatula, a double canula 
 with its wire, a seton-needle, and a razor. These, however, 
 are not so essential elements of the case, as those before 
 mentioned ; generally they can be dispensed with, or other 
 instruments may well be used in their stead ; and their pre- 
 sence will render the pocket-case much more bulky and 
 cumbersome. 
 
 The blades of the bistouries and scalpels may be so made 
 as, when not in use, to be concealed within the handle, as the 
 blades of the ordinary pocket-knife ; by this arrangement, 
 the edge of the instrument will be protected from injury. 
 
CHAPTER II. 
 
 ON SURGICAL DRESSINGS. 
 
 The various appliances used in surgical dressings may be 
 thus enumerated: lint, cotton, tow, compresses of various 
 kinds and forms, sponge-tent, setons, adhesive and other plas- 
 ters, poultices, lotions, cerates, ointments, liniments, bandages, 
 sponge, and apparatus of various kinds, more or less complex, 
 for special purposes. Some description of each of these will 
 be necessary. 
 
 1. Lint is the soft fleecy substance obtained by unravelling 
 old linen. It may be procured in the shops in the form of 
 what is called " patent lint," or it may be prepared as required 
 for use, by scraping, with a sharp knife, the surface of old 
 linen, previously put upon the stretch. The linen selected for 
 its preparation should be soft, from use and washing. As 
 thus obtained, the lint is very light and delicate, and admi- 
 rably adapted to absorb the secretions of parts to which it 
 may be^ applied. The " patent lint" is sold in sheets or rolls, 
 one of its surfaces is fleecy, the other is smooth : its texture 
 is compact, certainly not nearly so porous as the loose lint ; 
 hence it absorbs much less readily and freely than the latter. 
 Both varieties of lint are applied dry, or covered with cerates, 
 or saturated with some kind of lotion. 
 
 The French surgeons employ an admirable sort of lint, 
 which they term "charpie" It is now very generally used 
 in this city, and, indeed, throughout the country, when it can 
 be procured. It is thus made : — linen, of a coarse or fine tex- 
 ture, according to circumstances, is cut into small pieces, a few 
 inches square, and its tissue completely unravelled, thread by 
 thread. The coarser kind of charpie may be made of old 
 table-cloths; the finer sort of a lighter material. Velpeau 
 gives a decided preference to charpie made of old linen, as 
 being much more absorbent, and much less irritating, than 
 that made of the new fabric. 
 
 (Charpie of an excellent quality is made in this city by Mrs. 
 3 * ( 29 ) 
 
30 SURGICAL DRESSINGS. 
 
 Jones, southwest corner of Walnut and Juniper streets, and is 
 kept for sale in many of the apothecary shops.) 
 
 Lint, in its various forms, is used as a simple application to 
 ulcerated or excoriated surfaces ; to favour an equable and 
 even pressure upon any part ; to prevent adhesion between the 
 walls of cavities, natural or accidental ; to absorb various se- 
 cretions, and as a vehicle by which medicinal applications may 
 be made, when and wherever required. 
 
 Various arbitrary terms have been applied to no less arbi- 
 trary forms, which lint, and especially charpie, may be made 
 to assume, as an element of surgical dressings. Thus, there 
 is the plumasseau or pledget, the roll, the bullet, the mesh, 
 the tent, the tampon, the pellet, &c. 
 
 The plumasseau is prepared by simply folding, at the mid- 
 dle, a sufficient number of the filaments of charpie, previously 
 laid parallel to each other. For the sake of neatness, the 
 ends of the threads may be cut off evenly, or inverted, and 
 the mass thus formed moulded by the hands to any shape, flat, 
 round, circular, square, or oblong, to adapt it to particular 
 
 The roll is a mass of charpie, rendered cylindrical by the 
 hands, and firmly tied at the middle. It is chiefly used to ar- 
 rest hemorrhage, by pressure, from a deep-seated vessel, or to 
 absorb the secretions from wounds or cavities. For conveni- 
 ence in withdrawing the mass, the string, tied about the mid- 
 dle, may be left attached at this point, and projecting from 
 
 the orifice. 
 
 The term bullet is applied to a small mass ot charpie or 
 common lint, rolled into the form of a small ball. A number 
 of these may be advantageously used for the same purposes 
 as the roll just described. t m 
 
 The mesh resembles the roll very much m its uses ; its 
 fibres are left loosely floating, instead of being rolled together. 
 It is sometimes employed in the treatment of sinuses and 
 fistulous canals, by being thrust to the bottom of such cavi- 
 ties, on the end of a probe, with the view of preventing their 
 healing at the orifice. It may be introduced dry, or covered 
 with some lotion or cerate, more or less stimulating. 
 
 The tent of charpie is made by twisting a certain amount 
 of this substance into the form of a cone. For the purposes 
 
SURGICAL DRESSINGS. 31 
 
 for "which a tent is generally required, it is very much inferior 
 to the sponge-tent. 
 
 The tampon is merely a large ball of charpie, or it may 
 be a number of bullets. It is used in the plugging of bleed- 
 ing wounds, &c. 
 
 The pellet consists of a ball of charpie or common lint, 
 enclosed in a piece of soft linen, firmly tied. It may be used 
 as a tampon. 
 
 ■ The good sense of the surgeon or dresser will enable him 
 to employ these different forms of lint seasonably, or to 
 invent others still better. 
 
 2. Cotton may be used with advantage in many cases. 
 Its cheapness — and the almost universality of its diffusion — 
 are of themselves great recommendations, in connexion with 
 its softness, lightness, and the porosity of its texture. It is 
 sold either as "carded cotton,'' or, in the form of "sheet 
 cotton,'' in large sheets, of which both surfaces are smooth, 
 more or less glazed, forming, as it were, thin pellicles, between 
 which the true cottony mass is inclosed. As an application 
 to secreting surfaces, it will be found to be less absorbent than 
 lint, and probably more irritating. It is very much employed 
 as a covering to extensive superficial burns, to protect their 
 sensitive surface from the action of the air and other irritants. 
 But when there is much suppuration or other discharge, the 
 cotton, becoming more or less imbued with the secretion, is 
 heavy and heating, and is readily displaced by slight move- 
 ments of the patient, becoming rolled into hard masses. 
 Probably every dresser has been often much annoyed, by the 
 difficulty which he has experienced in removing from a large 
 moist sore, these numerous indurated pellets of cotton, which 
 sometimes adhere very tenaciously to the granulations. Its 
 chief uses — and for these it is almost invaluable — are, to 
 form a soft bed in which an injured part may be reposed, to 
 prevent unpleasant pressure and excoriation from bandages 
 and other apparatus, and to envelope parts, of which the 
 natural temperature has become depressed. 
 
 3. Tow is never applied directly to a secreting or abraded 
 surface ; being too harsh and irritating. It is made use of 
 in enveloping other dressings in cases of profuse discharges, 
 as in compound fractures, suppurating stumps, &c. 
 
 4. The compress is employed for a variety of purposes. 
 
32 SURGICAL DRESSINGS. 
 
 As the name imports, it was at first used to effect, or to fa- 
 cilitate, pressure upon any part ; now, however, it has acquired 
 a wider application, being equally adapted to the covering 
 and protection of injured surfaces; to retain other dressings, 
 and to give regularity and symmetry to the form of a limb, 
 or of any other part, to which a bandage is to be applied. 
 
 Compresses may be made of various materials, as linen, 
 muslin, woollen fabrics, lint, cotton, tow, &c. When intended 
 for direct application to secreting surfaces, they should be 
 of lint or soft linen, and applied dry or anointed. The ad- 
 vantages of a flannel compress are, its elasticity, its warmth, 
 and the readiness with which it imbibes any moisture of the 
 surface. The cheapness of the different fabrics of cotton 
 recommends them for many purposes ; for wherever economy 
 may be properly consulted, without conflicting with more im- 
 portant considerations, the surgeon, whether in hospital or in 
 private practice, should not fail to be influenced by it in the 
 choice of the material for his dressings. Whenever a com- 
 press is to be employed external to other dressings, or upon 
 an uninjured surface, it may, as a general rule, be formed of 
 cotton stuffs, as properly as of linen. 
 
 For convenience, accuracy, and neatness of application, 
 compresses are made of divers forms and shapes, to suit par- 
 ticular cases and indications ; Velpeau's division is a very sim- 
 ple one, into the plain, the divided, and the folded. The most 
 important are, the square, the graduated, the perforated, and 
 the split compresses. 
 
 The square compress is sufficiently well described by its 
 name, as are also the oblong and the triangular compresses ; 
 their size and thickness may vary at the pleasure of the sur- 
 geon, and with the requirements of each case. 
 
 The graduated compresses are so contrived as that they 
 shall present a gradually diminishing surface at the summit, 
 as their thickness increases. 
 
 The common graduated compress may be made by taking a 
 strip of any material of the required width, and folding it 
 upon itself so that each successive fold shall be shorter than 
 the one which preceded it. By thus regulating the length of 
 the folds at one end only, the single graduated compress is 
 made (fig. 4) ; by pursuing the same plan at both extremities, 
 the double graduated compress. The pyramidal compress is 
 
SURGICAL DRESSINGS, 
 
 33 
 
 Fig. 4. 
 
 Fig. 5. 
 
 formed by piling successively on each other pieces of any ma- 
 terial, of gradually and regularly dimi- 
 nishing size, — of square, oblong, or circu- 
 lar shape (fig. 5). 
 
 These varieties of the compress are 
 useful when firm pressure, made generally 
 with the aid of a bandage, or of the hand, 
 is required upon some deep-seated point, 
 as, for example, to arrest the circula- 
 tion through a bleeding vessel. 
 
 The perforated compress, as its name 
 indicates, is one in which an aperture has 
 been cut. The number of such aper- 
 tures may vary indefinitely. A very ele- 
 gant dressing to a suppurating surface consists of a compress, 
 or a simple piece of linen, perforated in a cribriform manner, 
 and spread with cerate of some kind. The pus has in this 
 way free escape, and may be absorbed by lint laid upon this 
 sieve-like covering. 
 
 The chief varieties of the split compress, are the retractor 
 of two and of three tails, and the Malta cross. 
 
 The retractors are formed by making one or two longitudi- 
 nal slits (as two or three tails are required) in a piece of mus- 
 lin three or four inches wide, and two and a half feet long. 
 They are used in amputations to draw up the soft parts, after 
 the incision has been made, for the purpose of protecting them 
 from the saw, while the bone is being removed as high up as 
 the incision of the soft parts will allow. The retractor of two 
 tails is employed in amputations of the arm and thigh ; the 
 other in the removal of the forearm and leg. In its applica- 
 tion, the former is made to grasp the bone between its tails, 
 which are then drawn upwards beneath the member, the body 
 of the retractor being carried in the same direction along its 
 superior face ; the soft parts are thus enclosed and shielded 
 between the two. In using the retractor of three tails, the 
 middle tail is thrust between the two bones of the leg, or fore- 
 
 arm. 
 
 To prepare the Malta cross, (fig. 6), take a square piece of 
 linen or patent lint, of the required size, and fold it through 
 the middle of one of its sides ; double the oblong thus formed 
 upon itself through the centre of one of its longitudinal dia- 
 
34 
 
 SURGICAL DRESSINGS. 
 
 Fig. 6. 
 
 meters, and from the free angle of the smaller square thus 
 produced, (the angle at which the vari- 
 ous laminae composing the square are se- 
 parable), make an incision along its ob- 
 lique diameter, to within a short dis- 
 tance of the opposite angle. When the 
 square is re-opened, it will present the 
 form of the Malta cross. It is used as 
 a direct application to stumps, having 
 been previously perforated at numerous 
 points, and spread with cerate. 
 
 The half Malta cross is made by fold- 
 ing an oblong piece of linen, or patent 
 lint, through the middle of its longitudi- 
 nal diameter, and continuing an incision from one of its free an- 
 gles, along the oblique diameter, nearly to the opposite angle. 
 Its uses are as those of the last described. 
 
 5. Sponge-tent is prep.ared by thoroughly saturating soft 
 sponge with melted beeswax, or gum tragacanth, and subject- 
 ing it to pressure as it cools. It is employed for the purpose 
 of dilating wounds, fistulous canals, &c, which it effects by 
 imbibing moisture from the cavity, and thereby swelling. For 
 use, a piece of the hardened mass of sponge is cut of the re- 
 quisite size and form, and gently introduced into the cavity, 
 where it may be easily confined by a piece of adhesive plaster 
 stretched across the orifice. 
 
 It is well to recollect that the prolonged retention of a 
 sponge-tent, particularly in irritable patients, frequently ex- 
 cites violent pain, swelling, and heat in the part, accompanied 
 often with considerable fever. In such cases, these effects 
 speedily disappear upon the removal of the tent, followed or 
 not by the application of some soothing dressing, as warm 
 water, or a poultice. 
 
 6. Setons are made of a variety of materials : as of a skein 
 of silk, a piece of linen tape, or a piece of ordinary soft linen, 
 which has been unravelled along its borders. 
 
 7. Adhesive plaster, is composed of some substance or 
 substances, possessed of tenacious or adhesive properties, and 
 susceptible of being spread upon linen, muslin, or some similar 
 material. 
 
 The " emplastrum resinse," of the U. S. Pharmacopoeia, is 
 
SURGICAL DRESSINGS. 35 
 
 the one generally employed in this country. It is sold in the 
 shops already spread upon linen or muslin. (The adhesive 
 plaster made by Charles Ellis, of this city, is particularly ex- 
 cellent.) 
 
 Adhesive plaster is one of the most indispensable articles of 
 dressing to the surgeon. Its uses are numerous. 
 
 Its most frequent employment is in the approximation of 
 the lips of wounds. For this purpose, the plaster should be 
 cut into strips, varying in width according to circumstances, 
 but, for neatness-sake, the strips intended for the same dress- 
 ing should be of equal width. In cutting them, the sheet of 
 plaster should be made tense by the hands of the surgeon and 
 an assistant, while the former forces a pair of sharp scissors, 
 without closing the blades, across the sheet parallel with the 
 course of its threads; in this way the strips may be cut 
 straight and very rapidly. 
 
 For application, the strip should be warmed, by being held 
 near a fire ; or, which is much better, by wrapping its un- 
 spread surface around a vessel containing boiling water; the 
 wound having been carefully cleansed, and the surrounding 
 surface washed and dried, and freed from hair, one extremity 
 of the strip is placed upon the skin at a suitable distance 
 from the edge of the wound, — the distance varying according 
 to the degree of force which shall be requisite to retain 
 the edges in contact, — the edges themselves are accurately 
 approximated by the fingers of the dresser, and the strip is 
 drawn across them, and pressed all along its course upon 
 the skin. 
 
 If the wound is so long as to require the application of two 
 or more strips, spaces should be left between them, to permit 
 ^he escape of fluid. 
 
 The length of time during which the plaster should remain 
 must vary in different cases. Generally, the strips should not 
 be disturbed until the wound has cicatrized, or until its edges 
 are somewhat firmly agglutinated, unless they shall have be- 
 come previously loosened from accidental causes, or productive 
 of some unpleasant effect. 
 
 ^ In removing the dressing, the portions of the strip on each 
 side of the wound should be raised alternately, and fresh 
 pieces applied as soon as possible, if the same dressing is to 
 be continued. Where a wound is traversed by more than 
 
36 SURGICAL DRESSINGS. 
 
 one strip, a fresh one should take the place of each, as it Is 
 removed, before a second is withdrawn. This precaution is 
 necessary, in order that the delicate adhesions of the lips of 
 the wound shall not be destroyed or weakened. 
 
 Many years ago, Mr. Baynton, an English surgeon, recom- 
 mended the employment of adhesive plaster in the treatment 
 of ulcers. The plaster which he used was composed of six 
 drachms of resin melted with a pound of lead plaster. He 
 directed that the ulcer be first carefully cleansed, and the 
 surrounding surface denuded of hair ; that adhesive strips, 
 two inches wide, and of sufficient length to encompass the 
 limb, and, in addition, to extend four or five inches over the 
 edges of the ulcer, be passed around the leg, from an inch 
 below to two or three inches above the sore, and with suffi- 
 cient force to approximate slightly its edges, — each successive 
 strip being in contact with that last applied ; that compresses 
 of soft calico be placed around the limb, and the whole enve- 
 loped with a bandage from the toes to the knee. If there 
 should be much heat or pain in the limb, cold water may be 
 applied over the dressing. This treatment is best adapted to 
 chronic indolent ulcers, attended with swelling and induration 
 of the limb. As the tumefaction abates, the dressings are 
 to be applied more tightly: they should be changed more or 
 less frequently, according to the greater or less amount of 
 suppuration, from twice in twenty-four hours, to once every 
 three or four days. According to the experiments of Velpeau, 
 Boyer, Roux, and others, ulcers are cured more speedily by 
 this method of treatment than by any other ; walking about 
 on the limb, moderately, facilitates the cure. Boyer found 
 that the average length of treatment by this mode, calculated 
 from a large number of cases, was twenty-six days ; while, ac- 
 cording to Duchatelet, of 690 cases treated by the ordinary 
 methods, the average duration of treatment was fifty-two anc 
 a half days. (Cutler, pp. 210, 211.) 
 
 The ordinary adhesive plaster of the shops will very wel 
 answer the purpose of that employed by Baynton. Previous 
 to its application, the limb, from the toes to within a few 
 inches of the ulcer, should be enveloped by a roller, which is 
 to be continued over the whole leg after the other dressings 
 have been applied. 
 
 In the drawing, fig. 40, this method of treatment is illus- 
 
SURGICAL DRESSINGS. 
 
 37 
 
 trated, the upper part of the ulcer being purposely left ex- 
 posed. 
 
 The same plan of treatment has been extended, by Vel- 
 peau, Boyer, and Roux, to all ulcers which have become 
 atonic or chronic, and by the former of these distinguished 
 surgeons, particularly, to burns (Velpeau, M£d. Op£rat., 
 vol. i., p. 257), and also to varicose and ganglionary tumours, 
 &c, &c. 
 
 M. Fricke, of Hamburgh, first called attention to the effi- 
 cacy of compression, methodically and carefully made by 
 strips of adhesive plaster, in the treatment of epididymitis. 
 They may be thus applied : the scrotum should be carefully 
 cleansed, and the hair shaved from it; the testicle is then 
 forced to the bottom of the sac, and the affected side of the 
 scrotum, clasped just below the ring by the thumb and fore- 
 finger of the left hand, is surrounded by a very narrow strip 
 of plaster, which is then carried down over the scrotum in 
 such a way as to apply itself neatly and smoothly to the 
 skin ; successive strips are used, until the part is entirely en- 
 veloped. The pressure should be moderate and regular. As 
 the swelling subsides, the strips will of 
 course become loose, when they may be re- 
 moved, and fresh ones applied as before. 
 If there be much pain, the employment of 
 the adhesive plaster may be preceded by the 
 application of leeches over the scrotum it- 
 self, or in the groin. 
 
 Chronic indurations generally of the 
 testicle are very often removed or dimi- 
 nished by this treatment. The annexed 
 drawing illustrates this application (fig. 7). 
 
 It will frequently be found that, after 
 the removal of adhesive strips from the 
 surface of the body, a portion of the ad- 
 hesive matter remains upon the skin ; 
 water alone will not easily remove it, but 
 gentle rubbing with a sponge moistened 
 with spirit of turpentine, will readily 
 cleanse the part. The black discoloration 
 often noticed is a matter of no consequence ; it is simply owing 
 
38 SURGICAL DRESSINGS. 
 
 to the action of the matter of the secretions of the surface 
 upon the lead plaster. 
 
 Several objections have been urged against the employ- 
 ment of the common adhesive plaster ; some of them are well 
 founded, others not so. It sometimes, though by no means 
 usually, irritates the skin, producing an erythematous inflam- 
 mation, and occasionally a papular or a vesicular eruption ; 
 this is particularly the case when the application is made to 
 the skin of young children and infants. To avoid such in- 
 conveniences, the " isinglass plaster" has been recommended 
 as a substitute for the other. It is prepared by spreading 
 upon oiled silk, or silk glazed on one side only, and on the 
 unglazed side, a solution of Isinglass in Spirit (Liston). When 
 dry, the silk may be laid aside until required for use, then it 
 is cut into strips of the desired width, and its adhesive sur- 
 face softened by the application to it of a hot moist sponge ; 
 the strips are to be employed as directed for the ordinary 
 adhesive plaster. The advantages of this preparation are, 
 its cleanliness, its perfectly unirritating nature, and its trans- 
 parency, whereby the surgeon is enabled to see the condition 
 of the surface upon which it is applied, without removing 
 the strips. It is, however, less adhesive than the common 
 plaster; for, as has been well observed by Dr. Smith 
 (" Minor Surgery," p. 38), the warm discharges from the 
 part to which the isinglass plaster is applied, soften its mate- 
 rial, as did the hot moist sponge. Therefore, whenever con- 
 siderable tenacity of adhesion is requisite, the ordinary plaster 
 is preferable. 
 
 (The isinglass plaster is made in this city by Mr. Hus- 
 band, Apothecary, Spruce Street.) 
 
 " Collodion," an ethereal solution of gun-cotton, will be 
 found to be a very convenient adhesive material. To apply 
 it, lay strips of muslin or linen across the wound, the edges 
 of the latter having been accurately approximated, and satu- 
 rate them with the collodion by the aid of a camel's-hair 
 pencil. The strips should be made of some unglazed fabric, 
 as this imbibes the solution more readily and thoroughly than 
 the glazed. 
 
 In slight wounds the strips may even be dispensed with, 
 the liquid being merely painted over the surface, the edges 
 of the wound being held together until the collodion is dry. 
 
SURGICAL DRESSINGS. 39 
 
 The contractility of this substance 13 such that it has been 
 recommended as a means of curing small ncevi, by the com- 
 pression which it induces in drying. 
 
 Various other plasters are frequently employed by the 
 surgeon. 
 
 The soap plaster — "Emplast. Saponis," — spread upon soft 
 sheepskin, and then cut into strips, or into pieces of any 
 shape and size, will be found oftentimes to answer a very ad- 
 mirable purpose, in making pressure upon an enlarged joint, 
 or an indolent tumour, &c, &c. It is very mild and unirri- 
 tating, and preserves the integuments soft and moist, and is 
 an excellent preventive of excoriation. 
 
 The mercurial plaster is very commonly employed as a re- 
 solvent of tumours, and other indurations. The belladonna 
 plaster is an excellent anodyne application. 
 
 Plasters should be smoothly and evenly spread on coarse 
 muslin, or stiff brown paper, or, which is much the best ma- 
 terial, on soft sheepskin. A piece of skin, or other material, 
 should be cut of a shape suitable for application to each par- 
 ticular part, and rather larger than the surface intended to 
 be covered by the plaster ; a narrow strip of paper may be 
 then pasted around its margin, and within the space thus 
 bounded, the plaster is to be spread, after which the paper 
 may be removed. In order that it may adapt itself smoothly, 
 accurately, and neatly to the surface, it is well to make 
 several slits from the margin of the plaster towards its centre. 
 
 8. One of the most common articles of dressing, both in 
 domestic and professional practice, is the poultice. When 
 badly made, it is undoubtedly deserving of the abomination, 
 with which it is so amusingly and feelingly regarded by Mr. 
 Liston; but when properly prepared, and correctly used, it 
 cannot, we think, be conveniently dispensed with for any 
 other substitute whatever. 
 
 The poultice should be always soft and moist, and these 
 requirements should be kept in view, as far as possible, in 
 the choice of the materials of which it is to be made. The 
 substance which is to form its basis is generally in the form 
 of a powder ; this should be stirred about with sufficient water 
 to give to the mass a soft consistence, yet not so moist as to 
 permit the fluid to flow from it. The water may be cold or 
 hot, according to circumstances, and may be best incorpo- 
 
40 SURGICAL DRESSINGS. 
 
 rated with the powder by adding sma,ll portions of each al- 
 ternately and successively. The semi-solid mass thus pre- 
 pared may be spread upon a piece of muslin smoothly and 
 evenly, by the aid of a wooden or iron spatula, or an ordinary 
 table-knife ; it should be from a fourth to half an inch thick, 
 and occupy just so much of the surface of the muslin as that 
 the margin of the latter may be reflected upon it, all around, 
 for the space of half an inch ; this latter arrangement gives 
 to the poultice a very neat and elegant appearance, and fa- 
 cilitates very much its removal from the surface to which it 
 may have been applied. 
 
 Some surgeons prefer to protect the part from immediate 
 contact with the poultice, by the intervention of a piece of 
 fine cambric or gauze, previously laid upon the surface of 
 the latter. For so doing, they urge that, otherwise, portions 
 of the poultice remain adherent to the skin or ulcer, after 
 the mass has been removed, and are displaced with some dif- 
 ficulty and occasional pain to the patient. If, however, the 
 poultice has been properly prepared and applied, and not too 
 long retained, this annoyance will rarely occur. Moreover, 
 by thus covering the poultice, we are deprived, in a great 
 measure, of the benefit derivable from the direct contact of 
 its materials with the affected part ; and this consideration is 
 an important one oftentimes, as, for example, when the poul- 
 tice is medicated; for, as Velpeau remarks, " poultices are 
 not intended to act merely as compresses saturated with warm 
 water." Yet when the application is intended for the eye, 
 or the neighbourhood of the nostrils or mouth, or when it 
 contains ingredients which may be too irritating for the sound 
 skin, it is very proper to use the precaution alluded to. 
 
 Generally, the smearing of the poultice with oil, or grease 
 of any kind, is unnecessary and objectionable. 
 
 In order to retain the warmth and moisture and softness of 
 the poultice as long and as completely as possible, it should 
 alwaj^s be covered externally with a piece of oiled silk, or thin 
 India-rubber cloth ; the unpleasant odour of the latter, how- 
 ever, renders the first a preferable application* 
 
 This dressing should be changed at least twice daily; and 
 when the discharge is profuse, in warm seasons, when the 
 poultice is very soon soured — or when the speedy production 
 of suppuration, or the relief of great pain is desired, the ap- 
 
SURGICAL DRESSINGS. 
 
 41 
 
 plications should be renewed as often as every two or three 
 hours, or even still more frequently. 
 
 In removing it, the poultice should be gently drawn up by 
 one side, and reflected upon itself gradually, until the whole 
 is lifted up ; if it adhere at any point, its detachment will be 
 easily effected by allowing a little warm water to trickle over 
 the part ; before applying a fresh dressing, the surface should 
 be carefully and gently cleansed. 
 
 To retain the application in its place, a roller may be passed 
 around it, extending a short space both above and below it. 
 But it often occurs that the part to which the poultice is ap- 
 plied, whether it be an irritable ulcer or otherwise, is too ten- 
 der and painful to bear the agitation to which it must be sub- 
 jected in the use of the roller ; in such cases the " bandage 
 of Scultetus" should be employed; thus, the entire dressing 
 may be renewed without moving the suffering part. 
 
 Fig. 8. 
 
 Fig. 9. 
 
 Dr. Hays, of this city, is in the 
 habit of making use of a bandage, 
 in similar cases, which may be con- 
 sidered as a modification of the 
 many-tailed bandage ; its simplicity 
 and perfect adaptation to this and 
 numerous other analogous pur- 
 poses, renders it worthy of descrip- 
 tion. 
 
 A piece of muslin more than 
 
 wide enough to envelope the part, 
 
 as the leg, for instance, and rather 
 4* 
 
42 Surgical dressings. 
 
 longer than the poultice, or other application which it is in- 
 tended to retain, is cut or torn, transversety from each mar- 
 gin, leaving a central space entire, of some few inches in 
 breadth ; this is laid on the pillow or bed, and the leg, with 
 the poultice applied, is placed upon it; then, commencing 
 from below, the tails, first on one side and then on the other, 
 are alternately and successively brought over, as the strips of 
 the bandage of Scultetus, and the last two tied in a single or 
 double bow-knot. This simple bandage will be found very 
 useful in retaining blisters, cerates, or any similar application, 
 upon parts too sensitive to admit of much disturbance : figs. 
 8, 9, exhibit this bandage, free, and applied. 
 
 If the discharge is at all profuse, it should be absorbed as 
 soon as possible by cotton, tow, or some similar substance, 
 arranged to receive it. Thus if the arm be the part affected, 
 it should be laid upon a pillow (the patient being in bed), pro- 
 tected by a piece of oil-cloth, upon which some tow or bran 
 has been placed ; the same disposition may be made with the 
 leg ; or this member may be conveniently put in a fracture- 
 box filled with bran, or containing a pillow protected as be- 
 fore. In order to preserve the bed-clothes from contact with 
 the discharged matter, a semi-circular framework of wire or 
 bamboo, should be thrown over the limb. (See fig. 10.) 
 
 The material of which the poultice shall consist must vary 
 with the indications to be fulfilled in each case. It may be 
 emollient, refrigerant, astringent, stimulating, or anodyne. 
 
 The emollient poultice, as its name implies, is made of per- 
 fectly bland and unirritating material. The materials of 
 which it is usually prepared, are bread and milk, bread and 
 water, and water with corn-meal, flaxseed meal, or slippery 
 elm powder. Each surgeon, probably, has some fancy of his 
 own with regard to what forms the best poultice, some pre- 
 ferring this, some that material. Abernethy, who seems pro- 
 foundly to have studied the philosophy of poultices, gives 
 decided preference to the bread and water, and the flaxseed 
 meal poultices ; after detailing the mode in which the latter 
 should be prepared, he exclaims, rapturously: " When thus 
 made, oh ! it is beautifully smooth ; it is delightfully soft ; it is 
 warm and comfortable to the feelings of the patient/' (South's 
 "Hints on Emergencies," p. 12.) 
 
 The bread poultices, made either with milk or water, be- 
 
SURGICAL DRESSINGS. 43 
 
 come dry and stiff sooner than those prepared with flaxseed 
 meal ; the latter contains a considerable portion of oil, which 
 imparts great softness to the mass when w T et ; but it also gives 
 it a not very pleasant odour, and in warm weather, or when 
 long in contact with an inflamed surface, it soon becomes 
 rancid and irritating; upon some skins, moreover, it pro- 
 duces a vesicular eruption. Perhaps the poultice least lia- 
 ble to objection, is that made of the powder of slippery elm 
 bark. 
 
 The above-named poultices when applied cold may be 
 termed refrigerant. An application of this kind may be 
 prepared by employing a solution of acetate of lead, in the 
 proportion of 3ij. or 3iij. to a pint of water, instead of simple 
 water, in mixing the poultice. In order to increase their 
 cooling effect, they may be applied without covering them 
 with oiled silk or any bandage, so that evaporation shall be 
 unchecked. It must be recollected, however, that although 
 cold when first laid upon the part, they soon acquire the same 
 temperature as the surface ; they require, therefore, frequent 
 renewal. 
 
 Astringent poultices may be made by incorporating any 
 powder of astringent property, with some one of the mate- 
 rials already mentioned. The substances most frequently 
 used are powdered oak bark, galls, and alum. A very elegant 
 poultice of this kind is prepared by rubbing up alum with the 
 white of egg. 
 
 Stimulating poultices are formed in the same way, by in- 
 corporating stimulating substances with some sort of meal, 
 and water. With this view the scrapings of carrot, or horse- 
 radish, are employed. Solutions of chloride of lime, or of 
 soda, of creasote, or of common soap, are often used ; or a 
 poultice may be made of stewed onions. One of the best 
 and most agreeable of the stimulating poultices is the cam- 
 phor poultice, made by incorporating spirits of camphor with 
 the meal or other substance used as the basis. It is particu- 
 larly serviceable as an application to gangrenous parts, slough- 
 ing ulcers, &c. 
 
 The fermenting poultice is made by incorporating yeast, or 
 porter, with corn meal, and is of great advantage in hastening 
 the separation of gangrenous parts. A very common prepa- 
 ration of this sort is the ordinary mustard poultice. These 
 
44 SURGICAL DRESSINGS. 
 
 applications are employed when a decided irritant or stimu- 
 lating effect is indicated. 
 
 An anodyne poultice may be made by stewing bruised 
 poppy-heads until they become somewhat soft and adhesive; 
 or the dregs of opium, left after the preparation of laudanum, 
 or this liquid itself, may be mixed with meal ; or the bruised 
 leaves of belladonna may be moistened, and applied. The 
 leaves of the tobacco plant moistened, may be used in the 
 same way, but their application should be carefully watched, 
 lest too great prostration ensue. Hops, or chamomile- 
 flowers, enclosed in a flannel bag wrung out of hot water, or 
 incorporated with meal or bran and hot water, form an ex- 
 cellent anodyne poultice. 
 
 Medicated poultices may be very elegantly prepared, by 
 making an infusion of the substance, whatever it be, which 
 has been selected as a medicament. Poppy-heads, the carrot, 
 potato, horseradish, various astringent substances, may be 
 simmered for an hour or two in a closed vessel containing 
 water, and the liquor, after having been strained, incorporated 
 with meal of some kind. (South, p. 11.) 
 
 Mr. Liston, and some others, object altogether to the use 
 of poultices, proposing to substitute water, medicated or 
 simple, cold or w T arm. For this purpose, some one of the 
 infusions above mentioned will answ r er very well. They should 
 be applied by means of linen, lint, or flannel, several times 
 folded, and saturated with them, thus constituting fomenta- 
 tions ; they should be kept constantly upon the part. To be 
 of real benefit, their employment demands assiduous and un- 
 intermitting care from the attendants, much more, indeed, 
 than can be generally expected or obtained, particularly in 
 hospitals ; this constitutes a serious objection to their being 
 generally used as substitutes for poultices. Neither do they 
 supply the same body of heat as the latter, when heat is re- 
 quired. They are, however, more cleanly than the poultice, 
 and this seems to be their chief advantage — an important one 
 truly. Where a cold application of this sort is desired to 
 reduce the temperature of a part, the most effectual is 
 pounded ice, with which a bladder, or a bag of India-rubber 
 cloth, may be partially filled : the temperature of the appli- 
 cation will remain as low as 82° F., so long as any particle 
 of ice remains unmelted, after which the water in the sac will 
 
SURGICAL DRESSINGS. 45 
 
 gradually acquire the temperature of the part to which it is 
 applied ; hence the hag must be examined from time to time, 
 and the ice renewed when necessary. Sacks, intended ex- 
 pressly to hold water, are made of thin India-rubber cloth ; 
 one of these may be partially filled with water containing 
 various^ saline substances which, during their solution, ab- 
 stract its heat ; this forms a very good substitute for the 
 bladder of ice, when ice cannot be obtained. One ounce of 
 nitre, one ounce of sal ammoniac (chloride of ammonium), 
 and half a pint of water, may be thus employed. (Thomson' 
 "Management of the Sick Room," p. 277.) 
 
 These applications, whether used in the form of poultice 
 or of fomentation, fulfil a variety of indications. When 
 employed warm, they relieve spasmodic pain, or sometimes 
 continued pain ; produce or promote suppuration ; allay irri- 
 tation frequently, and sometimes inflammation : diminish oede- 
 matous enlargements, by promoting local perspiration, or 
 transpiration ; induce resolution of acute or chronic inflamma- 
 tions and indurations, &c, &c. When cold, they are more 
 directly sedative, and are generally used to subdue inflamma- 
 tion, or to overcome muscular action, or the tonic rigidity of 
 tissues, as in the reduction of hernia. It must, however be 
 borne in mind, that the effects of these applications vary 
 much m different individuals ; thus in some, a warm poultice 
 or fomentation, will resolve a phlegmon which presents, as 
 nearly as can be judged, the same condition as one which, 
 in other individuals, is most relieved by cold. The feelings 
 of the particular patient should be consulted, to enable the 
 surgeon to determine when one mode of treatment should be 
 substituted for, or even be used instead of, the other. 
 
 In enumerating the circumstances to which these dressings 
 are particularly applicable, it is hardly necessary to remark 
 that the substances with which they may be medicated will 
 modify accordingly their general action. 
 
 Within the last two or three years, an article of English 
 manufacture, called. "Spongio-PUine," has been introduced 
 o the notice of the Profession, and recommended by the sur- 
 gical staffs of several of the London Hospitals. It is also 
 used to^a considerable extent in the Massachusetts General 
 iospitai, in Boston, and perhaps elsewhere in our own 
 country. 
 
46 SURGICAL DRESSINGS. 
 
 It is in sheets, three-fourths of an inch to an inch in thick- 
 ness, looking very much like a smoothly-cut slice of sponge, 
 one surface being covered with a sort of glazing of India- 
 rubber. 
 
 It imbibes water very freely, and the glazed surface pre- 
 vents evaporation, as a piece of oiled-silk when laid upon a 
 poultice. When wet it is not too heavy to be comfortable. 
 The advantages claimed for it are its durability, its capability 
 of being washed, and thus answering for different patients ; 
 and its cheapness, as compared with the cost of the materials 
 of which poultices are made, or of those used in the prepara- 
 tion of fomentations ; it being remembered that the same 
 piece of Spongio-Piline will last, as it is said, a very consi- 
 derable time, and be serviceable to a number of patients. 
 This last claimed advantage is, w T e think, of questionable 
 reality ; for there would certainly be, to say the least, great 
 probability that by thus preserving a piece of dressing as a 
 sort of heir-loom, various inconveniences and dangers would 
 arise from the transference from person to person of irritating, 
 offensive, or inoculable matters. To furnish a piece of fresh 
 " Spongio-Piline" to each hospital-patient w T ho required an 
 emollient application, would be a very expensive charity. 
 Having, by way of experiment, applied a piece of this article, 
 saturated with w r arm water, to our own person, we confess 
 that the effect was less agreeable than that produced by a 
 well-made poultice or a fomentation. 
 
 9. Lotions are composed of water variously medicated. 
 They are usually applied upon some soft porous material, 
 as lint or folded linen ; they may be used tepid or cold ; in the 
 choice of temperature, the feelings of the patient may be very 
 properly appealed to by the surgeon. If a refrigerant effect 
 is desired from the wash, it should be applied upon a single 
 fold of lint, or linen, and left exposed, or but slightly protected, 
 so that evaporation may not be interfered with ; where such 
 an action is not called for, several folds of the porous sub- 
 stance should be laid upon the part and covered by a piece of 
 thin oiled-silk — the whole to be retained in the manner alludec 
 to with regard to the poultice. 
 
 As a general rule, lotions should be employed preferably 
 to cerates, as being more cleanly, and not liable to become 
 
SURGICAL DRESSINGS. 47 
 
 irritating from high temperature of the part, or season of 
 the year. 
 
 Formulae for several lotions will be found at the end of the 
 volume, with the uses of each. 
 
 10. " Cerates are unctuous substances, consisting of oil 
 or lard perfectly fresh and sweet, united with wax, sperma- 
 ceti, or resin, to which various medicaments are frequently 
 added. Their consistence, which is intermediate between that 
 of ointments and of plasters, is such that they may be spread 
 at ordinary temperatures upon linen or leather, by means of 
 a spatula, and do not melt or run when applied to the skin." 
 (U. S. Dispensat.) They are used as applications to abraded 
 or ulcerated surfaces, and their composition is varied for 
 adaptation to each case. 
 
 11. " Ointments are fatty substances, of the consistence 
 of butter, such that they may be readily applied to the skin 
 by inunction. " (U. S. Disp.) They are simple, or com- 
 posed of various medicaments. The ointments, as well as the 
 cerates, are easily affected by a high temperature, becoming 
 rancid and unfit for use. They are usually applied upon the 
 sound skin. 
 
 A number of ointments and cerates, such as have been 
 found useful, are given at the end of the book, with their par- 
 ticular applications. 
 
 12. Liniments are intended for application to the unbroken 
 surface, by friction with the hand, or soft flannel. Oil should 
 constitute the basis of the liniment, and with it may be con- 
 joined a variety of modifying ingredients, so that it may be 
 rendered soothing, or irritating, as required. 
 
 The reader will find formulae for the preparation of many 
 very serviceable liniments, at the latter end of the volume. 
 
 13. The Sponge, though it is not chiefly used as an article 
 of dressing in surgery, is of such essential importance to the 
 surgeon, that a few words concerning it will be proper. 
 
 The common sponge, as found in the shops, is too full of 
 gritty particles to be fit for surgical purposes. It may be 
 sufficiently well prepared for ordinary uses, such as the 
 cleansing of uninjured surfaces, by maceration in boiling 
 water, and subsequent beating, until the sabulous or calcareous 
 particles are generally removed. But for nice purposes, as 
 the washing of inflamed or ulcerated surfaces, still farther 
 
48 SURGICAL DRESSINGS. 
 
 preparation is requisite ; after having been treated as above, 
 it should be macerated in water acidulated with about one- 
 thirtieth of its bulk of chlorohydric acid ; dried and beaten 
 again, and then bleached by exposure, when moist, to the 
 vapour of chlorine, or some other decolorizing agent. It is 
 now soft and clean. 
 
 Bandages and the variety of apparatus employed in the 
 treatment of surgical diseases and injuries, will be considered 
 hereafter. 
 
CHAPTER III. 
 
 GENERAL RULES FOR DRESSING. 
 
 If a surgeon is called upon to attend to an injury just 
 occurred, he should take a rapid, yet careful, observation of 
 the patient, in order to ascertain the condition of his strength 
 and mental functions, and to discover if there be any circum- 
 stances calling for prompt attention previous to the systematic 
 application of a dressing. Thus, if there be much prostra- 
 tion present from any cause, fresh air and cold water should 
 be freely employed to revive the patient ; or a little wine and 
 water, with or without laudanum, should be administered ; 
 and all obstacles to free respiration, such as a cravat, a tight 
 vest, pressure around the abdomen from tight pantaloons, 
 should be at once removed. If there be an external wound, 
 it should be immediately examined, and prompt measures taken 
 to arrest hemorrhage, if any exist. 
 
 As soon as these preliminaries have been attended to, the 
 surgeon may proceed to the regular application of the dress- 
 ing, as in an ordinary case where no such emergencies present 
 themselves. 
 
 Having first arranged such articles of dressing as are 
 likely to be needed in the case under consideration, and con- 
 veniently disposed of the necessary instruments, (all useless 
 display being avoided, as being not only uncalled for, but 
 positively annoying to the patient,) — and having at command 
 sponges and towels, and one or two basins of warm water, 
 the surgeon should expose the diseased or injured part. In 
 doing this, great care and the utmost gentleness should be 
 observed ; if the patient be dressed, and the affected part, 
 as, for example, the arm or leg, be very sensitive and painful, 
 the clothes should be removed by ripping them along a seam, 
 rather than be drawn off in the usual manner ; and any ap- 
 plication which may have already been made must be with- 
 drawn with the same care, so as not to inflict any unnecessary 
 suffering. 
 
 K (49) 
 
50 GENERAL RULES FOR DRESSING. 
 
 The affected part and the surrounding surface should now 
 be cleansed as perfectly as can be effected, without too much 
 pain, by means of a sponge and castile-soap and water ; in ad- 
 dition, if there be a wound, or if it be deemed advisable to ap- 
 ply adhesive plaster, the surface should be denuded of hair, 
 either by using a razor, or, which will answer equally well, a 
 sharp scalpel. 
 
 If there be hemorrhage to any notable amount, it should be 
 arrested at once, by means of ligature or the application of 
 cold, or some styptic ; or if it be very slight, a momentary ex- 
 posure to the air may control it ; or, finally, the surgeon may 
 trust for its arrest to the pressure of the dressing which he is 
 about to apply. 
 
 In the choice of the latter, the surgeon will, of course, con- 
 sider the indication to be fulfilled in each particular case as 
 of paramount importance ; but it should also be borne in mind 
 that, lightness, freedom from any undue heating qualities, and 
 cleanliness, are also essential to the perfection of a dressing. 
 The retaining bandage should be such as may be applied and 
 removed with as little difficulty and annoyance to the patient 
 as is consistent with its special object, and all unnecessary 
 pressure and envelopement are to be deprecated. 
 
 After the dressing has thus been completed, the patient, or 
 the particular part involved, must be placed in such a position 
 as will most conduce to his comfort and security. Generally, 
 a dependent position is to be avoided ; to prevent it, pillows 
 may be placed beneath the limb, if the leg be involved, or, if 
 it be the arm, a sling may be used to support it. 
 
 The surface may be protected, 
 Eig. 10. when necessary, from the pressure 
 
 of the bedclothes, by placing over 
 it an arch made of two semi-circles 
 of hoop crossed upon each other, or 
 of wires, or bamboo, fixed in 
 frame (fig. 10). 
 
 The dressing should be disturbed 
 as little and as seldom as is consist- 
 ent with the successful treatment of the case; all unnecessary 
 renewals should be avoided. Generally, a dressing should 
 not be renewed, or removed, so long as the first remains in 
 
GENERAL RULES FOR DRESSING. 51 
 
 place, is clean, free from unpleasant smell, and is comfortably 
 borne, and so long as no new and untoward symptom has 
 occurred. 
 
 All soiled dressings of every kind, the sponges, basins, and, 
 in short, every thing which mars the cleanly appearance of the 
 sick-room, or vitiates its atmosphere, should be removed as 
 quickly as possible, and the bedding and clothing of the pa- 
 tient be kept clean and well arranged. 
 
CHAPTER IV. 
 
 ON THE USE OF WATER. 
 
 The various modes in which water is made use of as a me- 
 dicinal agent, by the surgeon in his daily duties, constitute a 
 very important subject for study ; and one to which a few 
 pages may profitably be devoted in a treatise on Minor Sur- 
 gery. A brief consideration, therefore, will be here entered 
 into of Irrigation ; the Douche ; the Water and the Vapour 
 Baths, and finally the subject of Fumigations will be noticed. 
 The best modes of insuring purity of the atmosphere of a sick- 
 room, or of a hospital ward, will also be briefly alluded to. 
 
 SECTION I. 
 
 IRRIGATION. 
 
 The surgeon has a very admirable substitute for the refri- 
 gerant poultice in Irrigation, whereby the part may be kept 
 constantly bathed in cold water of an uniform temperature. 
 The water may be simple, or medicated by any of the sub- 
 stances before enumerated, or others similar. The same plan 
 might be used to insure a hot or warm fomentation, if the fluid 
 could be maintained at one and the same temperature, but 
 this would be attended with so much difficulty, that it would 
 scarcely be prudent to attempt it ; since the alternate chilling 
 and heating, to which the part would be exposed, from succes- 
 sive changes in the thermometrical condition of the water, 
 would be productive of serious inconveniences and dangers. 
 
 The simplest method of effecting irrigation is, to cover the 
 part with folds of soft linen, or lint, previously moistened, and 
 to conduct a constant current of water to it through strips of 
 linen, or cotton wick, from a reservoir, as, for example, a ba- 
 sin placed at some convenient point. In order that the clothes 
 of the patient, or his bedding, be not wetted, the part, — as a 
 
 (52) 
 
IRRIGATION. 
 
 53 
 
 limb, — should be laid upon a pillow protected by a piece of 
 oil-cloth so arranged as to form a sort of gutter, or funnel, 
 along which the water may pass and fall into another reser- 
 voir placed beneath it. M. Velpeau employs an apparatus, 
 to fulfil the same purpose, which possesses this advantage, viz., 
 that by it the amount of water and the force of the stream can 
 be accurately regulated at pleasure, by turning a stop-cock. 
 The annexed figure, (fig. 11,) taken from M. Velpeau's work, 
 
 (Med. Operat. i. 265,) sufficiently explains the apparatus 
 which he uses. 
 
 The very great benefits derivable from the free and constant 
 use of cold water in various surgical as well as medical dis- 
 5* 
 
54 TIIE DOUCHE. 
 
 eases, have been known for ages ; from time to time, however, 
 it has been neglected, and again invoked : it is now, once more, 
 resorted to, in the manner just described. It is particularly 
 applicable to the early treatment of severe contused and lace- 
 rated wounds ; sprains ; simple contusions ; dislocations, accom- 
 panied by much pain after reduction, and many other painful 
 injuries and diseases of the joints ; phlegmonous inflammation ; 
 some varieties of painful ulcers, &c, &c. (MM. Velpeau, Be- 
 rard, Malgaigne, South's Ed. Chelius, &c, &c.) The feelings 
 of the patient should be consulted, in determining the propriety 
 of continuing or relinquishing this plan of treatment. It 
 should be discontinued, or at least suspended, if it increase the 
 pain which it was intended to relieve, or induce sensations of 
 chilliness and discomfort. 
 
 SECTION II. 
 THE DOUCHE. 
 
 Another, and a very beneficial mode in which water, either 
 warm or cold, may be applied to the surface of the body is, 
 by the douche, which consists of a column of water varying 
 in volume, made to fall upon the body from a greater or less 
 elevation. Two series of phenomena attend the action of 
 the douche: the immediate effect, or the shock, and that 
 w r hich follows it, or the reaction. The intensity of these 
 vary according to the temperature of the water, its volume, 
 and the height from which it falls ; so that by regulating 
 these circumstances, the peculiar effect to be derived from 
 the douche, in each case, may be obtained. The primary, or 
 direct result of the cold douche is sedative ; but, in ordinary 
 cases, the nervous system more than recovers from its tem- 
 porary depression, and an excitement ensues. This depres- 
 sion may be prolonged, and the period of excitement post- 
 poned, by gradually increasing the mass of water which falls 
 upon the surface, or the force with which it descends, or the 
 height of the column, or finally, by gradually lowering its 
 temperature; and by combining all these modifications, a 
 still greater effect will ensue. These circumstances should 
 be attended to, therefore, where a sedative influence is re- 
 
THE DOUCHE. 55 
 
 quired. So soon as a certain amount of depression occurs, 
 the action of the douche may be suspended, and again re- 
 sumed when reaction commences, as indicated by the return 
 of the previous temperature, colour, and fulness of the part. 
 This alternate action and suspension of the agent may be 
 continued so long as may be indicated. After the douche, 
 the surface should be gently dried by the application of a 
 soft towel, so as not to excite a glow. After successive and 
 repeated employment of the remedy, as above recommended, 
 it will generally be found that reaction does not occur, or 
 that it is very moderate and within bounds. 
 
 The warm douche is productive of less depression, and the 
 reaction is proportionally less in degree, than when the cold 
 is resorted to. Generally, the warmer the water, other cir- 
 cumstances being equal, the less the effects, both primary and 
 secondary. 
 
 To constitute the cold douche, the temperature of the water 
 should be about 40° P., rarely lower ; that of the warm douche 
 may very well be borne as high as 180° F. (Thomson, op. 
 cit. 289.) The duration of their employment must vary very 
 much ; in this respect the condition of each patient at the time 
 must be the criterion. 
 
 The water used for the douche is rarely medicated, except- 
 ing by the addition of salt or of sea-water. 
 
 The douche is especially applicable to cases in which it is 
 desirable to invigorate the vital functions, generally, or to in- 
 crease the tone of particular parts or organs. 
 
 In cases of considerable general debility, the system may 
 not be able to react sufficiently if the cold douche is employed 
 at first ; here it is best to use the warm water, and gradually, 
 on successive occasions, to lower the temperature of the douche, 
 as the individual may have become stronger. When carefully 
 employed in this way, it is one of the best general tonic reme- 
 dies which can be made use of. 
 
 In local paralysis its good effects are very manifest ; as, for 
 instance, when directed upon the lower part of the spine, in 
 cases of paralysis, partial or otherwise, of the sphincter mus- 
 cle of the anus, or neck of the bladder ; in a similar condition 
 of some of the voluntary muscles, as of the deltoid, resulting 
 from an injury to the muscle itself, the douche should be di- 
 rected upon the particular part. When the loss of power is 
 
 i 
 
56 
 
 THE DOUCHE. 
 
 Fig. 12. 
 
 more general, the effect of lesion of one of the central organs 
 of the nervous system, it is advisable not to employ this re- 
 medy until all the active symptoms of such lesion shall have 
 been removed : such cases demand great watchfulness on the 
 part of the surgeon. 
 
 The simplest mode of applying the douche is to pour the 
 ■water from the nose of a teapot, or pitcher, from some conve- 
 nient height ; if a large stream is desired, a basin or a bucket 
 can be employed. The shower-bath is a common name for a 
 variety of the douche. It is made in numerous ways. A very 
 simple form, and one which is very convenient for surgical 
 purposes, particularly in young patients, " consists of a hollow 
 vessel made of tin, with a perforated bottom. The body of 
 the vessel is of a bell-shape, with a hollow tube rising from the 
 top, (b) and terminating in a broad perforated rim.(<?) When 
 the bath is to be used, it must be sunk in a bucket of water, 
 until it is completely submerged ; the air is thus driven out of 
 
 the bath, which is filled with 
 water. The thumb of an at- 
 tendant is then to be placed 
 upon the orifice in the centre 
 of the rim, (c) and the bath 
 raised from the bucket of wa- 
 ter. The pressure of the air 
 upon the holes in the bottom 
 retains the water in the bath, 
 and on raising the thumb from 
 the upper orifice, the water is 
 rapidly discharged. " (Fig. 12.) 
 Portable shower-baths, holding 
 from a quart to a gallon or 
 more of water, are now made 
 so that the patient may hold 
 the vessel himself above his 
 head, and discharge the water by raising a valve with his fin- 
 ger. The shower bath may act on the whole surface, or upon 
 a single part which is alone exposed. After its use, the body, 
 or the parts which have been wet, should be thoroughly dried 
 by friction with a towel, and the person covered as soon as 
 possible. The best time for making use of the shower bath, 
 
BATHING. 57 
 
 or the douche, if other circumstances will permit, is probably 
 soon after rising in the morning. 
 
 
 SECTION III. 
 BATHING. 
 
 Bathing forms a very important item in the treatment of 
 many surgical diseases, so that a brief consideration of it will 
 not be out of place here. 
 
 Baths are of water, simple or medicated, and of vapour, — 
 of water, or of some medicinal substance ; or, again, it may 
 be a simple air-bath ; the latter is not much resorted to as a 
 remedial agent. 
 
 The water-baths are of most frequent use. For conve- 
 nience-sake, they may be classed as the cold (temp. 33° to 
 60° F.) ; the cool (60° to 75°) ; the temperate (75° to 85°) ; 
 the warm (92° to 98°); and the hot (98° to 112°). (Forbes, 
 art. " Bathing," in Cyclop. Pract. Med.) The thermometer, 
 though answering very well as a general index of the tem- 
 perature of the bath, is really a very arbitrary guide in pre- 
 paring baths for particular individuals; since a degree of 
 temperature which one person may consider "warm," or 
 "temperate," may to another be disagreeably cold; the feel- 
 ings of the patient, guided by the judgment of the attendant, 
 constitute a much more rational and a safer guide. 
 
 As in the case of the douche, two series of effects are ma- 
 nifest when one takes a bath : the primary and the secondary. 
 These vary in degree, with the temperature of the water. 
 The greater the difference between the temperature of the 
 bath and that of the body, the more marked will be the im- 
 mediate effects, or the shock ; and these will be depressing, or 
 stimulating, as the temperature of the water is below or 
 above that of the surface, and proportionally so. A cool, 
 and still more a cold, bath produces directly a sedative or 
 depressing effect ; but in the course of a few minutes, unless 
 the patient be very feeble indeed, the system recovers from 
 this, and an excitement, proportioned to the previous de- 
 pression, takes its place. This condition continues a longer 
 or shorter time, and a second stage of depression ensues, 
 
58 BATHING. 
 
 from which reaction does not occur, so long as the individual 
 is exposed to the same temperature. After the patient is 
 removed from the bath and properly attended to, the excite- 
 ment continues for a time, and then gradually the system re- 
 acquires its former standard, or retains permanently a mode- 
 rate elevation. 
 
 A hot bath produces immediately an excitement of the 
 system, as indicated by fulness of the superficial vessels, 
 flushing of the face, increased force and frequency of the 
 heart's action, throbbing of the vessels of the head and neck ; 
 the latter phenomena are sometimes so strongly manifest as 
 to require the employment of cold applications to the head, 
 and even the use of the lancet. Soon, however, either with 
 or without the aids just mentioned, perspiration breaks out 
 very freely upon the face, the excitement of the heart sub- 
 sides, and the patient becomes more and more relaxed, and 
 not unfrequently faints ; this condition of relaxation continues 
 for a considerable time after the bathing has ceased. 
 
 The warm bath generally produces a soothing, tranquil- 
 lizing influence, allays restlessness, assuages pain, and often 
 induces delightful sleep. The excitement which it causes is 
 very moderate, and if used permanently, it may be considered 
 an excellent tonic, as is the cool or cold bath, under proper 
 regulations. 
 
 Bathing is, therefore, applicable to a variety of surgical 
 diseases. As a calmative agent, it is employed in numerous 
 subacute inflammations, in many diseases of the skin, &c, &c. 
 As a tonic, it is applicable to cases of generalor local debility ; 
 as a stimulant, to the same sorts of complaints ; as a depress- 
 ing remedy, it is often made use of to overcome violent pain, 
 spasmodic muscular contraction, as in the reduction of dislo- 
 cations, to allay spasm of the neck of the bladder, to aid in 
 the return of a hernial protrusion, and the like. 
 
 In giving a bath, the water should be preserved, as far as 
 possible, at the same temperature throughout its use. When 
 the bathing is completed, the individual should be carefully 
 rubbed dry with towels, and protected from exposure to a 
 current of air. 
 
 Common sense will suggest at the time some apparatus 
 suitable for the administration of this remedy; if possible, 
 it should be large enough to contain the entire person, but in 
 
BATHING. 
 
 59 
 
 the absence of such a convenience, a common water-cask 
 might be employed, or a washing-tub ;— care being observed, 
 if the bath be warm, to protect, by a blanket, such portion 
 
 Fig. 13. 
 
 of the surface as may be uncovered by the water. Dr. 
 Thomson (op. cit., p. 296) has contrived a very convenient 
 apparatus for bathing ; he thus describes it : — " It consists 
 of a hammock (a) of Macintosh's cloth, which is extended 
 upon two long poles (6 5), passed through a broad seam on 
 each side of the hammock, and kept asunder by the cross 
 pieces (c c\ which are attached to the poles by the thumb- 
 screws (d d d). At one end of the hammock is an air-pillow, 
 which can be readily blown up ; and below it, is a flexible 
 tube (/), made of the same material as the hammock, by 
 which any water it may contain can be readily drawn off. 
 "When the poles are fixed, as in the above figure, and the 
 open end of the flexible tube is twisted around one of the 
 thumb-screws, the bath is ready to receive the water. It may 
 be supported upon two chairs, or upon folding tressels (e e). 
 The advantage of this bath is, that it requires a very small 
 quantity of water compared to that demanded for other 
 baths ; that it requires no sheet for the bather to rest upon ; 
 and, when the bathing is completed, the poles and the folding 
 tressels can be placed aside in a small closet, or in the corner 
 of a dressing-room, and the hammock, when dried, put into a 
 drawer." This apparatus will be found very convenient on 
 board ship, or in camp, where convenience in transportation 
 and economy of space must be consulted. (Fig. 13.) 
 
 Partial baths are very often used, and are of great service 
 in many cases. Thus the pediluvium, or foot-bath, may be 
 the means of effecting powerful and efficient derivation from 
 
60 
 
 BATHING. 
 
 Fig. 14. 
 
 the head, and of inducing a considerable degree of relaxation 
 of the whole frame. An ordinary bucket may be partially 
 filled with water of as high a temperature as the patient Gan 
 bear, rendered more powerful, if desired, by the addition of 
 mustard-flour or cayenne pepper, or some liquid stimulant ; 
 the patient may sit up in a chair, while the feet are in the 
 water, or he may remain in bed, with his limbs projecting 
 over its edge into the bucket which is supported upon a chair 
 conveniently placed. He should be well wrapped up during 
 the process ; from time to time, portions of water should be 
 withdrawn from the bucket, and hot water added. The bath 
 may be continued for fifteen or twenty minutes, or longer. 
 
 The hip-bath furnishes a very conve- 
 nient and powerful means of acting upon 
 the lower part of the spinal marrow and 
 the pelvic organs. It may be very well 
 taken in a vessel, of which the annexed 
 drawing illustrates the form ; it has the 
 important advantage of well supporting 
 the back, while the patient is in the sit- 
 ting posture. (Fig. 14.) 
 
 Baths are variously medicated to suit 
 particular indications ; several of such 
 modifications will be given at the end of the volume. 
 
 The vapour bath may be made to answer many of the in- 
 dications fulfilled by the water bath ; its general effects are 
 very similar. The intensity of its action varies much, accord- 
 ing as it is allowed to act upon the surface merely, or as it is 
 inhaled also. Dr. Forbes, (art. "Bathing/' op. cit.) gives the 
 following comparative statement, by which it is supposed that 
 the vapour bath produces effects equal to 
 
 The tepid bath, at 85°— 92°, its own temp, being 90°— 106°,' 90°— 100° 
 " warm " 92°— 98°, " " 106°— 120°, 100°— 110° 
 
 " hot " 98°— 106°, " " 120°— 160°, 110°— 130° 
 
 Not breathed. Breathed. 
 
 Their administration is very simple, and is attended with 
 less inconvenience, oftentimes, than the use of the w r ater bath. 
 The readiest mode of giving a vapour bath is to seat the pa- 
 tient upon a chair, and at his feet place the vessel of water 
 sufficiently heated ; surround the whole, — patient, chair, and 
 
FUMIGATIONS. 61 
 
 water, — with a blanket, or a mantle of waxed or oiled cloth, 
 or of India-rubber cloth, which may envelope the head, if it be 
 considered advisable that the vapour be inhaled, or simply en- 
 closing the neck, if otherwise; to keep the water at a proper 
 temperature, a heated brick may be immersed in it, or the 
 vessel placed upon it, from time to time, as required by the 
 lowering temperature of the fluid. If the patient remain in 
 bed, a flexible tube can be easily introduced beneath the bed- 
 clothes, communicating with the interior of a vessel, as an or- 
 dinary tea-kettle, in which vapour is being generated : or a 
 plate containing the fluid and a hot brick may be placed in 
 the bed, and an arched framework thrown over it to protect 
 the bedclothes. 
 
 SECTION IV. 
 ON FUMIGATIONS. 
 
 When solid substances are vaporized, and thus made to act 
 upon the surface, as medicinal agents, the process is called 
 Fumigation, and is effected by placing the substance to be 
 used in contact with a body heated at a sufficient temperature, 
 and so arranging the position of the patient as that the fumes 
 may come in contact with his surface. The arrangements 
 recommended above in the application of the vapour bath may 
 be employed likewise in fumigating ; the same, or even greater, 
 care being observed to protect the air-passages, if the fumes 
 are irritating, or not intended to be inhaled : again, a large 
 box, or a hogshead, may answer very well, being so contrived 
 as that the head may be guarded against the vapour. 
 
 The articles most frequently employed in fumigating the 
 surface, or a particular part of it, — are sulphur, nitre, cinna- 
 bar, arsenic, benzoic acid, chlorine gas, nitrous acid, &c, &c. 
 
 Vapours, whether by the vapour bath, or by fumigation, are 
 chiefly employed in affections of the skin, some forms of chro- 
 nic rheumatism, periostitis, and the like. 
 
62 DISINFECTING AGENTS. 
 
 SECTION V. 
 ON DISINFECTING AGENTS. 
 
 A pure atmosphere is one of the most important requisites 
 in the treatment of disease, and it is one which, in surgical 
 practice particularly, is difficult of acquisition oftentimes. It 
 becomes necessary, therefore, that the surgeon should devote 
 some attention to this matter. 
 
 The method which suggests itself most naturally to the 
 attendant is, to effect as perfect ventilation as circumstances 
 will permit. For this purpose, some method should be 
 adopted whereby the air in the patient's apartment shall be 
 frequently renewed by the introduction of fresh air from 
 without, displacing that within the room. When the tempe- 
 rature is such as to admit of keeping a fire in the chamber, 
 the vitiated atmosphere will ascend freely through the 
 chimney, thus allowing pure air to take its place; but in 
 warm weather this source of purification is cut off, and the 
 surgeon is obliged to rely chiefly upon the windows and doors, 
 as affording avenues through which an interchange may be 
 effected of the air within and without. This mode of purifi- 
 cation may be much aided by the use of various disinfecting 
 agents, which neutralize, more or less, the exhalations and 
 effluvia within the sick-room. Of these, the various sub- 
 stances which contain chlorine are most in use. They pro- 
 bably produce their effect by the liberation of chlorine gas, 
 which combines with the offending gases. The chlorides of 
 calcium and of sodium are the compounds generally employed 
 as disinfectants ; they are used in a solid state, placed in 
 different parts of the room, in some suitable dish, and kept 
 moistened with water, or with dilute sulphuric acid, which is 
 still better ; or they may be rendered liquid for application to 
 the surface of the body and to the bedclothes of the patient. 
 The liquid chloride of calcium may be prepared thus :- 
 Introduce into a common glass retort fourteen parts of black 
 oxide of manganese, six parts of chloride of sodium, the same 
 proportion of sulphuric acid, and twelve parts of water. The 
 chlorine gas will be evolved without the aid of heat applied, 
 
DISINFECTING AGENTS. 63 
 
 and should be transmitted through a tube attached to the 
 neck of the retort to the bottom of a vessel filled with a satu- 
 rated solution of lime, until the evolution ceases. The water 
 thus impregnated should be diluted with about forty parts of 
 fresh water, for ordinary use. 
 
 The liquid chloride of sodium is prepared in the same 
 manner : a solution of one part of sub-carbonate of soda, in 
 twenty parts of water, being substituted for the lime-water. 
 The solution should be diluted with about thirty parts of 
 water. These liquids are sprinkled upon the patient's clothes 
 and bedding, and a portion may be added to the water used 
 in washing any diseased part : for this latter purpose, the so- 
 lution of the chloride of sodium is generally preferred, (Cyclop. 
 Pract. Med.) 
 
 Labarraque's solutions of these chlorides are now sold very 
 generally throughout the country. 
 
 A solution of the chloride of zinc is also employed as a cor- 
 rector of the atmosphere. 
 
 Chlorine gas may be very easily liberated from common 
 salt, by pouring concentrated sulphuric acid upon it, in the 
 proportion of one part of the acid to three parts of the 
 salt. 
 
 An objection to the use of the chlorides arises from the 
 smell of the preparations themselves being disagreeable to 
 many persons. 
 
 Fumigations by nitrous acid vapour have been resorted to, 
 and with much success. The vapour is obtained by the action 
 of sulphuric acid on nitrate of potassa, in equal proportions, 
 without the aid of heat ; care is necessary lest the fumes be 
 disengaged too rapidly and too abundantly, and thus prove a 
 source of irritation to the respiratory muscles. 
 
 The common quicklime possesses the power of absorbing 
 many of the gases on which the noisome atmosphere of the 
 sick room depends. It is placed in plates, or other dishes, 
 and set in various parts of the chamber. 
 
 M. Le Doyen has recently recommended a disinfecting 
 agent which seems to possess many advantages over the 
 others, and a very important excellence of this preparation 
 is, that it has no odour itself. It consists of a solution of 
 the nitrate of lead, and can be prepared by dissolving litharge 
 
64 DISINFECTING AGENTS. 
 
 in one part of nitric acid, mixed with about ten parts of 
 water. It is used in the same way as the liquid chlorides. 
 
 To insure any degree of purity of atmosphere, it is abso- 
 lutely essential that the patient's apartment be kept clean, 
 and that all useless clothing and furniture, which may attract 
 offending gases, be removed. The dressings which have been 
 changed, the water with which diseased parts have been 
 cleansed, all vessels containing discharges from the patient, 
 should be taken out of the room as soon as possible. Fre- 
 quent white-washing of the walls and ceiling of the chamber 
 will conduce very much to the preservation of a pure atmo- 
 sphere, probably on account of the absorbing property of the 
 lime over the effluvia. 
 
 The most efficacious method for disinfecting substances, 
 such as clothing, which retain infectious agents, is to expose 
 them to an elevated temperature, as, for example, a tempera- 
 ture of 200° or more, of Fahrenheit's scale; the heat may 
 be employed dry, or in the form of steam. The action of 
 heat is effectual in a very much shorter time than an ordinary 
 current of air. 
 
PART II. 
 
 ON BANDAGES AND THEIR APPLICATION. 
 CHAPTER I. 
 
 Bandages are employed in surgery to retain dressings 
 upon the surface of the body, or other applications ; and also 
 as a means of restoring and confining to their natural situa- 
 tion parts which may have become displaced. 
 
 The materials used for bandages are generally muslin, 
 linen, flannel, or calico : sometimes gum-elastic cloth may be 
 employed. Of these materials that which is most frequently 
 selected is muslin, either bleached or unbleached ; it is cheap, 
 and everywhere to be found. Flannel is, in some circum- 
 stances, preferable to muslin, in consequence of its greater 
 warmth and elasticity. 
 
 Bandages are simple, as when formed from the roller ; or 
 compound, when prepared from one or more pieces adapted 
 by size and conformation to particular objects. 
 
 We shall first describe the different bandages commonly 
 employed, and then treat of their several uses, as applicable 
 to the different regions of the body. 
 
 SECTION I. 
 THE ROLLER, OR SIMPLE BANDAGE. 
 
 There are but very few of the ends ordinarily to be attained 
 by bandaging, which may not be gained by a skilful dresser 
 with the simple roller. 
 
 It is prepared from any of the materials above-mentioned, 
 but for general purposes muslin is selected. It should be 
 torn or cut into strips, varying in length and width, accord- 
 ing to the part to which it is to be applied, and rolled into 
 6* (65) 
 
G6 
 
 THE ROLLER, OR SIMPLE BANDAG: 
 
 the form of a solid cylinder: this latter object maybe effectec 
 by the hands alone, or by making use of a very simple ma 
 chine contrived for the purpose. If rolled by the hands, th( 
 strip should be folded at one extremity several times, until il 
 shall have acquired a certain degree of solidity; then th( 
 ends of this axis are held, and its mass made to revolve, be- 
 tween the thumb and forefinger of the right hand, while th< 
 free portion of the strip is pressed by the thumb and fore 
 finger of the left hand, and allowed to pass from between them 
 smoothly, and with some degree of tension, as the cylinder h 
 gradually forming. 
 
 Figure 15 presents a view of a machine for rolling the 
 simple bandage : it sufficiently explains itself. 
 
 Fig. 15. 
 
 If but a single cylinder is formed, the roller is said to b( 
 " single-headed ;" if there be a cylinder rolled at each extre- 
 mity of the strip, it is called " double-headed," and the un- 
 rolled portion between the two cylinders is termed the " body" 
 of the roller. 
 
 In applying this bandage, the external surface of the free 
 extremity of the roller is laid upon the part, and retained 
 there by the fingers of the left hand, until fixed by a few 
 turns of the roller, the cylinder being held in the palm of the 
 right hand by the thumb and fingers ; care is necessary thai 
 the bandage be laid smoothly and evenly upon the surface, 
 and that a uniform degree of pressure be exerted by each 
 successive turn. After the rolling is completed, the free 
 
THE ROLLER, OR SIMPLE BANDAGE. 67 
 
 extremity of the bandage is most easily confined by a pin 
 inserted transversely, or if parallel with the length of the 
 bandage, the pin should be introduced with its point towards 
 the free end of the roller, otherwise it is liable to be drawn 
 out by the constant strain of the bandage upon it. When 
 the part to which the bandage has been applied is very small 
 in circumference, and the bandage itself very narrow, the 
 extremity of the latter may be conveniently attached by slit- 
 ting it longitudinally through the middle, and tying the ends 
 around the part ; as, for example, the finger or toe. 
 
 Sometimes the roller may be wetted previous to its appli- 
 cation, as, for instance, when it is used to confine the band 
 to which the pulleys are attached, in the process for reducing 
 a dislocation ; the band is thus more firmly secured than when 
 a dry roller is employed. But in ordinary cases of bandaging, 
 a wet roller should not be used, for as it dries, it shrinks and 
 produces a much greater degree of pressure upon the soft 
 parts than is consistent with safety. 
 
 In some cases it may be advisable to saturate the bandage 
 with starch, which, wiien it has become dry, forms a stiff, 
 firm casement. A more particular mention of this, consti- 
 tuting what is generally called "the immovable dressing," 
 w r ill be made hereafter. 
 
 The simple bandage receives different appellations ac- 
 cording to the mode of its application, or the direction w T hich 
 the roller is made to assume ; and again, with reference to 
 the object to be accomplished by it. Under the first division 
 we have the circular, the spiral, the crossed, the spica, and 
 the recurrent bandages. The second division embraces the 
 uniting, the dividing, the compressing, the expelling, and the 
 retaining bandages. 
 
 1. The circular is that of which the folds are horizontally 
 disposed, or nearly so ; each successive fold almost completely 
 overlapping that which preceded it. (Fig. 16, a.) 
 
 2. The spiral ascends obliquely around parts more or less 
 conical in form, each fold of the roller applying itself 
 smoothly and flatly to the surface. Sometimes the edges of 
 the roller overlap each other at each successive turn, when 
 the bandage is termed by the French, u en doloires ; some- 
 times a space intervenes between the folds, in which case it is 
 termed "rampant:" fig. 16, c and b. If a limb, or any 
 
68 
 
 THE ROLLER, OR SIMPLE BANDAGE. 
 
 Fig. 16. 
 
 other part of irregular form, is to be bandaged in its length, 
 it will be impossible to cover its surface wholly, and at the 
 
 same time to make equable 
 pressure upon it at all points, 
 by simple spiral turns : one 
 of the edges of the roller 
 will compress the surface 
 more or less tightly, while the 
 other will be loose. In order 
 to obviate this difficulty it is 
 necessary to reverse the turns 
 of the roller, from time to 
 time, as the varying form of 
 the part may require : fig. 16, 
 d. Some considerable prac- 
 tice is needful to enable the 
 dresser to make these reverse 
 turns rapidly and neatly. 
 The object is to reverse the 
 relative positions of the edges 
 and surfaces of the bandage, 
 whereby its superior edge 
 shall become the inferior, and 
 the external face the internal. 
 To accomplish this end properly, the spiral should be discon- 
 tinued so soon as the bandage ceases to apply itself smoothly 
 and flatly to the surface ; at this point two or more fingers 
 of the left hand should be laid upon the roller at its superior 
 edge, and the right hand, in which the cylinder is held as 
 before directed, and which, until now, has been kept supine, 
 should be pronated, while the body of the roller, thus re- 
 versed, is suffered to apply itself, without traction, partly 
 upon the preceding fold, and partly upon the surface which 
 is to be covered ; then the cylinder is carried around to the 
 opposite side of the limb, and the process just described re- 
 peated. " The hand should press tightly upon each reverse 
 to flatten and equalize it. (Fig. 17.) 
 
 " Two precautions are to be observed in applying the re- 
 versed bandage ; one is, not to unroll, in making the angle, 
 more of the band than is absolutely necessary; the other, to 
 carry the angles upwards in a perpendicular line, and always 
 
THE ROLLER, OR SIMPLE BANDAGE. 
 
 69 
 
 far from the part affected," in order that the increased thick- 
 ness of the bandage at the angle or fold, shall not produce a 
 corresponding pressure and indentation upon the diseased or 
 injured surface. (Cutler, p. 25.) Each successive turn of 
 
 Fig. 17. 
 
 the roller should overlap from one-third to one-half of that 
 which preceded it, the edges being made, as far as possible, 
 parallel with each other. 
 
 3. The crossed bandage is made by giving the turns of 
 the roller the form of the figure 8, as is exemplified in the an- 
 nexed drawing (fig. 18), in which the bandage is supposed to 
 be applied to the bend of the arm after the operation of phle- 
 botomy, to compress the incised vein. 
 
 4. u When the turns of the roller cross each other in the 
 form of the Greek lambda, and leave the band about one-third 
 discovered, the a's being applied upon each other, the bandage 
 
70 
 
 THE ROLLER, OR SIMPLE BANDAGE. 
 
 Pig. 18. 
 
 receives the name of spica ; fig. 16 e : it is said to be ascend- 
 ant when the doloires are directed 
 towards the superior part of the 
 member, and descendant when they 
 regard inferiorly." (Cutler, p. 25.) 
 5. The recurrent bandage is 
 applied to the head more frequently 
 perhaps than to any other part. 
 It derives its name from the fact 
 that the roller, after covering a 
 certain portion of the surface, is 
 reflected in its course and brought 
 back to its original point of depar- 
 ture, at which it is again reversed 
 towards the opposite point. This 
 process is continued until the en- 
 tire surface is covered ; each successive fold overlaying one- 
 third, or more, of that which preceded it, and being confined 
 at its point of reflection, temporarily by the fingers, -and per- 
 manently by pins or by a circular turn of the roller, when the 
 bandaging is completed. It forms an exceedingly neat and 
 beautiful dressing. 
 
 The same bandage is employed as an envelope to stumps, 
 after amputation, for the purpose of retaining the other appli- 
 cations which have been made. 
 
 1. The uniting bandage, as it has its almost exclusive ap- 
 plication to the treatment of wounds, will be considered when 
 that class of affections is treated of. 
 
 2. The dividing bandage is employed in the treatment of 
 burns and granulating surfaces, where there has been much 
 loss of substance, and where unsightly cicatrices are liable to 
 be formed, and deformities from the approximation of opposed 
 surfaces. The object of this bandage is, to obviate such ap- 
 prehended difficulties by maintaining a proper separation of 
 the parts : thus, for example, when the anterior face of the 
 neck has been deeply injured by a burn, the lower jaw and the 
 head should be prevented from being drawn towards the chest, 
 as the ulcer cicatrizes, by means of a dividing bandage, hav- 
 ing its point oVappui around the shoulders and in the axilla. 
 It is generally formed of the simple roller. 
 
 3. The compressing bandage, as may be inferred from its 
 
THE ROLLER, OR SIMPLE BANDAGE. 71 
 
 name, is employed to exercise pressure upon a superficial, or 
 a deep-seated, part. Sometimes the roller is used alone, some- 
 times its action is assisted by a compress. 
 
 4. The expelling bandage, like the one last mentioned, 
 consists of a roller, generally applied over a compress. It is 
 employed to facilitate the expulsion of fluids from morbid ca- 
 vities and canals. 
 
 5. The RETAINING bandage is used to confine dressings in 
 place, as also parts of the body which, having become re- 
 moved from their natural positions, are replaced. 
 
 6. The knotted bandage is sometimes advantageously em- 
 ployed to arrest bleeding, particularly of the temporal artery ; 
 it will be described hereafter. 
 
 The ability skilfully and neatly to apply and adjust the 
 roller, is of very great importance to the surgeon; and the 
 time which the young dresser devotes to its acquisition is well 
 spent. It can only be gained by frequent practice ; verbal 
 descriptions, and the best executed illustrations, should be con- 
 sidered merely as guides and aids ; they cannot impart prac- 
 tical skill, any more than the perusal of volumes on anatomy, 
 to the exclusion of dissections, can render the student ac- 
 quainted with the mysterious construction of his material 
 frame. Let each one, therefore, spend a few leisure moments 
 every day, with some companion, in the practical application 
 of the roller : at first, reference to some book on bandaging 
 will be necessary, but after a certain degree of skill has been 
 icquired, the volume may be laid aside ; the student's good 
 sense, and the familiarity which he has already gained with 
 the mode of bandaging, combined with his knowledge of the 
 particular object to be attained in each case, will be his best 
 guides and his best adviser. The more skilful he becomes in 
 the management of the roller, the more entirely will he be 
 able to dispense with compound and complicated bandages ; 
 the more capable will he be to accomplish all that he desires 
 by this simple means. 
 
 i 
 
72 COMPOUND BANDAGES. 
 
 SECTION II. 
 COMPOUND BANDAGES. 
 
 These are intended to fulfil some especial indication, which 
 owing, it may be, to the peculiar conformation of the part or 
 parts involved, cannot be so well attained by the simple roller. 
 They are formed of one piece, or many pieces, of muslin, or 
 of some other material, to which are given a shape and con- 
 formation varying according to the judgment of the dresser. 
 There are some bandages, however, so commonly made use of, 
 that they require particular description. Such are the cru- 
 cial, or, as it is generally called, the T bandage ; the invagi- 
 nated ; the many-tailed, or the split ; the laced ; the sheath, 
 and the suspensory bandages. 
 
 1. The T bandage derives its name from its shape. It con- 
 sists of a horizontal band to which is attached another at about 
 its middle, having a vertical direction, perpendicular to the 
 first ; when there are two vertical bands, it forms the double 
 T bandage. The length and breadth of the strips vary with 
 the dimensions of the part of the body to which the bandage 
 is to be applied, and the particular end which it is expected 
 to secure. Sometimes, as for example, when it is employed 
 to retain dressings upon the hand, one of the bands is perfo- 
 rated to admit of the insertion of the fingers. 
 
 2. The invaginated bandage is used to approximate the 
 edges of wounds, or fragments of bone, as in fracture of the 
 patella. It is made in two different ways, according to the 
 indication to be fulfilled by it. Thus, if the object be to draw 
 together the lips of a longitudinal wound of a limb, a roller 
 should be selected corresponding in width to the length of the 
 wound, and long enough to be passed several times around the 
 limb. At its free extremity it should be slit into two or more 
 tails of a convenient length, and corresponding fenestra be 
 made in the band at a distance from the end rather greater 
 than the circumference of the limb. In its application, the 
 undivided portion of the band should be placed opposite to the 
 wound, and the tails passed through the fenestra, thus sur- 
 rounding the limb ; then, with a compress placed near each lip 
 
COMPOUND BANDAGES. 73 
 
 of the wound, its edges should be gently but accurately ap- 
 proximated, and retained in apposition by several turns of the 
 roller. For an illustration of this, see the Chapter on 
 Wounds. 
 
 The invaginated bandage for transverse wounds, fracture 
 of the patella, &c, is made upon the same principle precisely ; 
 it consists of two bands of convenient length and width, and 
 of two rollers. Slits, as in the other bandage, are made at 
 one end of one of the bands, and corresponding fenestras near 
 one extremity of the other ; then, by means of the rollers, 
 firmly attach the bands to the limb, the one above and the 
 other below the wound, or the point of fracture, and having 
 passed the tails of one through the fenestra of the other, draw 
 the divided parts together, and confine them in this position 
 by successive turns of the roller. If necessary, compresses 
 may be used, as in the other case. 
 
 3. The split or tailed bandage consists of a piece of 
 muslin, or of some other fabric, divided at its extremities into 
 a convenient number of tails, leaving the central portion of 
 the band entire. Or a piece of muslin of the proper dimen- 
 sions may be selected, to each extremity of which bands of 
 suitable length and width shall be attached. Constructed 
 after either method, this bandage is very useful and conve- 
 nient in confining dressings. 
 
 A very elegant modification of this bandage consists of a 
 number of strips, varying in width from two to four inches, 
 generally, and sufficiently long to extend about once and a 
 half around the affected part, as the leg : these strips are so 
 placed upon each other, successively, that each has about 
 one-third of its width covered by that which succeeds it in the 
 order of super-position, commencing from above. The strips, 
 so arranged, may be attached in mass along the centre, by 
 Imeans of a needle and thread, thus constituting the bandage 
 of Pott, or they may remain unconnected, forming the band- 
 lage of Scultetus ; the last possesses this great advantage over 
 Ithe other, that any strip, or strips, which may have become 
 boiled, can readily be withdrawn without deranging or removing 
 the others, by simply pinning the fresh band to the extremity 
 )f that which is to be rejected, and drawing it to the situation 
 >ccupied by the latter in the bandage. 
 
 These divided bandages form very light retaining and com- 
 7 
 
74 COMPOUND BANDAGES. 
 
 pressing dressings, and present an exceedingly neat and ele- 
 gant appearance, when carefully adjusted. That of Scultetus 
 is the one most frequently used. 
 
 4. The laced bandage is made of some more or less elastic 
 material, as buckskin, flannel, or caoutchouc, so shaped as to 
 correspond accurately to the contour of the part to which it 
 is to be addressed, and retained in situ by means of straps 
 and buckles, or cords passed through a series of eyelet-holes, 
 ranged along the edge of each flap. 
 
 The laced bandage may be advantageously applied to any 
 part of the surface, upon which a constant and equable 
 pressure will be useful; its most frequent employment, how- 
 ever, is around the joints, in some chronic affections, and on 
 the leg in case of varicose veins. 
 
 A very good substitute, in many instances, for the true 
 laced or buckled bandage will be found in a knit woollen band 
 of suitable width, having its two extremities firmly sewed to- 
 gether, thus forming a circlet somewhat less in circumference 
 than that of the affected part, and capable, thereby, of im- 
 parting firm and elastic pressure around it. Or a similarly 
 shaped band of gum elastic cloth may be used, with care to 
 protect the skin from its irritating effects by lining it with 
 linen, or by inserting a piece of linen, or silk, between the 
 skin and the band. 
 
 5. The sheath comes to hand already prepared for use, in 
 the fingers of a glove ; or when a larger envelope is needed, it 
 may be easily made after this pattern, of any suitable mate- 
 rial. It is serviceable as a means of retaining applications 
 upon the fingers, toes, or penis, and will be found to be much 
 better adapted to this purpose than a narrow roller, which 
 cannot be very neatly and conveniently arranged upon these 
 parts, owing to their situation and size. 
 
 6. The suspensory bandage is intended to afford support 
 and protection to particular parts, as the nose, penis, or scro- 
 tum. In its simplest forms its preparation is easy, being made 
 of a piece of muslin or linen of convenient shape and dimen- 
 sions, and having bands or pieces of tape attached to it, for 
 the purpose of retaining it in position. In the stores in which 
 surgical apparatus is sold, suspensory bandages for the scrotur 
 will be found very elegantly made of network. 
 
mayor's system of bandaging. 75 
 
 section iii. 
 
 M. mayor's system of bandaging. 
 
 Struck with the little change and improvement effected du- 
 ring the preceding half-century, in that branch of surgery 
 which is the subject of this volume, and aware of the difficulty 
 often experienced, in some situations and circumstances, in se- 
 curing a constant supply of the materials ordinarily employed 
 in surgical dressings, M. Mayor, Chief-Surgeon to the Hospi- 
 tal of Lausanne, Switzerland, has originated and developed a 
 new system of bandaging. In the year 1832, he published a 
 treatise on this subject, entitled, " Nouveau Systeme de Deli- 
 gation Chirurgicale," which has now passed through three edi- 
 tions. The object which M. Mayor had in view in his inves- 
 tigations was, " To discover some simple means, easy of appli- 
 cation, always at hand, or readily procurable, and well adapted 
 to serve as a substitute for charpie, compresses, cushions, 
 bands, bandages, and ligatures, which surgery requires for all 
 sorts of dressings." His researches and practical experience 
 have at length led him to the conclusion, that he has succeeded 
 "in reducing, as far as is practicable, all kinds of apparatus 
 to their simplest form, by associating them under one common 
 principle ; so that the different parts of such apparatus, and 
 the materials for all dressings, will be found to be so common 
 and of such nature, that they may be always, or nearly always, 
 at the disposition of the surgeon, and of all other persons, and 
 in the absence of the practitioner, may be readily applied, 
 after some little instruction, by the first comer." (Op. cit. 3d 
 ed. p. 16 of the Introduction.) 
 
 The whole ' materiel' of M. Mayor's system of bandaging 
 
 may be reduced to a single square piece of muslin, or other 
 
 suitable fabric ; or, in the absence of this, an ordinary pocket 
 
 handkerchief, or a square cravat. From this primary form he 
 
 makes four others, which constitute his whole array of ban- 
 
 Idages ; these are the oblong band, made by folding the square 
 
 [several times, until the desired width be attained ; the trian- 
 
 Igular, formed by folding the square diagonally ; the cravat, 
 
 Iprepared from the triangle, as the cravat for ordinary wear is 
 
76 MAYORS SYSTEM OF BANDAGING. 
 
 made ; and the cord, which is merely the cravat rolled into the 
 form indicated by the name. With these simple forms of ban- 
 dage, M. Mayor proposes to replace all the ordinary bands 
 and bandages of surgery. He contends that all or nearly all 
 the indications which can be fulfilled by the latter, are equally 
 well attained by the former, while these are always at hand 
 in town and in the country, at sea or on land, in civil and in 
 military practice. 
 
 The above is a mere sketch, an outline, of M. Mayor's 
 plan. For a detailed account of it, and for its adaptations 
 to particular cases, the reader is referred to the treatise it- 
 self. The system is very simple, and its applications may be 
 acquired without difficulty. Where the object is merely to 
 confine dressings, or to protect parts of the surface, or to 
 support a limb, the simple means recommended and employed 
 by M. Mayor will probably be found perfectly efficacious; 
 but in the treatment of fractures, and in cases requiring 
 well-regulated and firm compression, the author is inclined to 
 think that they cannot be advantageously substituted for the 
 roller and other bandages, ordinarily employed, excepting as 
 temporary means, or in the absence of the others. In justice 
 to M. Mayor, it must be observed, that he himself admits 
 that there are some circumstances in which his own system 
 of bandaging will be found less serviceable than the other. 
 
 In the different sections on regional bandaging, the author 
 will give such of M. Mayor's dressings as seem to him to be 
 most worthy of attention. As an admitted system for prac- 
 tical adaptation, it is not, according to the most accurate 
 information which the author has been able to obtain, em- 
 ployed in any country ; he deems it, therefore, superfluous to 
 give its details. 
 
CHAPTER II. 
 
 REGIONAL BANDAGING. 
 
 SECTION I. 
 BANDAGES FOR THE HEAD AND NECK. 
 
 1. The recurrent bandage of the head is composed of a. 
 single-headed roller about five yards long and two inches 
 wide. 
 
 Application. — The initial extremity of the roller is placed 
 upon the lower part of the forehead, or on the temple, or 
 occiput, and confined by a few turns circling around the head 
 in a line running from just above the eyebrows to a point 
 a little below the occipital protuberance : at the middle of 
 this line, as at the forehead, the course of the bandage is 
 reversed, and the reversed turn held by a finger of the left 
 hand, while the cylinder of the roller is carried over the top 
 of the head along the sagittal suture, to meet the circular 
 turns at the occiput ; here a reverse is made again, and con- 
 fined by an assistant, while the cylinder returns in an ellip- 
 tical course to the forehead, w T here it is retained upon the 
 first reverse by the finger of the dresser. In this manner 
 successive reverses are made at the forehead and occiput, and 
 repeated returns of the roller to and from these points in 
 elliptical folds, each successive fold overlapping about one- 
 third of the preceding, until at length the side of the head 
 is completely covered. The other side is covered in the same 
 manner by successive folds similarly overlaying each other, 
 and the bandage completed by circular turns firmly applied 
 over the common points of reverse, in front and behind : to 
 render the dressing still more secure, a single turn of the 
 roller, commencing at the middle of the last circular, laterally, 
 may be passed beneath the jaw, to terminate at the corre- 
 sponding point of the circular on the opposite side. Pins 
 7 * (77) 
 
78 BANDAGES FOR THE HEAD AND NECK. 
 
 Fig. 19. should be inserted in the 
 
 bandage to confine the 
 reversed turns, at the 
 forehead and occiput, 
 and one also at the ex- 
 tremity of the roller. 
 (Fig. 19.) 
 
 Use.— To retain dress- 
 ings upon the scalp, and 
 to exercise moderate 
 pressure where such may 
 be required. 
 
 2. The T bandage of 
 the head is composed of 
 a band two yards long 
 and two inches wide, to 
 which is attached, at right 
 angles, another strip of 
 the same width and half a yard in length. The longer band 
 is then rolled into two cylinders. 
 
 Application. — The dresser, taking his station in front of 
 the patient, applies the bandelette to the top of the head, 
 over which it passes to the nape of the neck, while the 
 longer portion of the bandage starting from the middle of the 
 forehead, circles around the base of the cranium, on each 
 side, to the occiput, where, just beneath the occipital protu- 
 berance, it meets the vertical portion ; the latter having been 
 crossed and confined in this position by the other division of 
 the bandage, is reflected over the vertex to the forehead, 
 where it is retained by the folds of the longer band which 
 expends itself in circular turns. 
 
 A double T bandage may be used instead of the single, if 
 more convenient ; in either case, the course of the limbs of 
 the bandage may be more or less varied to suit particular 
 purposes. 
 
 Use. — To retain dressings upon the scalp. 
 3. The four-tailed bandage of the head is formed of a piece 
 of muslin one yard long and six inches wide, split at each 
 extremity to within about three inches of the centre. 
 
 Its application may be varied according to the part of the 
 head upon which it is intended particularly to act. 
 
BANDAGES FOR THE HEAD AND NECK. 
 
 79 
 
 Fig. 20. 
 
 "When the wound is on the forehead, the unsplit portion 
 is applied there, and the two upper tails, carried posteriorly, 
 are fixed at the back of the head; 
 the lower tails are then fastened 
 either upon the vertex or beneath 
 the chin, as the surgeon may con- 
 sider it most convenient. 
 
 " To confine a dressing upon 
 the summit of the head, the poste- 
 rior tails, (#, fig. 20,) are brought 
 down and secured beneath the 
 chin ; the anterior tails (5, b y ) after 
 being carried to the nape of the 
 neck and crossed, are fixed before 
 the throat. 
 
 " In applying it to the nape of 
 the neck, the upper tails are con- ' 
 
 ducted over the forehead, from whence, after being made to 
 cross each other, they are returned, and fastened at the occi- 
 put ; the lower tails pass round the neck." (Cutler.) 
 
 Use. — As the last. 
 
 4. The six-tailed, or the bandage of Galen,, consists of a 
 piece of muslin a yard long, and a quarter of a yard wide, 
 split at each extremity, to within three inches of the middle, 
 into three portions, of which the central is rather the 
 widest. 
 
 Application. — Place the unsplit portion, a, of the bandage 
 upon the top of the head ; then folding the edges of the cen- 
 tral, bj tails inwards, so as to give them a triangular form, 
 the base of the triangle being at the top of the head, draw 
 the tails down over the ears and tie their extremities beneath 
 the chin. Reverse the relative position of the anterior and 
 posterior tails, bringing the latter, c, to the front, where they 
 shall cross each other upon the forehead, and be confined : 
 while the anterior tails, (i, are drawn round to the occiput, 
 are crossed beneath the protuberance, and retained, as on the 
 forehead, by pins. (Fig. 21.) 
 
 Use, as the preceding, over which it possesses a supe- 
 riority in being more secure, and in covering a large surface 
 of dressing. 
 
 5. The fronto-occipital triangle of Mayor, serves very well 
 
80 BANDAGES FOR THE HEAD AND NECK. 
 
 the purpose of a retaining bandage. Its application is very- 
 simple : place the centre of the base of a triangle upon the 
 
 Fig. 21. 
 
 forehead, just above the superciliary ridges, while the body 
 of the triangle covers the top of the head, the apex hanging 
 down upon the back of the neck ; draw the tails around the 
 base of the cranium to the occiput, cross them beneath the 
 protuberance, and then continue them respectively to the 
 temples, or forehead, and confine their extremities by pins. 
 The apex of the triangle, overlapped at the occiput by the 
 tails, is reflected upon the latter, and, being continued up- 
 wards upon the body, is pinned. 
 
 The occipitofrontal and the bi-temporal triangles are ap- 
 plied in the same manner as the last, excepting that in one 
 case the base of the triangle is laid upon one of the temporal 
 regions, and in the other upon the occiput. 
 
 Uses, the same as of the bandage of four tails, &c. They 
 are much more simple in their application than those hereto- 
 fore described, and may very well supersede them. 
 
 6. The knotted bandage is composed of a double-headed 
 roller four yards long and two inches wide, and of a graduated 
 compress. 
 
BANDAGES FOR THE HEAD AND NECK. 
 
 81 
 
 Application. — Place the compress over the wounded 
 artery, and apply upon it the body of the roller ; then con- 
 duct the heads around the cranium, one over the brow, and 
 the other over the occiput, to cross each other at the opposite 
 temple, whence they are returned to the compress ; on reach- 
 ing this point they are twisted upon each other, and their 
 courses changed, one mounting over the top of the head, the 
 other descending beneath the chin, and both made to cross 
 again at the opposite temple, after which the same route is 
 continued to the compress, where a second twist is effected, 
 and the course of the roller changed to the horizontal direc- 
 tion, as at first ; again the heads cross each other upon the 
 temple of the sound side, the compress is again reached, and 
 a third twist made, after which the vertical course of the 
 roller is resumed, and the bandage completed by a few cir- 
 cular turns. 
 
 Use. — To arrest hemorrhage from the temporal artery. 
 This somewhat complicated bandage may be very properly 
 superseded by a simple roller, and a compress which shall be 
 retained and pressed upon the bleeding vessel by a few cir- 
 cular turns. 
 
 7. The four-tailed bandage of the chin is composed of a 
 strip of muslin a yard long and three inches wide, and split 
 longitudinally from each extremity, so as to leave but three 
 inches of the central portion of the band undivided. 
 
 Application. — Place the middle of the band upon the 
 chin, and carry the two upper tails, a, a, 
 along the base of the lower jaw around 
 to the nape of the neck, where they are 
 crossed, and afterwards conducted along 
 the base of the cranium to the forehead, 
 and there secured. The lower tails, 5, 5, 
 ascend over the base of the jaw and the 
 sides of the face, in front of the ears, to 
 the top of the head ; here they cross each 
 other and then descend, each on its re- 
 spective side, to the base of the jaw, and 
 are confined beneath the chin, (fig. 22). 
 
 To increase the pressure exercised by 
 this bandage, a compress may be applied upon any desired 
 point. 
 
 Fig. 22. 
 
82 BANDAGES FOE THE HEAD AND NECK. 
 
 Use. — To retain dressings upon the chin ; it is also used in 
 fractures of the lower jaw, and in dislocations of its condyles 
 after reduction. For the same purposes the bandages for 
 fracture of the lower jaw, invented by Drs. Barton and 
 Gibson, of this city, may also be applied. (See Fractures of 
 Lower Jaw.) 
 
 8. The T bandage of the ear is formed of a horizontal 
 limb two yards long and two inches wide, and of a vertical 
 strip of the same width and half a yard in length. 
 
 Application. — Place the vertical limb upon the ear, and 
 exhaust the horizontal band in circular turns around the base 
 of the cranium, passing just above the ear and over the fore- 
 head and occiput ; then conduct the vertical limb beneath the 
 jaw, up over the opposite side of the face and the top of the 
 head to the point whence it started, and confine its extremity 
 to the horizontal band. 
 
 Use. — To serve as a means of retaining dressings upon 
 the ear. 
 
 9. The double T bandage of the nose is composed of a 
 band one yard long and half an inch wide, upon the middle 
 of which are attached at moderately acute angles, and at the 
 distance of one inch from each other, two other strips half a 
 yard long and of the same width as the first. 
 
 Application. — The middle of the horizontal band is placed 
 upon the upper lip, and its extremities 
 are conducted below the lobe of the ear 
 on each side to the nape of the neck, 
 where they are tied in a bow-knot. 
 The other strips are then carried 
 obliquely upwards over the top of 
 the head, crossing each other at the 
 root of the nose ; having reached the 
 occiput, they are inserted beneath 
 the horizontal band, over which they 
 are reverted upon the back of the 
 head and confined, (fig. 23). 
 
 Use. — To retain dressings upon 
 the nose. 
 
 10. The sheath of the nose is thus prepared : "A piece of 
 linen is cut into a triangular form, of a sufficient size to cover 
 the nose, with two holes perforated near the inferior angles 
 
 Fig. 23. 
 
BANDAGES FOR THE HEAD AND NECK. 83 
 
 to correspond with the nostrils ; a triangular portion is cut 
 out from the superior angle of this, the apex of which looks 
 downwards upon the median line of the nose, and the divided 
 edges are sewed together ; thus a sort of bag is formed, 
 capable of exactly lodging the nose. To the lower part of 
 the bag is stitched a narrow band, half a yard long and half 
 an inch wide, and to the summit a second band of like 
 dimensions. 
 
 "Application. — The bag is applied upon the nose; the 
 surgeon lays hold of the inferior tails, and, passing them be- 
 neath the ears, ties them in a bow upon the nape of the neck ; 
 he then conducts the superior tail along the sagittal suture 
 as far as the transverse band, under which he passes it, 
 reflecting the end upwards to secure it upon the descending 
 portion." 
 
 Use. — The same as of the foregoing. (Cutler, p. 61.) 
 
 11. A simple bandage for both eyes may consist of a strip 
 of muslin two inches wide, and three feet long, of which the 
 central part is placed upon the eyes, and the extremities tied 
 upon the occiput. 
 
 Use. — To retain dressings upon the eyes. 
 
 If the object be merely to protect the eyes from the light, 
 without exercising any compression upon them, it may be 
 very conveniently attained by attaching to each side of a 
 piece of muslin, or of green silk, of sufficient length and 
 width to cover the eyes, a piece of tape, and then tying the 
 two upon the occiput. Or the silk, or muslin, may be in- 
 serted beneath the lower edge of a strip which passes just 
 above the superciliary ridges, around the base of the cranium 
 to the occiput, where its extremities are tied. By this latter 
 arrangement cold or warm lotions may be applied to the eyes, 
 or to one eye only, simply by saturating the pendulous flap, 
 made in this case of linen. 
 
 12. The monocle, or bandage for one eye, consists of a sin- 
 gle-headed roller four yards long and two inches wide. 
 
 Application. — Two circular turns are made around the 
 head, crossing the forehead and occiput, after which the course 
 of the roller is somewhat depressed, traversing the nape of the 
 neck and passing beneath the ear of the affected side, to as- 
 cend obliquely towards the affected eye, which it crosses dia- 
 gonally ; continuing the same direction, it mounts over the fore- 
 
84 BANDAGES FOR THE HEAD AND NECK. 
 
 Fig. 24. 
 
 head and side of the head, crossing the top of the parietal su- 
 ture, to descend again to the nape of the 
 neck, from which point it renews its course, 
 as just described. Two or three succes- 
 sive turns are thus made obliquely around 
 the head, in the form of doloires present- 
 ing inferiorly, a, a, a ; and the bandage is 
 then terminated by circular sweeps around 
 the forehead and occiput, 5, 5, (fig. 24.) 
 
 Use. — To confine dressings upon the 
 eye. 
 
 13. The invaginated bandage for the 
 lip consists of a double-headed roller, from 
 two to three yards long, and three- 
 fourths of an inch wide, and of two small 
 compresses. 
 
 Application. — Place the body of the roller upon the fore- 
 head, and conduct the heads, on each side respectively, around 
 the cranium to the nape of the neck ; cross them at this point, 
 and then carry them beneath the ears to the upper lip, over 
 the compresses previously placed near to, and parallel with, 
 the edges of the wound ; make a longitudinal slit in one of the 
 tails, opposite the centre 'of the lip, and through it pass the 
 other head; make, very gently and gradually, a sufficient 
 
 strain upon the heads of the 
 roller, and conduct them again 
 to the nape of the neck, and 
 thence to the forehead ; repeat 
 this process until the requisite 
 support is acquired for the lip, 
 and then confine the extremities 
 of the roller, in the customary 
 manner, (fig. 25). 
 
 Use. — To approximate the 
 edges of transverse wounds of 
 the lip, and to give support, also, 
 to the hare-lip suture, or to re- 
 place it after the withdrawal of 
 the pins. 
 
 14. A sheath for the tongue has been contrived by Pibrac, 
 to serve as a means of confining it, in some measure, when 
 
 Fig. 25. 
 
BANDAGES FOR THE HEAD AND NECK. 
 
 85 
 
 Fig. 26. 
 
 wounded. It consists " of a little purse, a, for enclosing the 
 point of the tongue, having at- 
 tached to its base two silver 
 wires, which are to be bent un- 
 derneath the chin ; to this frame 
 two ribbons are appended, which 
 pass from the chin backwards, 
 beneath the ears, to the nape of 
 the neck, and thence ascend to 
 be tied across the forehead. ,, 
 (Velpeau, op. cit., vol. i. p. 198.) 
 -(Fig. 26.) 
 
 15. The mask for the face is 
 made of a piece of muslin, or 
 linen, as large as the face itself, 
 having apertures cut in it to cor- 
 respond with the eyes, nostrils, 
 and mouth, and a strip of mus- 
 lin attached to each angle. 
 
 Application. — Place the 
 mask upon the face so that the 
 apertures shall be accurately 
 adapted to the parts for which they were intended ; carry the 
 superior strips along the base of the cranium to the nape of 
 the neck, cross them there, then conduct them round to the 
 chin and tie them upon the mask ; cross the inferior bands 
 also upon the nape of the neck and terminate the bandage by 
 knotting them upon the forehead. 
 
 Use. — To serve as a simple covering to the face, and to 
 confine dressings upon it. 
 
 16. The cervical cravat of Mayor consists simply of a tri- 
 angular piece of muslin, or an ordinary handkerchief, folded 
 to the form of a cravat. 
 
 Application. — Place the centre of the cravat opposite the 
 larynx, the side of the neck, or the back of the neck, as may 
 be most proper, and tie its extremities at the opposite point. 
 Use. — To retain dressings. 
 
 A simple piece of muslin or flannel is often used as a re- 
 taining band, in this region. The objection to such an appli- 
 cation, as commonly prepared, is that it soon becomes rolled, 
 and ceases to cover the part properly. This difficulty may be 
 
86 
 
 BANDAGES FOR THE HEAD AND NECK. 
 
 Fig. 27. 
 
 obviated by a simple method : take a piece of flannel or mus- 
 lin, rather longer than the circumference of the neck, and 
 wide enough to cover it completely ; fold it upon itself in its 
 length, and cut from its anterior border, while folded, a trian- 
 gular piece, of which the base presents upwards ; then sew the 
 cut edges together, and unfold the band, which has thus ac- 
 quired the form of a common stock, and will not become corded 
 when worn upon the neck. Its extremities should overlap 
 each other, and be confined by pins, posteriorly. 
 
 17. The flexor bandage of the neck, which appears to be 
 
 the most secure, and at the same time the most simple and 
 
 convenient, is the one described by Velpeau, (op. cit. p. 203). 
 
 It consists of a strong muslin cap for the head ; a band of 
 
 stout material, three or four 
 inches wide and about three- 
 fourths of a yard long ; a roller 
 two yards in length, and a circu- 
 lar bandage for the chest, (to be 
 described in the next section,) 
 with shoulder and pelvic strips 
 attached. 
 
 Its mode of application varies 
 somewhat with the indication it 
 is intended to fulfil. 
 
 If it be employed in the treat- 
 ment of a transverse wound of 
 the neck, for instance, it is thus 
 applied : Fix the cap firmly to 
 the head by means of a band 
 passing under the chin ; place 
 the undivided portion of the 
 strong band above-mentioned 
 upon the top of the head, its ex- 
 tremity reposing upon the occi- 
 put, while the split portion of the 
 same band hangs down over th 
 face upon the chest ; secure 
 firmly upon the head, in this po 
 sition, by several circular turn 
 of the roller, and then, having 
 flexed the head to the requisit 
 
 
BANDAGES FOR THE HEAD AND NECK. 
 
 87 
 
 degree upon the anterior face of the neck, pin the tails of the 
 band, at a convenient distance from each other, to the tho- 
 racic bandage which has been previously applied to the 
 chest. 
 
 The same may be used as a dividing bandage by simply 
 reversing the relative positions of the extremities of the band, 
 the undivided end being placed upon the forehead, and the 
 split portion hanging down over the occiput, so that the head 
 may be flexed backwards on the neck, or maintained upright, 
 and so retained by confining the tails of the band upon the 
 posterior aspect of the thoracic bandage. Thus applied, it 
 will be of advantage in the treatment of burns, &c., &c, upon 
 the front of the neck. 
 
 Again, a lateral flexion maybe given to the head, as is seen 
 in the annexed figure, (fig. 27). 
 
 18. Professor Jorg's apparatus for the treatment of " wry- 
 neck" consists of a pair of leather stays for the chest, and of 
 a band or strong circlet for the head. On the centre of the 
 
 Fig. 28. 
 
88 BANDAGES FOR THE TRUNK. 
 
 stays, in front, is a ratchet-wheel, having the edge serrated in 
 such a way as that it revolves only in one direction upon its 
 axis, the reverse motion being prevented by a spring pressing 
 against the teeth ; a band passes upwards from the wheel to 
 be attached to the fillet opposite the side of the head ; then 
 by turning the wheel by means of a key, a, the side of the 
 head is approximated to the sternum, so as to counteract 
 or overcome the opposing muscles of the affected side, 
 (fig. 28). 
 
 This instrument may be employed in those cases of torti- 
 collis in which a considerable degree of force has to be exerted 
 and continued for a length of time ; where less power is requi- 
 site, the simpler bandage last-mentioned may be used. 
 
 SECTION II. 
 BANDAGES E0R THE TRUNK. 
 
 1. The dorso-thoracic triangle. (Mayor.) 
 Application. — Place the base of the triangle upon the 
 
 anterior, or the posterior, aspect of the chest, as the seat of 
 the injury may require, and tie the tails upon the thorax either 
 before or behind, while the apex is allowed to repose over one 
 of the shoulders, being attached to the base of the triangle 
 through the intermedium of a band, if it be not sufficiently 
 long of itself to reach this point. 
 
 Use. — To retain dressings upon the anterior or posterior 
 face of the chest. 
 
 2. Circular bandage with straps, for the thorax. 
 Composition. — A strong towel, or an oblong piece of 
 
 muslin, folded upon itself to acquire sufficient strength ; and a 
 band two feet long and four inches wide, split from one end 
 through almost its entire length. 
 
 Application. — The napkin is wrapped around the chest, 
 its extremities overlapping and pinned; the undivided ex- 
 tremity of the band is then attached in the same manner to 
 the middle of this posteriorly, and its tails brought to the 
 front, one over each shoulder, and pinned likewise to the 
 same. 
 
 Instead of the split band, a triangular piece of muslin may 
 
BANDAGES FOR THE TRUNK. 
 
 89 
 
 be used for the scapulary, by applying its base to the back 
 of the neck, and attaching the apex to the thoracic bandage 
 posteriorly, while the tails cross, one over each shoulder, to 
 be pinned to the bandage in front. 
 
 Again, the thoracic band itself may be rendered more effi- 
 cient, if a constant compression be desirable, by substituting 
 straps and buckles, or by lacing it, instead of securing it by 
 means of pins. 
 
 Use. — To confine dressings upon the thorax ; to restrain 
 the motions of the chest in wounds of this part, or in case 
 of fracture of the ribs ; and to secure, by the aid of com- 
 presses, the coaptation of the fragments, in the latter injury. 
 
 3. The compressive bandage of Velpeau, consists of a 
 roller seven or eight yards long and three inches wide. 
 
 Application. — Let about two feet of the free end of the 
 roller hang over the shoulder of the sound side, down the 
 back ; then carry the cylinder over the front of the chest, 
 below the axilla of the affected side, to surround the thorax 
 
 Fig. 29. 
 
90 
 
 BANDAGES FOE THE TRUNK. 
 
 with several circular turns, and to confine the pendant portion 
 of the roller ; ascend the chest gradually by circular folds, 
 each one successively overlapping about two-thirds of the 
 preceding; pass the bandage around the axillae in the form 
 of the figure 8, and terminate by circular folds ; now, finally, 
 raise the pendant extremity of the roller, and crossing it over 
 the shoulder of the affected side, attach it to the inferior 
 circular turns by pins (fig. 29). 
 
 Use : as of the preceding ; it has the advantage over the 
 ordinary circular bandages of the thorax, in being more 
 secure, and less easily deranged. 
 
 4. The crossed bandage of the chest, or the figure 8 
 bandage of the shoulders. 
 
 Composition. — A roller five yards long and two and a 
 half inches wide : cotton, or folded muslin, to protect the 
 surface at the axillae, and compresses if indicated. 
 
 Application. — If the object be to approximate the 
 shoulders to the sternum, the folds of the bandage should 
 cross in front of the chest. Place the free extremity of the 
 
 roller in one of the 
 axillae, and pass two 
 or three circular turns 
 around the thorax ; 
 then, the axillae being 
 protected by the cot- 
 ton, and the shoulders 
 drawn towards the 
 sternum, by an as- 
 sistant, if necessary, 
 — traverse the axillae, 
 say of the left side, 
 and ascend over the 
 shoulder from behind 
 forwards ; cross the 
 front of the chest to 
 the right axilla; mount 
 over the right shoulder 
 from its posterior to 
 its anterior face ; de- 
 scend obliquely over 
 the front of the chest 
 
BANDAGES FOR THE TRUNK. 91 
 
 to the left axilla, whence repeat the same course as before, 
 until four or five folds have been laid upon each shoulder, 
 each successive fold, in approaching from the shoulder to the 
 neck, overlapping about two-thirds of the preceding. Ter- 
 minate the bandage in circular sweeps around the thorax. 
 (Fig. 80.) 
 
 If it be desired to draw the shoulders from the breast, it 
 can be effected by simply reversing the course of the roller, 
 crossing the shoulders from before backwards. 
 
 Use. — To aid in the treatment of wounds of the chest, by 
 approximating or withdrawing the shoulders from the sternum, 
 as may be indicated by the situation of the wound ; to effect 
 pressure upon the clavicular regions, and upon the sternum, 
 or back, or in the axillae. 
 
 5. Suspensory for the breast. 
 
 Composition. — Double twice upon itself a piece of linen 
 ten inches square, and from the free extremity of each folded 
 border cut a triangular portion, of which the apex shall ter- 
 minate in the fold ; then open the square and sew the divided 
 edges together ; thus, a concave cap is formed adapted to the 
 globular conformation of the breast. Attach a piece of tape, 
 or a band of muslin, to each angle of the square. 
 
 Application. — Place the cap upon the mamma and confine 
 it in situ by tying the two superior bands around the neck, 
 and the inferior around the chest below the gland. 
 
 Use. — To support the mamma, and to retain dressings 
 upon it. 
 
 6. The triangle-cap for the breast is applied, with the base 
 passing just below the mamma, the tails knotted on the poste- 
 rior part of the chest, and the apex ascending upon the gland 
 to cross over the shoulder of the same side, and be confined 
 to the tails, directly or through the intervention of a strip of 
 muslin, or tape. 
 
 Use. — As of the last. 
 
 7. The compressive bandage of one breast. 
 
 It will be found exceedingly difficult, if not impossible, en- 
 tirely to envelope one of the mammary glands by means of a 
 roller, which shall be so applied as not to become deranged 
 very soon, and yet to leave the sound breast free; but such a 
 concurrence of conditions is frequently desirable. To fulfil 
 these indications the following bandage may be employed. 
 
92 BANDAGES FOR THE TRUNK. 
 
 Composition. — The same as of the suspensory of the mam- 
 ma, described above, the degree of concavity of the cap being 
 proportioned to the volume and convexity of the gland; gra- 
 duated compresses. 
 
 Application. — Place the compresses upon such points of 
 the gland as require most pressure, and cover the whole with, 
 the cap ; then pass one of the superior bands over the shoul- 
 der of the sound side, and the other beneath the axilla of the 
 side affected (the surface being protected, if necessary, by cot- 
 ton interposed between the bands and the skin) ; knot the two : 
 draw the inferior bands around the chest, beneath the breasts, 
 and tie them either in front or behind. The degree of pres- 
 sure exercised upon the diseased mamma can be easily regu- 
 lated by the size of the compresses, and the force with which 
 the bands shall be drawn. 
 
 Use. — To effect a regulated compression of the breast, in 
 chronic induration or engorgement of this organ, and to obli- 
 terate the canals of sinuses, if such exist. 
 
 8. The straight jacket is a garment made of strong but light 
 canvass, extending from the root of the neck to the upper 
 third of the thigh. It is closed in front, and has straps and 
 buckles attached to its posterior borders, or eyelet holes 
 worked in them. Along its inner surface sleeves are firmly 
 attached, throughout their entire length, open above but closed 
 below, and at the proper distance from each other to corres- 
 pond with the arms ; opposite the wrists, a slit may be made 
 through the jacket, to enable the professional attendant to 
 feel the pulse of the patient; shoulder straps should be attached 
 to the superior border of the canvass, to prevent the possibility 
 of the jacket slipping down, from the efforts of the patient. 
 
 Application. — Insert the arms of the patient into the 
 sleeves, and having nicely adapted the jacket to the body, 
 draw its borders together behind, and confine them by the 
 straps and buckles, or by lacing. 
 
 Use. — To assist in the restriction of the insane, or of those 
 who are unmanageable from any cause. 
 
 A very convenient substitute for the straight jacket, and 
 one which, while it is equally secure, is less irksome to the pa- 
 tient, may be found in a pair of leather mittens, made suffi- 
 ciently loose to be easy to the hand, and slit at the wrist so 
 that, after the hand is introduced, one border of the wrist- 
 
BANDAGES FOR THE TRUNK. 93 
 
 band, in which a fenestra has been made, shall overlap the 
 other, and be confined upon it by an iron loop, which passes 
 through the fenestra ; then insert through the loop on each 
 wrist a leather strap, having a buckle at one end, and enclose 
 the waist therewith. 
 
 9. The body-bandage of the abdomen consists of a piece of 
 muslin or linen folded to an oblong shape, a foot or more in 
 width, and long enough to envelope the abdomen ; and of two 
 narrow straps sewed to its inferior posterior margin, to serve 
 as thigh-straps. 
 
 Application. — Place the centre of the bandage upon the 
 median line of the loins, and bring its extremities round to the 
 front of the abdomen, where they should be overlapped and 
 pinned; then draw the thigh-straps to the front along the 
 perineum, and attach them to the anterior part of the bandage. 
 
 Use. — To retain surgical dressings, to give support to the 
 walls of the abdomen, and to exercise pressure thereon, as in 
 umbilical hernia; in the latter case a graduated compress 
 should be employed to assist the compressive action of the 
 bandage. 
 
 There are many cases, however, in which a bandage formed 
 of a plain piece of muslin, will not support the walls of the 
 abdomen sufficiently well. In order to effect this object more 
 satisfactorily, an apparatus should be made resembling the 
 corsets of ladies ; adapted to the conformation of the belly, 
 and rendered firm, and yet elastic, by the introduction into its 
 folds of strips of whalebone. Its inferior margin in front 
 should be curved, to correspond with the shape of the lower 
 part of the abdominal parietes, so that, by being properly 
 laced in front or behind, either a uniform pressure, diffused 
 equally over the whole surface, can be effected, or a more par- 
 tial action may be exerted in a particular direction. 
 
 An apparatus of this sort will be found applicable to many 
 cases : in umbilical hernia, in ascites, in pregnancy, and in 
 other instances of abdominal distension, a very agreeable sup- 
 port will be afforded by its use ; and very considerable, if not 
 complete, relief will be given to symptoms simulating, and 
 sometimes, perhaps, depending upon prolapsus uteri, or other 
 displacements of this organ ; such, for example, as dragging 
 pain and weight in the pelvis, a sense of exhaustion, of " fall- 
 ing-in of the belly," of faintness, &c, &c. 
 
94 
 
 BANDAGES FOR THE TRUNK. 
 
 Fig. 31. 
 
 The annexed drawing of an apparatus of this kind is copied 
 from Velpeau, (fig. 81). 
 
 10. The posterior 
 pelvic triangle, of 
 Mayor, is applied 
 -with the base along 
 the top of the sacrum, 
 and the apex de- 
 pending over this 
 bone : the tails are 
 brought round to the 
 front of the abdomen 
 and knotted, and the 
 apex passed between 
 the thighs, along the 
 perineum, and pubis, 
 to be attached to the 
 tails. 
 
 Use. — To retain 
 dressings upon the 
 sacrum and peri- 
 neum. 
 
 11. The anterior 
 pelvic triangle has 
 
 the base applied to the abdomen just above the pubis, while 
 the apex passes from before backwards between the thighs, to 
 be attached to the tails which are tied upon the sacrum. 
 
 Use. — To confine applications to the pubis or genitals, or 
 simply to cover these parts. 
 
 12. The triangular bandage for the groin is composed of a 
 piece of muslin of a triangular shape, and sufficiently large to 
 extend from the median line of the abdomen to the fold of 
 the groin : to the base is sewed a band long enough to pass 
 around the abdomen, and to the apex another band of about 
 the same length. 
 
 Application. — Place the triangle upon the groin, the apex 
 pointing downwards ; tie the superior band around the waist, 
 and bring the inferior round the thigh, from before backwards, 
 to be pinned to the first, opposite the centre of the base of 
 the triangle. (Fig. 32.) 
 
 Use. — To retain dressings upon the groin. 
 
BANDAGES FOR THE TRUNK. 
 
 95 
 
 13. The cruro-inguinal triangle, of Mayor. 
 Application. — Dispose the base, a, a, so that it shall run 
 obliquely from the summit of the affected groin to the edge 
 of the iliac crest of the opposite side, the apex pointing ob- 
 liquely downwards along the groin ; wrap the inferior tail 
 around the thigh of the affected side, from behind forwards, 
 and pin its extremity to the body of the triangle, at b ; to the 
 superior tail attach a band, e, and carry this around the loins 
 to the affected side, down along the fold of the groin, d, cZ, 
 crossing the body of the triangle, and the apex, — pinning the 
 
 latter to it, — around the 
 posterior and outer as- 
 pects of the thigh, to be 
 confined at e. (Fig. 33.) 
 Use. — As of the last. 
 
 Fig. 33. 
 
 Fig. 32. 
 
 14. The spica of the groin. 
 
 Application. — Place the initial extremity of a roller seven 
 yards long and two inches wide, upon the sound side of the 
 pelvis, between the anterior spines of the ilium, and confine 
 it by circular turns passing around the body, from before 
 backwards. After having made two or three circular turns, 
 carry the head of the roller obliquely downwards over the 
 groin affected, around the posterior aspect of the thigh to the 
 ilium again, then across the groin to the opposite side of the 
 pelvis, from which it returns to the affected side and repeats 
 the same process several times, terminating at length by one 
 
96 BANDAGES FOR THE TRUNK. 
 
 or two circular turns. Each successive layer of the roller 
 should leave exposed about one-third of that which preceded 
 it ; see fig. 16, e, e. 
 
 Use. — To confine dressings upon the groin, and to exercise 
 some degree of compression upon it, as in chronic glandular 
 enlargements and indurations. 
 
 15. The cruro-inguinal cravat, of Mayor, will be found a 
 very good substitute for the spica just described, and much 
 more simple in its application. 
 
 Place one end of the cravat upon the affected groin, over 
 a compress, or not, and conduct the remainder downwards, 
 along the groin, to pass between the genitals and the thigh, 
 and thus gain the posterior face of the limb ; ascend obliquely 
 upwards and outwards over the thigh, cross the affected 
 groin, and the end of the cravat already spoken of, to the 
 iliac crest of the opposite side ; wind around the loins to the 
 ilium of the affected side, pass obliquely downwards along the 
 groin, and gain the external face of the thigh, as before, where 
 the extremity is to be pinned. 
 
 16. The spica for both groins. 
 
 Application. — Place the initial end of a roller, ten yards 
 long and two inches wide, upon the pelvis, as in the single 
 spica, and confine it by circular turns running around the 
 pelvis from right to left, (this being the most convenient 
 course in practice) ; having reached the left side, descend 
 along the outer face of the thigh, around it posteriorly, and 
 so gain the groin ; then carry the roller upwards over the 
 groin to the ilium of the same side, and thence around the 
 loins to the opposite groin ; descending this obliquely, pass 
 the bandage between the genitals and the thigh, and around 
 the limb to mount over its outer face ; cross the right groin, 
 and the lower part of the abdomen to the left ilium, and then 
 wind around the left groin, and so proceed as before. After 
 several turns have been made in this manner, terminate the 
 bandage by a few circulars around the pelvis. 
 
 Use. — To effect pressure upon both groins. 
 
 The same object may be attained by the use of cravats. 
 
 17. The double T bandage of the pelvis is prepared from 
 a band two or three yards long and three inches wide, 
 having sewed to it at right angles, and at a convenient dis- 
 tance from one extremity, two other strips, distant from each 
 
BANDAGES FOR THE TRUNK. 
 
 97 
 
 other about two inches, each being an inch wide and half a- 
 yard long. 
 
 Application. — Place the horizontal band so that the ver- 
 tical strips shall depend, one on each side of the median line 
 of the sacrum. Confine the first by two or three circular 
 turns around the body, and draw the vertical bands forwards 
 between the thighs, crossing them upon the perineum, to be 
 attached to the horizontal strip in front. 
 
 Use. — To retain applications made to the anus, vagina, or 
 perineum. 
 
 Instead of two vertical pieces, a single strip may be used, 
 half a yard long and as wide as both the others combined, slit 
 at its free extremity to near the horizontal portion. 
 
 18. The suspensory of the scrotum may be made of two 
 pieces of linen or muslin, or of network, of a 
 size varying according to the volume of the 
 scrotum. In general, they should be each 
 " six inches long and four wide ; the pieces 
 being laid together with exactness, two por- 
 tions are cut out curvilinearly, as shown in 
 the wood cut (fig. 34), by dotted lines ; the 
 divided edges from a to b being sewed to- 
 gether, a sort of bag is formed, which pre- 
 sents at the middle of its upper part an opening, / (fig. 35), 
 through which the penis passes. A 
 
 belt, <?, two inches wide and rather 
 
 Fig. 35. 
 
 longer than is requisite to encircle 
 the body twice, is then sewed along 
 the upper edges of the bag, as from 
 c to d (fig. 34) ; to the superior bor- 
 der of this belt, at about two inches 
 each way from the centre, are 
 attached two small loops of tape or 
 riband, 6?, d, fig. 35, and about as 
 far again from the centre two mould- 
 buttons, e, e. 
 
 " Two bandelettes are next fas- 
 tened to the lower angle of the bag, 
 each about half a yard long, with 
 two button-holes near their free extremities. 
 
 "Application. The penis being engaged in the triangular 
 
98 
 
 BANDAGES FOR THE TRUNK. 
 
 Fig. 36. 
 
 opening, /, of the bag, and the scrotum perfectly enveloped, 
 the belt is carried round the pelvis, and being returned 
 through the loops, d* d, is tied above the pubis ; the two 
 bandelettes are then passed between the thighs, to ascend 
 from the perineum along the inferior borders of the glutei 
 muscles, and buttoned to the belt in front, e 9 e. 
 
 " Use. — To support and confine dressings upon the scro- 
 tum ; to serve also as points of attachment for other appa- 
 ratus. It is chiefly employed in the treatment of swelled 
 testicle, hydrocele, and irreducible scrotal hernia." (Cutler, 
 pp. 101-2.) 
 
 19. The suspensory triangle of Mayor. 
 Application. — Pass a cravat around the abdomen and 
 
 pelvis, and knot it securely. Ap- 
 ply the base of a triangle to the 
 under part of the scrotum at its 
 origin, and draw the tails upwards 
 in front of the cravat, to be re- 
 flected over its superior edge, be- 
 tween it and the abdomen, and tied 
 as represented in the annexed fi- 
 gure (fig. 36). Carry the apex of 
 the triangle upw 7 ards, inserting it 
 behind the transverse portion of the 
 tails (see fig. 86), between the abdo- 
 men and the girdle, to be reflected 
 forwards over the superior border 
 of the latter and pinned to it. 
 Use. — The same as of the last. 
 
 20. Bandage for the penis. 
 It is requisite sometimes to make use of some means for 
 
 confining applications upon the penis. For this purpose 
 sheath is the most convenient covering. When, however, a 
 certain degree of compression is w 7 ishecl for, the organ should 
 be enveloped in circular and reversed turns of a piece of tape, 
 or some very narrow strip prepared at the time. 
 
 For the compressive bandage of the scrotum, see remarks 
 in the section on "adhesive plaster." 
 
BANDAGES FOR THE UPPER EXTREMITIES. 99 
 
 SECTION III. 
 BANDAGES FOR THE UPPER EXTREMITIES. 
 
 1. The axillo-clavicular cravat, of Mayor. 
 Application. — Place the centre of the cravat upon the 
 
 axilla, and draw the tails obliquely upwards over the chest, 
 one in front and the other behind, to be knotted together 
 upon the clavicle of the opposite side. 
 
 Use. — To confine dressings in the axilla. 
 
 This may be varied a little, and still fulfil the same end, 
 by crossing the tails of the cravat upon the shoulder of the 
 affected side, — the centre being in the axilla, as before, — and 
 then conducting them, one in front of and the other behind 
 the chest, to the axilla of the sound side, where they are to 
 be secured. 
 
 2. The compound bis-axillary cravat is applied, by arrang- 
 ing one cravat in the manner first pointed out above ; and 
 then placing the centre of a second in the other axilla, its 
 tails being conducted obliquely upwards, one before and the 
 other behind the chest, to be attached to the tails of the first 
 at their point of junction. 
 
 Use. — To retain dressings in both axillae at once. 
 
 3. The crossed bandage of the shoulder and axilla. 
 Composition. — A roller eight yards long and two inches 
 
 wide. 
 
 Application. — Confine the initial extremity of the roller 
 to the arm of the affected side, by a few circular turns pass- 
 ing from before backwards and from without inwards. Then 
 carry the roller obliquely upwards over the shoulder of the 
 same side, and downwards obliquely over the front of the 
 chest to the opposite axilla. From this point, the roller 
 should cross the back obliquely upwards to the shoulder of 
 the affected side, and, traversing the descending turn, regain 
 the arm from which it started. Several crosses may be made 
 in the same manner, and the roller terminated by circular- 
 sweeps around the arm. 
 
 Use. — To confine applications made to the shoulder, or to 
 the axilla, — or to exercise pressure upon these parts, which 
 may be aided by the employment of compresses. 
 
100 BANDAGES FOR THE U'PPER EXTREMITIES. 
 
 4. For the crossed bandage of both shoulders and axillae, 
 see Section II. 
 
 5. A sling for the fore-arm. 
 
 h Place the middle of a triangle beneath the fore-arm, with 
 the apex towards the elbow; then carry the extremities 
 obliquely upwards, the anterior over the shoulder of the 
 sound side, and the posterior over that of the affected side, 
 and tie them around the neck. 
 
 To suspend the hand and wrist, an oblong piece of linen, 
 or muslin, or a cravat, may be employed, and the part placed 
 upon its centre ; then tie the lateral portions together, leaving 
 the hand loosely confined, and suspend the whole to some 
 convenient part of the patient's dress, or to the neck. 
 
 6. The carpo-digito-dorsal triangle, of Mayor. 
 Application. — Place the triangle upon the back of the 
 
 hand, its base being upon the wrist, around which the tails 
 are to be wrapped and confined ; then, having flexed the 
 fingers to the proper degree, draw the apex of the triangle 
 over them and attach it to the envelope of the wrist. 
 
 Use. — To approximate the edges of wounds in the palm 
 of the hand, or on the palmar surface of the fingers ; also to 
 prevent the deformities which are likely to occur from the 
 cicatrization of burns on the dorsal aspect of the hand. 
 
 7. The palmo-digito-brachial triangle. 
 
 Application. — Tie a band around the arm, just above the 
 condyles of the humerus; then place a triangle upon the 
 palmar surface of the hand, its base overlaying the wrist, 
 around which the tails are wrapped and confined, — and reflect 
 the apex over the fingers and back of the hand, to be attached 
 to the extremity of the supra-condyloid band. 
 
 Use. — In transverse wounds of the dorsal aspect of the 
 hand and fingers, and in burns of their palmar face. 
 
 8. The spiral bandage of the upper extremity is effected 
 by the use of a roller, eight yards long and two and a half, 
 inches wide : compresses if required,, 
 
 Application. - — Confine the initial extremity of the roller 
 upon the wrist by circular turns passing from the radial to- 
 wards the ulnar side, — the hand being supine; traverse the 
 palm and the back of the hand obliquely to gain the ends of 
 the fingers, and then return to the frsenum of the thumb by 
 simple spiral turns : envelope the ball of the thumb and the 
 
BANDAGES FOR THE UPPER EXTREMITIES. 
 
 101 
 
 wrist by folds in the form of a figure 8, and ascend the 
 fore-arm by spiral and reversed sweeps around the part. 
 Having reached the elbow, place the arm in the proper posi- 
 tion; if straight, continue the spiral and reversed turns to 
 the shoulder ; if flexed, cover the elbow with crossed folds in 
 the form of the figure 8, and then ascend as before. 
 
 Use. — To envelope the arm, and to make uniform, or 
 graduated, compression upon it. Great care is necessary, 
 especially in case of injury, to avoid exercising too much 
 pressure upon the member, as serious inconveniences and 
 accidents have resulted from inattention in this respect. 
 
 9. The spica bandage of the upper part of the arm and 
 the shoulder. 
 
 Composition. — A roller, eight yards long and two and a 
 half inches wide, with compresses for the axilla of the affected 
 side. 
 
 Application. — The right arm being the one which requires 
 the bandage, place the roller upon the upper part of the arm, 
 so that about two feet of 
 
 its free portion shall de- FlG * 3r< 
 
 pend from the outer side 
 of the member; confine it 
 in this position by one or 
 two spiral and reversed 
 turns, passing around the 
 limb from its outer towards 
 its inner face ; then carry 
 the roller up over the outer 
 aspect of the shoulder, to 
 descend obliquely across 
 the chest, in front, to the 
 axilla of the sound side, 
 and return to the affected 
 shoulder along the back of 
 the chest : descend into the 
 axilla along the front of 
 the shoulder, and then 
 mount over its posterior 
 face to traverse the front 
 of the chest, as before ; 
 
 having thus laid several folds, secure the terminal end of the 
 9* 
 
102 BANDAGES FOR THE UPPER EXTREMITIES. 
 
 roller by a pin ; now bring the initial portion of the bandage, 
 which was left depending from the posterior face of the arm, 
 to the front, over the anterior fold of the axilla and the 
 shoulder, and around the back of the neck, to terminate in 
 front of the chest, on the sound side, (fig. 37.) 
 
 Use. — To exercise compressing force around the upper 
 part of the arm and shoulder. 
 
 10. The spica bandage of the thumb. 
 
 Composition. — A roller three yards long and one inch 
 wide. 
 
 Application. — Confine the initial extremity to the wrist 
 by circular turns passing from the radial to the ulnar margin, 
 the hand being held in a vertical position with the thumb 
 above; now carry the roller from the palmar towards the 
 dorsal aspect of the thumb, between it and the index finger, 
 sweep around the base of the former and the wrist to regain 
 the palmar surface of the thumb ; repeat this process until 
 the roller is exhausted, and then confine its terminal end. 
 
 Use. — To compress the thumb and to restrain its motions, 
 as after dislocation. 
 
 A spica bandage may be applied around any of the fingers, 
 after the same manner. 
 
 11. The gauntlet. 
 
 Composition. — A roller eight yards long and an inch wide. 
 
 Application. — Confine the initial extremity to the w T rist 
 by a few circular turns, then descend to the tip of each 
 finger, successively, by oblique sweeps of the roller, returning 
 in spiral and reversed turns to the metacarpophalangeal ar- 
 ticulation : terminate the bandage by circulars around the 
 body of the hand and the wrist. (Fig. 88.) 
 
 Use. — To prevent the opposed surfaces of the fingers from 
 uniting in the cicatrization of burns ; to make general com- 
 pression upon the hand, and to assist in the cure of fractures 
 and dislocations of its bone 
 
 12. The demi-gauntlet. 
 
 Composition. — A roller five yards long and one inch wide. 
 
 Application. — The hand being prone, confine the initial 
 extremity of the bandage about the wrist by circular turns 
 passing from its ulnar to its radial side ; then discontinuing 
 the circular at the cubital side, carry the roller obliquely 
 across the back of the hand to the radial margin of the 
 
BANDAGES FOR THE UPPER EXTREMITIES. 103 
 
 index finger at the junction of the phalanx with the meta- 
 carpus, across the palmar face to the cubital margin, and 
 thence around to the radial border of the hand; cross the 
 
 Fig. 38. 
 
 palm to its cubital side, over the back of the hand to the 
 index side of the middle finger, around the base of this to its 
 cubital aspect and then to the radial border of the hand ; so 
 continuing 'until the root of each finger is covered : terminate 
 the bandage by a circular sweep around the wrist. (Fig. 39.) 
 Use. — A light retaining bandage for the back of the hand* 
 
 13. The triangle cap for the hand. 
 
 Application. — Lay the hand upon the triangle, the base 
 overlapping the wrist ; reflect the apex over the extremities 
 of the fingers upon the wrist, and secure it in this position 
 by wrapping the tails of the triangle around the same part. 
 
 Use. — To retain applications upon the hand, which it 
 effects very perfectly and readily. 
 
 14. The cravat bandage for the palm or back of the hand. 
 Application. — Place the palm, or the back of the hand, 
 
 upon the centre of the cravat; reflect the tails upon the 
 
104 BANDAGES FOR THE LOWER EXTREMITY. 
 
 other surface, and cross them ; after which, tie them about 
 the wrist. 
 
 Use. — An effectual and convenient retaining bandage for 
 the body of the hand. 
 
 15. The perforated bandage of the hand is made of a 
 piece of muslin or linen large enough to envelope the hand, 
 having attached to its lower margin a band half a yard or 
 more in length, and an inch wide, and being perforated 
 near its superior border by holes corresponding with the 
 fingers. 
 
 Application. — Insert the fingers through their respective 
 fenestra, and draw the piece over the hand, enveloping the 
 latter neatly and accurately ; secure it thus by the band. 
 
 Use. — Same as of the preceding. 
 
 SECTION IV. 
 BANDAGES FOR THE LOWER EXTREMITY. 
 
 1. The cruro-iliac triangle, of Mayor. 
 Composition. — A cravat, and a triangle. 
 Application. — Knot the cravat around the pelvis, passing 
 
 it just below the crest of the ilium ; place the centre of the 
 base of the triangle immediately beneath the great trochanter, 
 encompass the thigh with the tails of the bandage, and tie 
 their extremities, or confine them with pins ; then raise the 
 apex of the triangle, and inserting it between the surface of 
 the body and the cravat which girdles the pelvis, reflect it 
 back upon the body of the triangle and pin it. 
 
 Use. — To confine applications made upon the gluteal 
 region. 
 
 2. The bandage of Scultetus is described fully in Sect. II. 
 Chap. I. 
 
 3. The eighteen-tailed bandage for the lower extremity. 
 Composition. — Stitch transversely to a band of muslin, of 
 
 sufficient length, and about four inches wide, eighteen other 
 strips, three or four inches in width, and long enough to 
 make one circuit and a half about the limb ; — the centre of 
 each transverse band crossing the vertical, and the individual 
 pieces arranged in the same manner as the strips of the ban- 
 dage of Scultetus, which it resembles in its application and 
 uses ; as before stated, it has the disadvantage of requiring 
 
BANDAGES FOR THE LOWER EXTREMITY. 105 
 
 the removal of the whole, if a single portion of the bandage 
 become deranged or unfit for longer employment ; hence it 
 is but little used, the other being preferred. 
 
 4. Invaginated bandages for longitudinal and transverse 
 wounds of the thigh. For a description of the composi- 
 tion of these, consult Sect. II. Chap. I. Their application 
 will be illustrated in the chapter on wounds. 
 
 5. The crossed bandage of the knee. 
 
 Composition. — A roller four yards long and two and a 
 half inches wide. 
 
 Application. — Confine the initial extremity upon the 
 thigh, just above the knee, by circular turns sweeping around 
 the limb from left to right (of the dresser) ; then conduct the 
 roller obliquely across the top of the knee to the posterior 
 aspect of the leg, around which a circular turn is effected, 
 and the roller made to ascend diagonally over the knee, 
 crossing the first oblique : having reached the lower part of 
 the thigh, a circular turn is made, after which the oblique 
 and circular folds alternate with each other in the manner 
 described, and the bandage terminates in a circular turn below 
 or above the knee. 
 
 r Use. — To exercise compression upon the knee, or to retain 
 dressings in this situation. The same object may be attained 
 in the popliteal region, by crossing the bandage behind, 
 instead of in front. 
 
 It will readily be seen that a triangle, or a cravat, will 
 fulfil the same purpose ; the former as a retaining, the latter 
 as a compressing bandage, when only a moderate degree of 
 force is called for. 
 
 6. Weiss's elastic knee-cap, made of some elastic web, and 
 lined with India-rubber cloth, or having strips of India rubber 
 inserted between its layers, gives a very agreeable and suffi- 
 ciently compressive support to the knee : it is confined about 
 the joint by lacing. 
 
 As a substitute for this, the elastic bandage made of wool- 
 len yarn knit, — described with the laced bandage, in the 
 second section of the first chapter, — may be employed. 
 
 7. The spiral bandage of the lower extremity. 
 Composition. — A roller six yards long and two and a half 
 
 inches wide. 
 
 Application. — This maybe accomplished in several ways. 
 
106 BANDAGES FOR THE LOWER EXTREMITY. 
 
 1st. Confine the initial extremity of the roller around the 
 ankle, say of the right leg, by circular turns revolving from 
 its outer to its inner side : having reached, in the second cir- 
 cular turn, the external malleolus, conduct the roller across 
 the instep obliquely to the inner side of the foot, and beneath 
 the sole to the little toe ; then retrace the course, covering 
 the foot with two or more spiral turns; having regained the 
 instep, ascend it obliquely and sweep around the leg from the 
 inner to the outer side ; thence cross obliquely to the inner 
 margin of the instep, wind beneath the sole and the outer side 
 of the foot, in advance of the malleolus, mount over the instep 
 to the tibial side of the leg, and then conduct the roller to the 
 knee in spiral and reversed turns. If the limb be straight, 
 continue the same with a fresh roller, if necessary, until the 
 whole limb shall be covered. If, however, the knee be flexed, 
 the joint must be enveloped with folds in the form of the figure 
 8, and circular if need be ; then ascend the thigh as in the 
 other case (fig. 16, d). 
 
 This mode of bandaging the limb is very simple and secure ; 
 the only objection to it is that it leaves the heel uncovered ; 
 and as this part sometimes swells and becomes painful if left 
 exposed while the parts above are protected, it behooves the 
 dresser to avoid this difficulty, as in the following mode : 
 2d. The right leg being selected, confine the initial extre- 
 mity of the roller as above ; then, 
 instead of crossing the instep, 
 wind around the inner malleolus, 
 and over the ridge of the tendo 
 Achillisjust above its attachment 
 to the heel, over the space between 
 the external malleolus and the ex- 
 tremity of the heel, and then cross 
 the sole of the foot by a single 
 oblique sweep, to the great toe ; 
 cover the foot from the toes to 
 the instep by spiral turns, and 
 then wind around the inner side 
 of the heel, crossing the space 
 between the inner malleolus and 
 the point of the calcaneum, over 
 the arch of the tendo Achillis to the outer side of the leg, just 
 
 Eig. 40. 
 
BANDAGES FOR THE LOWER EXTREMITY. 107 
 
 above the malleolus ; now pass over the instep and the point 
 of the heel to the instep again, and wind the roller in the 
 form of the figure 8, around the leg, the instep, and the sole, 
 when, having conducted the bandage to the tibial margin 
 of the leg, ascend the limb by spiral and reversed turns 
 (fig. 40). 
 
 3d. The French spiral, as it is termed, differs but little 
 from the first. It is usually commenced by merely placing 
 the initial extremity upon the outer margin of the instep 
 (but this is less secure than if it is confined around the ankle); 
 now wind obliquely around the foot to the great toe, and 
 beneath the sole to the opposite side ; from this point cover 
 the foot with spiral and reversed turns, extending as high up 
 on the instep as may be consistent with the firmness of the 
 bandage, and ascend the leg at once, in spiral and reversed 
 sweeps, without enveloping the heel. 
 
 Use. — To restrain the action of the muscles of the leg ; to 
 compress the limb uniformly, and to assist in procuring the 
 removal of indolent swelling of the soft parts, whether caused 
 by serous infiltration, chronic inflammation, or otherwise. 
 
 8. Baynton's bandage for the treatment of ulcers. 
 
 This mode of treatment has been already described in the 
 first part of the book, in the course of the remarks on Adhe- 
 sive Plaster. For an illustration of its application, see fig. 40. 
 
 9. The laced stocking is made of buckskin, or of some elas- 
 tic web. It is formed of two pieces fitted to the shape of the 
 limb and sewed together along the back of the leg and the sole 
 of the foot : the anterior margins are provided with eyelet 
 holes, for the purpose of lacing the stocking when applied ; 
 and in order to obviate the inconveniences which might arise 
 from the direct contact of the lacing apparatus with the skin, 
 a piece of some soft material should be sewed along the inner 
 surface of one of these anterior borders. 
 
 Use. — To exert a uniform and equable pressure around the 
 leg, particularly in case of varicose veins. 
 
 10. An elastic gaiter for the foot and ankle may be very 
 well made of India-rubber cloth, lined with linen or silk, so 
 contrived as to correspond with the shape of the part, and 
 still be elastic : it should be confined upon the foot by lacing 
 along the outer side. 
 
 Use. — To support the foot and ankle after sprains of the 
 part, or in chronic intumescence from any cause. 
 
PAKT III. 
 
 BANDAGES AND APPARATUS EMPLOYED IN THE TREAT- 
 MENT OF FRACTURES. 
 
 CHAPTER I. 
 
 GENERAL CONSIDERATIONS ON THE TREATMENT OF FRACTURES. 
 
 The method by which nature effects the cure of a fracture 
 is, the formation of what is technically called " The Callus ;" 
 the different steps of this process are thus briefly stated by 
 Muller, (Physiol., vol. i. p. 454): — "The inflammation which 
 ensues immediately after the fracture of a bone affects princi- 
 pally the surrounding soft parts, viz., the periosteum, cellular 
 tissue, and muscles, which all become enlarged and aggluti- 
 nated together, so as to form a firm capsule around the frac- 
 ture. On the inner surface of this capsule there is formed, as 
 a result of the inflammation, a semi-fluid substance which gra- 
 dually acquires more consistence and becomes traversed by 
 vessels. A similar substance is effused by the medullary tis- 
 sue of the broken bone; and this, together with the substance 
 poured out by the capsule, at length coalesces, and forms the 
 mass enclosed in the capsule and investing the ends of the 
 bone, to which the name of ' substantia intermedia' has been 
 given. This substance acquires a fibrous texture, and fills all 
 the space between the bones ; while the muscles, cellular tis- 
 sue, and periosteum return to their former normal condition. < 
 The inflammation does not affect the bone so soon as it does 
 the soft parts ; it commences in it at some little distance from 
 the fractured extremities, namely, at the part where the bone 
 is still invested with periosteum, and at the corresponding 
 point in the interior. The bone likewise now pours out a ge- 
 latinous exudation, in which vessels become developed, and 
 
 (108) 
 
TREATMENT OF FRACTURES. 109 
 
 ■which continues to grow ; while, on the side by which it is con- 
 nected with the bone, it becomes converted into cartilage and 
 bone. This new mass — the proper callus, — also occupies to 
 a greater or less extent the medullary cavity. On the exte- 
 rior, its formation is continued towards the fractured extremi- 
 ties, till the exudations of the two portions of bone meet and 
 unite. Thus is formed the primitive callus. 
 
 " In the meantime, the surface of the bone unites with the 
 capsule formecl by the soft parts and the primitive callus, and 
 the margins of the fracture unite with the ' substantia inter- 
 media.' Callus, too, is formed, and developes itself at the ex- 
 pense of the now ligamentous ' substantia intermedia.' Peri- 
 osteum is formed anew on the external uneven surface of the 
 callus. 
 
 " The further changes which the callus undergoes after the 
 ends of the bone have united, consist in the restoration of the 
 medullary cavity in its substance, and in the change of its 
 form. The texture of the callus undergoes the same changes 
 as the cartilage of bone in ossification. While it is cartilagi- 
 nous, it contains the peculiar corpuscles of cartilage ; when it 
 ossifies, it assumes the cellular texture of bone." 
 
 According to Dupuytren, the period during which the pro- 
 visional callus is being formed, continues until the thirtieth or 
 fortieth day. In the subsequent period, the ossification of the 
 cartilaginous intersubstance — " substantia intermedia" — takes 
 place not before the fourth or sixth month ; the swelling of the 
 soft parts having been first removed by absorption, the bony 
 mass filling up the medullary canal is likewise absorbed, and 
 this cavity restored at the end of six to twelve months. 
 
 According to the observations of Mr. Paget, the provisional 
 callus rarely exists in the human subject, excepting in the 
 case of those bones which cannot be kept at rest, as the ribs ; 
 while it is of common occurrence in the inferior animals. 
 (Paget's Lectures on Surgical Pathology, vol. 1.) 
 
 Now, the aim of the surgeon, in the treatment of fractures, 
 should be to place and preserve the injured parts in such cir- 
 cumstances as shall most conduce to the accomplishment of 
 the reparative processes just mentioned. To effect this, three 
 steps are necessary : 
 
 1st. To secure the proper apposition of the fragments, if, 
 10 
 
110 TREATMENT OF FRACTURES. 
 
 as is generally the case, the broken ends have suffered 
 displacement ; 
 
 2d. To retain the fragments in this position ; 
 
 3d. To prevent or remedy any unpleasant symptoms attend- 
 ing or following the fracture. 
 
 The method by which these indications may be best ful- 
 filled claims a brief consideration. 
 
 1. The reduction of the fracture is effected by extension 
 and counter-extension, the first acting upon the inferior or 
 distal fragment, the last on the superior or proximal. 
 
 There is some diversity of opinion respecting the point 
 from which the fragments should be operated upon : sur- 
 geons of the French school applying the extending force to 
 that portion of the limb which articulates with the inferior 
 fragment, and the counter-extension to that with which the 
 superior is connected ; while the English make the extending 
 force upon the lower fragment itself, and the counter-extend- 
 ing upon the upper. 
 
 To each of these plans there are objections and disad- 
 vantages attached, if exclusively insisted upon. The argu- 
 ment urged by the Continental surgeons against the latter, 
 viz., that by grasping the muscles which are connected with 
 the fragments themselves, the reduction is rendered more 
 difficult and more painful, because the muscles are made to 
 counteract more vigorously the reducing forces, — is not really 
 of much weight. For the efforts made to reduce a fracture 
 need never be violent ; the force operates gradually, and is 
 exerted mediately or immediately by the hands ; and, more- 
 over, the muscular contraction with which the surgeon has to 
 contend is induced, probably, by the irritation inflicted upon 
 the muscular fibres as the irregular and sharp extremities of 
 the fractured bone glide over them, during the action of the 
 extending and counter-extending forces, rather than by the 
 mere grasping of the muscles by the hands ; and it will, there- 
 fore, be excited, whether the forces act upon the broken bone, 
 or upon portions of the limb more distant from the seat of 
 injury. If the French mode of reduction be practised, the 
 surgeon is obliged to overcome the contractile force, not only 
 of the muscles directly connected with the broken bone, but 
 of those likewise which have their attachments to the more 
 distant parts through which he operates. 
 
TREATMENT OF FRACTURES. Ill 
 
 In reducing a fracture, the surgeon may, therefore, consult 
 his convenience as to which mode he shall adopt ; if the thigh 
 has been broken, it will be most conveniently reduced by 
 acting upon the pelvis, and the ankle and leg just above the 
 ankle ; if the fore-arm is the seat of fracture, the injury may 
 most easily be remedied, and with least assistance of attend- 
 ants, by placing this member upon a proper splint, and ope- 
 rating upon the elbow and wrist, the surgeon himself making 
 both extension and counter-extension, while the splint, with 
 the fore-arm resting upon it, is supported by his knee, or by 
 an attendant. 
 
 The amount of force employed in the reduction must be 
 adapted, of course, to the resistance to be overcome ; it 
 should be gradually and steadily exerted. Much assistance 
 will be derived from so arranging the position of the limb as 
 that the most powerful muscles — those whose contraction is 
 most opposed to the proper restoration of the fragments, — 
 shall be shortened, and thus rendered in a measure quiescent : 
 i. e., the limb should be more or less flexed ; and after the 
 reduction of the fracture has been effected, this flexed posi- 
 tion may be maintained, or the limb may be slowly and 
 cautiously straightened, as the 'views of the surgeon, with 
 regard to the permanent position of the limb during the treat- 
 ment, shall dictate. The irritability of the muscles may be 
 lessened by the administration of opium, and by distracting 
 the patient's attention from his injury, while the reduction is 
 being effected. 
 
 The extending force should be made in the direction which 
 the limb has assumed since the fracture: and then, as the 
 proper line is gradually regained, the traction should coincide 
 with it. 
 
 As soon as the natural length of the limb has been re- 
 stored, the surgeon should adjust the fragments as accurately 
 as possible. To this step the term " coaptation " is commonly 
 applied. It is accomplished by pressing gently all around 
 the neighbourhood of the seat of fracture, avoiding, as far as 
 may be practicable, all pressure directly over and upon the 
 fragments, in order not to give pain, and that the soft parts 
 immediately in contact with the splintered ends of the bone 
 shall not be wounded and irritated, more than may be un- 
 avoidable. The points of the fingers should not be used, 
 
112 TREATMENT OF FRACTURES. 
 
 therefore, but the hand should be laid flatly upon the part, 
 and very gentle pressure be gradually made from side to side. 
 
 2. The fracture having been thus reduced, the aim of the 
 surgeon is to maintain the fragments in apposition, until con- 
 solidation shall have become perfected, or, in other words, to 
 preserve these parts in a state of perfect rest. This can be 
 accomplished only by mechanical appliances which shall pre- 
 vent displacement of the fragments arising either from simple 
 muscular contractions, or from external causes, or both. 
 There are some exceptional cases from time to time occurring, 
 in which, — from the fracture being perfectly transverse, and 
 unattended by displacement of the fragments, — it may not 
 be absolutely necessary to confine the injured part ; but even 
 in such cases, no prudent surgeon would neglect to do so, in 
 order to guard against accident or violence. 
 
 The mechanical means of retention employed in the treat- 
 ment of fractures consist, of bandages, compresses of various 
 forms and sizes, and splints. These will be more particularly 
 enumerated and described, when special fractures are treated 
 of. 
 
 The operation of these means of reduction and retention 
 will be much aided by a proper position of the limb which is 
 the seat of the fracture, — that position, namely, which will 
 relax the most powerful muscles, connected with either frag- 
 ment. The question of position will be more particularly 
 referred to in the section on the treatment of fractures of the 
 thigh, to which it has more especial reference. 
 
 There are some exclusive plans of treating fractures which 
 merit description : these are chiefly, — 1st. The treatment by 
 the " immovable apparatus;" and 2d. The hyponarthecic 
 method of Sauter and Mayor. 
 
 The first — or the method of treatment by the " immovable 
 apparatus," — seems to have been introduced into France 
 from Spain, under the auspices of the celebrated Baron 
 Larrey. As employed by this surgeon, the mode of its appli- 
 cation was to surround the limb — the fracture having been 
 reduced, and the limb placed in the straight position, — by 
 compresses, of suitable form and dimensions, saturated with a 
 mixture of white of egg, comphorated alcohol and subacetate 
 of lead, and retained upon the limb by folds of the bandage 
 of Scultetus, likewise saturated with the same mixture; the 
 
TREATMENT OF FRACTURES. 113 
 
 member was kept completely quiescent until the bandage had 
 become perfectly stiff and firm, forming a rigid case around 
 the limb. (Vidal de Cassis, Trait, de Pathol. Ext. vol. ii. 
 237, &c.) 
 
 Since the time of Larrey, several modifications of this 
 method of treatment have been originated, and adopted in 
 practice. 
 
 M. Seutin, of Belgium, employs the following apparatus : 
 it consists of strips of muslin arranged as in the bandage of 
 Scultetus ; compresses of old linen, or of lint, and pieces of 
 pasteboard softened in boiling water so as to be moulded to 
 the limb. In applying this dressing, the fracture is reduced, 
 the limb restored, as nearly as possible, to its natural shape, 
 and then covered with folds of the bandage of Scultetus, or 
 of the simple roller ; upon this a layer of freshly prepared 
 starch is applied by the hand, or by me'ans of a brush ; then, 
 having filled up the irregularities upon the surface with suit- 
 able compresses, the whole is enveloped in several layers of 
 the bandage of Scultetus, or of the roller, thoroughly im- 
 pregnated with the paste ; for the sake of cleanliness the last 
 envelope should be applied dry. 
 
 If there be a wound of the integuments, or if the fracture 
 be compound, M. Seutin directs that an aperture, correspond- 
 ing in situation with the wound, should be made in the band- 
 age, or that the various dressings should not be applied upon 
 this point. 
 
 During the thirty-six or forty-eight hours required for the 
 hardening of this case, the limb should be retained motionless 
 in some secure apparatus. 
 
 At the expiration of from two to four days, M. Seutin 
 directs that a slit should be made running longitudinally 
 through the entire thickness of the envelope, so as to permit 
 of the inspection of the limb ; if its condition be favourable, 
 the case is closed again by applying an additional layer or 
 two of the starched bandage ; if the parts be too much com- 
 pressed, throughout, a longitudinal section is made and a 
 strip removed ; or if there be too much pressure upon any 
 point merely, only portions of the case are cut away at cor- 
 responding points ; after which the apparatus is again secured 
 as before. In this way, during the whole duration of the 
 10* 
 
114 TREATMENT OF FRACTURES. 
 
 treatment, the limb should be inspected from time to time, 
 and any difficulty remedied. 
 
 As soon as the dressing has become perfectly solid, M. 
 Seutin allows the patient — the lower extremity being the seat 
 of fracture — to walk about upon crutches, the broken limb 
 supported from contact with the ground by a sling attaching 
 it to the neck. 
 
 M. Velpeau advocates a plan somewhat different from M. 
 Seutin's. The solidifying material which he employs consists 
 of one hundred parts of dextrine beaten up w T ith sixty parts 
 of comphorated alcohol, to which is added forty parts of hot 
 water, and the mixture is then shaken; in two minutes the 
 solution is ready for use. Having reduced the fracture, M. 
 Velpeau applies a dry roller around the limb, and, after filling 
 up the inequalities of the surface by compresses, follows it by 
 a roller saturated with the above solution ; sometimes he uses 
 also pasteboard splints properly softened and moulded to the 
 limb, or, if these be not employed, he applies in succession a 
 sufficient number of bandages, previously saturated, to afford 
 firm support and protection. The limb is kept at rest until 
 the dextrine shall have become dry. 
 
 M. Velpeau makes use of this dressing immediately after 
 the occurrence of the injury, notwithstanding the existence 
 of swelling and inflammation, considering that the compres- 
 sion w r hich the bandage exercises upon the tissues, and the 
 perfect immobility in which they are preserved, hasten very 
 much the removal of this condition. He treats in this way 
 comminuted and compound fractures, in the latter cases 
 leaving the wound uncovered by the bandage. Unless some 
 symptom occur to demand the removal of the dressing, M. 
 Velpeau does not disturb it until the fracture has become 
 consolidated. 
 
 M. Laugier employs strong paper instead of muslin, to 
 envelope the limb. He cuts this paper into strips arranged 
 as in the bandage of Scultetus, and having saturated them 
 with the agglutinating mixture, covers the limb, including the 
 foot, — if the leg be broken, — - forming thus a firm and un- 
 yielding boot. This plan is resorted to immediately, and the 
 limb inspected from time to time, as symptoms call for it, in 
 which event the apparatus should be adjusted accordingly. 
 
 The "Immovable Apparatus" may be very advantageously 
 
TREATMENT OF FRACTURES. 115 
 
 and safely used in the treatment of fractures, — particularly 
 of the upper extremity, and of the leg, — after the injury has 
 been treated in the ordinary way, for a sufficient time to have 
 allowed of the cessation of liability to displacement of the 
 fragments; in other words, w T hen some degree of firmness has 
 taken place. And it offers this great advantage over all 
 other plans of treatment, that the individual upon whom it is 
 applied may be permitted to walk freely with the aid of 
 crutches, — exercising a reasonable caution, of course, — even 
 with a broken leg. There are many persons who, from bad 
 health, or from the pressing requirements of business, will 
 not bear the long confinement to bed which the ordinary 
 modes of treating a fracture of the lower extremity require : 
 to such this plan is very happily adapted, suitable care being 
 impressed upon them. 
 
 If this method is resorted to from the first occurrence of 
 the fracture, the limb should be carefully inspected daily, and 
 at short intervals should be exposed, particularly until it has 
 become quite stiff, otherwise an irremediable degree of de- 
 formity may have occurred unsuspected by the surgeon, or 
 other accidents equally, or even more, serious. 
 
 Another variety of the immovable apparatus has been re- 
 commended by M. Dieffenbach, of Berlin. It is made of 
 piaster, poured when fluid upon the part, which has been pre- 
 viously denuded of hair and smeared with oil. The case is 
 made in several pieces, according to the shape of the limb, 
 and when it has become solidified it forms a very unyielding 
 envelope. It presents the same advantages and disadvantages 
 as the methods already alluded to, and is much less frequently 
 employed than the others. (For an account of the mode in 
 which it is prepared and applied, the reader is referred to 
 Vidal de Cassis, op. cit., vol. ii. p. 240. — Paris, 1846.) 
 
 The second plan of treating fractures, to which allusion 
 has been made, is that to which the term "Hyponarthecid 9 
 has been applied by M. Mayor, of Lausanne. This method 
 was first recommended by M. Sauter, but afterwards more 
 fully developed by M. Mayor. The apparatus employed con- 
 sists of a piece of board, somewhat wider and longer than 
 that division of the limb which may be the seat of the frac- 
 ture, and covered with a cushion of about the same dimensions. 
 The cushion is stuffed with oat-chaff, and is of sufficient 
 
116 TREATMENT OF FRACTURES. 
 
 thickness to allow at least one-third of the posterior part of 
 the circumference of the limb to sink into it, and receive 
 support from it. The fracture having been reduced, the limb 
 reposing upon the cushion, if there be but little tendency to 
 displacement of the fragments, a wide cravat-shaped bandage 
 merely is made to embrace both the splint and the limb, op- 
 posite to the seat of the injury ; if this arrangement be found 
 insufficient to retain the fragments in apposition, extending 
 and counter-extending cravat bands are applied to the limb 
 below and above the fracture, and attached to corresponding 
 extremities of the board. If the leg be broken, the extending 
 band is made to act upon the foot and ankle and confined to 
 a foot-board, while the counter-extension is made upon the 
 leg just below the knee ; any disposition to lateral displace- 
 ment can be remedied by acting upon the fragments by means 
 of cravats passing to the sides of the board, one operating 
 upon the upper and the other upon the lower fragment; or a 
 single cravat may be so applied as to act directly upon the 
 angle of displacement, and having its " point d'appui" upon 
 the opposite side of the board. 
 
 This apparatus may be stationary, or it may be suspended 
 off the bed, — if the leg be broken, — by means of cords at- 
 tached to the sides of the board, and allowed to vibrate gently 
 in the air. M. Mayor has even permitted his patients to sit 
 up in chairs, to the back of which a framework is attached 
 arching over in front, with the apparatus suspended from it. 
 If the arm be broken, the apparatus is suspended from the 
 neck upon the chest, and the limb placed upon it and suitably 
 confined by cravats. 
 
 Under the head of special fractures, this apparatus will be 
 illustrated. (See fig. 53.) 
 
 The chief advantages which M. Mayor claims for this 
 method of treatment are, that it leaves the fractured limb 
 constantly open to inspection, that it is very simple in its ar- 
 rangement and employment, and that it allows of a certain 
 degree and kind of movement of the limb as a whole, with- 
 out permitting the fragments of the bone to become displaced; 
 this last proposition, however, admits of so much doubt that, 
 in most cases, we should dissuade from the employment of 
 M. Mayor's method, considering it to be not sufficiently 
 secure; indeed the very fact that the apparatus, with the 
 
TREATMENT OF FRACTURES. 117 
 
 limb upon it, is allowed to execute, and is even arranged for, 
 a degree of motion, though it be practised gently and with 
 caution, renders some displacement almost certain. 
 
 There are various accidents which are liable to occur, and 
 many complications to be met with, in the treatment of frac- 
 tures, which render necessary corresponding modifications of 
 the methods ordinarily pursued. Such, for example, are ex- 
 coriations, and sloughings of different parts of the surface ; 
 wounds ; a tendency to particular varieties of displacement : 
 these subjects will be more properly attended to in the con- 
 sideration of special fractures, when the mode of obviating, 
 or remedying, them will be pointed out. As, however, it is 
 oftentimes necessary in cases of fracture to subdue inflamma- 
 tion, it will be convenient to state here that, the plan to be 
 pursued in such circumstances is to apply leeches upon the 
 part, if required, and to leave the surface exposed, as much 
 as shall be consistent with the proper security of the frag- 
 ments, in order that cooling lotions shall be laid upon it, or 
 other local antiphlogistic applications. 
 
 Before proceeding to the special bandages and apparatus 
 used in the treatment of this class of injuries, it will be pro- 
 per to allude to two or three subjects of correlative interest 
 and importance. 
 
 When an individual suffers a fracture of the lower ex- 
 tremity, — or meets with any injury which incapacitates him 
 for walking, the proper mode of removing him to his home, 
 or to the hospital, is a serious concern. Generally, it is ne- 
 cessary, in such cases, to make use of any means of trans- 
 portation which shall chance to present itself, as a window T - 
 shutter, a door, or a settee ; but every public institution for 
 the relief of the sick should have attached to it, as an im- 
 portant part of its apparatus, a vehicle contrived expressly 
 for the purpose. This may be made like the ordinary hand- 
 barrow, having its body about seven feet long and two and a 
 half or three feet wide, provided with a slatted or sacking- 
 bottom, and with a mattrass and cushions, and supported off 
 the ground upon legs, two feet, or more, in length : when 
 used in carrying a patient, two men should be employed, one 
 to sustain each extremity. The patient should be extended 
 upon the mattrass, the injured part comfortably and securely 
 reposing upon the cushions. If one of the extremities be 
 
118 TREATMENT OF FRACTURES. 
 
 fractured, or otherwise hurt, the limb should be so placed as 
 that the painful action of the muscles shall be counteracted, 
 as much as possible, by position, and attention should be 
 directed, temporarily at least, to any pressing emergency, — 
 for example, to the existence of hemorrhage, excessive pain, 
 syncope, &c. 
 
 The part which is the seat of the injury, should be exposed 
 very gently by cutting off the clothes or other coverings which 
 envelope it, rather than by drawing them away ; the panta- 
 loons, for instance, should be ripped along the outer seam, 
 and the boots divided in the most convenient manner by a 
 knife. In cleansing the surface, and in making the necessary 
 examinations, delicacy of manipulation should be invariably 
 studied, and the infliction of any unnecessary pain scrupu- 
 lously avoided. In removing the patient from the litter, and 
 in placing him upon the bed, the same care should be exer- 
 cised, the injured part being supported by the surgeon 
 himself. 
 
 Not the least important desideratum in the treatment of 
 those fractures, or other injuries, which require that the 
 patient shall lie perfectly quiescent for a considerable length 
 of time, is a proper bed, which is rarely to be met with. The 
 fracture-bed in general use is an ordinary mattrass firmly and 
 smoothly filled, and having a circular aperture cut through 
 its centre, to correspond with a similar aperture in the sack- 
 ing or floor of the bedstead. When the patient is about to 
 have an evacuation, the cushion which covers the hole in the 
 mattrass is removed, and a suitable vessel made to slide along 
 a double groove, placed across the bottom of the bedstead, to 
 receive the passage. The objections to this bed are that, the 
 patient is obliged to raise himself, or to be raised, when the 
 cushion is withdrawn and replaced, and that after the bed 
 has been in use for a short time, it sinks very much in the 
 middle, so as no longer to present a flat surface to support 
 the body and hips ; both of these are serious objections and 
 inconveniences. They may be, in a great measure at least, 
 obviated, by employing a bed constructed after the following 
 method : the mattrass should be very firmly and evenly filled 
 with hair ; it should be five or six inches in thickness, with 
 the margins, or border, perpendicular, about seven feet long 
 and from four to four and a half feet wide. An oblong sec- 
 
TREATMENT OF FRACTURES. 119 
 
 tion of about eight inches in width, and extending across the 
 middle from one side to the distance of a few inches beyond 
 the median line, should be removed, and, after having been 
 properly prepared, be arranged so as to be drawn backwards 
 and forwards at pleasure upon the floor of the bedstead. The 
 bottom of the bedstead should be made of board, and should 
 be entire, with a movable section opposite that of the mat- 
 trass, corresponding with it in length and breadth, and so 
 adapted as always to afford a perfectly firm support to it, 
 which may be readily accomplished by allowing the slat to 
 play upon a double groove. When an evacuation is to be 
 received, one hand of the attendant should be placed under- 
 neath the hip of the patient, and the section of the bedstead 
 and of the mattrass be withdrawn only so far as to allow the 
 passage to take place freely, while the hip still reposes upon 
 the edge of the section of the mattrass ; the vessel for receiv- 
 ing the evacuation may be supported in any convenient man- 
 ner underneath the bedstead. Or an aperture of suitable size 
 to permit of the evacuation, but not unnecessarily large, may 
 be cut in the centre of the mattrass, and the portion which 
 was removed adapted, by a hinge joint on its inferior surface, 
 to close the aperture when the evacuation has been accom- 
 plished, being kept closed by a movable strip passing across 
 the bedstead and constituting part of its floor. 
 
 A very good substitute for the fracture-bed, particularly 
 for children, will be found in the clinical frame, such as is 
 described in the Appendix of Cutler's treatise on bandaging. 
 It consists of a simple framework, of two longitudinal and 
 two transverse bars attached at their extremities, about seven 
 feet long and a yard wide ; a single piece of canvass, with a 
 circular aperture in its centre, is firmly stretched upon it, or 
 several strips of webbing are nailed across it, intersecting 
 each other in various directions, but leaving a sufficiently 
 large vacant space in the middle. The frame thus prepared 
 is habitually placed upon the mattrass, having been pre- 
 viously covered with a sheet in the centre of which a circular 
 hole has been cut, and the patient reposes upon it ; when he 
 desires to have a passage, the frame is raised sufficiently off 
 the bed, and supported in this position in any convenient and 
 secure manner, while the evacuation is received in a proper 
 vessel. The frame may be raised by two attendants, or by 
 
120 TREATMENT OF FRACTURES. 
 
 means of the tripod arrangement of Cutler, which consists of 
 three strong bars united by a hinge-joint at their upper 
 extremities, and having an iron ring or hook secured to their 
 point of union and presenting downwards : through this ring 
 a long lever is passed, having attached to one end of it the 
 cords by which the frame is suspended, while the force for 
 elevating the latter is exerted upon the other extremity : when 
 the frame is raised, the lever may be secured in position by 
 cords attached to some fixed point. 
 
 b The apparatus of Jenks, of which a description and a 
 drawing are given in Gibson's Surgery, vol. i., is more com- 
 plicated and very much more costly than the simple contri- 
 vance above described : it is, however, a much more perfect 
 arrangement, and should be introduced into every hospital. 
 But in private practice it is generally sufficient to trust to the 
 fracture-bed for adults, and to the simple frame described 
 for children, who can be lifted from the bed by mere muscular 
 strength. 
 
 
CHAPTER II. 
 
 BANDAGES AND DRESSINGS FOR FRACTURES OF THE BONES 
 OF THE HEAD AND TRUNK. 
 
 SECTION I. 
 FOR FRACTURES OF THE BONES OF THE SKULL AND FACE. 
 
 1. When, in fractures of the cranial bones there is displace- 
 ment of the fragments, it is produced by the violence, what- 
 ever this may have been, which occasioned the solution of 
 continuity, and not, as in similar injuries of the long bones, 
 by muscular action. Hence, after the displacement has been 
 remedied, — if it be necessary, or advisable to attempt it, — 
 bandages are only required for the purpose of protecting the 
 injured parts from external irritation, and of retaining such 
 dressings as may be applied ; they are, therefore, very simple, 
 as for example, strips of adhesive plaster, the triangle of Mayor, 
 the T bandage, or an ordinary night-cap, or finally, the recur- 
 rent bandage : — these have already been described. 
 
 2. Generally, the same remarks may be extended to frac- 
 tures of the facial bones, those of the nose for instance : the 
 fragments having been restored as well as possible, to their 
 natural positions, they need no bandages to preserve them 
 44 in situ;" the latter are serviceable only as retentive or pro- 
 tective means. 
 
 3. In fractures of the inferior maxillary bone, however, the 
 fragments are almost always displaced, and retained in their 
 abnormal situations, by the direct action of the muscles which 
 are connected with them, as the digastric, the hyoid, the pte- 
 rygoid muscles, &c, &c. ; it becomes necessary, consequently, 
 to employ some kind of bandage or apparatus which shall coun- 
 teract the influence of these displacing agents. 
 
 The bandages most frequently used for this purpose, and 
 which will probably be found sufficient in all cases, — are the 
 11 (1*1) 
 
122 FRACTURES OF THE SKULL AND FACE. 
 
 four-tailed of the chin, and those of Drs. Gibson and Barton, 
 of this city. 
 
 1. The four-tailed bandage of the chin. 
 Composition. — An oblong piece of stout pasteboard divided 
 
 at each end to within an inch of the middle ; — a four-tailed 
 bandage, prepared as directed in the section on bandages of 
 the head ; — compresses. 
 
 Application. — The pasteboard, previously softened by im- 
 mersion in hot water and moulded to the form of the chin and 
 jaw, (fig. 41,) is applied upon the seat of 
 Fig. 41. fracture ; then the middle portion of the 
 
 bandage is placed upon the chin, over the 
 splint; the two superior tails, #, a, fig. 
 20, are carried, one on each side, towards 
 the nape of the neck, where they are 
 crossed, and then conducted, one along 
 each side of the head, obliquely upwards 
 and forwards to the forehead, and pinned ; 
 the lower tails, 5, 5, are now carried upwards before the ears, 
 to the summit of the head, where they in turn are crossed, 
 and then returned and confined beneath the chin. (Cutler, 
 p. 70.) 
 
 2. The bandage of Professor Gibson, and its application are 
 thus described by the author himself: "The surgeon having 
 carefully examined the injured parts, and replaced such teeth 
 as may have been shaken or loosened, runs his finger along 
 the margin of the jaw, models the parts to a proper shape, and 
 closes the mouth firmly, making the lower teeth press fairly 
 against the upper. Then a cotton or linen compress of mode- 
 rate thickness, reaching from the angle of the jaw nearly to 
 the chin, is placed beneath and held by an assistant, while the 
 surgeon takes a roller, four or five yards long and an inch and 
 a half wide, and passes it by several successive turns under 
 the jaw, up along the sides of the face and over the head ; 
 now changing the course of the bandage, he causes it to pass 
 off at a right angle from the perpendicular cast, and to encir- 
 cle the temple, occiput, and forehead horizontally by several 
 turns ; finally, to render the whole more secure, several addi- 
 tional horizontal turns are made around the back of the neck, 
 under the ear, along the base of the jaw, and over the point 
 of the chin. To prevent the roller from slipping or changing 
 
FRACTURES OF THE SKULL AND FACE. 123 
 
 its position, a short strip may be secured by a pin to the hori- 
 zontal turn that encircles the forehead, and passed backyards 
 along the centre of the head as far as the neck, where it must 
 be tacked to the lower horizontal turn, — care being taken to 
 insert pins at every point at which the roller has crossed. 
 This simple method of securing a fractured jaw I have prac- 
 ticed very successfully for several years." (Fig. 42.) 
 
 3. Dr. J. R. Barton's bandage. 
 
 Composition. — A roller five yards long and two inches 
 wide ; suitable compresses. 
 
 Application. — Place the initial extremity of the roller upon 
 the occiput just below its protuberance, and conduct the cy- 
 linder obliquely over the centre of the left parietal bone to the 
 top of the head ; thence descend across the right temple and 
 the zygomatic arch, and pass beneath the chin to the left side 
 
 Fig. 42. 
 
 Fig. 43. 
 
 of the face ; mount over the left zygoma and temple to the 
 summit of the cranium, and regain the starting-point at the 
 occiput by traversing obliquely the right parietal bone ; next 
 wind around the base of the lower jaw on the left side to the 
 chin, and thence return to the occiput along the right side of 
 the maxilla; repeat the same course, step by step, until the 
 roller is spent, and then confine its terminal end. (Fig. 43.) 
 
 These bandages are easily applied, and are very efficacious; 
 the pasteboard splint described in connexion with the first, 
 
124 FRACTURES OF THE BONES OF THE TRUNK. 
 
 will be found to be a very useful adjunct to the two latter. 
 The bandage may be made to act upon any particular portion 
 of the jaw, as required by the situation of the fracture, by mo- 
 difying slightly the course of the roller in its successive turns, 
 and by a proper position of the compresses ; a little reflection 
 on the part of the dresser will enable him to adapt his means 
 of treatment to the ends indicated in each case. 
 
 Mr. Lonsdale invented a complicated apparatus for the 
 treatment of a particular case of fracture at the symphysis of 
 the lower jaw, in which much difficulty was experienced. He 
 found it to answer perfectly in this instance, and in several 
 other cases which occurred afterwards. The ends which he 
 had in view, and which he gained by this apparatus, were " to 
 apply all the force and pressure to the lower jaw alone ; to fix 
 the two portions of bone between two parallel forces, by ap- 
 plying one on the teeth, and the other under the base of the 
 jaw ; lastly, to keep the two portions of bone on the same ver- 
 tical plane, by fixing them in a grooved plate placed along the 
 teeth. " For the description and illustration of Mr. Lonsdale's 
 apparatus, the reader is referred to this gentleman's " Practi- 
 cal Treatise on Fractures," p. 234, et seq. ; or to Mr. Cutler's 
 book, p. 71, et seq. 
 
 If the fracture be compound, or in a simple fracture com- 
 plicated with a wound of the cheek, or chin, the folds of the 
 bandage must be so arranged as not to press with too much 
 force directly upon the wound, and to allow of the applica- 
 tion of suitable dressings, of which the first object is to pro- 
 mote immediate closure of the wound. 
 
 SECTION II. 
 BANDAGES FOR FRACTURES OF THE BONES OF THE TRUNK. 
 
 1. For fractures of the vertebra. 
 
 The bones of the spinal column are very much screened 
 and protected from fracture by their peculiar shape and situ- 
 ation ; hence they are rarely broken. When they are thus 
 injured, it is most frequently the spinous process which suffers, 
 as being the most exposed, and, from its form and structure, 
 
FRACTURES OF THE BONES OF THE TRUNK. 125 
 
 the most readily broken. But very little displacement fol- 
 lows when it is fractured, since it is imbedded in muscles and 
 ligaments, and acted upon with equal force from both sides. 
 A bandage is not, therefore, really needed in cases of this 
 kind ; it is very proper, however, to make use of the roller, 
 as exhibited in fig. 29, or of the laced bandage of the chest, 
 already described, with compresses placed upon the spinous 
 process, in order to insure perfect apposition of the frag- 
 ments, and to prevent injury from the movements of the pa- 
 tient in bed. The injury done to the spinal medulla is gene- 
 rally such as to demand more attention on the part of the 
 surgeon than the mere fracture. The condition of the blad- 
 der, especially, will require watchfulness, retention of urine 
 being a very common accompaniment of the accident, and 
 demanding the introduction of the catheter at least twice daily. 
 Sloughing of the integuments, wherever pressure falls, is also 
 a troublesome complication, and one which should be pre- 
 vented, if possible, by frictions of such parts, and by the proper 
 adjustment of pillows. 
 
 2. For fractures of the ribs and sternum. 
 
 A little reflection upon the shape and connexions of these 
 bones will show that there cannot, as a general rule, be much 
 displacement of their fragments when they are broken. The 
 ribs are attached to each other both above and below, and 
 throughout their entire length, by the intercostal muscles ; 
 they are strongly bound to the vertebrae, and connected to the 
 sternum in front by a very elastic tissue ; while the sternum is 
 itself securely united to the clavicles, and retained "in relief," 
 as it were, by the numerous costal arches which subtend it on 
 each side. Thus the whole, and each part, are so elastic that 
 they regain their original shape, when this has been altered 
 in case of fracture, unless the fragments are driven into the 
 cavity of the chest by great violence. 
 
 The general indication of treatment in fractures of the ribs 
 and sternum is to prevent, as much as practicable, the play 
 of the thoracic respiratory muscles, devolving the perform- 
 ance of the mechanical acts of respiration upon the diaphragm, 
 thereby preserving the broken bones in a state of comparative 
 repose. To accomplish this, compresses and a bandage of 
 some sort are necessary. The laced or buckled bandage of 
 the chest will answer very well in many cases, but generally 
 11* 
 
126 FRACTURES OF THE BONES OF THE TRUNK. 
 
 the roller 13 to be preferred. Its application should be com- 
 menced from below, the patient having previously made a 
 forcible expiration ; the roller should ascend to the axilla by 
 circular turns, made with considerable tightness, and then 
 pass obliquely upwards and outwards from the axilla to the 
 root of the neck on the opposite side, and down in front of 
 the chest, crossing the circular folds of the bandage which it 
 serves to secure by means of pins inserted at intervals. The 
 roller for this bandage should be about eight yards long and 
 three inches wide. 
 
 The proper disposition of the compresses is a matter of 
 much importance in the treatment of these fractures. If a 
 rib has been broken by force acting upon its anterior portion, 
 the solution of continuity has occurred probably near the 
 angle, where the anterior and posterior curves meet ; the first 
 effect of the violence has been to increase the bend of the 
 rib at this region, and finally to rupture its fibres ; of course 
 there will be an angular displacement externally, and the 
 compress should be applied either directly over the fracture, 
 or one should be placed a little anteriorly and another just 
 posteriorly to it. But when the force impinges upon the 
 angle or side of the rib, if there be any displacement appre- 
 ciable, it is probably towards the cavity of the chest, and the 
 compresses should be so placed as to restore, if possible, the 
 natural curve of the bone, and thus to throw the fragments 
 outwards. To effect this object, apply one compress upon 
 the rib near its junction with its cartilage, and another near 
 its angle, as far posteriorly as may be ; or, as Mr. Lonsdale 
 advises, a broad lath or piece of pasteboard, may be laid 
 upon the side of the chest and confined by a roller, being 
 made to press with especial force upon points remote from the 
 seat of fracture. 
 
 If the sternum has been broken, and there be depression 
 of one of the fragments, a compress should be laid upon the 
 portion which is not depressed, near the line of fracture, and 
 another upon the depressed portion of the bone at a point 
 remote from the rupture, so that, when the roller is made to 
 act forcibly upon the two, the first fragment will be depressed 
 and the other elevated, at the broken margin. 
 
 The bandage should be worn four or five weeks. 
 
 3. For fractures of the pelvic bones. These bones are 
 
FRACTURES OF THE BONES OF THE TRUNK. 127 
 
 very rarely broken, and they are so enveloped, individually 
 and collectively, in muscular and ligamentous expansions 
 covering their whole surfaces, that in the event of fracture 
 there can be but slight displacement, unless when the frag- 
 ments are violently forced inwards. 
 
 The indication for the treatment is, of course, to keep the 
 fragments at rest. To accomplish this a broad roller should 
 be passed firmly around the upper part of the thighs and the 
 pelvis, and compresses judiciously applied to enable the band- 
 age to act upon particular points, as may be required. Per- 
 fect quiescence should be enjoined upon the patient for a 
 length of time, — from two to two and a half months. The 
 state of the bladder must be carefully attended to. 
 
 In cases of compound fracture of the bones of the head 
 and trunk, the dressings must be so applied as not to press 
 with too much force upon parts surrounding the wound, other- 
 wise sloughing of the integuments may ensue. The bandage 
 should cover the wound very lightly, in order that suitable 
 applications may be made to it : it is better indeed that the 
 bandage for the fracture itself shall leave the wound exposed, 
 and that an additional retentive band be employed for such 
 dressings as may be called for. 
 
CHAPTER III. 
 
 ON THE APPARATUS AND DRESSINGS FOR FRACTURES OF THE 
 BONES OF THE SHOULDER. 
 
 SECTION I. 
 
 FOR FRACTURES OF THE CLAVICLE. 
 
 The slender proportions and exposed situations of this 
 bone render it very liable to be broken ; and in the great 
 majority of instances a considerable degree of displacement 
 accompanies the fracture ; the exceptional cases are those in 
 which the solution of continuity has occurred at the acromial 
 extremity of the bone, where the surface is broad and covered 
 with ligamentous expansions. But when, as generally hap- 
 pens, the fracture has involved the more central portions of 
 the clavicle, an angular deformity is produced, presenting an- 
 teriorly, the scapular fragment being dragged downwards by 
 the weight of the arm, and drawn towards the median line 
 of the chest, in front, by the action of the pectoral muscles ; 
 the sternal fragment is but little deviated from its natural 
 position, being held in place by the combined but counteract- 
 ing forces of the sternoclavicular and costo-clavicular liga- 
 ments, and of the sterno-cleido-mastoid muscle; the promi- 
 nence seen and felt at the point of fracture is due, in most 
 cases to the sternal fragment, the scapular portion being 
 drawn rather below and behind the other ; sometimes, how- 
 ever, the scapular fragment projects in advance of the ster- 
 nal. The fracture is usually oblique and simple ; comminuted 
 and compound fractures occur, however, at times. 
 
 The indication to be pursued in the treatment of this injury 
 is, of course, to reverse the line of displacement of the sca- 
 pular segment of the bone ; viz., to force the shoulder, and 
 with it the fragment of the clavicle which is attached to it, 
 upwards, outwards, and backwards ; and having thus restored 
 
 (128) 
 
FRACTURES OF THE CLAVICLE. 129 
 
 the natural form of the clavicle, to retain the parts in this 
 position until consolidation of the fracture shall have taken 
 place. The first, or the reduction, is not difficult ; the last 
 demands constant care from the surgeon, and a well-contrived 
 apparatus. In regard to this, M. Vidal (de Cassis) says — 
 "fracture of the clavicle is almost always followed by de- 
 formity;" and he adds very truly, "but this deformity is not 
 attended with much inconvenience, and does not seriously 
 impair the movements of the limb." In females particularly, 
 however, a deformity in so exposed a situation as this, must 
 be unpleasant, and every endeavour should be made to pre- 
 vent its occurrence. 
 
 It is interesting to trace the progressive steps which have 
 been made in the treatment of this injury. " Hippocrates 
 considered it necessary merely to draw the shoulder outwards 
 and backwards. With this view he directed the patient to 
 lie upon some prominent body, the back only being sup- 
 ported, while the shoulders were forced backwards and out- 
 wards by their simple weight. Paulus OEgineta, in addition 
 to this, placed a pad in the axilla. Guy de Chauliac en- 
 deavoured to fulfil the same indication by means of a bandage 
 applied around the shoulders in the form of the figure 8, 
 which plan was generally adopted, and of which many sur- 
 geons recommended modifications without, however, increasing 
 its efficacy.' ' (See Vidal de Cassis, op. cit., vol. ii. p. 291, 
 et seq.) Thus from time to time, until the present day, many 
 varieties of apparatus, some of them very complicated, pos- 
 sessing different degrees of excellence, have been contrived 
 for the treatment of fractures of the clavicle. It was re- 
 served, however, for one of our own countrymen, a surgeon 
 of this city, Dr. George Fox, — to invent, in the year 1828, 
 an apparatus which admirably fulfils every indication, is very 
 simple in its construction and application, is more comfort- 
 ably borne, perhaps, than any other, and yet leaves the in- 
 jured clavicle freely and constantly exposed to the view of 
 the surgeon, and for the application of topical remedies, if 
 required. 
 
 The apparatus of Dr. Fox consists of a firmly stuffed pad 
 of a wedge shape, and about half as long as the humerus, 
 having a band attached to each extremity of its upper or 
 thickest margin : a sling to suspend the elbow and fore-arm, 
 
130 FRACTURES OF THE CLAVICLE. 
 
 made of strong muslin, with a cord attached to the humeral 
 extremity, and another to each end of the carpal portion ; 
 and a ring made of muslin stuffed with cotton to encircle the 
 sound shoulder, and serve as means of acting upon and se- 
 curing the sling. The apparatus is applied thus : — Pass the 
 arm of the uninjured side through the ring, so that the latter 
 may surround the shoulder ; press the thick end of the pad 
 firmly against the summit of the axilla of the affected side, 
 and carry the bands which are attached to it, one in front of 
 and the other behind the corresponding shoulder, to cross 
 upon the root of the neck and traverse the chest obliquely, 
 before and behind, and to be tied to the ring ; then having 
 fixed the elbow and the fore-arm corresponding with the frac- 
 tured clavicle in the sling, conduct its posterior cord behind 
 the thorax, and the two anterior cords in front of it, and 
 secure them to the ring. The shoulder can be operated upon 
 very powerfully by means of these cords ; it can be thrown 
 upwards, or backwards and outwards, to any required degree, 
 and one of these motions can be impressed upon it at plea- 
 sure, until the surgeon shall be satisfied with the position of 
 the fragments. 
 
 Soft pads of cotton should be interposed between the sur- 
 face and the apparatus at different points ; and, from time to 
 time, when the surgeon re-arranges the dressings, he should 
 endeavour to make the pressure bear upon parts of the sur- 
 face which have not previously, or recently, been acted upon. 
 The point of the elbow will require protection in this way ; 
 frequently it is well to make a circular aperture in the sling 
 and, having covered it with a flattened mass of cotton, to 
 allow the point of the elbow to sink into it. 
 
 If the fracture is comminuted, a compress may be placed 
 over the fragments, to assist in the securing of perfect appo- 
 sition. 
 
 Fractures of the clavicle, treated by this apparatus, are 
 daily dismissed from the Pennsylvania Hospital, and by sur- 
 geons in private practice, cured without perceptible deform- 
 ity ; and no one who has employed it will be disposed to use 
 any other as a substitute. 
 
 The annexed drawing exhibits this dressing as applied. 
 (Fig. 44.) A mere inspection of it will show the advantages 
 of this apparatus over all others, in the complete performance 
 
FRACTURES OF THE CLAVICLE. 
 
 131 
 
 of the requisite revolutions of the shoulder, the exposure of 
 
 the injured parts, its 
 
 lightness, and the avoid- Fig. 44. 
 
 ance of impediment to 
 
 respiration, and of pres- 
 sure upon the mammary 
 
 glands when it is applied 
 
 to females ; in each of 
 
 these particulars the com- 
 plicated bandage of Des- 
 
 sault, which is still used 
 
 by some surgeons, is open 
 
 to serious objection ; the 
 
 same remark is likewise 
 
 applicable to the plan of 
 
 treatment recommended 
 
 and illustrated by M. 
 
 Velpeau (op. cit., vol. i. 
 
 p. 229) ; indeed this must 
 
 be less efficacious than 
 
 the other, since it merely confines, by means of a roller, the 
 
 hand corresponding with the broken clavicle upon the sound 
 
 shoulder, no pad being 
 
 placed in the axilla to 
 
 force the scapular frag- 
 ment outwards. (See fig. 
 
 46.) 
 
 As a temporary band- 
 age, to be employed 
 during the short time ne- 
 cessary for the prepara- 
 tion of Fox's apparatus, 
 if the surgeon have not 
 one already made, that 
 recommended by Mr. 
 Lonsdale may be used. A 
 pad, resembling in shape 
 that already described, is 
 to be secured in the axilla by means of a roller. " The elbow 
 is next to be brought before the chest as far as possible, and 
 to be held there, while a few turns of the roller are passed 
 
132 FRACTURES OF THE CLAVICLE. 
 
 around to confine it to the thorax ; a sling is then to be 
 applied, which must be made very short, so as to prevent the 
 elbow from falling from the position into which it has been 
 brought, for upon this depends the whole action of the hume- 
 rus on the scapular end of the clavicle." (Lonsdale, op. cit., 
 pp. 212, 213.) (Fig. 45.) 
 
 A bandage very similar to this was described by Dr. Brown, 
 of New York, in the Philadelphia Medical Recorder of 1821. 
 It requires that a pad of a wedge shape shall be confined in 
 the axilla by means of a roller, which also fixes the fore-arm, 
 previously flexed at an acute angle upon the breast, leaving 
 the wrist and hand to be supported by a sling. This band- 
 age is described in detail and illustrated by a drawing in the 
 Medical Recorder, as above mentioned. 
 
 Many other plans of treatment have been proposed and 
 resorted to, but the apparatus of Fox will be found of itself 
 sufficient for all cases which may occur. Latterly, an en- 
 tirely novel method has been instituted in France by M. 
 Guillou ; this gentleman reported it to the Academy of Sci- 
 ences of Paris, and the description of his mode of treatment 
 was published in full in "L'Abeille M&licale," for October, 
 1847 ; the following summary is taken from that journal : 
 
 The apparatus consists of five pieces, — 1st, of a sling 
 made of a handkerchief of proper length ; 2d, of a cravat 
 folded in the middle ; 3d, of a body-bandage formed of a 
 towel; 4th, of a square cushion of linen, thicker in the 
 middle than along the margin ; 5th, of a pad for the axilla, 
 having a band of about a foot and a half long attached to its 
 base on each side. 
 
 In the adjustment of the apparatus, the pad is placed in 
 the axilla of the injured side, and secured in this position by 
 crossing its bands upon the sound shoulder ; the forearm is 
 then thrown behind the back and supported by the sling, 
 which is passed around the neck, and made longer or shorter, 
 according to the degree of force which it may be necessary 
 to exert upon the external fragment of the clavicle, since the 
 more the fore-arm is raised, the more the external fragment 
 will be thrown outwards, backwards, and upwards ; in order 
 to confine the arm securely in this position, the body-bandage 
 is applied, to compress the lower part of the humerus against 
 the thorax, while the cravat band acts in a similar manner 
 
FRACTURES OF THE SCAPULA. 133 
 
 upon the upper portion of the arm, being wrapped around 
 this part of the humerus, and fastened upon the sound 
 shoulder ; to increase the power of the cravat, the square 
 cushion is inserted between it and the back, and the cravat 
 and the body-bandage are pinned to it. 
 
 M. Guillou has employed this method of treatment for 
 some years, and prefers it to all others. 
 
 The author has treated several cases of fracture of the 
 clavicle after this method, and has found it to accomplish all 
 the indications as well as Fox's apparatus. It is, however, 
 rather more irksome to the patient, during the first few days, 
 than the dressing of Dr. Fox. The pieces composing the 
 latter apparatus may be used instead of those described by 
 M. Guillou. 
 
 The duration of treatment of cases of simple fracture of 
 the clavicle may be stated at six or eight weeks. 
 
 SECTION II. 
 FOR FRACTURES OF THE SCAPULA. 
 
 Viewing merely the prominent situation of the scapula, and 
 its rather delicate physical conformation, one would fancy 
 that it was particularly subject to breakage; but this is not 
 really the case. It reposes upon a soft and yielding bed of 
 muscular tissue, and is covered by the same sort of structure, 
 so that any force which acts upon the scapular region is de- 
 prived of a large part of its capacity to injure, before its in- 
 fluence has extended to the bone itself. Even its projecting 
 processes, little adapted as they are in themselves to resist 
 violence, are sheltered and protected in the same way. 
 
 The parts of the scapula which are most often broken are, 
 in the order of frequency, the acromion process, the inferior 
 angle of the bone, the body, the coracoid process, and, finally, 
 the neck. 
 
 1. Of the body and inferior angle. 
 
 When the body of the scapula is fractured either obliquely 
 or transversely, there cannot be much separation or displace- 
 ment of the fragments, since its whole surface, both in front 
 and posteriorly, is covered by an expansion of muscular 
 12 
 
134 FRACTURES OF THE SCAPULA. 
 
 fibres, having an attachment around the margin of the bone. 
 The indication to be kept in view, therefore, in the treatment 
 of this accident, is merely to maintain the fragments at rest, 
 by preventing the action of the muscles which operate upon 
 them directly and indirectly. This object is readily and 
 completely attained, by applying over the body of the scapula 
 a broad compress, and securing it in this situation by passing 
 a wide roller around the chest ; the arm should be kept at rest 
 in the flexed position, supported in a sling, and confined upon 
 the breast. 
 
 When a fracture separates the inferior angle from its con- 
 nexion with the body of the scapula, the former is more or 
 less drawn away from the latter by the action of the teres 
 major muscle. Hence, in the treatment of this fracture, the 
 arm should be carried backwards towards the scapula, in order 
 to relax this muscle, and confined in this position by means 
 of a broad roller, which shall likewise press upon the body of 
 the bone and its inferior angle, — the fragments having been 
 put in apposition, — by the intervention of compresses placed 
 directly upon these parts. The fore-arm should be supported 
 by a sling. 
 
 2. Of the coracoid process. 
 
 This portion of the scapula is placed very much out of the 
 reach of injury, yet it is occasionally broken. When frac- 
 tured, a certain amount of displacement will probably occur 
 as a result of the action of the three muscles attached to it, 
 viz., the pectoralis minor, the coraco-brachialis, and the short 
 head of the biceps, whose combined agency will drag the frag- 
 ment downwards and somewhat inwards, towards the point of 
 origin of the smaller pectoral muscle. 
 
 To re-adjust the fragments, the above-named muscles must 
 be relaxed, and some small compression made over the broken 
 process. The fore-arm should be flexed to an acute angle and 
 supported upon the breast, the hand of the injured side rest- 
 ing upon the sound shoulder, while a graduated compress is 
 confined over the natural situation of the coracoid process by 
 means of the spica bandage (fig. 37). Or the bandage which 
 M. Velpeau recommends for the treatment of fractures of the 
 clavicle (op. cit., p. 229), will fulfil the same indications very 
 well; thus: select a roller from ten to twelve yards long and 
 two and a half inches wide, and apply its initial extremity to 
 
FRACTURES OF THE SCAPULA. 
 
 135 
 
 the axilla of the sound side; then conduct the cylinder 
 obliquely upwards over the back to the affected shoulder, 
 place the hand of this side upon the opposite shoulder, the 
 fore-arm reposing upon the chest, and continue the roller over 
 the clavicle of the injured side, across the upper part of the 
 arm to the outside of the same, and so under the arm, the 
 elbow and the fore-arm to the axilla of the sound side ; from 
 this point, repeat the same course until several turns have 
 been made in doloires opening towards the point of the 
 shoulder. Having reached the axilla after the fourth or fifth 
 fold, continue the roller in circular sweeps passing horizontally 
 around the back, the axilla of the injured side, the arm, elbow 
 and fore-arm, and thus alternate the oblique and horizontal 
 turns until the roller is exhausted. In order to make the 
 folds secure, insert pins at the different points of crossing, or 
 cover the whole with the starch or dextrine solution. A 
 
 Fig. 46. 
 
136 
 
 FRACTURES OF THE SCAPULA. 
 
 graduated compress applied upon the coracoid process, before 
 crossing it with the roller, will adapt this bandage more per- 
 fectly to this particular fracture (fig. 46). 
 
 3. Of the acromion process and the neck of the scapula. 
 When the neck of the bone is separated from the body, it 
 is drawn downwards by the weight of the arm, and the course 
 of treatment is at once rendered manifest, viz., to apply such 
 a dressing as shall restore the bone to its natural situation 
 and preserve its apposition with the main fragment. A pad 
 should be placed in the axilla against the head of the humerus 
 and firmly supported, while the shoulder is raised and the 
 arm maintained in repose upon the breast, with the fore-arm 
 flexed. Fox's apparatus for fractures of the clavicle fulfils all 
 the indications very perfectly. (See fracture of the clavicle.) 
 When the acromion process is broken, the weight of the 
 arm, as in the other case, draws the fragment from its natural 
 position, and the same kind of treatment is indicated, with 
 the addition of a certain degree of compression upon the pro- 
 cess itself. The apparatus of Dr. Fox is applicable to this 
 injury, also — with a figure-8 bandage applied to act upon a 
 compress placed upon the acromion process (see crossed ban- 
 dage of shoulder and axilla) ; or the mode of dressing recom- 
 mended by Mr. Lonsdale will fulfil the indications very ele- 
 gantly. The process may 
 be steadied by the spica 
 bandage, which is to be 
 applied over the shoulder 
 and then under the axilla 
 of the affected side, &c, 
 &c, until the roller is 
 nearly exhausted. The 
 last part of the bandage 
 may be made to cross the 
 shoulder, to descend in 
 front and pass under the 
 elbow and lower part of 
 the fore-arm, by which 
 means any degree of pres- 
 sure can be made upwards 
 with the head of the hu- 
 merus, by simply shortening that portion of the roller which 
 
 Fig. 47. 
 
FRACTURES OF THE SCAPULA. 137 
 
 passes under the elbow. The wood-cut (fig. 47) represents 
 this bandage applied. (Lonsdale, p. 202, 3.) It will be seen 
 at once that, by regulating the length of the sling on which 
 the elbow reposes, and allowing the wrist and hand to droop 
 more, or less, as may be required in each particular case, the 
 degree of pressure upwards against the acromion process 
 may be much modified. This bandage of Mr. Lonsdale 
 is open to the objection, that it does not sufficiently confine 
 the arm. 
 
 The bandage of Velpeau, above described, will also answer 
 very well for the treatment of this fracture. (Fig. 46.) 
 
 After fractures of the scapula, generally, the parts should 
 be kept at rest in a secure apparatus for six or eight weeks, 
 and when the neck of the bone is detached from the body, a 
 longer time is required to complete the union ; Sir A. Cooper 
 fixes it at from ten to twelve weeks. But as soon as the 
 fragments have become so far united, as that there is no per- 
 ceptible motion between them, upon careful and gentle hand- 
 ling, passive motion should be resorted to : this is particularly 
 important in fracture of the neck of the scapula, for, if the 
 shoulder-joint is allowed to remain perfectly motionless 
 during the ten or twelve weeks which are requisite for entire 
 solidification of the fracture, the head of the humerus will be 
 found to have become so firmly fixed in its socket, that ano- 
 ther series of weeks will be required to restore to the joint its 
 ease of motion. 
 
 In compound fractures of the scapula and clavicle, an object 
 of primary importance is, as in all other compound fractures, 
 to convert the injury as speedily as possible into a case of 
 simple fracture, by inducing closure of the wound by the first 
 intention. The mode of effecting this is the same as in other 
 similar injuries : by approximating the edges of the wound, 
 and retaining them in contact by adhesive plaster. If the 
 surgeon fails of accomplishing this purpose, and suppura- 
 tion ensues, the poultice, or the water-dressing, must be 
 substituted. 
 
 12 
 
CHAPTER IV. 
 
 ON THE APPARATUS AND DRESSINGS FOR FRACTURES OF THE 
 BONES OF THE UPPER EXTREMITY. 
 
 SECTION I. 
 FOR FRACTURES OF THE HUMERUS. 
 
 It is in fractures of the long bones of the extremities, that 
 displacements are most frequent and most varied in direction ; 
 for these bones are acted upon at different points of their 
 surface by numerous muscles, having contractile fibres, vary- 
 ing in their lengths and in their directions of contraction. 
 Hence, in a measure, the great numbers of apparatus which 
 have been contrived for the treatment of these injuries. 
 
 The humerus may be broken in its shaft, or at the condy- 
 loid, or scapular extremity ; the first is the most frequent seat 
 of fracture. 
 
 1. Fracture at the shaft of the bone may occur either 
 above, or below, the line of insertion of the deltoid muscle ; 
 in either case, there will be displacement of the portions of 
 the bone, excepting in rare instances, when the fracture is 
 strictly transverse, and has been caused by a force insufficient 
 to throw the lower fragment from the axis of the upper ; and 
 even if the arm be not shortened, it will probably be some- 
 what curved by the action of the muscles, which operate from 
 above the fracture upon the lower fragment. 
 
 When the fibres of the bone have been ruptured above the 
 insertion of the deltoid, the upper segment will be drawn in- 
 wards towards the chest, by the action of the pectoralis 
 major, chiefly, while the lower fragment will be drawn up- 
 wards and outwards by the combined action of the deltoid, 
 and the triceps and biceps muscles. 
 
 If the fracture has occurred below the attachment of the 
 deltoid, this muscle will raise the upper fragment outwards, 
 while the lower portion will be drawn a little upwards, and 
 inwards also with reference to the assumed position of the 
 
 038) 
 
FRACTURES OF THE HUMERUS. 139 
 
 V 
 
 upper fragment, by the contraction of the muscles which 
 pass from the scapula to the lower part of the arm and the 
 elbow. 
 
 Whether the shaft of the bone has been broken above, or 
 below, the point under consideration, the indications of treat- 
 ment will be the same, viz. : to restore the limb to its proper 
 length and axis, if these have been altered, and to keep the 
 parts at rest. This object will be best accomplished by the 
 following plan, which is adapted to both of the supposed 
 cases : — Envelope the arm, from the fingers to the axilla, by 
 a roller applied so as to make uniform and moderate pressure 
 upon the muscles ; then, the arm being carefully supported 
 by an assistant, take four splints made of thin wood, — (the 
 sides of a cigar-box will answer perfectly well,) — and evenly 
 padded w T ith cotton, and apply them separately in front, and 
 at the sides of, and behind the arm, and secure them in these 
 situations by a roller. The splint for the anterior face of 
 the arm should extend from the head of the bone to just 
 above the bend of the elbow ; the others from the same point 
 to the extremity of the humerus, the projections of the con- 
 dyles being carefully protected from too much pressure. 
 After the splints have been bandaged to the arm, this should 
 be brought a little forwards, so that the fore-arm resting in a 
 sling, may be supported on the front of the chest, in the 
 flexed position. In order to give greater security to the arm, 
 a few circular turns of the roller should confine it to the 
 chest. 
 
 If, from any cause, it be desirable to dispense with the 
 inner splint, the fracture may be treated equally well, by se- 
 curing a wedge-shaped pad in the axilla, the thick end down- 
 wards, so as to present a perpendicular surface from the 
 glenoid cavity to the extremity of the humerus, upon w r hich the 
 latter may rest: then, having applied the roller, and the three 
 other splints, as directed above, place the inner surface of the 
 arm against the pad, and bandage it to the chest by circular 
 sweeps of the roller : the fore-arm should be supported in a 
 sling, as above directed. 
 
 Another modification of the same plan consists in substi- 
 tuting for the short splint, which is applied upon the inner 
 aspect, or on the front of the arm, a rectangular splint, made 
 to extend all along the inner or the anterior face of the limb, 
 
140 
 
 FRACTURES OF THE HUMERUS. 
 
 Fig. 48. 
 
 from the head of the humerus to the ends of the fingers. 
 Thus, all motion of the fore-arm will be prevented. 
 
 There is rarely much disposition to great shortening of the 
 arm, in fracture of the shaft of the humerus; so that, in the 
 vast majority of cases of this accident, the lateral pressure 
 effected in the manner just described, is 
 amply sufficient to retain the fragments in 
 apposition. Mr. Lonsdale, however, has 
 met with several cases in which he found it 
 necessary to keep up permanent extension 
 and counter-extension; and, to accomplish 
 this object, he invented a splint which he 
 thus describes : — " It consists of a thin bar 
 of iron, about an inch and a half wide, and 
 long enough to extend from the axilla to the 
 elbow, — marked B in the wood-cut. (See 
 fig. 48.) The lower end of the bar curves 
 upwards underneath the elbow, so as to 
 allow of this part of the limb fitting into it, 
 at C. This curve terminates in a hook, E, 
 for the attachment of a bandage ; and on 
 the splint opposite to this hook is a small 
 bar, placed across the perpendicular, also 
 for the attachment of a bandage. To the 
 upper extremity of the splint a crutch is adapted, A, which 
 fits underneath the axilla, and is movable up and down, being 
 confined at pleasure by means of a small screw, placed at the 
 side of the vertical bar." In applying it, the crutch-like ex- 
 tremity is secured in the axilla, the upper part of the arm fit- 
 ting into it, and the elbow is confined in the inferior curve by 
 means of a bandage passing around the limb at the elbow, 
 and having attachments to the splint at the hook, and at the 
 transverse bar, as already indicated. The whole arm should 
 be enveloped by a roller, and one or two lath splints applied 
 on the exterior, or anterior, surface of the limb ; the fore- 
 arm should be supported in a sling. (Lonsdale, op. cit., 
 p. 173, &c.) 
 
 It is very conceivable that a splint of this kind would be 
 of much use in cases of compound fracture of the humerus, 
 where the limb cannot be wrapped in splints and bandages in 
 the usual manner, and where some degree of compression 
 
FRACTURES OF THE HUMERUS. 141 
 
 and support is required to keep the fragments, in any mea- 
 sure, in place. If employed in such cases, the straight 
 splints and the enveloping of the limb should he omitted; 
 but the arm should be lightly secured to the splint at the 
 axilla, and also at the elbow, while another roller, or a band- 
 age of Scultetus, shall at once serve to retain the fragments 
 in tolerable apposition, to confine upon the seat of fracture 
 any proper application, and to support the whole against the 
 side of the splint. A little ingenuity on the part of the sur- 
 geon will enable him to form a splint of wood, after the pat- 
 tern of Mr. Lonsdale, which will answer the purpose equally 
 well. But compound fractures of the humerus may be 
 treated very well, in most instances, by placing the arm in a 
 curved splint made of sheet tin, or of pasteboard, moulded 
 to an arm of somewhat larger diameter than that of the 
 patient, and well padded ; the limb should be secured to the 
 splint, above and below the seat of fracture, by means of a 
 roller carefully applied, and leaving the wound exposed ; 
 then, by a bandage of Scultetus, a suitable dressing should 
 be retained upon the wound, and this part of the arm pressed 
 gently against the splint : the fore-arm must be supported as 
 usual. 
 
 After a certain time, when the fracture, whether it may 
 have been simple or compound, has become tolerably firm, two 
 curved splints, made of pasteboard, may be conveniently sub- 
 stituted for the ordinary lath splints ; or the immovable appa- 
 ratus may be used. The usual time required to insure the 
 consolidation of this form of fracture is about six weeks. 
 
 2. Fractures of the upper extremity of the humerus. 
 
 The humerus may be broken either at its surgical neck, 
 that portion of the bone, namely, which is included between 
 the margin of the articular head and the point of the inser- 
 tion of the pectoralis major muscle, or at its anatomical neck, 
 a narrow rim of bone separating the curved head from the 
 tubercles. Fracture at the surgical neck is much the most 
 common. 
 
 When the bone is broken at the anatomical neck, there is 
 often little or no displacement, the fractured surfaces being 
 so broad at this point. But there is generally some derange- 
 ment of the axis of the limb, the lower fragment being drawn 
 
142 FRACTURES OF THE HUMERUS. 
 
 inwards by the pectoralis major, and upwards by the muscles 
 which pass from the scapula to the lower part of the arm. 
 
 The displacement is greater when the fracture occurs at 
 the surgical neck, for the upper fragment will be rotated out- 
 wards by the supra and infra-spinatus muscles, while the 
 lower portion is acted upon as before mentioned. 
 
 In both cases the same indication is to be fulfilled, and it 
 will be readily accomplished by confining a pad in the axilla, 
 with the thick end downwards, so as to present a plane, per- 
 pendicular surface to the shaft of the limb ; then apply a 
 roller from the fingers up to the head of the arm, and having 
 reduced the fragments to apposition, place a compress over 
 the seat of fracture on the outer face of the arm, and upon 
 this a curved pasteboard splint extending from the acromion 
 process to the outer condyle ; support the fore-arm in a sling, 
 and confine the arm to the side of the chest by circular folds 
 of a roller passing from the elbow to the shoulder. Or an 
 angular splint may also be bandaged to the inner face of the 
 arm and fore-arm, the hand being semi-pronated, — and the 
 pad used as above. 
 
 The limb should be kept perfectly at rest for six or eight 
 weeks, excepting that after the fracture has become sufficiently 
 firm, passive motion should be gently made, every day or two, 
 as the bandages are freshly applied. 
 
 3. Fractures of the condyloid extremity of the humerus. 
 
 Fig. 49. 
 
 The shaft of the bone may be broken just above the con- 
 dyles, as is represented in the annexed drawing (fig. 49), 
 taken from Sir A. Cooper's Treatise on Dislocations and 
 
FRACTURES OF THE HUMERUS. 
 
 143 
 
 Fractures, p. 401, American edition; or the fracture may 
 implicate the condyles themselves, " extending in three direc- 
 tions : First, the extremity only of either condyle may be 
 broken off, as represented at A, in the wood-cut (see fig. 50). 
 Secondly, the fracture may include a large portion of one 
 condyle only, but extend directly into the joint, as at B. 
 
 Fig. 50. 
 
 Thirdly, both the condyles may be severed from each other, 
 and from the shaft of the bone, as well as shown at C." 
 (Lonsdale, p. 181.) 
 
 When the solution of continuity has involved the shaft of 
 the bone, immediately above the condyles, the lower fragment 
 will be drawn upwards and behind the humerus by the contrac- 
 tion of the triceps muscle, dragging with it, of course, the fore- 
 arm, as represented in fig. 49, — or it may be drawn up on the 
 front of the arm, depending, in a great measure, upon the di- 
 rection of the force which caused the fracture. The same sort 
 of displacement may ensue when the whole of the internal 
 condyle is split off, as shown at B, fig. 50, since the ulna will 
 be acted upon by the same muscles as in the other case ; but 
 there need not be this separation of the fragments, unless the 
 violence has been sufficient to rupture the external lateral and 
 the capsular ligaments. So also when the external condyle 
 alone is severed from its bony connexions, the ligaments may 
 still retain it in place, if they have escaped rupture ; and dis- 
 placement is still less necessary if the point merely of the in- 
 ternal condyle be broken off, as at A, fig. 50. But when, as 
 at C, the condyles are not only separated from each other but 
 from the shaft of the bone likewise, shortening of the arm is 
 an almost certain result, from the operation of the same causes 
 as when the shaft of the bone has been fractured above the 
 epiphysis. The treatment in every case is pretty much the 
 same, although the degree of success which attends it will vary 
 
144 
 
 FRACTURES OF THE HUMERUS. 
 
 very much, agreeably to the extent to which the joint may 
 have been implicated. 
 
 The method recommended by Sir Astley Cooper, when the 
 shaft of the bone has been broken as above described, — and, 
 with some modifications and additions, it is applicable to the 
 other cases, — consists "in bending the arm, and drawing it 
 forwards to effect replacement; then a roller should be applied 
 while it is in the bent position. The best splint for it is one 
 formed at right-angle, the upper portion of which should be 
 placed behind the arm, and the lower portion under the fore- 
 arm ; a splint must also be placed upon the anterior face of 
 the upper arm, and both should be confined by straps : evapo- 
 rating lotions should be used, and the fore-arm be kept in the 
 flexed position and supported by a sling. In a fortnight, if 
 the patient be young, passive motion may be gently begun to 
 prevent the occurrence of anchylosis ; and in the adult, at the 
 end of 'three w T eeks, a similar treatment should be pursued. 
 But even after the most careful and judicious means which 
 can be adopted, there is sometimes considerable loss of motion ; 
 
 and when the accident 
 has not been understood, 
 or has been carelessly 
 treated, the deformity 
 and loss of motion be- 
 come very considera- 
 ble." (See fig. 51, in 
 which, however, the 
 roller should have been 
 represented as applied 
 to the fore-arm and el- 
 bow.) 
 
 The mode of treat- 
 ment generally adopted 
 in this city consists in 
 enveloping the limb, from the fingers to above the line 
 of fracture, in a roller, the fore- arm being flexed and the frag- 
 ments having been restored to apposition ; then a flat, or 
 slightly grooved, rectangular splint is applied upon the ante- 
 rior face of the arm, fore-arm, and hand — or upon their inner 
 aspect, the hand being semi-pronated, — and secured thus by 
 means of a roller, a compress having been placed upon the 
 
 Fig. 51. 
 
FRACTURES OF THE HUMERUS. 145 
 
 point of the internal condyle if this has been severed : the 
 fore-arm should then he supported upon the chest by a sling. 
 But if the fracture has involved the articular face of one or 
 both condyles, it is advisable, in addition to the splint, to 
 give increased support to the posterior face of the elbow. 
 For this purpose a piece of pasteboard should be taken, suffi- 
 ciently long to extend from three to four inches above the 
 elbow, and for the same distance below it, and wide enough 
 to envelope the joint laterally; this should be notched at 
 different points, so that after it has been softened in hot 
 water, it may be made to fit the elbow. Then, the arm 
 having been bandaged, as before directed, and the anterior 
 splint applied, this cap should be placed upon the posterior 
 face of the elbow — care being taken to protect the bony pro- 
 jections from great pressure — and confined by the roller which 
 secures the other splint. At the end of ten days or two weeks, 
 or earlier if all pain has ceased and if the bone has become 
 sufficiently firm, passive motion should be resorted to from 
 day to day, the condyles being supported by the hand, and 
 the angle of the anterior splint changed. After the lapse of 
 eight or ten weeks, the confinement may be omitted. It 
 should be borne in mind that daily motion of the joint is of 
 the greatest importance in the treatment of fractures about 
 the elbow, but it should be practised cautiously and with the 
 limitations above mentioned. 
 
 When the fracture is compound, the same indications are 
 still to be accomplished as when it is simple, and the same 
 plan is to be pursued. The splints must be so contrived, 
 however, as to allow of frequent inspection and dressing of 
 the wound, without requiring the removal of the whole ap- 
 paratus. This may be effected by using splints of binders' 
 board previously softened and moulded to the shape of the 
 part, and large enough to give easy support to the fractured 
 limb ; an aperture should be made in the splint opposite the 
 wound, sufficiently large to permit of free examination of the 
 injury to the soft parts. The limb should be softly cushioned 
 in the splints, and secured to them above and below the 
 wound, while the particular dressing required for the latter 
 may be laid over the aperture corresponding with it in 
 situation, and confined by the bandage of Scultetus. Or, 
 when the wound is on the anterior face of the arm, the fore- 
 13 
 
146 
 
 FRACTURES OF THE HUMERUS. 
 
 arm may be enveloped in a roller, as in the other cases, and 
 a bandage of Scultetus be applied immediately to the upper- 
 arm, over the wound, or upon the dressing which covers it, 
 while a curved angular splint supports the posterior aspect of 
 the whole limb. The fore-arm should be sustained by a sling 
 in either case. 
 
 Mr. Mayo contrived a very simple splint for the treatment 
 of a case of bad compound fracture of the condyles, by which 
 the requisite support was given to the bones, and the wound 
 still allowed to discharge freely, and sufficiently exposed to 
 be dressed without much disturbance of the limb. As such 
 instances sometimes occur, it is well to have an acquaintance 
 with the mode employed to treat them, as adopted by so high 
 an authority as Mr. Mayo. The apparatus " consists of two 
 splints joined together by two small bars, so as to leave a 
 space between them for the elbow to fit into. One of the 
 splints, B, in the wood-cut, (see fig. 52,) is made for the back 
 part of the arm to lie upon, w T hile the other, C, is for the 
 forearm ; the second splint terminates in a horizontal portion, 
 D, for the hand to rest upon ; the intervening space, A, is 
 formed by the two lateral bars, which are slightly curved out- 
 wards, to prevent pressure upon the joint." This splint 
 should be padded, and the limb secured to it above and below 
 the seat of injury, by an ordinary roller, while opposite the 
 wound itself the bandage of Scultetus should be used for the 
 same purpose, and also to retain suitable dressings upon the 
 part. (Lonsdale, p. 189.) 
 
 Fig. 52. 
 
 With regard to the frequency with which the apparatus 
 should be removed, and the fracture dressed, in cases of this 
 injury generally, only conditional directions can be given. 
 If, in a simple fracture, there be no unpleasant symptom or 
 
FRACTURES OF THE HUMERUS. ■ 147 
 
 appearance after the limb is first dressed, the bandage need 
 not be removed for two or three days, and this quiescence of 
 the limb is attended with many advantages, especially when 
 the fracture has involved the joint directly or indirectly. But 
 if the patient should complain of pain in the injured part, the 
 envelopes should be removed at least once daily, and the 
 injury examined ; unless this attention is practised, sloughing 
 of the soft parts, or troublesome excoriations, will often occur. 
 The first application of the roller and splints should be made 
 carefully, so as to exert only a moderate degree of pressure, 
 and to allow of the swelling which follows upon almost every 
 fracture ; and the compression made around the lower part 
 of the limb should be proportioned to that upon the upper, 
 else the soft parts below will become swollen and painful, and 
 finally gangrene may ensue. 
 
 In the wards of the Pennsylvania Hospital, in this city, it 
 is rare that blood is taken from about the joint in case of 
 fracture ; but the fragments are placed in apposition as speed- 
 ily as possible, and confined, as above advised, — perfect rest 
 being considered a sufficiently powerful antiphlogistic remedy ; 
 frequently, indeed, this is aided by the influence of evapo- 
 rating or sedative lotions, as diluted spirits, or lead-water. 
 
 In compound fractures, the best local application to the 
 seat of injury, after the means hereinbefore advised for the 
 promotion of direct closure of the wound have failed, is a 
 poultice, or the water-dressing: if the former be used, it 
 should be changed at least twice daily, and as much oftener 
 as may be required by the amount or nature of the discharge : 
 as the wound contracts, and the suppuration becomes very 
 scanty, some stimulating lotion, or cerate, may be advanta- 
 geously substituted. Passive motion should be resorted to, 
 and diligently practised, as soon as the condition of the parts, 
 internal and external, will allow; this injunction is of the 
 utmost consequence after compound fractures near to, or 
 involving, the joint, because it cannot be resorted to so early 
 as in simple fractures, owing to the greater length of time 
 requisite for the union of the fragments, and because also the 
 joint has suffered more, in most cases, than in the other class 
 of injury. In both, the rigidity of the parts may be lessened 
 by frequently soaking the joint in warm water. 
 
 Comminuted fractures of the humerus require no different 
 
148 FRACTURES OF THE 
 
 treatment, as a general rule, from the simple, excepting rather 
 nicer manipulation in reducing them, and in the application 
 of compresses, and a somewhat longer confinement. 
 
 SECTION II. 
 FOR FRACTURES OF THE BONES OF THE FORE-ARM. 
 
 The complicated movements of the fore-arm, and the varied 
 action of the numerous muscles necessary to effect them, 
 occasion, when one or both bones are broken, many forms of 
 displacement of the fragments. To remedy these, so as to 
 preserve unimpaired the mobility of the limb, it becomes 
 necessary for the surgeon to resort to a variety of expedients, 
 which it is the object of this section to set forth. 
 
 In fractures of the fore-arm, whether of one or both bones, 
 there is one common indication to be fulfilled, excepting when 
 the fracture has occurred very near to the extremities of the 
 bones ; — this is to preserve the interosseous space, which is 
 almost always encroached upon by the fragments. 
 
 1. For fractures of both bones. 
 
 The displacement in these cases may be in the diameter or 
 in the length of the fore-arm, or in both directions. Gene- 
 rally, there is not much difficulty in retaining the fragments 
 in proper apposition after reduction. The mode of accom- 
 plishing it, as it is commonly practised, consists in applying 
 upon the anterior face of the fore-arm, a long compress which 
 fits over the interosseous space, and then placing a straight, 
 padded splint, sufficiently long to extend from the elbow to 
 the ends of the fingers, upon the front, and another of the 
 same length upon the back of the fore-arm, and securing them 
 by circular and reverse turns of the roller. The width of the 
 splints should be greater than that of the arm, so that the 
 convolutions of the bandage shall not press the two bones 
 towards each other. 
 
 Sometimes considerable difficulty is experienced in coun- 
 teracting a lateral angular displacement : but generally this 
 may be overcome by applying a compress of suitable thick- 
 ness over the point of deformity, at the side of the fore-arm, 
 
BONES OF THE FORE-ARM. 149 
 
 and by removing also, if necessary, the compression exercised 
 upon the interosseous space at this point. 
 
 After the fore-arm is thus suitably dressed, it is placed in 
 a position midway between pronation and supination, — the 
 palm of the hand towards the chest, the thumb, which is left 
 uncovered, presenting upwards, — and supported in a sling in 
 the flexed position. 
 
 Both bones are not commonly broken at the same level, 
 but this circumstance does not alter the general mode of 
 treatment. 
 
 Mr. Lonsdale objects to this mode of treatment, on the 
 ground that the position in which the fore-arm is placed, — 
 that of semi-pronation, — is not the one which is most calcu- 
 lated to insure perfection in the motions of the limb. The 
 muscles which tend to throw the upper fragment of the radius 
 in supination, are the supinator radii brevis and the biceps 
 flexor cubiti, and, agreeably to Mr. Lonsdale's argument, 
 these combined exert more power than the pronator muscle 
 which operates upon this fragment, — the pronator radii teres ; 
 hence the upper portion of the radius is placed in a much 
 more supine position than the lower, if the palm of the hand 
 is turned towards the chest, with the thumb presenting 
 directly upwards ; and if union of the two fragments of the 
 radius takes place in this faulty relative position, the extent 
 to which pronation and supination can be effected will be 
 impaired, as is not unfrequently noticed. 
 
 To obviate this difficulty, Mr. Lonsdale recommends that 
 the hand be placed supine, and that two straight splints be 
 bandaged to the fore-arm, precisely as in the ordinary plan of 
 treatment ; then the fore-arm should be supported in a sling, 
 the elbow approximated to the chest, and the hand projecting 
 before the body. 
 
 The splints should be retained for five or six weeks in frac- 
 ture occurring to an adult, and for four or five weeks when a 
 child is thus injured. I 
 
 In compound fractures of the fore-arm, only one splint can 
 be used, as a general rule, with advantage. Tolerably good 
 apposition of the fragments can be effected with a single splint, 
 by a judicious arrangement of compresses and a roller, or ban- 
 dage of Scultetus ; pressure upon the wound itself should be 
 13* 
 
150 
 
 FRACTURES OF THE 
 
 Fig. 53. 
 
 avoided, but, on the contrary, every facility should be offered 
 to the escape of the pus. 
 
 The " Ante-Brachial Hyponarthecia," of Sauter and May- 
 or is quite well adapted to the treatment of compound frac- 
 tures of the fore-arm, of one or both bones. It is thus described 
 by M. Cutler : 
 
 " Composition. — A board of convenient width, a little 
 longer than the fore-arm and hand, a cushion, a cord for arc- 
 loops, and three cravats. 
 
 " Application. — The fracture being reduced, the fore-arm 
 
 is placed upon the cushioned 
 board, a, b (fig. 53), which is im- 
 mediately suspended from the pa- 
 tient's neck by means of the arc- 
 loops, e e, — the ring /, and the 
 cervical cravat, g. The second 
 cravat, <?, is now passed under 
 the wrist, and crossed upon the 
 back of the hand, the tails being 
 then made to embrace the cush- 
 ioned board, and knotted at its 
 anterior border, as represented 
 at h. The third cravat is made 
 to pass around the apparatus at 
 its upper part, so as to confine the 
 corresponding portion of the fore-arm, and is then knotted as 
 the other. If it be necessary to counteract any lateral dis- 
 placement, a fourth cravat may be made use of, to serve as a 
 ' traction ligature,' which will of course be knotted at the in- 
 ner margin of the suspension-board." This apparatus leaves 
 the fore-arm exposed to constant inspection, and suitable dress- 
 ings can be applied to the wound without deranging the limb ; 
 if the discharge be very profuse, bran may be conveniently 
 placed upon the board and around the arm to absorb the pus. 
 When the patient lies down, the apparatus should be detached 
 from the cervical cravat and placed upon a pillow, or suspended 
 from the top of the bed, or from the ceiling. If it be deemed 
 expedient, for greater security, to confine the whole limb, it 
 can be very easily accomplished by selecting a longer board 
 and cushion, extending from the axilla to the extremities of 
 
BONES OF THE FORE-ARM. 151 
 
 the fingers, and employing a sufficient number of cravats ar- 
 ranged after the plan indicated. 
 
 2. For fractures of the radius. 
 
 This bone may be broken at its neck, at its carpal extremity, 
 or at any intermediate point. The first and the last cases 
 should be treated as if both bones of the fore-arm were broken ; 
 the hand may be placed in a state of semi-pronation, or in su- 
 pination, as advised by Lonsdale. 
 
 It sometimes happens that the lower fragment of the radius, 
 when the fracture is near the carpal extremity, is driven very 
 forcibly towards the ulna, so as to require the operation of a 
 force gradually exerted, and for a considerable time, to restore 
 it to its natural line. For such cases Dupuytren recom- 
 mended the following plan of treatment : " Take a bar of 
 iron about an inch w T ide and of the length of the fore-arm, 
 and which at its lower extremity, opposite the part corre- 
 sponding with the wrist, curves downwards in a semicircle, 
 to the concavity of which some buttons are placed at equal 
 distances." Along the ulnar edge of the fore-arm, place a 
 firm compress, extending from just above the extremity of 
 the bone upwards, about an inch thick at the lower end, and 
 gradually tapering : upon this compress apply the splint, its 
 straight portion extending from the elbow to the termination 
 of the compress, and secure it in this position by a roller 
 which, on reaching the hand, causes the latter to approximate 
 the curve of the bar, 
 
 more or less, according FlG - 54 - 
 
 to the amount of force 
 required to rectify the 
 displacement of the 
 
 lower fragment of the ^V^^^ ^^i IZ^^^^i 
 
 radius, with which the 
 hand is connected. 
 (See fig. 54.) 
 
 The most common seat of fracture of the radius is at the 
 lower or carpal extremity of the bone. Two varieties of this 
 accident have been described : one by Dr. Colles, of Dublin, 
 in the Edinburgh Medical and Surgical Journal, 1814, and 
 the other by Dr. J. R. Barton, in the Philadelphia Medical 
 Examiner, 1838. 
 
 Colles' fracture usually occurs from three-fourths to one 
 
152 FRACTURES OF THE 
 
 inch above the radio-carpal articulation, and is very much 
 more commonly transverse than oblique. (R. W. Smith, 
 Treatise on Fractures, &c, Dublin, 1847.) Barton s frac- 
 ture, on the other hand, extends obliquely into the wrist-joint ; 
 and, perhaps in consequence of this implication of the joint 
 directly, there is likely to be more inflammation of the articu- 
 lation, and more permanent impairment of its motion than in 
 case of Colles' fracture. 
 
 The resulting deformity is very much the same in both 
 forms of the injury. 
 
 In this accident, the lower fragment of the radius, and 
 ■with it the carpus, is drawn upwards upon the back of the 
 fore-arm, as is represented in the annexed drawing (fig. 55.) 
 
 Fig. 55. 
 
 The treatment as advised by Dr. Barton, is very simple : 
 place the fragments in apposition by drawing down the hand, 
 the upper part of the fore-arm being fixed; then place a 
 compress upon the posterior face of the lower fragment, and 
 another on the anterior face of the upper, and apply padded 
 splints along the anterior and posterior faces of the fore-arm, 
 as directed for the other fractures ; the splints should extend 
 from the elbow to the ends of the fingers. After the lapse 
 of a week or ten days, passive motion of the wrist and finger- 
 joints should be commenced and repeated daily for five or 
 six weeks, when the splints may be omitted. When the 
 dressings are removed from time to time, the hand, and indeed 
 the whole fore-arm also, should be bathed, otherwise the con- 
 finement will be attended with want of cleanliness of the 
 part, and with a very unpleasant sour smell, disagreeable 
 both to the patient and to the surgeon. 
 
 The line of fracture sometimes assumes the opposite direc- 
 
BONES OF THE FORE -ARM. 
 
 153 
 
 tion, extending from the dorsal face of the radius obliquely 
 upwards to its palmar surface. The treatment is the same as 
 in the first variety of the injury, a slight change being made 
 in the disposition of the compresses to correspond with the 
 different kind of deformity, as will at once suggest itself to 
 the dresser. 
 
 During the continuance of the splints, and for some time 
 later, the fore-arm should be supported in a sling. 
 
 The frequency with which these fractures of the radius 
 occur, and the considerable impairment of the mobility of 
 the wrist and the finger-joints which result from them, and 
 which is sometimes permanent, especially in elderly persons, 
 and in those who are subject to chronic rheumatism, have 
 induced surgeons to devote a great degree of attention to 
 their treatment. Consequently, the simple plan of treatment 
 above described, has been variously modified. 
 
 M. Kelaton recommends the following method : Bring 
 the fragments into proper apposition by the necessary exten- 
 sion, counter-extension, and other manipulations ; place the 
 fore-arm in a position midway between pronation and supina- 
 tion, the hand being well brought down to its ulnar side ; 
 then apply a well padded pistol-shaped wooden splint, extend- 
 ing from the elbow to the extremity of the fingers, along the 
 outer side of the fore-arm, with a compress opposite the lower 
 fragment, and a straight splint along the inner face, reaching 
 from the elbow to the wrist, well padded opposite the upper 
 fragment, and along the. radial border of the fore-arm, to coun- 
 teract the tendency of this part of the bone to pixmation. 
 (See fig. 56.) 
 
 Fig. 56. 
 
154 FRACTURES OF THE 
 
 Dr. Bond, of tins city, has contrived recently a splint, by 
 the use of which the liability to stiffness of the joints is very 
 much diminished. The splint is made of light wood, cut to 
 the shape of the fore-arm, and extends from the elbow to the 
 second joint of the fingers. (Fig. 57.) To its palmar ex- 
 
 Fig. 57. 
 
 tremity is to be firmly attached, by screws or nails, a carved 
 and rounded block of wood of the size of the patient's hand, 
 which the latter may grasp when the arm is extended upon 
 the splint. The splint may or may not be, according to fancy, 
 or convenience, covered with binders' board, the edges of 
 which shall project beyond the sides of the splint, and be 
 turned up, so as to form a kind of box for the arm. (Fig. 58.) 
 
 Fig. 58. 
 
 If the binders' board be not used, the splint is wrapped, as 
 usual, in a roller or in muslin, the arm is placed upon it, the 
 fingers are allowed to rest comfortably, or to be moved at 
 pleasure, upon the carved block ; a compress is to be placed 
 under the arm at the point of fracture, just large enough to 
 fill up any vacuity which the shape of the member may occa- 
 sion after the fracture has been reduced. Another compress 
 is to be laid upon the dorsal face of the limb, opposite the 
 first, and the arm lightly secured to the splint by a roller. 
 The patient is permitted to use as much motion of his fingers 
 
BONES OF THE FORE-ARM. 
 
 155 
 
 and wrist as the apparatus will allow. (See Dr. Bond's paper 
 in the American Journal of Medical Sciences, April, 1852.) 
 
 If Dr. Bond's splint be not at hand, (any surgeon, how- 
 ever, can make one in a few minutes, of a shingle and a block 
 of pine wood), a common splint of the proper length can be 
 prepared in imitation of Dr. Bond's, by wrapping a roller 
 about it, as recommended by Dr. Hays, and as illustrated 
 in the annexed drawing. (Fig. 59.) 
 
 Fig. 59. 
 
 Frequently, patients become wearied of any splint, after a 
 certain time, the confinement of the arm in a particular posi- 
 tion being irksome to them. If this be the case in the treat- 
 ment of these fractures by Bond's, Hays', Nelaton's or Bar- 
 ton's plan, the splint suggested by Good, which is applied to 
 the back of the fore-arm, may be employed. 
 
 Latterly, it has been proposed by Professor Fauger, of 
 Copenhagen, to treat these fractures without splints. " The 
 hand having been brought into a position of strong flexion, 
 the fore-arm is placed, pronated, on an oblique plane, with 
 the carpus highest, the hand being permitted to hang freely 
 down the perpendicular end of the plane." (London Lancet, 
 May 8, 1847.) 
 
 8. For fractures of the ulna. 
 
 The ulna may be broken in its shaft, or at the coronoid or 
 olecranon processes. The first-named variety is treated after 
 the same method as when both bones are involved ; fractures 
 of the processes require a different plan. 
 
 When the coronoid process is broken off from its bony and 
 ligamentous connexions, the brachialis anticus muscle, which 
 is inserted upon it, draws it up on the lower portion of the 
 humerus; and the chief difficulty in treating this accident 
 
156 FRACTURES OF THE 
 
 successfully consists in counteracting entirely the force of 
 this muscle, so as to maintain the fragments in perfect appo- 
 sition. There is also another cause of failure, since when 
 this process is detached, " like the head of the thigh-bone, it 
 loses its ossific nourishment, and has no other than a liga- 
 mentous support. Its life is preserved by the vessels of the 
 reflected portion of the capsular ligament upon the end of 
 the bone, which do not appear capable of supporting the 
 least attempt at ossific union." (Sir A. Cooper, op. cit., 
 p. 406.) 
 
 For the treatment of this injury, apply a roller from the 
 ends of the fingers, around the fore-arm and about the elbow, 
 making firm pressure upon the restored process, through the 
 intervention of a compress, and then continue the roller 
 around the arm, so as to confine the brachialis anticus : over 
 the roller place an angular splint, extending from near the 
 the head of the humerus to the fingers, along the anterior 
 surface of the limb, and retain it thus by a roller. The fore- 
 arm should be supported in a sling, and the apparatus should 
 be worn for six or eight weeks, passive motion being resorted 
 to very cautiously. The splint which is employed should be 
 flexed at rather less than a right angle, in order that the bra- 
 chialis anticus may be relaxed as much as possible, and every 
 facility be afforded for a bony union of the fragments. 
 
 The angular splints for the upper extremity may be made 
 with the angle fixed, or this may be movable and changeable 
 at pleasure, the two segments of the splint being fastened at 
 the desired angle, by a pin traversing both portions : if the 
 former arrangement be adopted, it will be necessary to have 
 a multiplicity of splints made at different angles; by the 
 latter, the same splint will answer the purposes of all the 
 others. 
 
 The olecranon process is more frequently broken than the 
 coronoid, and the reparation of the injury is equally, if not 
 more, difficult. The triceps muscle acts upon the fragment 
 of bone to great advantage, so that when the ligamentous 
 fibres are severed, which connect it with surrounding points, 
 the retraction is sometimes very great. 
 
 The indication is, of course, to relax the muscle, so that 
 the fragments may be kept in apposition ; the fore-arm should 
 
BONES OF THE FORE-ARM. 157 
 
 be extended upon the arm, and some means should be resorted 
 to for securing the broken surfaces together. 
 
 Sir Astley Cooper advises the following plan of treatment : 
 — " If there be much swelling and contusion, it is right to 
 apply evaporating lotions and leeches for two or three days ; 
 and after the inflammation is reduced, a bandage should be 
 applied." — "If the swelling and inflammation do not prevent 
 it, the surgeon is, at once, to place the arm in a straight posi- 
 tion, and to press down the upper portion of the fractured 
 olecranon, until he brings it in contact with the ulna ; a piece 
 of linen is then laid longitudinally on each side of the joint ; 
 a wetted roller is applied above the elbow, and another below 
 it ; the extremities of the linen are then to be doubled down 
 over the rollers and tightly tied, so as to cause an approxi- 
 mation ; thus the portions of bone are brought and held 
 together ; a splint well padded is to be applied upon the fore 
 part of the arm, to preserve it in a straight position, and con- 
 fined to it by a circular bandage ; the whole finally, is to be 
 frequently wetted with spirits of wine and water." (See 
 fig. 60.) 
 
 Fig. 60. 
 
 " In a month the splint is to be removed, and passive mo- 
 tion is to be begun : but, if it be attempted earlier, the ole- 
 cranon will be separated from the shaft of the bone, and the 
 ligament will become lengthened and weakened ; all attempts 
 at motion must, therefore, be made with the greatest gentle- 
 ness." (Sir A. Cooper, op. cit., p. 410.) 
 
 Another method of treating this fracture consists in apply- 
 ing a roller from the fingers to the elbow, then drawing down 
 the fragment of the olecranon to its natural situation ; and 
 while an assistant holds it thus, by means of a compress 
 placed just above it, the surgeon makes a few figure-8 turns 
 around the elbow, permanently confining the compress and 
 
158 FRACTURES OF THE 
 
 the process of bone, and exhausts the roller upon the upper 
 arm. A straight splint is now taken and laid upon the front 
 of the limb, extending from near the head of the humerus 
 to the wrist ; some cotton should be interposed between the 
 splint and the bandage at the bend of the elbow, in order 
 to fill up the vacuity at this point, — the fore-arm not being 
 extended quite to the utmost, — and the whole secured by an- 
 other roller. 
 
 The same precautions, with regard to the institution of 
 passive motion, are to be attended to, as in the other 
 method. 
 
 The extension of the fore-arm, and the confinement of the 
 fragment of the olecranon, may be effected also by the " ole- 
 crano-metacarpal cravat" of Mayor, as follows: — Extend 
 the fore-arm, and place upon its anterior face a pasteboard 
 splint moulded to its form, and reaching from the lower third 
 of the upper arm to the fingers ; draw down the fractured 
 process to the corresponding surface of the ulna, and upon it 
 lay a compress, which should be held by an assistant ; then 
 pass a cravat around the lower extremity of the humerus, so 
 as to retain in place the splint and the compress, and knot it 
 behind, leaving the tails hanging about half way down the 
 back of the fore-arm ; to the palm of the hand, below the ball 
 of the thumb, apply the centre of another cravat, and tie it 
 upon the back of the wrist, thus securing the lower extremity 
 of the splint, the tails of the cravat being free ; now tie the 
 ends of the two cravats together. (See fig. 61.) 
 
 Fig. 61. 
 
 This method can scarcely be relied upon for the permanent 
 treatment of this form of fracture, when the other methods 
 can be employed. 
 
 Desault advises that the fore-arm should be maintained in a 
 
WRIST AND HAND. 159 
 
 state between semi-flexion and extension, in case of fracture 
 of the olecranon process, and that a splint slightly curved be 
 applied on the anterior face of the limb, as in the plans 
 already mentioned. 
 
 In compound fracture of this portion of the bone, the limb 
 should be extended by means of a splint laid upon its anterior 
 face, and confined thus by a roller, which, however, should not 
 cover the wound ; the edges of the latter should be retained in 
 apposition by strips of adhesive plaster, and over it a piece 
 of lint saturated with blood or solution of starch should be ap- 
 plied, the whole being enveloped, and the elbow tightly con- 
 fined to the splint, by a bandage of Scultetus. The patient 
 should be kept in bed with the arm extended on pillows, the 
 hand elevated rather higher than the shoulder. If no unplea- 
 sant symptom occur, the dressing should be undisturbed for a 
 week or ten days. Treated in this way, these injuries are 
 sometimes very well recovered from. But if inflammation and 
 suppuration come on, the accident must be treated as ordinary 
 compound fractures presenting the same symptoms ; here 
 again, adhesive strips properly applied, so as to maintain the 
 necessary degree of extension and counter-extension, will be 
 found of great service in the treatment. 
 
 Partial fractures of the bones of the fore-arm, those namely 
 in which some of the fibres only of the bone are ruptured, the 
 others being bent, require the same treatment, in general 
 :erms, as the complete fractures. After the line of the bone 
 a as been restored, however, by suitable manipulations, there 
 is usually less disposition to a reproduction of the deformity, 
 and hence less compressing force is required to counteract it ; 
 generally, too, union takes place sooner than in the other 
 cases, and the splints need not be worn so long as in the 
 latter. 
 
 SECTION III. 
 FOR FRACTURES OF THE BONES OF THE "WRIST AND HAND. 
 
 1. Fractures of the carpal bones are almost necessarily com- 
 pound and attended with much injury to the soft parts; they 
 
 
160 FRACTURES OF THE WRIST AND HAND. 
 
 require no especial apparatus to keep tliem in place. The 
 best plan of treatment in such cases is, to adapt a splint to 
 the lower part of the fore-arm and hand, increasing in width 
 at the wrist, being retained lightly in this situation by a roller, 
 or bandage of Scultetus ; if the wound is on the palmar sur- 
 face of the wrist, the splint should be applied to the back of 
 the fore-arm and hand, and vice versa;. If, as is generally the 
 case, there is no probability of securing direct closure of the 
 wound, poultices, or water-dressings, should be laid upon it, 
 at first, or the treatment by irrigation should be adopted, and 
 other applications used as required: the fore-arm and hand 
 should be supported in a sling, or should repose upon a pillow, 
 as most expedient. 
 
 2. Simple fractures of the metacarpal bones are, in gene- 
 ral, attended with but little displacement ; after the fragments 
 have been restored to apposition, they are easily retained in 
 situ by merely laying a compress upon the bone, and confining 
 it thus, with the hand and fore-arm upon a broad splint as 
 above. 
 
 3. Simple fractures of the bones of the fingers require for 
 their treatment merely that the fingers shall be supported by 
 a thin strip of pasteboard placed on each side of them, and 
 confined by a piece of tape applied in circular turns. For 
 greater security and to insure perfect repose to the injured 
 finger, the hand and fore-arm should be bound to a splint, as 
 in the cases just considered, and supported in a sling. 
 
 4. Compound fractures of the metacarpal and phalangeal 
 bones are often met with, as occasioned by the bursting of 
 firearms, the explosion of rocks, and by the hand becoming 
 entangled in machinery. Such injuries appear very formi- 
 dable at first, and as if beyond reparation ; but the hand is of 
 such vast importance to the patient, — and the accident gene- 
 rally happens to those who earn their subsistence by their 
 daily labour, — that an attempt at saving it should be made, 
 and the most unpromising cases do very often recover with 
 very useful hands. 
 
 A splint long enough to extend from the elbow to the ends 
 of the fingers, or a little beyond them, and grooved on its 
 palmar portion to receive the fingers (see fig. 62), should be 
 padded with cotton, or covered w 7 ith a poultice or other 
 suitable dressing, and placed underneath the limb : a roller 
 
FRACTURES OF THE WRIST AND HAND. 161 
 
 should be passed around the fore-arm and splint, to retain the 
 latter in place, and this, with the weight of the dressings that 
 are laid upon the hand, will be found in most cases to be suf- 
 
 Fig. 62. 
 
 ficiently retentive for the latter. Generally, the continued 
 application of cold water upon the lacerated parts, will prove 
 the best and the most agreeable dressing that can be em- 
 ployed ; it should be used as advised under the head of irri- 
 gation, in the first part of this volume. The feelings of the 
 patient form the best guide as to the length of time during 
 which this application should be retained ; so long as he finds 
 it comfortable, it may be continued ; so soon as he complains 
 of increasing pain in the injured part, or if he becomes chilly 
 under its use, it will be best to substitute for it a warm poul- 
 tice, or folds of soft lint saturated with warm water ; and the 
 dressings should be varied to suit the particular conditions of 
 the wound. When there is free suppuration, particularly in 
 warm weather, the bran dressing will be found very service- 
 able, as it not only absorbs the discharges, but covers the 
 injured parts and renders it less likely to be infested with 
 vermin, — a source of much trouble and annoyance both to 
 the surgeon and the patient. (Some of the strong aromatic 
 oils are of service in destroying these nuisances ; but it is 
 generally necessary to dislodge them from their burrowing- 
 places by means of the dissecting forceps, and by injecting a 
 stream of water upon them from a small syringe.) 
 
 After the suppuration has in a measure ceased, and the 
 wounds have assumed the appearance of healthy ulcers, the 
 hand may be placed upon a flat splint, of the same shape as 
 the other, and the bones pressed into proper line, by inserting 
 pledgets of lint between the fingers and using gentle com- 
 pression upon the whole hand by the folds of a bandage of 
 Scultetus, enveloping both the hand and the splint ; the ten- 
 dency to recurring displacement of the fragments of bone is 
 14* 
 
162 FRACTURES OF THE WRIST AND HAND. 
 
 so slight in these cases, that very little force is requisite to 
 keep them in tolerable apposition. 
 
 During the early part of the treatment, the patient should 
 be kept in bed, with the arm reposing upon pillows, the hand 
 somewhat elevated ; in the latter stages, he may be allowed 
 to leave the bed, with the arm supported in a sling. 
 
 The disposition of the pus to run underneath the soft parts, 
 forming collections at points remote from the wound, should 
 be counteracted by position, by compression, and finally, if it 
 can be prevented in no other way, by incisions practised 
 wherever a deposit is formed. 
 
CHAPTER V. 
 
 ON THE APPARATUS AND DRESSINGS FOR FRACTURES OF 
 THE BONES OF THE LOWER EXTREMITY. 
 
 SECTION I. 
 FOR FRACTURES OF THE OS FEMORIS. 
 
 Greater difficulty is experienced in the treatment of frac- 
 tures of the femur, than in those of any other bone. The 
 constant action of powerful muscles ; the injurious effects of 
 pressure upon the soft parts, from long-continued position, 
 and from the compression of bandages ; the hurtful influence 
 upon the general health of protracted confinement, and the 
 direct impression upon the system resulting from the injury 
 itself, are all to be combated in the same case. The attention 
 which has been devoted to the consideration of this subject, 
 has been proportioned to its importance. 
 
 The proper position in which the thigh shall be maintained 
 during the treatment, is the main point of discussion among 
 surgeons — some preferring the flexed, others the extended 
 position of the limb. A variety of apparatus, more or less 
 complicated in structure and arrangement, has been contrived 
 with reference to each plan of treatment. 
 
 1. Modes of treatment, the thigh being in the flexed posi- 
 tion, — This position is most in vogue in Great Britain ; it was 
 first particularly recommended by Mr. Pott, who founded it 
 upon the idea that it is possible " to put the limb into such a 
 position as shall relax the whole set of muscles belonging to, 
 or in connexion with, the broken bone." This idea is mani- 
 festly incorrect, since the position which relaxes the flexor 
 muscles renders the extensors more tense ; that which approxi- 
 mates the extremities of the adductors has the reverse effect 
 upon the abductors. 
 
 The following is the plan of treatment adopted by Mr. 
 
 (163) 
 
164 FRACTURES OF THE OS FEMORIS. 
 
 Pott : — " The position of the fractured os femoris should be 
 on its outside, resting on the great trochanter ; the patient's 
 whole body should be inclined to the same side ; the knee 
 should be in a middle state between perfect flexion and exten- 
 sion, or half-bent ; the leg and foot, lying on their outside 
 also, should be well supported by smooth pillows, and should 
 be rather higher in their level than the thigh; one very broad 
 splint of deal, hollowed out and well covered with wool, rag, 
 or tow, should be placed under the thigh, from above the 
 trochanter quite below the knee ; and another, somewhat 
 shorter, should extend from the groin to below the knee on 
 the inside, or rather, in this posture, on the upper side. The 
 bandage should be of the eighteen-tail kind, and when the 
 bone has been well set, and the thigh well placed upon the 
 pillow, it should not, without necessity, (which necessity will, 
 in this method, seldom occur,) be moved from it again until 
 the fracture is united ; and this union will always be accom- 
 plished in more or less time, in proportion as the limb shall 
 have been more or less disturbed.'' (Cooper's Surg. Diet.) 
 The chief and sufficient objections to this plan of treatment 
 are, that the means employed are insufficient to keep the 
 ends of the fragments in apposition, and too insecure against 
 sudden and accidental movements of the limb, or of the 
 whole body ; and that the pressure exerted upon the tro- 
 chanter for the space of many weeks is too great to be safely 
 borne. 
 
 There are some cases, however, in which this position may 
 be adopted as a temporary one ; these will be mentioned here- 
 after. 
 
 Sir C. Bell recommended another method of treating this 
 class of injuries in the flexed position of the thigh : — The pa- 
 tient lies upon his back, w T hile the limb is supported upon a 
 double inclined plane, one portion of which extends from the 
 tuberosity of the ischium to the ham, and the other from the 
 ham to the heel ; straight splints are confined to the outer and 
 inner sides of the thigh. Numerous apparatus have been 
 contrived, in modification of the original suggestion of Bell, 
 some of which are much used in England. 
 
 2. The plan of treatment by the straight position of the 
 limb was first employed by Desault. In this method, a con- 
 stant extending and counter-extending force is maintained 
 
FRACTURES OF THE OS FEMORIS. 165 
 
 upon the fragments, while lateral pressure is exerted upon the 
 limb by means of splints and bandages. The original appa- 
 ratus of Desault has been modified and improved upon, in va- 
 rious ways, by European and American surgeons, so that frac- 
 tures of the thigh may be more successfully treated in the 
 straight position, than in any other. 
 
 The os femoris may be broken at its condyloid, or trochan- 
 teric extremity, or at any point in its shaft ; and although the 
 general plan of treating the injury, at whatever part the frac- 
 ture may have occurred, is the same, yet there are some minor 
 points of difference, which are nevertheless of importance in 
 practice. 
 
 1. For fractures occurring in the shaft of the bone. 
 
 The injury may be simple or compound, and the line of frac- 
 ture transverse or oblique. Displacement of the fragments 
 almost invariably occurs, even when the bone is transversely 
 broken, for the force which caused the fracture nearly always 
 deranges the axis of the bone, pushing the two portions from 
 contact with each other, and then the muscles have uncon- 
 trolled action, and draw the lower fragment upwards, above, 
 or underneath, the superior. Even if the contact of the ex- 
 tremities of the two portions, at the point of fracture, be not 
 completely sundered by the original violence, the muscles 
 which pass from the pelvis to the lower extremity of the fe- 
 mur will act upon the latter, and thus derange the natural 
 line of the bone. But when the fracture is oblique, shorten- 
 ing of the limb is a necessary consequence, and its degree will 
 depend very much upon the muscular development of the 
 patient. 
 
 The solution of continuity may occur at any point between 
 the smaller trochanter and the condyles, but its most frequent 
 seat is within the lower two-thirds of the bone. The inferior 
 fragment is drawn upwards and, generally, inwards by the 
 extensor and adductor muscles, while the superior is elevated 
 at its lower extremity by the action of the iliacus internus and 
 psoas magnus, and this tilting-up of the fragment will be 
 greater or less, as the fracture is near to, or remote from, the 
 insertion of these muscles. The direction which the upper 
 portion of the bone will assume will be modified also by the 
 operation upon it of the glutaeus maximus, if the fracture be 
 above the middle of the shaft, — it will be thrown outwards. 
 
166 FRACTURES OF THE OS FE MORIS.' 
 
 And farther there is almost invariably a considerable degree 
 of eversion of the foot as well as of the lower end of the upper 
 fragment, in consequence of the weight of the limb, or the 
 contraction of the external rotator muscles of the thigh. The 
 choice and management of the apparatus employed to treat a 
 case of fracture of the shaft of the femur must, of course, be 
 based upon its adaptation to the counteraction of these causes 
 of deformity. It will be most convenient, with reference to 
 this point, to consider, first, the different kinds of apparatus 
 used in the treatment of these injuries, in the flexed position 
 of the limb ; and, secondly, those adapted to the extended 
 position. 
 
 The plan proposed by Pott has been already described, and 
 the objections to it have been stated : it should not be adopted 
 in ordinary cases as a permanent method of treatment, but 
 in some instances it may be used with advantage. Thus, 
 when there is much contusion of the soft parts, or in cases 
 of compound fracture with the wound on the under surface 
 of the thigh, as may perhaps happen occasionally, it is the 
 only plan which can be resorted to, — temporarily in the first 
 class of cases, and as a permanent mode in the latter. 
 
 The apparatus contrived by Sir Charles Bell consisted of 
 two boards, ten or eleven inches wide, one of which was made 
 to extend from the tuberosity of the ischium to the popliteal 
 flexure, and the other from the latter point to the heel : these 
 two portions of the apparatus were united at an angle under 
 the knee-joint, w 7 hile their other extremities were connected 
 by a horizontal piece, which served also to support the 
 double inclined plane upon the bed. Holes were pierced 
 along the margin of the inclined planes, in which pegs were 
 inserted to steady the limb. When about to be used, the 
 apparatus was placed upon a mattrass, the inclined surfaces 
 covered with a cushion, and the limb laid upon it, so that the 
 under surface of the knee should correspond with the angle 
 of the plane, and the tuberosity of the ischium should check 
 against the upper extremity of the horizontal board. A lath 
 splint was bound to the upper surface of the thigh, and 
 another along the inner face of the same. 
 
 Many modifications of this simple apparatus have been 
 contrived since the original was proposed. Mr. Lonsdale's 
 book contains a description of the one which was — at the 
 
FRACTURES OF THE OS FEMORIS. 
 
 167 
 
 time he wrote, 1888, — in ordinary use at the Middlesex 
 Hospital, London, arid which, he thinks, " possesses all the 
 advantages that the more complicated ones are said to have." 
 It differs from the one just described in having the plane3 
 joined by means of a hinge at the point corresponding with 
 the knee ; and the same sort of union exists between the 
 thigh-piece and the horizontal frame, while the portion on 
 which the leg reposes may be fixed at any angle upon the 
 latter, by means of a serrated edge. " The letter A marks 
 the screw that secures a slide in the thigh-portion of the 
 plane, to allow of the latter being adapted to limbs of dif- 
 ferent lengths." (See fig. 63.) A slide, having a foot-board 
 
 Fig. 63. 
 
 attached to it, could be very easily adapted to the lower plane, 
 so that it might be fastened at a suitable distance from the 
 angle, to correspond with the length of the leg. 
 
 In making use of this apparatus, the length of the thigh 
 and leg portions of the plane should be made to agree with 
 that of the unbroken thigh and leg ; " the points from which 
 the measurement should be taken are the tuberosity of the 
 ischium and the angle of the knee," and the latter point and 
 the heel; "and the plane should be applied to the sound 
 limb first, to see that it corresponds exactly with the points 
 above mentioned." (Lonsdale, p. 298.) It is advised to 
 have the cushion made of flannel folded several times, as this 
 is supposed to offer a more smooth and level surface, upon 
 which the limb shall rest, than if pillows are employed. The 
 whole limb is then gently raised, the thigh and leg being 
 flexed, and the seat of fracture carefully supported, the plane, 
 having a bandage of Scultetus arranged upon the thigh- 
 portion of it, slid underneath, and the limb now lowered 
 
168 
 
 FRACTURES OP THE OS FEMORIS. 
 
 gradually down upon it. Care should be taken that the 
 angle of the knee corresponds exactly with that of the plane, 
 and that the tuberosity of the ischium presses well against 
 the upper extremity of the apparatus. The hand should be 
 passed gently underneath the limb, and the cushion smoothed. 
 The proper angle of the plane must be determined by the 
 degree of elevation which may be required to make the line 
 of the lower fragment level with that of the upper, — the 
 latter, as has been already pointed out, being tilted more or 
 less upwards by the action of the psoas magnus and iliacus 
 internus muscles. An assistant should support the limb 
 while the surgeon confines upon the outer, upper, and inner 
 aspects of the thigh three splints of the length of the bone, 
 by means of the bandage of Scultetus. The limb is secured 
 to the plane by a roller, the foot is attached to the foot-board 
 by the same means, and the legs are inserted into the holes 
 made for them. The annexed drawing, taken from Mr. 
 Lonsdale's book, p. 302, "represents the apparatus when 
 properly applied. The lines A, B, show the two important 
 points that are to be attended to ; — A, that the angle of the 
 
 knee corresponds with the angle of the plane — B, that the 
 tuberosity of the ischium presses well against the upper end." 
 (See fig. 64.) 
 
 Any disposition to the lateral angular deformity, in conse- 
 quence of the gluteus maximus muscle acting upon the upper 
 
FRACTURES OF THE OS FEMORIS. 169 
 
 fragment, may be easily counteracted, by directing the appa- 
 ratus outwardly from the middle line of the body, thus giving 
 the lower fragment a direction parallel and continuous with 
 that of the upper. 
 
 The chief modification of this simple apparatus is that of 
 Mr. Amesbury, who contrived it to remedy the objections 
 which appeared to him to be well-founded against the other : 
 these objections were, that it allowed of motion of the pelvis, 
 and consequently of the upper fragment, thereby disturbing 
 the apposition of the broken extremities of the bone, and that 
 it did not allow of sufficient extension being made. It will be 
 seen, by examining the double inclined plane above described, 
 that the pelvis is not well confined, and that the counter- 
 extension is effected chiefly by the weight of the body, aided 
 by the pressure of the apparatus against the tuberosity of the 
 ischium, and by the attachment of the upper fragment to the 
 thigh-portion of the plane, — while the extension is made by 
 the weight of the leg and its confinement, together with that 
 of the foot, to the lower plane and foot-board. 
 
 Dr. Spaulding, of Buffalo, has been very successful in 
 treating these injuries by the inclined plane. He fixes the 
 pelvis more securely, by allowing the horizontal portion of 
 the plane to extend high up, so that the tuberosity of the 
 ischium shall rest upon it. 
 
 Mr. Amesbury's apparatus is much more complicated. It 
 consists of three parts, exclusive of straight splints and straps : 
 one portion, a, corresponds with the thigh, another, Z, with 
 the leg, and the third, e, with the foot. (Fig. 65.) There are 
 
 Fig. 65. 
 
 two thigh-pieces to each apparatus, " one is bevelled off at 
 the lower end to the right; and the other to the left," to 
 render the shape of the upper part of the plane conformable 
 15 
 
170 FRACTURES OF THE OS FEMORIS. 
 
 to that of the thigh, — a perfectly-formed thigh being not 
 straight, but curving a little inwards towards the knee. The 
 thigh and leg-pieces are connected together by a hinge-joint, 
 fastened by a pin, d. The foot-board is fitted upon the lower 
 plane at a right angle, and may be fixed at a greater or less 
 distance from the angle of the two planes, by means of a pin 
 or a screw. The length of the thigh-piece may be adapted 
 to any limb, by means of a sliding plate which is arranged at 
 its upper part, and which may be fixed as required by a screw. 
 The two portions of the plane are connected underneath by a 
 steel rod, e, and the angle of the plane may be altered at 
 pleasure, by varying the point of fixation of this rod to the 
 under surface of the thigh-piece, a rack being there placed 
 with several projections, each of which has a hole bored 
 through the middle, for the purpose of receiving a bolt, which 
 also perforates the extremity of the rod. At the back of the 
 sliding plate, a couple of bars are placed, which serve to 
 render the plate more secure, and also to confine the pelvis- 
 strap which retains the apparatus in apposition with the 
 ischium. 
 
 In applying this apparatus, it should first be adapted to the 
 sound limb, in order that the proper length may be ascer- 
 tained. Then, the requisite angle having been given to the 
 planes, and their surfaces smoothly and evenly cushioned by 
 means of flannel, the broken limb should be carefully depo- 
 sited upon the apparatus, a roller having been previously 
 
 Fig. 66. 
 
 applied from the foot to the knee. The shoe, a (see fig. 66), 
 should now be buckled over the foot securely, and the pelvis- 
 strap passed between the bars and the plate of the sliding 
 portion of the thigh-piece. The leg should be confined to the 
 
FRACTURES OF THE OS FEMORIS. 171 
 
 lower plane, by a roller, c7, and the fragments of the femur 
 properly adjusted, by extension and counter-extension, and 
 retained in position by three straight splints, one on the 
 outer, £, another on the upper, /, and the third on the inner 
 face of the thigh, in which situations they are secured by the 
 straps, g, g, g, fixed to the back of the apparatus. " The 
 pelvis-strap, A, should now be carried round the limb under 
 the strips of leather, on the back of the short splints, and 
 made to cross on the outer side, and then the buckle-end with 
 the sliding-pad should be conducted round the pelvis, and 
 made to meet the other end in front, where it should be 
 buckled.''' 
 
 When there is much inflammation, Mr. Amesbury omits 
 the front splint, and applies evaporating lotions, &c, &c. 
 
 When the apparatus is thus securely arranged, it may be 
 placed on its side, or rest upright. Mr. A., thinks that 
 "half way between the side and the heel is a better position 
 for a continuance. I generally," he continues, " place the 
 apparatus upright, or a very little rolled outwards. It is 
 maintained in either of these positions by pillows, assisted by 
 a couple of tapes, a, i, carried from the lower end of the 
 apparatus to the foot of the bed." 
 
 This apparatus certainly seems to offer much more security 
 than the more simple one before described, and by it, accord- 
 ing to the testimony of its author and many others, cures are 
 effected of fractures of the thigh, without apparent shorten- 
 ing of the limb. 
 
 Professor Nathan R. Smith, of Baltimore, has constructed 
 a very light and portable double inclined plane, for the treat- 
 ment of these injuries, which is believed to be equally valu- 
 able and efficacious. A full account of it may be seen in 
 <; Gedding's Baltimore Medical and Surgical Journal," vol. i. 
 1833. It allows of suspension of the limb, and a gentle 
 swinging motion. The annexed figure will convey an idea of 
 its construction. (See fig. 67.) 
 
 The inclined plane which seems to be most in vogue in 
 England, is M'Intyre's, as modified by Mr. Liston. It con- 
 sists of a thigh and leg piece of sheet iron, and a foot- board 
 of wood ; the former are connected together by a couple of 
 hooks and a screw, which is so placed that the two plates can 
 be set to any angle at which it may be desirable to bend the 
 
172 FRACTURES OF THE OS FEMORIS. 
 
 Fig. 67. 
 
 knee ; and the foot-board is affixed in such a manner, that it 
 may be slid upwards or downwards to suit the length of the 
 leg, and fastened by a side-screw in any position that maybe 
 wished. At the lower end of the apparatus there is a cross 
 plate of iron, which is so attached, that if the foot be raised 
 or depressed, the plate will always rest flatwise on the mat- 
 trass, or a board placed at the foot of the bed for the purpose 
 of supporting it. (Fig. 68, taken from Fergusson's book.) 
 
 Fig. 68. 
 
 The hyponarthecia of Mayor and Sauter, is a modification 
 of the same principle, — a double inclined plane, upon which 
 the thigh and leg are confined, in the same manner as is the 
 arm in the hyponarthecia for the upper extremity ; as in the 
 latter case, the apparatus is suspended from the bed or ceil- 
 ing. Those who would see a drawing of this apparatus, are 
 referred to the book of Mayor, to that of Cutler, or to that 
 of Dr. H. H. Smith. 
 
 The only way in which any individual can form a satis- 
 
FRACTURES OF THE OS FE MORIS. 173 
 
 factory opinion, as to the real comparative efficacy of the 
 treatment of fractures of the thigh by position, is to test it 
 for himself. The statements respecting it are of the most 
 opposite kind, and by surgeons of equal eminence, — among 
 whom are Amesbury, Lonsdale, Cooper, Bell, Earle, in 
 favour of it, while Liston, Fergusson, and most of the con- 
 tinental and American surgeons prefer the method by ex- 
 tension. 
 
 This latter mode of treatment, as it is now generally prac- 
 tised, was proposed by Desault. The apparatus employed 
 by him consisted of two straight splints rather broader than 
 the antero-posterior diameter of the limb, tapering gradually 
 from the upper to the lower end, — one long enough to extend 
 from the crest of the ilium to four inches beyond the foot, 
 and the other from the perineum to the sole of the foot along 
 the inner side of the limb ; near the upper end of the long 
 splint a hole was perforated for the attachment of the coun- 
 ter-extending band, and a notch was cut at the lower extrem- 
 ity, with a perforation just above it, for the securing of the 
 extending strap. The rest of the apparatus consisted of a 
 splint-cloth ; long pads filled with chaff, to equalize the pres- 
 sure of the splints along the outer and inner faces of the 
 limb ; a counter-extending band, to pass between the pubis 
 and the upper part of the thigh, and to be attached to the 
 upper extremity of the long splint, and an extending band, 
 for the purpose of firmly connecting the foot with the lower 
 end of the same splint ; lateral pressure was made by means 
 of several strips of muslin, which drew the splints and the 
 pads firmly against the limb on each side, while the thigh was 
 enveloped in a bandage of Scultetus. 
 
 The objection to this particular apparatus is, that the ex- 
 tending and counter-extending forces do not act sufficiently 
 parallel with the axis of the limb. This difficulty is obviated 
 by the very simple modification which Dr. Physick made of 
 the apparatus of Desault. This consisted in making the 
 outer splint long enough to extend from the axilla to about 
 four inches beyond the sole of the foot, and in attaching to 
 its inner side, at about two inches above its lower end, a 
 block, grooved on its inner margin, and broad enough to 
 reach the line of the middle of the foot (fig. 69) ; the other 
 component parts of the apparatus are the same as are used 
 15* 
 
174 
 
 FRACTURES OF THE OS FEMORIS. 
 
 Fig. 69. ■ 
 
 in Desault's. The counter-extending band is best made by 
 filling a narrow bag of muslin, about three-fourths 
 of a yard long, firmly with bran, or oat-chaff, so as 
 to form a cylinder of an inch in diameter ; to each 
 extremity a piece of strong tape should be securely 
 sewed, for the purpose of attaching the band to the 
 upper extremity of the splint ; when this is applied, 
 a piece of soft buckskin should be interposed be- 
 tween it and the skin, as a preventive of excoriation 
 and chafing. Extension is best effected by means 
 of a gaiter, similar in shape to that represented in 
 the annexed wood-cut (see fig. 70) ; it should be made 
 of strong muslin lined with soft buckskin, both to be 
 cut "bias" so that the gaiter will set smoothly to the 
 ankle ; stout tapes should be attached to its lower 
 edge, one on each side, to make traction upon it and 
 to secure it to the splint, and three or four shorter 
 tapes should be sewed to each free margin, to tie the 
 gaiter upon the anterior part of the foot. Previous 
 to its application, the ankle should be bathed with 
 whiskey, or soap-liniment, or spirits of camphor, and 
 enveloped smoothly in a pad of soft carded cotton ; 
 then the gaiter should be fitted nicely to the part, 
 and tied. The following plan may be pursued in 
 arranging and applying this apparatus, or that of 
 Desault : Place upon the mattrass, and in a position 
 to correspond with the fractured limb, the splint- 
 cloth — a piece of muslin about two yards long, and 
 as wide as the length of the inner splint, — and upon 
 this arrange the strips of a bandage of Scultetus ; 
 then lay the patient carefully upon the mattrass, so 
 that the broken thigh, previously divested of clothing, 
 shall repose upon the strips and the splint-cloth ; 
 next pass the perineal band under the buttock, and 
 tie the gaiter around the ankle, as before directed ; 
 the limb being carefully steadied by an assistant, roll 
 the splints in the cloth, commencing at the margins, leaving 
 only space enough between each side of the limb t and the cor- 
 responding splint, thus enveloped, to admit of the presence 
 of the junk-bag, — the long pad before spoken of. (The 
 proper rolling up of the splints requires some time and 
 
FRACTURES OF THE OS FE MORIS. 175 
 
 trouble — they should be tightly wrapped, so that when 
 pressure is used laterally upon 
 the limb, they may not slip, and FlG - ' r0 - 
 
 thus leave a larger space be- 
 tween them and the leg than is 
 compatible with the accomplish- 
 ment of one of the objects for 
 which they are employed, viz., 
 the exercise of an equable and 
 firm compression upon the limb, 
 by the aid of the junk-bags.) 
 The splints being thus prepared for use, extension and counter- 
 extension should be made by assistants, the one grasping the 
 foot and ankle, and the other fixing the pelvis — by one hand 
 passed between the thigh and the pubis and ischium, and the 
 other on the outside of the hip — while the surgeon coaptates 
 the fragments, and adjusts the shape of the thigh ; he then 
 arranges the bandage of Scultetus, and afterwards presses 
 the junk-bags and the splints firmly against the sides of the 
 limb ; the counter-extending and extending bands should now 
 be tightly secured to their corresponding extremities of the 
 long splint, — the tapes attached to the gaiter passing over the 
 grooved margin of the block, before described. To secure 
 the limb in this adjustment, three or four strips of muslin 
 should be passed underneath the apparatus, at intervals along 
 the limb, and tied across, the knot being made upon the edge 
 of one of the splints, to prevent it slipping ; and a broad band 
 should likewise confine the upper part of the long splint to 
 the side. It is sometimes advisable to give additional support 
 to the foot, by tying a strip of muslin around it, and then pin- 
 ning the ends to the snlint-cloth. An arched frame of wire, 
 
 Ox " 
 
 or of hoop, should be placed over the foot, to protect it from 
 the pressure of the bed-clothes. 
 
 The limb should be placed out from the axis of the body, 
 particularly in those cases where the fracture is at such a 
 point as that the gluteus maximus muscle will draw the upper 
 fragment of bone outwards. 
 
 It is well to use the bandage of Scultetus during the first 
 few days after the injury, since it makes gentle and equable 
 pressure upon the muscles of the thigh, and assists some- 
 what to keep the fragments of the bone in apposition ; after 
 
176 FRACTURES OF THE OS FE MORIS. 
 
 the first week or ten days, however, it is probably as well, or 
 better, to remove it, leaving the thigh exposed to the eye of 
 the surgeon. 
 
 Cold lotions should be applied at any time, as they may be 
 called for by the condition of the soft parts ; anodyne lini- 
 ments are sometimes of service in allaying muscular irritabi- 
 lity, and in alleviating pain in the limb. 
 
 Very excellent cures may be effected, undoubtedly, by the 
 use of this apparatus ; but it is one which demands, in its 
 employment, the greatest care and attention on the part of 
 the attendant. There are some points to which the author 
 would call particular notice: — the accidents chiefly to be 
 feared, as directly connected with the use of this splint, are, 
 excoriations and sloughs upon the heel, on the inner side of 
 the knee, at the prominence of the inner condyle of the 
 femur and the corresponding point of the tibia, and in the 
 perineum. These are not necessary accompaniments of the 
 mode of treatment now under consideration, and with proper 
 care they will never occur ; but without great watchfulness 
 they are exceedingly likely to happen ; they may be avoided 
 in this way : — 
 
 The gaiter should be unbound daily, so long as it is worn, 
 and the instep, ankles, and heel carefully examined. During 
 the first week, or ten days, the gaiter should be loosened 
 every morning and evening, and these parts bathed with 
 whiskey, or soap-liniment ; this may be done without in the 
 slightest degree deranging the fragments of bone, simply by 
 turning up the lower ends of the junk-bags, so as to give 
 room for the introduction of the hand between the splint and 
 the foot, — the strips which maintain the lateral pressure 
 being securely tightened. The inner side of the knee should 
 be gently rubbed in the same way, and a little indentation 
 should be made in the junk-bag, corresponding with the bony 
 prominences of the femur and tibia at this point. The peri- 
 neal band should be loosened daily, — the limb being sup- 
 ported the w T hile by an assistant, and the lateral compression 
 maintained, — and the parts upon which it presses bathed, as 
 the others. Whenever the apparatus is thus re-adjusted, re- 
 newed extension and counter-extension should be made, and 
 in order that this may be persevered in until the end of the* 
 treatment, it is highly necessary that the splints shall be so 
 
FRACTURES OF THE OS FEMORIS. 177 
 
 closely wrapped in the cloth, and shall approach the limb, on 
 each side, so nearly, as that firm lateral pressure may be kept 
 up, and thus the strain upon the foot and perineum rendered 
 yery supportable. 
 
 It is advisable, oftentimes, to vary the means by which the 
 extension and counter-extension are effected. Thus, after 
 having used a perineal band of the dimensions and form 
 above recommended, let one be substituted flattened in shape 
 and broader, so as to act upon a larger surface, and thus 
 relieve that part which has been already pressed upon. So 
 with regard to the gaiter, — it will occasionally, perhaps, be 
 well to substitute for this a handkerchief folded into the 
 cravat-shape, and applied so as to press upon the instep and 
 the point of the heel, the tails passing from the sides of the 
 foot, parallel with the 
 
 axis of the limb, and FlG - 71 - 
 
 reaching to the ex- 
 tremity of the long 
 splint upon which 
 they are tied. (See 
 fig. 71.) Another 
 mode of making ex- 
 tension is by means 
 of adhesive plaster, 
 as follows : — Cut two very long strips, of an inch, or more, 
 in width, and apply them to the leg, commencing at a point 
 halfway between the foot and the knee, descending spirally to 
 the side of the foot, one on each side : then, when adhesion 
 between the strip and the integuments has become firm, 
 attach the strips to the extremity of the long splint, as by 
 the other method. This plan was first employed by Dr. 
 E. Wallace, of this city, while Resident Surgeon at the Hos- 
 pital ; he used it as a substitute for the gaiter, which had 
 produced excoriation just above the heel; the author had the 
 pleasure of witnessing the complete success which attended 
 the operation of this novel extending band, both in the in- 
 stance in which it was first tried and in several other cases, 
 and he would recommend it highly, as being perfectly secure 
 and efficacious. It may be proper to make use of a few turns 
 of a roller, or of a bandage of Scultetus, to compress the 
 adhesive strips against the leg, but this is scarcely called for, 
 
178 FRACTURES OF THE OS FE MORIS. 
 
 since the junk-bags exercise sufficient pressure of them- 
 selves. 1 
 
 If there is any disposition to excoriation or sloughing upon 
 the points of the malleoli, pressure should be taken ofi* from 
 them, by not allowing the junk-bags to extend so low down. 
 The same accident may be prevented from occurring upon 
 the point of the heel by placing a cushion just above it, 
 under the leg, so that the weight of the limb shall not fall 
 upon this point. The same simple method may be resorted 
 to when a similar accident threatens the hips or back, — a 
 judicious arrangement of pillows will often obviate much mis- 
 chief, aided also by stimulating liniments applied to the parts. 
 When, in spite of these precautions, sloughing does occur — 
 as it sometimes will in old persons, or in those of lax fibre, — 
 all pressure should be at once withdrawn from the affected 
 surface, and the separation of the dead tissue aided by the 
 application of poultices ; afterwards stimulating washes 
 should be used, among the best of which is Labarraque's 
 solution of the chloride of soda, diluted with three or four 
 parts of water, and applied to the ulcer upon rags, or, if the 
 slough has extended beneath the skin, injected from a 
 syringe. 
 
 There is one objection to the employment of this apparatus 
 of Desault and Physick in the treatment of fractures of the 
 thigh, occurring particularly in the upper third of the shaft 
 — (and the same objection is applicable to the treatment by 
 extension in the straight position, generally) : it is sometimes 
 impossible to counteract, by it, the deformity which arises 
 from the powerful contraction of the iliacus internus and psoas 
 magnus muscles, which tilt up the lower end of the upper 
 
 1 I am greatly indebted to the kindness of Dr. Gross, the distinguished 
 professor of surgery at Louisville, for the knowledge of the fact that this 
 application of adhesive plaster was originally made more than twenty years 
 ago, by Dr. Swift, of Easton. 
 
 In his treatise on " the Anatomy, Physiology, and Diseases of the Bones 
 and Joints" (Philadelphia, 1830, p. 50), Dr. Gross points out the reasons 
 which led Dr. Swift to suggest this means of making extension ; they are 
 precisely those which induced Dr. Wallace to resort to this expedient. Dr. 
 Wallace, I am sure, had no knowledge that any one had previously recom- 
 mended or employed the adhesive plaster for this purpose. 
 
 Latterly, the employment of adhesive strips has been very much extended 
 to the treatment of many other fractures ; as by Dr. Crosby, to fracture of 
 the clavicle. (New York Journal of Medicine, 1851.) 
 
FRACTURES OF THE OS FE MORIS. 179 
 
 fragment. When this action is but slight it may be over- 
 come, gradually, by compression with a splint bound upon the 
 anterior face of the thigh, or by a compress, or, finally, by a 
 little elevation given to the lower fragment by means of a 
 folded sheet placed beneath the thigh, at this point. But in 
 very athletic patients the muscles in question may contract 
 too powerfully, and then these means will fail ; if the straight 
 splints are retained, a permanent deformity will ensue and 
 the limb will be always weak, in consequence of the imper- 
 fect apposition of the fragments. In such cases as these, the 
 double inclined plane should be substituted for the other 
 apparatus. 
 
 The apparatus of Desault, improved as above described, is, 
 we think, the best which has yet been contrived for the treat- 
 ment of fractures of the thigh, in the extended position. 
 
 There are several other modifications of Desault's appara- 
 tus, less simple than the one which we have explained. 
 
 The late Dr. Hartshorne, of this city, invented one in 
 which the long and the short splints are connected together 
 by a transverse piece, through which a long wooden screw 
 passes, having a foot-board attached to it. 
 
 Dr. T. H. Bache, lately resident Surgeon to the Pennsyl- 
 vania Hospital, has modified Physick's apparatus as follows : 
 A long, narrow fenestrum is cut in the outer splint, extend- 
 ing upwards from near its lower extremity ; in this slides 
 an iron arm, capable of being firmly fixed by screw-clamps at 
 any point, so as virtually to lengthen or shorten the splint in 
 adaptation to limbs of different length; through this arm 
 passes a long screw, its axis being continuous with that of the 
 limb when placed between the two splints, and to the upper 
 or proximal end of the screw is attached a transverse piece 
 of iron, having a hole pierced through each extremity. To 
 apply this apparatus, the limb is placed between the two 
 splints, and a counter-extending band and junk-bags are 
 arranged just as in Physick's method ; but the extending tapes 
 or adhesive strips are secured to the transverse iron plate 
 last spoken of, so that the elongation of the limb is accom- 
 plished by acting upon the screw which passes through the 
 arm that is connected to the outer splint. The arrangement 
 is very neat, and the apparatus light and strong. Its action 
 is very well spoken of by the gentlemen who are attached to 
 
180 FRACTURES OF THE OS FE MORIS. 
 
 the Pennsylvania Hospital; it is believed by them that it 
 effects elongation of the shortened limb more gradually than 
 Physick's splint, and that it enables the surgeon to judge 
 accurately whether or not he is really gaining in this 
 particular. 
 
 I must confess that I should prefer the simpler apparatus 
 of Dr. Physick. From having seen Dr. Bache's splint in use 
 at the Hospital in two or three cases of fractured thigh, my 
 impression is that the foot is not as securely and steadily held 
 by this as by the other ; and it appears to me that to make 
 extension by the screw, rather than by the hands directly ap- 
 plied to the limb, is more likely to endanger excoriation of 
 the foot. The stretching of the extending strips or tapes, 
 under the force constantly acting upon them, will readily de- 
 ceive any one who trusts to the mere operation of the screw 
 to inform him as to the improvement in the length of the 
 limb. Moreover, the simplicity of Physick's apparatus is in 
 itself an advantage and a recommendation. Perhaps the 
 splint of Dr. Bache might be improved by attaching to the 
 screw a foot-piece, to which the foot should be immediately 
 secured, instead of having a simple transverse piece. 
 
 Boyer's apparatus is composed of a long splint for the ex- 
 ternal side of the limb, with a movable foot-board connected 
 therewith ; of two straight splints for the anterior and inner 
 faces of the limb ; a belt enclosing the upper part of the 
 thigh and the groin, and giving a "point d'appui" to the 
 upper extremity of the outer splint ; straps to secure the foot 
 to the foot-board ; cushions, and tapes to confine the appara- 
 tus upon the limb. The outer splint is the only complicated 
 part of the apparatus. It is about four feet long and as 
 many inches in width ; from its lower extremity upwards, 
 along about half its length, runs a groove in which a screw 
 plays ; the upper end of the screw turns upon an iron plate, 
 while the other extremity, at the end of the splint, has a key 
 attached to it, by which it is made to revolve. A foot-piece, 
 made of iron, and padded, is connected with the screw, upon 
 the inner side of the splint, and is moved nearer to, or far- 
 ther from, the lower extremity of the latter by revolutions 
 of the screw, so as to make the necessary extension, while 
 the upper end of the splint fits into a little pouch upon the 
 thigh-strap, thus effecting the counter-extension : the foot- 
 
FRACTURES OF THE OS FE MORIS. 
 
 181 
 
 piece has two legs upon which it rests. In the application 
 of this apparatus the foot is attached to the iron plate ; the 
 upper end of the splint is inserted into the pocket of the 
 thigh-belt, which has been previously passed around the 
 upper part of the thigh and groin ; a long pad protects the 
 limb from contact with the outer splint, and equalizes the 
 pressure from it ; then, after the reduction of the fracture, 
 the inner and anterior splints, well padded, are placed upon 
 the thigh, and the whole is secured by means of several 
 bands, as shown in the figure. (See fig. 72.) As much ex- 
 tension as the surgeon thinks necessary is made by turning 
 the screw, thus drawing down the foot, and with it, of course, 
 the lower fragment of the broken femur. 
 
 Fig. 72. 
 
 Mr. Liston recommends the employment of a single 
 straight splint of deal-board, long enough to extend from 
 opposite the nipple to three or four inches beyond the foot ; 
 near its upper end two holes are bored, and the lower extre- 
 mity is notched, while just above the latter is a perforation 
 large enough to accommodate the malleolus ; the splint is co- 
 vered on its inner face by a cushion. The leg is bandaged 
 
 Fig. 73. 
 
 from the toes nearly to the seat of fracture, before the splint 
 is applied: then the fracture is reduced, and the perineal 
 16 
 
182 
 
 FRACTURES OF THE OS FE MORIS. 
 
 Fig. 74. 
 
 band — made as for Desault's apparatus — is tied to the upper 
 end of the splint, to which the whole limb and the side of the 
 body are now confined by means of a roller, — several turns 
 being passed around the foot, and gaining support from the 
 notches made in the lower end of the splint. (Liston's Pract. 
 Surg.) (See fig. 73.) 
 
 Drs. Kimball and Sanborn, of Lowell, Mass., have contrived 
 a single splint for the treatment of fractures 
 of the thigh, which is figured in Miller's Prac- 
 tice of Surgery. (Fig. 74.) 
 
 It extends from the axilla to below the foot, 
 but is so contrived as to be capable of being 
 lengthened at each extremity. The upper end 
 terminates in the manner of a crutch ; the 
 lower has a sliding bar fitted to it, upon which 
 a transverse arm is secured at right-angles. 
 In using this splint, " two long pieces of strong 
 adhesive strap are applied, one on each side 
 of the limb, extending from above the knee to 
 the ankle, and these are secured by a roller. 
 The end of each strap is uncovered with adhe- 
 sive matter, and hangs loose from the foot. 
 The ends of each strap are secured to the 
 cross-bar at the splint's extremity, and the 
 limb is made one with the splint in the ordi- 
 nary way. By turning the screw, the cross- 
 bar is moved up or down, at will, and extension 
 consequently is regulated with both accuracy 
 and power. The perineal band is employed 
 besides, but should its pressure prove at any 
 time galling, it may be temporarily discon- 
 tinued with safety, the crutch of the splint 
 being moved up into the axilla, to supply its 
 place." (Miller's Practice, p. 652.) 
 
 We do not see that the screw-extension 
 power is of much advantage, and we can by 
 no means advise any one to dispense with the 
 perineal counter-extending band, because the 
 axilla does not offer a fixed point of resistance. 
 And, moreover, it is impossible to preserve the proper shape 
 and direction of the limb if only one splint is used. 
 
FRACTURES OF THE OS FE MORIS. 
 
 183 
 
 The same objection is applicable to the original splint of 
 Hagedorn, which consists of a single long splint and a foot- 
 board, the latter being broad enough to support both feet, 
 and moving up and down, but capable of being secured at any 
 point upon the splint. 
 
 Dr. Gibson, Professor of Surgery in the University of 
 Pennsylvania, has introduced a modification of Hagedorn's 
 apparatus, which he thus describes — (" Institutes and Prac- 
 tice of Surgery," vol. i.): — " This method consists in extend- 
 ing the patient's limbs upon a mattrass, and confining both 
 feet, by gaiters, or a handkerchief, to a footboard which is 
 firmly supported upon the ends of two splints passed through 
 mortices near its edges. These splints extend from the arm- 
 pit, where they are padded like the head of a crutch, along 
 each side of the body, thigh and leg, beyond the foot, and, 
 being well stuffed on their inner surfaces to prevent irritation, 
 are confined by six or eight 'broad tapes or bandages passed 
 around the limbs, pelvis, chest, &c. (See fig. 75.) 
 
 ." The principle upon which extension and counter-extension 
 are effected by this contrivance, will instantly be understood. 
 The sound limb being extended, serves as a splint to the bro- 
 
 Fig. 75. 
 
 *i(f?Tw 
 
 ken one. Counter-extension then is made upon the acetabu- 
 lum of the sound side, and extension upon the ankle of the 
 injured limb, which, so long as the two feet are kept on the 
 same level, cannot be shortened, provided rotation of the 
 pelvis be prevented. This purpose is answered by extending 
 the splints to the arm-pits, and not with a view, as might be 
 supposed, of producing counter-extension from these points. 
 Finding that the patient, in the original machine of Hage- 
 dorn, could incline the pelvis towards the affected side, and 
 
184 FRACTURES OF THE OS FE MORIS. 
 
 thereby shorten the limb, by causing the superior fragment 
 to descend and overlap the inferior, the additional splint 
 was added, and has been found to answer completely the end 
 designed/' 
 
 During my residence in the Pennsylvania Hospital, I had 
 the opportunity of testing the efficacy of this apparatus, in 
 two cases of fracture of the thigh, — one in a child, the other 
 in an adult. In both instances, the result was as satisfactory 
 as I have ever seen to follow the employment of any other 
 method : I was led to make use of this apparatus, because the 
 skin about the ankle and perineum of the child was so very 
 tender, as to render the pressure upon these parts, from the 
 gaiter and counter-extending band of Desauit's apparatus, 
 insupportable, and, moreover, he was not sufficiently restrained 
 by this last-mentioned apparatus; — and because, in the in- 
 stance of the man, the whole instep was much bruised by the 
 same fall which caused the fraclure of the thigh. The plan 
 which I adopted was the following : — A straight splint was 
 first confined to the under surface of the sound limb, to pre- 
 vent flexion of the knee ; the splints were then placed on 
 each side of the patient ; the sound foot was secured to the 
 foot-board ; long pads protected the outer sides of the limbs 
 from contact with the boards ; the fractured thigh was brought 
 to the same length as the other, and the foot bandaged to 
 the foot-board; a firm junk-bag was now inserted between the 
 limbs along their whole length, so that the injured limb should 
 be supported at every point by the other, and several wide 
 strips of muslin were made to enclose in their grasp each 
 thigh, with its splint and the junk-bag; finally, the splints 
 above the pelvis were pressed against the patient's sides, by 
 means of muslin bands, and in the same manner lateral 
 pressure was effected upon the whole apparatus. 
 
 The management of this apparatus requires great atten- 
 tion ; its confinement is very irksome to the patient, as it 
 imprisons both limbs. It is particularly troublesome, when 
 he has an evacuation of the bowels to effect, because he can- 
 not assist himself, nor the attendant, with the sound leg ; 
 when it is employed, therefore, a clinical frame, such as has 
 been described, should be used instead of an ordinary frac- 
 ture-bed, or the fracture-bed herein described, will be found 
 serviceable and convenient. 
 
FRACTURES OF THE OS FEMORIS. 185 
 
 The same care as when the other splints are resorted to, 
 is requisite, with regard to the prevention of injury to the 
 parts of the integuments pressed upon, as the heel, ankles, 
 hips, &c. 
 
 It is proper to mention that, in the man upon whom this 
 apparatus of Dr. Gibson was tried, the fracture was at the 
 lower third of the femur, and that the thigh was not a very 
 muscular one. "Whether a sufficient degree of extension can 
 be accomplished by it, to maintain in coaptation the frag- 
 ments of a thigh-bone, when the muscles of the limb are fully 
 developed, and when the fracture is higher up, within the 
 operation of the glutaeus muscle, the author cannot affirm ; he 
 has a sufficiently good opinion of the apparatus, however, to 
 be induced to use it again. 
 
 In fractures of the shaft occurring in young children, the 
 method recommended by Mr. Liston, as before described, 
 with the addition of curved splints for the anterior, posterior, 
 and inner surfaces of the thigh, is the most convenient and 
 the best plan of treatment. The naturally slightly curved 
 shape of the bone should be recollected, and this conforma- 
 tion should be secured by the proper use of compresses. 
 
 2. For fractures of the thigh at its upper extremity. 
 
 The general principles of treatment in these cases are the 
 same as when the shaft is broken ; but there are so ae ana- 
 tomical and physiological peculiarities of the pelvic extremity 
 of the os femoris, which require corresponding modifications 
 of treatment, when this part of the bone is ruptured. 
 
 When the fracture occurs within the capsular ligament of 
 the joint, bony union, according to the best authorities, is at 
 least exceedingly improbable, though not impossible. (See 
 Sir A. Cooper, Cruvelhier, R. W. Smith, &c.) The acci- 
 dent happens, moreover, for the most part, to persons ad- 
 vanced in life and incapable of supporting long confinement 
 in bed in any one position. Concerning the treatment of 
 these cases, Sir A. Cooper makes the following remarks : — 
 " I would prefer a ligamentous union to the confinement and 
 danger of bony union, in regard to the health and life of the 
 person, and, as I believe, to the subsequent use of the joint. 
 Baffled in our various attempts to cure these cases, and find- 
 ing the life of the patient occasionally sacrificed under the 
 trials made to procure bony union, I should, if I sustained 
 16* 
 
186 FRACTURES OF THE OS FE MORIS. 
 
 this accident in my own person, direct that a pillow should be 
 placed under the limb throughout its length ; that another 
 should be rolled up under the knee, and that the limb should 
 be thus extended until the inflammation and pain had sub- 
 sided. I should then daily rise and sit in a high chair, to 
 prevent a degree of flexion which would be painful ; and, 
 walking with crutches, bear gently on the foot at first, then, 
 gradually more and more, until the ligament of union had 
 become thickened, and the muscles increased in their power. 
 A high-heeled shoe should be next worn, by which the halt 
 would be much diminished. Our hospital patients, treated 
 after this manner, are allowed in a few w T eeks to walk with 
 crutches ; after a time a stick is substituted, and in a few 
 . months they are able to use the limb without any adventitious 
 support." (Sir A. Cooper, op. cit., p. 142.) 
 
 When the solution of continuity has occurred partly within 
 and partly without the capsular ligament, or through the 
 great trochanter, the displacement is less, and it is more 
 easily obviated. The limb should be kept in the extended 
 position, by any of the methods which have been described, 
 and the outer splint should be pretty firmly pressed against 
 the trochanter and the side of the body by a circular band- 
 age. The apparatus of Dr. Gibson would answer admirably 
 in these cases. 
 
 If the trochanter major be merely severed from the root 
 of the neck, the axis of the bone not being involved, there is 
 no shortening of the limb, and the treatment of the accident 
 is very simple. The patient should be kept upon his back, 
 with the limb in the extended position, and rendered in- 
 capable of flexion at the knee and thigh by means of a well- 
 padded splint, extending from above the tuberosity of the 
 ischium to near the heel, and secured thus by rollers ; in 
 addition, a broad band should be passed around the pelvis, to 
 compress the fragment of the trochanter upon its place. 
 
 The annexed wood-cut illustrates a method pursued by Sir 
 A. Cooper, in the treatment of this injury. The patient is 
 lying upon a fracture-mattrass, to the foot of which is attached 
 an upright support for the sole of the foot ; a broad band 
 grasps the trochanter and presses it upon its natural seat. 
 (See fig. 76.) 
 
 3. For fractures at the lower extremity of the femur. 
 
FRACTURES OF THE 08 FEMORI: 
 Fig. 76 
 
 187 
 
 I'llllII llllll II li"" I 
 
 The thigh-bone may be broken transversely just above the 
 condyles, or obliquely, or the fracture may extend through 
 the condyloid expansion into the joint. 
 
 In the first case, there is oftentimes no displacement, or if 
 the axis of the limb has been deranged, the fragments, after 
 reduction, are easily retained in apposition by lateral com- 
 pression and rest in the extended position. 
 
 When, however, the fracture extends obliquely from behind 
 forwards and downwards, as is usually its line of direction, or 
 even from before backwards and downwards, the powerful mus- 
 cles which descend from the pelvis act with great energy upon 
 the lower fragment, and draw it upwards, leaving the ex- 
 tremity of the upper fragment, in the first-mentioned variety, 
 projecting anteriorly and penetrating the rectus muscle, 
 sometimes perforating the integuments even. The treatment 
 of this injury consists in keeping up strong extension and 
 counter-extension in the straight position, and in making as 
 firm compression upon the fragments, when reduced, as the 
 condition of the parts will allow, aided generally by evapora- 
 ting lotions, leeching, &c, &c. After the lapse of three or 
 four weeks, passive motion should be commenced cautiously 
 and persisted in. (Sir A. Cooper.) 
 
 Others advise that the limb should be secured upon the 
 double inclined plane, the foot being well supported. They 
 urge in favour of this position, that it relaxes the muscles 
 which act so powerfully upon the lower fragment, and thus 
 renders sufficient a less degree of extension upon the inflamed 
 joint, while the mere pressure of the under surface of the 
 limb upon the plane counteracts in a great measure the 
 retraction of the lower fragment. 
 
188 FRACTURES OF THE OS FEMORIS. 
 
 A strong argument in favour of the straight position is 
 that, if anchylosis should occur, the limb is in a much 
 more desirable position than if the double inclined plane is 
 employed. 
 
 When one of the condyles is separated from its connexion 
 with the lower portion of the femur, the extended position is 
 certainly the most favourable one for the relief of the acci- 
 dent. A piece of pasteboard, large enough to inclose the 
 posterior two-thirds of the joint, and notched along its mar- 
 gins to enable it to adapt itself better to the form of the part, 
 should be softened in hot water and then moulded about the 
 posterior face of the knee, and secured thus by means of a 
 roller ; Desault's apparatus, or a single straight splint for the 
 under surface of the limb, will complete the necessary con- 
 fining means. 
 
 4. For compound fractures of the thigh, the same general 
 principles of treatment exist as for the simple : the accident 
 should be converted into a simple fracture, if practicable, by 
 immediate closure of the wound ; and during the whole pro- 
 gress of the case, the natural conformation and length of the 
 limb should be preserved, as far as possible. It must be 
 borne in mind, however, that some degree of shortening will 
 occur almost of necessity, in consequence of necrosis of the 
 broken extremities of the bone, and because, from the nature 
 of the injury, the same degree of extension and of lateral 
 compression cannot be maintained as in cases of simple 
 fracture. 
 
 The limb may be placed in the flexed position on a double 
 inclined plane, or it may be extended by means of any of the 
 different sorts of apparatus already described, or, finally, it 
 may be placed in a long fracture-box, the sides of which are 
 connected by hinges with the bottom piece, and extend, on 
 the outer side to the axilla, and on the inner to trj.e pelvis, 
 the foot being secured to a perpendicular plane attached to 
 the lower extremity of the bottom-piece. In this box, the 
 limb may repose upon a bed of bran, which also affords the 
 necessary lateral pressure when the sides of the box are 
 closed. Probably, if the fracture be seated in the vicinity 
 of the middle of the bone, it can be treated as well in Phy- 
 sick's apparatus as in any other. Either of the splints can 
 be bracketted opposite the point of injury, as is represented 
 
FRACTURES OF THE OS FE MORIS. 
 
 189 
 
 in the accompanying drawing from Mr. Erichsen's Treatise, 
 in which Mr. Liston's splint is thus arranged. (Fig. 77.) 
 
 Fig. 77. 
 
 The bandage of Scultetus is, as in other compound frac- 
 tures, the best compressing bandage, as it admits of removal 
 and adjustment without disturbing the limb. The wound 
 itself should be uncovered, excepting by a poultice, or some 
 similar dressing, so that the matter may have free escape, 
 and this should be aided by moderate pressure upon the thigh, 
 above and below the wound, effected by the bandage, which 
 should be made to act with particular care on any point or 
 points beneath which the matter may be disposed to collect : 
 if an abscess should form at any point remote from the wound, 
 as happens in almost every compound fracture, it should be 
 opened by the knife. 
 
 The dressing for the wound must be varied to suit its ap- 
 pearance at different times. Great cleanliness of the parts, 
 and also of the dressings, should be observed. 
 
 The great length of time during which it is necessary to 
 confine the patient to bed renders it advisable to resort to 
 every expedient to prevent sloughing ; besides the frictions 
 heretofore recommended in compound fractures, the position 
 of the patient should be changed, from time to time, as far as 
 may be consistent with the security of the limb ; the use of the 
 inclined plane, for example, may be alternated with that of 
 the straight splints. 
 
 When the condition of the wound will allow of more direct 
 compression being exercised about the seat of fracture, this 
 means should be instituted as an aid in securing a proper shape 
 to the thigh. For this purpose, strips of adhesive piaster, or 
 of soap plaster, may be employed, — while the roller, or the 
 
190 FRACTURES OF THE PATELLA. 
 
 bandage of Scultetus, cannot be used, — an interval being left 
 between the strips, for the ready escape of the pus. 
 
 SECTION II. 
 
 ON THE APPARATUS AND DRESSINGS FOR FRACTURES OF THE 
 
 PATELLA. 
 
 The patella may be broken longitudinally, or transversely. 
 
 1. Longitudinal fractures of this bone are attended with 
 little or no displacement of the fragments, as a general rule ; 
 hence the probability of perfect reunion by bony matter is 
 great, and the treatment is very simple. The leg should be 
 extended upon the thigh, and the thigh flexed to a moderate 
 degree upon the pelvis, while a roller is passed around the 
 limb, from the toes to the upper part of the thigh, being made 
 to exercise considerable lateral pressure upon the fragments 
 of the patella, by means of compresses placed at each side of 
 the bone. The limb should be laid on a simple inclined plane, 
 and, for the sake of greater security, a splint should be bound 
 to its under surface. The application of these retentive means 
 should be preceded, if there be much inflammation about the 
 joint, by leeching; and after the bandage is applied, cold lo- 
 tions may be employed, if required. 
 
 2. When the fracture has assumed a transverse direction, 
 a considerable degree of separation of the fragments is una- 
 voidable, the retraction of the upper portion varying from one 
 to three or four inches, according to the power of the exten- 
 sor muscles which are connected with the base of the patella, 
 and to the position in which the limb has remained after the 
 injury. 
 
 A variety of mechanical contrivances have been resorted to, 
 to remedy the effects of this accident and to maintain the frag- 
 ments in apposition. The bond of union is usually ligamen- 
 tous, so commonly that Pibrac offered a prize of one hundred 
 louis d'or to any one who would show him a specimen of trans- 
 verse fracture of the patella cured by bony union. Specimens 
 of this mode of healing do, however, exist. But it must be 
 borne in mind by the surgeon that, although a very good ap- 
 
FRACTURES OF THE PATELLA. 
 
 191 
 
 position may have been gained and retained during the treat- 
 ment, the ligament of union almost invariably becomes elon- 
 gated after the patient commences to use the limb, even when 
 a splint has been bandaged to its under surface and worn thus 
 for a long time after confinement to bed has ceased. This fact 
 should always be impressed upon the patient and his friends, 
 as otherwise the surgeon may suffer in reputation. 
 
 The treatment recommended by Sir A. Cooper is, that the 
 limb be lightly bandaged to a straight splint placed all along 
 the under surface of the limb, the knee being left entirely un- 
 covered ; that the extensor muscles of the leg be relaxed by 
 elevating the limb upon an inclined plane, while the trunk is 
 flexed upon the pelvis, and that local antiphlogistic remedies 
 be applied upon the joint, until inflammation shall have ceased. 
 Then " a roller is applied from the foot to the knee, to pre- 
 vent the swelling of the leg, and the upper portion of the pa- 
 tella is pressed downwards towards the lower, as far as it can 
 be without violence, so as to produce the approximation of the 
 fragments. Rollers are applied above and below the joint, 
 confining a piece of broad tape next the skin on each side, 
 which crosses the rollers at right angles ; these tapes are next 
 bent down and tied over the rollers, so as to bring the latter 
 near to each other, and thus to keep down the upper portion 
 of bone. Sometimes, instead of the tape on each side, a broad 
 piece of linen is bent over the rollers on the fore part of the 
 joint, and is there confined, so as to approximate the portions 
 of bone and to bind down the upper fragment of the patella, 
 that its lower broken edge may not turn forwards." (Op. cit. 
 p. 205.) (See fig. 78.) 
 
 Fig. 78. 
 
 Another method recommended by the same high authority 
 
192 
 
 FRACTURES OF THE PATELLA. 
 
 is the following : — A leathern strap may be buckled around 
 the lower part of the thigh, above the broken and retracted 
 fragment of bone ; from this circular band another strap should 
 be passed along the side of the leg across the sole of the foot, 
 the leg being extended and the foot flexed as much as possible. 
 This strap is then carried up along the other side of the leg, 
 and buckled to that which has been fixed around the thigh ; 
 it may be confined to the foot by a tape tied to it, and to the 
 leg, at any part, in the same manner. This is a very conve- 
 nient bandage for the fractured patella, and for the patella 
 dislocated upwards by the laceration of its ligament. A roller 
 is to be applied around the leg. (Op. cit. p. 205.) (See fig. 79.) 
 
 Fig. 79. 
 
 M. Desault directed that the limb should be held in the po- 
 sition above advised, by an assistant, and a roller passed 
 around the leg from the toes to the knee, confining on the 
 front of the leg a band about two inches wide and of the 
 length of the limb ; then that two longitudinal slits be made 
 in this band, opposite the patella, through which the surgeon 
 passes tw T o fingers and approximates the fragments : that a 
 compress be applied just above the upper fragment and re- 
 tained there by several turns of the roller passing around the 
 knee in the form of the figure 8 ; the bandage now should cover 
 the thigh, a padded splint, as long as the limb, should be con- 
 fined upon its under surface, and the whole supported on an 
 inclined plane. 
 
 M. Gerdy employs an invaginated bandage, such as is used 
 in the approximation of the lips of transverse wounds. (See 
 chap, on Wounds.) The leg, as high as the knee, is enveloped 
 by a roller, which also confines upon the front of the leg the 
 tailed portion of the bandage, the slit portion being secured 
 upon the front of the thigh by a second roller ; then, having 
 
FRACTURES OF THE PATELLA. 
 
 193 
 
 placed a compress above the upper fragment, and another "be- 
 low the inferior, pass the tails of the bandage through the 
 slits, and approximate the fragments ; this having been effected, 
 lay the portions of the bandage smoothly along the limb, and 
 secure them by turns of a roller. 
 
 Mr. Amesbury has invented an apparatus consisting of 
 two wide leathern pads, to be placed one on the anterior face 
 of the thigh above the knee, the other on the leg below the 
 knee, and attached to each other by straps and buckles. In 
 order to compress the extensor muscles of the leg, and at the 
 same time to avoid unnecessary constriction of the limb, 
 these pads are secured by means of straps and buckles, to a 
 splint placed on the under surface of the member, with a 
 foot-board attached, and made sufficiently wide, opposite the 
 knee, to project a little beyond it upon each side. The upper 
 pad, and with it the corresponding fragment of the patella, 
 is made to approximate the lower by means of a strap, which 
 passes from the lower edge of the upper pad, along the side 
 of the leg, and across the foot-board, to ascend on the other 
 side of the leg and be buckled to the pad. (Amesbury, vol. 
 ii. p. 492, &c.) 
 
 Mr. Lonsdale has contrived an instrument, which he has 
 found very efficacious in the treatment of this fracture. It 
 consists of a splint upon which the limb reposes, and to which 
 a foot-piece is attached in such a way as to be movable up 
 and dow T n, to accommodate the splint to limbs of different 
 lengths ; to the under surface of this splint two vertical iron 
 bars are connected, AB, (see fig. 80,) at about its centre, 
 each one supporting a horizontal arm bent at right angles, 
 G G ; these horizontal pieces slide upon the upright staffs, but 
 
 Fig. 80. 
 
194 FRACTURES OF THE PATELLA. 
 
 can be arrested at any point by the screws, C D ; from these 
 arms depend other vertical rods, movable upon the former, 
 and, like them, fixable by similar screws, E ; finally, to the 
 lower end of each of these second perpendicular rods, an iron 
 plate, F, F, of a horse-shoe form, is attached, by means of a 
 hinge-joint. In the application of this apparatus, the splint 
 should be well padded, and the foot and leg secured to it by 
 a roller, a bandage having been first passed around these 
 parts ; then the surgeon places the fragments of the patella 
 in juxtaposition, the muscles being relaxed as before directed, 
 and applies the upper horse-shoe plate to the upper part of 
 the thigh, a soft pad intervening, just above the superior 
 fragment, — not touching the patella itself, while the other 
 plate is applied just below the inferior fragment ; the plates 
 are secured in these relations by means of the screws, and a 
 roller is passed around the thigh and the upper part of the 
 splint. The limb is retained during the treatment in the 
 same position as in the other modes already described. 
 
 Mr. Lonsdale states the advantages of this apparatus to be, 
 that it may be applied immediately after the fracture occurs, 
 that it produces no constriction of the limb, and that it 
 leaves the injured part exposed to the inspection of the sur- 
 geon during the w 7 hole course of the treatment, and allows of 
 the application of antiphlogistic remedies ; he has found it to 
 answ 7 er the purpose for which it was intended, in a very satis- 
 factory degree. (Op. cit., p. 427, &c.) 
 , Mr. Fergusson describes a very simple and neat apparatus, 
 contrived by Mr. John Wood, for the treatment of this injury. 
 It consists of a splint extending from the pelvis to the sole 
 of the foot, hollowed to receive the limb, and a foot-piece 
 attached ; the lower extremity of the splint rests upon 
 block, so that when applied, the plane upon which the member 
 reposes, is inclined. The limb is confined upon the splint by 
 means of rollers, the fragments of the patella being retained 
 in apposition by a few turns after the manner of the figure 8, 
 and to prevent these latter turns of the roller from slipping, 
 two hooks are screwed into each side of the splint, above and 
 below the position of the knee, around which the bandage 
 passes. (Fig. 81.) 
 
 The apparatus of Boyer, of Dorsey, Mogridge, and others, 
 
FRACTURES OF THE PATELLA. 195 
 Fig. 81. 
 
 offer no particular advantages above those which have been 
 described. 
 
 M. Malgaigne, in his excellent " Traite des Fractures, p. 
 764, states, that he has seen M. Gama, surgeon to the mili- 
 tary hospital of Val de Grace, treat successfully cases of 
 transverse fracture of the patella, by means of strips of adhe- 
 sive plaster passed above and below the fracture, in the form 
 of the figure 8, the limb being placed upon the simple in- 
 clined plane. And in the Philadelphia Medical Examiner, 
 p. 5, Jan., 1854, Dr. John Neill reports two cases of this 
 injury in which this method was pursued. It is, undoubtedly, 
 the simplest and the best plan which can be resorted to. 
 
 After the limb has been thus confined for six or eight 
 weeks, passive motion should be commenced and practised 
 cautiously but diligently ; in the course of two weeks' longer 
 time, the patient may be permitted to bear moderately upon 
 the foot in walking, a splint being bound to the under surface 
 of the limb ; he should step on the sole of the foot flatly, 
 and not on the toe ; the splint should be worn thus, for a few 
 weeks. 
 
 3. Rupture of the tendon, and of the ligament of the 
 patella should be treated in the same manner as if the bone 
 itself were broken. 
 
 4. Compound fractures of the patella require the same 
 general principles of treatment as the simple forms. But in 
 addition to the injury done to the bone, that which is inflicted 
 upon the soft parts and on the joint demands attention, and 
 modifies the treatment. The indications are, to close the 
 
 ound immediately, in the hope that it will heal without being 
 accompanied by violent constitutional disturbance, and to 
 
196 FRACTURES OF THE PATELLA. 
 
 retain the fragments of the patella in as close apposition as 
 the condition of the parts will permit. The limb must be 
 placed upon a splint in the same position as directed for 
 simple fracture, the body being well supported in the flexec 
 position on the pelvis, by pillows arranged behind the back. 
 The lips of the wound, after all foreign matter has been 
 removed from the opened joint, should be drawn together by 
 strips of adhesive plaster, which strips may be so applied as 
 to draw down the upper fragment of the patella, and to retain 
 it in apposition with the lower : then a piece of lint shoulc 
 be dipped in the blood which flows from the part, or in some 
 adhesive and glutinous fluid, and laid upon the wound, where 
 it should be retained by a light bandage ; all pressure being 
 avoided upon the joint itself, the muscles of the thigh may 
 be moderately compressed by a roller, the same which con- 
 fines the splint upon the limb. Thus arranged, the dressing 
 should not be disturbed so long as no unpleasant symptom 
 arises ; such as severe inflammation, free suppuration, &c. 
 In a case recorded by Sir A. Cooper (op. cit., p. 210, 11), 
 the first applications were not removed until a month after 
 the accident, when the wound was found nearly healed ; the 
 patient in this case recovered with a perfectly useful limb. 
 
 The author treated in this manner, at the hospital, a case 
 of compound fracture of the patella, produced by a kick from 
 a horse, in which a similarly happy cure followed. If, how- 
 ever, violent inflammation follows the injury, with profuse 
 discharge and much constitutional suffering, the primary 
 dressing must be at once removed, and antiphlogistic reme- 
 dies resorted to, — as local and general depletion, poultices, 
 or water-dressings, &c, &c. Passive motion should be cau- 
 tiously instituted as soon as circumstances will admit of it. 
 The introduction of sutures should be avoided as much as 
 possible ; if employed, care should be exercised not to include 
 the ligament in the suture. (Sir A. Cooper, op. cit., case 137, 
 p. 210.) 
 
FRACTURES OF THE BOXES OF THE LEG. 197 
 
 
 
 SECTION III. 
 FOR FRACTURES OF THE BONES OF THE LEG. 
 
 Like those of the fore-arm, the two bones of the leg may- 
 be broken at the same time, or each may be fractured sepa- 
 rately. 
 
 1. When both the tibia and fibula are broken, the maximum 
 degree of displacement is produced, partly by the violence 
 causing the fracture, and partly by the action of the powerful 
 muscles situated about the leg. The line of fracture is gene- 
 rally oblique, in almost any direction, and this direction influ- 
 ences the course of displacement which the lower fragment 
 assumes. When the solution of continuity of the fibres of the 
 bone is in a transverse direction, there is often no shortening 
 of the leg, but merely a lateral derangement ; when, however, 
 the fracture is oblique, there is both lateral deformity and 
 shortening ; in the former injury, the fragments are easily 
 retained in apposition, after reduction, by rest alone ; in the 
 latter, a continued confining apparatus is necessary to coun- 
 teract the disposition on the part of the muscles to contract 
 and to draw upwards the inferior portion of the bones. Gene- 
 rally, a moderate degree of mechanical force, with the limb 
 in the straight position, suffices for the successful treatment 
 of simple fractures of the leg ; there are instances, however, 
 in which, from the powerful action of the muscles and the 
 direction of the line of fracture, such deformity is produced 
 that it becomes desirable to take advantage of the effect of 
 position to aid the treatment, as in fractures of the thigh. 
 
 The simplest plan of treatment by mechanical means, con- 
 sists in the employment of the " junks ;" — these are generally 
 made of pieces of wood, or of bags of straw, or chaff, rolled 
 firmly in a splint cloth, and long enough to extend from the 
 lower third of the thigh to below the ankle, on each side of 
 the limb. In the application of this apparatus, the junks 
 thus rolled are glided underneath the leg upon a pillow, which 
 supports the whole leg and the heel ; the fracture is reduced, 
 and the mechanical supports brought in contact on each side 
 with the knee and the ankle, all the intermediate parts of the 
 leg being likewise apposed to the lateral supports, either 
 17* 
 
198 FRACTURES OF THE 
 
 directly, or through the intervention of compresses of cotton, 
 or tow ; the whole is secured thus by strips of muslin passed 
 around the junks. 
 
 This apparatus leaves the anterior face of the leg exposed 
 to the examination of the surgeon and to the action of local 
 applications, while at the same time it exerts a sufficiently 
 powerful lateral compression upon the leg, to retain in appo- 
 sition the fragments of the bones, in all cases of transverse 
 fracture, and in many, or most, of the oblique. It does not, 
 however, offer so great a degree of security against sudden, 
 or accidental, movements of the limb, as another apparatus, 
 which is almost as simple as itself, — the fracture-box, of which 
 mention will be made directly. 
 
 Many different kinds of splints have been contrived at 
 various times, and by different surgeons, for the treatment 
 of these injuries. The best have all sought to give support 
 to the inferior surface of the leg and the foot, and also to 
 exert more or less lateral compression. Thus the splints of 
 Mr. Neville, highly recommended by Mr. Lonsdale and others, 
 consist of a light iron piece padded, for the inferior face of 
 the leg, extending from the lower part of the thigh to the 
 foot, at which point it curves upwards, to form a support for 
 the sole of the latter, — and of two lateral splints, of the same 
 length as the other, and also padded, and secured to the sides 
 of the foot-piece by a mortice-and-pinion joint ; circular strips 
 of muslin complete the apparatus. 
 
 The fracture-box, however, combines all the advantages of 
 these with many others which these do not possess, as greater 
 simplicity of construction, and in consisting of but a single 
 piece, as it were, by which greater solidity is gained. It is 
 composed of a horizontal plane of board extending from a 
 little above the knee to the sole of the foot, where a piece, 
 rather longer than the foot, and of the same width as the 
 other plane, is firmly secured to it at right angles : side- 
 pieces, also made of wood, six or seven inches wide, and of 
 the same length as the bottom-piece, are connected with the 
 latter by hinges. (Fig. 82.) To apply this apparatus to the 
 treatment of fractures of the leg, open the sides of the box, 
 and place a pillow upon it, soft enough to adapt itself well to 
 the inequalities of the leg ; then, having reduced the fracture, 
 secure the foot to the foot-board by a strip of bandage, and 
 
BONES OF THE LEG. 
 
 199 
 
 Fig. 82. 
 
 close the sides of the box, more or less tightly, according to 
 
 the condition of the limb 
 
 and the degree of pressure 
 
 requisite to retain the 
 
 fragments of the bones in 
 
 apposition ; the sides are 
 
 thus secured by strips of 
 
 muslin. If the pillow alone 
 
 is insufficient to exert the 
 
 Fig. 83. 
 
 requisite pressure, com- 
 presses should be used in 
 
 addition, and these should be so placed as that the pressure 
 may bear upon those particular points where they are most 
 needed. Thus the proper shape of 
 the limb may be easily preserved, 
 being made more or less curved by 
 the action of the pillow and com- 
 presses. In this manner, some of 
 the most marked deformities may 
 be obviated. Thus, for example, in 
 treating the fracture of which the 
 annexed drawing from Fergusson's 
 Practical Surgery (Am. ed., p. 304) 
 illustrates the appearance, the leg 
 should be placed in the fracture- 
 box, as above directed, and a com- 
 press be applied upon the tibial side 
 of the limb, just above the promi- 
 nence of bone, while another is laid 
 on the fibular side, a little below the seat of fracture ; the 
 compression exercised upon these points, when the sides of 
 the box are closed, will suffice to restore the leg to its proper 
 shape, and to retain the fragments in complete apposition. 
 (Fig. 83.) 
 
 The shape of the sound leg should be compared daily with 
 that of the broken one, and any deviation from the proper 
 line in the latter should be rectified in the manner pointed 
 out. The foot should be kept upright against the foot-board, 
 the heel supported by the pillow, and an additional pad, if 
 necessary. If there be any signs of excoriation or sloughing 
 on the heel, or malleoli, pressure should be immediately 
 
200 FRACTURES OF THE 
 
 removed from these points, and brought to bear upon others, 
 and the surface protected by simple cerate, or stimulated by 
 frictions with spirits of camphor, soap liniment, &c, &c. Care 
 is requisite lest the foot fall below its proper line, as com- 
 pared with that of the sound leg ; to obviate this liability to 
 displacement of the lower fragment, a pad of cotton should 
 be placed under the heel. 
 
 The advantages of the fracture-box are evident : it is per- 
 fectly secure ; very simple in its construction ; fully capable 
 of retaining in place the fragments of the bones, in the vast 
 majority of fractures of the leg, and it leaves the limb always 
 open to inspection, and for the application of local remedies. 
 In very many cases of this fracture, it is necessary or advisa- 
 ble to employ sedative lotions ; one of the best of these is the 
 solution of the acetate of lead ; an objection to this, however, 
 is that in many persons it irritates the skin too much, and in 
 all it is apt to leave a deposition of the salt upon the surface, 
 which is sometimes the source of irritation. When any liquid 
 application is made, or any other dressing which may soil the 
 pillow, a piece of soft oil-cloth should be spread upon the 
 latter, before the leg is placed in the box. 
 
 The fracture-box may be rendered more perfect by placing 
 brackets in each side, through which pieces of iron-wire shall 
 be passed, arching over the box to protect the limb from the 
 pressure of the bed-clothes. 
 
 Very often, indeed, in fractures of the leg, the skin will 
 be found, in the course of a day or two after the accident, 
 covered with small vesicles, particularly near the seat of the 
 injury. This appearance, in persons of ordinarily good con- 
 stitutions, is a matter of no importance, being indicative merely 
 of a certain degree of irritation of the skin, which soon sub- 
 sides under the application of cold water, and often it disap- 
 pears if no local means are used ; but the same appearance in 
 persons of bad constitution, especially in habitual drunkards, 
 is frequently the precursor of erysipelas or mortification, and 
 should be carefully watched. 
 
 The most troublesome simple fracture of the leg is that in 
 w T hich the tibia has been broken obliquely, the line of frac- 
 ture extending downwards and forwards. Here the powerful 
 muscles of the posterior surface of the leg draw the inferior 
 fragment upwards, leaving the sharp extremity of the upper 
 
» BONES OF THE LEG. 201 
 
 part of the bone projecting against the skin, and threatening 
 to produce ulceration of the integuments at this point. Where 
 this action of the muscles is but slight, the fracture-box may 
 be employed, care being had that the inferior fragment, at 
 the seat of the injury, is well supported by a compress placed 
 beneath it. In other instances it will be necessary to adopt 
 some plan of treatment which shall oppose the muscular con- 
 traction by direct extension and counter-extension, or which 
 shall produce the same effect by simply relaxing the muscles 
 in question. If the first mode be resorted to, the splints 
 advised by Dr. Hutchinson, of this city, may be employed. 
 They are two in number, extending from the knee to some 
 inches beyond the foot; the upper end of each splint has 
 perforations made in it, for the attachment of the counter- 
 extending bands, and at the lower extremity of each is a 
 mortise, through which a bar is passed. The leg is laid upon 
 a pillow, upon which a bandage of Scultetus is arranged ; 
 tapes are secured upon each side of the leg, just below the 
 knee, by means of a roller, and a gaiter, or a cravat, is fast- 
 ened to the foot and ankle ; then the fracture having been re- 
 duced, the leg is supported by an assistant, and the bandage 
 of Scultetus folded upon it ; the splints are now placed by the 
 sides of the leg, pads intervening, the counter-extending bands 
 are fastened to the upper ends of the splints, and the extend- 
 ing to the transverse bar passed through the mortises at the 
 lower extremities, and the whole apparatus thus secured by 
 strips of muslin tied around it. The long thigh splints of 
 Desault may also be used for the same fracture, instead of the 
 shorter splints of Hutchinson. 
 
 Mr. Fergusson describes an apparatus contrived by himself 
 and Mr. Weiss, which is intended to obviate the above men- 
 tioned deformities resulting from muscular contraction. It 
 consists of a straight bar of iron, extending from the knee 
 beyond the sole of the foot, to which a foot-piece is attached 
 in such a way as to be movable upwards towards the knee, 
 and also laterally, so as to enable the surgeon to counteract 
 any tendency to inversion or eversion of the foot : screws are 
 so adjusted as to secure the different parts of the apparatus 
 in any desired position. The lower extremity of the splint 
 rests upon an upright arm, which reposes steadily upon the 
 
202 FRACTURES OF THE 
 
 bed (fig. 84). For a more detailed exposition of this appara- 
 tus, the reader is referred to Mr. Fergusson's book, p. 303. 
 
 Fig. 84. 
 
 Whichever of the apparatuses described shall be employed, 
 the surgeon may, if he so choose, suspend the part, — a prac- 
 tice supposed by many to be attended with advantages. At 
 any rate, it serves very well to vary the position, and may 
 thus add to the comfort of the patient. To accomplish the 
 suspension, two or more strong iron bars may be made to 
 arch over the limb, and the apparatus may be suspended 
 from them. Or the more elegant arrangement of Mr. Salter, 
 recommended and described by Mr. Fergusson, (p. 305,) may 
 be used. It is " in most respects like a common metal cradle, 
 but at the top will be seen a strong and smooth bar of iron, 
 on which a couple of pulleys play ; these glide readily along 
 the bar, and there is a hook attached to them below, to which, 
 by means of a chain, a case for holding the leg is attached. 
 When the leg is placed in this case, it will, in slight move- 
 ments of the body, swing from the hook by means of the 
 chain ; and in larger movements — as in using the bed-pan, or 
 taking a new position in bed — -the pulleys will roll to and fro, 
 so that there is no probability of the fragments gliding upon 
 each other, or the seat of fracture being in any way disturbed. 
 The case below is so constructed that various parts of it can 
 be unhooked, so as to permit of dressings being applied in 
 instances of compound fracture." (Fig. 85.) 
 
 If the treatment by position is decided upon, the ordinary 
 double inclined plane may be used, as advised in fractures 
 of the thigh, a foot-board being attached to the lower plane, 
 so that the foot may be well supported in the proper position. 
 
BONES OP THE LEG. 
 
 203 
 
 Or the fracture-box just described may be placed upona 
 double inclined plane, and the leg properly arranged in it. 
 
 Fig. 85. 
 
 The last will probably be found to be the best plan, as the 
 leg can thus be more securely disposed of, than when the 
 plane alone is used ; in the latter case, lateral splints should 
 be employed to steady the leg, and to make the necessary 
 compression upon the sides. By thus flexing the knee, the 
 muscles which draw up the lower fragment of the tibia are 
 rendered almost inoperative, and the apposition of the two 
 portions of bone is secured very readily ; a bandage of Scul- 
 tetus may be advantageously employed for a few days, around 
 the seat of fracture, but it should be removed daily, and the 
 condition of the leg be inspected. 
 
 Mr. Liston has devised a double inclined plane for the 
 treatment of fractures of the leg, which he thinks superior to 
 any other ; it is also well recommended by Fergusson and 
 many other English surgeons. " It consists of a thigh and 
 leg-piece of sheet-iron, and a foot-board of wood ; the former 
 are joined to each other by a couple of hooks and a screw, 
 which is so placed that the two plates can be set to any angle 
 at which it may be desirable to bend the knee, and the foot- 
 board is so affixed that it may be slid upwards or downwards, 
 
204 FRACTURES OF THE 
 
 to suit the length of the limb, and fastened by a side screw 
 in any position that may be advisable. At the lower end of 
 the machine there is a cross-plate of iron, which is so attached 
 that, in the event of the foot being raised or depressed, it 
 will always rest flatwise on the mattrass, or on a board 
 placed at the foot of the bed for the purpose of supporting 
 it." (Fig. 86.) The limb is to be laid upon the splint, 
 which has been well padded ; cotton or tow should be used to 
 adapt the surfaces to each other, and to aid in making press- 
 ure upon particular points, and a roller is then to be passed 
 around the limb and the splint. The angle of the apparatus 
 may be varied as may be judged proper. 
 
 Fia. 86. 
 
 2. If the tibia alone is broken, the displacement cannot be 
 very great ; the accident may be treated by any of the methods 
 above spoken of, or a splint of pasteboard, previously moulded 
 to the leg, may be applied upon the inner or inferior surface, 
 and confined by a roller, or by the starched bandage, and the 
 limb kept at rest upon a pillow. But even in simple fracture 
 of the tibia, it is safer to make use of the fracture-box, at least 
 during the first week or ten days : the same precautions and 
 attentions should be used during the treatment, as in the cases 
 above considered, though they are less necessary. 
 
 3. In fracture of the fibula only, when the injury has oc- 
 curred above the lower three inches of the bone, nothing more 
 than a simple lateral or angular displacement ensues, and the 
 treatment demanded is the same as has been just advised for 
 simple fracture of the tibia. But when the fracture has oc- 
 curred at the lower two or three inches of the bone, consti- 
 tuting what is called "Pott's fracture,'' a great lateral dis- 
 placement is produced, rendered more remarkable by rupture 
 of the internal lateral ligament of the ankle, which in the ma- 
 
BONES OF THE LEG, 
 
 205 
 
 Fig. 87. 
 
 jority of cases is caused simultaneously with the fracture of 
 the fibula. The annexed drawing, taken from 
 Mr. Lonsdale's book, p. 522, exhibits the point 
 at which the bone is usually broken, the rup- 
 ture of the internal ligament, and the peculiar 
 deformity ; (fig. 87,) and it shows the applica- 
 bility of the mode of treatment recommended 
 by Dupuytren. This method consists in the 
 application to the tibial side of the leg of a 
 splint and cushion of peculiar conformation. 
 The cushion, made of cloth and filled two- 
 thirds with chaff, should be two feet and a half 
 long, four or five inches wide, and three or four 
 inches thick. The splint, from eighteen to 
 twenty inches long, two and a half inches wide, 
 and three or four lines thick, should be made 
 of firm and slightly flexible wood. Lastly, the 
 two bandages used should be each four or five 
 yards in length, and two and a half inches wide. 
 The cushion, folded upon itself in the form of a 
 wedge, is applied to the inner side of the fractured limb, upon 
 the tibia, its base directed downwards, being laid upon the in- 
 ternal malleolus, and not passing below it, its apex reposing 
 upon the internal condyle of the femur. The splint laid upon 
 this cushion should extend beyond it, from four to six inches, 
 and beyond the inner edge of the foot three or four inches." 
 One of the rollers is used to confine the upper part of the 
 splint and cushion upon the leg, while the other draws the foot 
 towards the inferior end of the splint, " being directed succes- 
 sively from the latter over the upper surface of the foot, upon 
 its outer side, under the sole of the foot, upon the splint ; then 
 from this upon the instep and under the heel, to return again 
 to the splint, and to be continued in the same manner until all 
 the bandage is used. The foot is brought into such a state of 
 adduction, that its external margin becomes inferior, the sole 
 of the foot being directed inwards, and its internal edge up- 
 wards." (Dupuytren, Lemons Orales, torn. i. p. 226.) The 
 annexed figure illustrates the application of this splint. 
 (Fig. 88.) 
 
 Most cases of this fracture may be treated with complete 
 success by the fracture-box. A reference to fig. 87 will show 
 18 
 
206 FRACTURES OF THE 
 
 the points upon which compresses should be placed, to rectify 
 g8 the deformity ; viz. -one upon the external mal- 
 
 leolus, and the other upon the side of the tibia, 
 just above the extremity of the bone ; then, 
 •when the sides of the box are brought up 
 against the foot-board, the foot will be forced 
 into its proper position, and thus retained. The 
 advantages of Dupuytren's splint are, that the 
 patient need not be confined to bed for any 
 length of time, but may walk with his broken 
 leg supported in a sling depending from the 
 neck, or he may be allowed to travel, if his cir- 
 cumstances require it, provided care be taken 
 to support the member. 
 
 The apparatus, whichever it be that is used 
 in the treatment of fractures of the leg, may be 
 suspended from the ceiling, or from the top of 
 the bed, according to the plan recommended 
 by Sauter and Mayor : this method has been 
 already sufficiently explained, to enable the surgeon to adapt 
 it to the fractures in question. It is difficult, however, to see the 
 particular advantages which would result from such a modi- 
 fication of the stationary apparatus. 
 
 When fractures of the leg occur in persons who are at the 
 same time affected with mania-a-potu, perhaps the most secure 
 bandage will be the starch bandage with splints of pasteboard. 
 4. Compound fractures of the leg must be treated after the 
 general principles recommended in similar injuries of the arm 
 and thigh. The bran-dressing, first resorted to by Dr. J. K. 
 Barton, of this city, and to which allusion has been before 
 made in these pages, is particularly well adapted to the treat- 
 ment of compound fractures of the leg. In such cases, the 
 bran is used as a substitute for the pillow employed in simple 
 fractures. The fracture-box has a sufficient quantity of the 
 bran laid upon the bottom of it, to afford a soft resting-place 
 for the leg ; the leg is placed upon it, the form of the limb ad- 
 justed as well as possible, the foot is properly attached to the 
 foot-board ; then the sides of the box are closed, and the box 
 itself filled with bran. The requisite degree of lateral pres- 
 sure can generally be gained by packing the bran pretty firmly 
 opposite particular parts of the leg : and in addition, a few 
 
BONES OF THE LEG. 207 
 
 strips of adhesive plaster may be drawn around the limb at 
 the point of fracture, without closing the wound entirely, or 
 materially interfering with the ready exit of the pus. Thus 
 the leg is imbedded in the midst of a substance which absorbs 
 at once the discharged matters ; which diminishes the unplea- 
 sant foetor, by secluding the pus from the action of the air ; 
 which is itself clean, light, and cool, and which is easily re- 
 newed. It will be found, moreover, to be the most effectual 
 mode of preventing the deposition of the ova of flies and other 
 insects which, in our warm summers, become developed in the 
 wound and are the source of great inconvenience and annoy- 
 ance. 
 
 The disposition to the formation of abscesses at points 
 remote from the wound is often met with in compound frac- 
 tures of the leg. When formed, they should be opened as 
 soon as possible, and the matter confined between the point 
 of incision and the original wound by a few strips of the 
 bandage of Scultetus laid above the seat of abscess, or below 
 it, as the case may be. 
 
 Very generally in these injuries, the wound is on the ante- 
 rior face of the leg ; but it sometimes happens that the in- 
 teguments are ruptured on the posterior face, or on one side ; 
 in the latter cases the fracture-box may still be employed, 
 care being had that too great pressure is not exercised upon 
 the wound itself. But when the solution of continuity exists 
 on the posterior part of the leg, some apparatus must be re- 
 sorted to which will allow the limb to repose upon its side. 
 For this purpose, a wooden splint may be used, grooved to 
 receive the leg, and terminating below in a foot-piece. The 
 patient should repose upon his side, the thigh and leg flexed 
 and resting upon pillows. The broken leg should be placed 
 in the splint, (on the side opposite to the wound, so as to 
 leave the latter exposed,) and confined to the splint at the 
 knee and at the foot, by means of rollers. Little force will 
 be required, generally, to retain the fragments in apposition, 
 the flexed position in which the whole limb is placed itself 
 relaxing the muscles : but compression may be resorted to, if 
 necessary, by strips of adhesive plaster, or of the bandage 
 of Scultetus, laid above and below the wound, while this is 
 covered with a poultice, or some other suitable dressing ; the 
 pillows should be protected by a piece of oil-cloth, upon 
 
208 FRACTURES OF THE 
 
 which bran, cotton, or any absorbing material, should be 
 placed, to catch the discharges from the wound. 
 
 SECTION IV. 
 FOR FRACTURES OF THE BONES OF THE FOOT. 
 
 Very little displacement accompanies simple fractures of 
 the bones of the foot, as a general rule, and therefore the 
 treatment is very simple. The foot should be kept at rest, 
 with a splint of wood, or of pasteboard, bound to its sole, 
 and a broad compress applied on the superior surface. Or 
 an equally good plan consists in placing the leg in a fracture- 
 box, with the sole of the foot confined to the foot-board, by 
 a broad band, which leaves the dorsum of the foot sufficiently 
 exposed to the action of local antiphlogistic applications. 
 
 When the posterior extremity of the os calcis is broken, 
 there need not be much displacement, if, as is generally the 
 case, the strong plantar ligaments connected with this part 
 of the bone remain unruptured. Under other circumstances, 
 however, the fragment is more or less drawn from its natural 
 position, by the contraction of the gastrocnemius and soleus 
 muscles, and the treatment employed must be adapted to 
 counteract their influence. For this purpose the apparatus 
 recommended by Mr. Lonsdale is very simple and effectual. 
 It consists of a foot-piece of wood, to the extremity of which 
 the end of a slipper is attached, for the reception of the toes. 
 The foot-board should be rather shorter than the sole, so as 
 to extend from the toes not quite Co the heel ; to its under 
 surface a ring is attached. A pad, or compress, is placed 
 upon the extremity of the os calcis, (the fragment having 
 been restored to its proper position), and confined thus by a 
 few turns of a roller ; then a strap of leather, or a band of 
 webbing, is passed through the ring of the foot-board, 
 upwards over the heel and the pad, over the calf of the leg 
 to the lower third of the thigh, where it is reflected upon 
 itself, — the knee being flexed, and the foot extended, — and 
 confined to the surface by turns of a roller, (fig. 89.) 
 
 This same apparatus will answer for the treatment of rup- 
 ture of the tendo Achillis, with the addition of a roller 
 
BONES OF THE FOOT. 
 
 209 
 
 Fig. 
 
 Fig. 90. 
 
 applied carefully from the toes to the knee. The same effect 
 may be gained by a method even more simple than this, as 
 follows : Encircle the lower part of the thigh with a strap, or 
 a roller tightly applied, and connect this, by means of a 
 strip of muslin, to the heel of a slipper placed upon the foot, 
 — the leg being flexed upon the thigh ; envelope the foot and 
 leg in a roller. The annexed drawing, from Druitt, exhibits 
 this plan of treatment, (fig. 90.) 
 
 In compound fractures of the bones, the foot should be 
 kept in the same position as in case of simple fracture, with 
 a poultice, or other proper dressing applied over the part, 6 
 
 18* 
 
PAET IV. 
 
 ON THE MECHANICAL MEANS EMPLOYED IN THE TREAT- 
 MENT OF DISLOCATIONS. 
 
 A dislocation, or luxation, is defined by Sir Astley 
 Cooper to be, " a displacement of the articulating portion of 
 a bone from the surface on which it was naturally received. " 
 This faulty position is maintained, and the reduction of the 
 dislocation opposed, by a combination of causes ; sometimes, 
 and partially, by the conformation of the bony surface on 
 which the displaced member rests, as the prominent margin 
 of the acetabulum, in dislocations of the hip ;— occasionally, 
 to a certain extent, by the situation and condition of the liga- 
 ments about the joint ; — but chiefly and in every case, by the 
 powerful clonic and tonic action of the muscles. These ob- 
 stacles cannot be overcome without resort, on the part of the 
 surgeon, to physical force. 
 
 It does not fall within the province of this volume to dis- 
 cuss the pathology of this class of accidents ; its limits and 
 its legitimate intention permit only a description of the me- 
 chanical means employed in their treatment. The subject 
 naturally divides itself into two branches : 1st, the means of 
 reducing the dislocation, or of restoring the displaced bone to 
 its natural situation ; 2d, the mode of retaining the bone in 
 place, until the necessary reparation of the injury done to 
 the tissues shall have become perfected. 
 
 Luxations are replaced by means of muscular force acting 
 directly upon the two bones involved, or indirectly through 
 the intervention of some mechanical apparatus, the object of 
 which is to increase the power of the muscles, and to render 
 it more uniform and more equable in its operation. The force 
 thus excited must act in two opposite directions: one, — the 
 extending, — upon the movable part, that which has been dis- 
 placed ; while the counter-extension is exercised on the oppo- 
 site part, serving merely to fix and steady it. The points 
 
 (210) 
 
DISLOCATIONS. 211 
 
 upon which these forces operate vary in different dislocations : 
 generally, the muscles which directly surround the joint, and 
 which, if they are excited to contraction by any cause, 
 may interfere with the execution of the object in view, should 
 not be compressed by the extending and counter-extending 
 powers, unless from motives of convenience and expediency. 
 
 To assist the action of the mechanical means, in all in- 
 stances where the resistance of the muscles is great, or where 
 much pain is likely to be experienced for any length of time, 
 it is important to depress the irritability and power of the 
 muscles, and the nervous sensibility, by anaesthetics, or some 
 other agent. 
 
 When the dislocation has been reduced, there is, generally, 
 but little disposition to re-displacement : it is necessary merely 
 to keep the muscles surrounding the joint, and the joint itself, 
 in a state of repose, for a certain time. This object is secured 
 by the application of retentive bandages and splints. 
 
 The special dislocations will be briefly considered, with 
 particular reference to the mode in which the various me- 
 chanical means alluded to are applied. 
 
CHAPTER I. 
 
 DISLOCATIONS OF THE BONES OF THE HEAD AND TRUNK. 
 
 SECTION I. 
 
 DISLOCATION OF THE LOWER JAW. 
 
 Reduction. — In this accident the articular surface of one, 
 
 or of both, of the condyloid processes of the inferior maxilla 
 
 rests upon the base of the zygomatic process, being thrown 
 
 „ „ forwards out of the 
 
 Fig. 9 It i -j 
 
 glenoid cavity, as is 
 
 represented in the an- 
 nexed wood cut, (fig. 
 91.) To remedy the 
 deformity, the surgeon 
 places his thumbs, well 
 wrapped around with 
 muslin, to protect them 
 from injury, between 
 the posterior molar 
 teeth on each side of 
 the jaw, grasping the 
 base of the bone on 
 each side with his fin- 
 gers ; then, the patient's head being well supported against 
 the back of a chair, or by the hands of an assistant, the sur- 
 geon presses his thumbs strongly downwards upon the molar 
 teeth, while with his fingers he forces the chin upwards ; thus 
 the condyloid processes are removed from their false position, 
 and by the contraction of the muscles connected with the 
 posterior part of the bone, are draw r n into the glenoid 
 cavities. 
 
 The succeeding treatment consists in the application of a 
 simple retentive bandage, as that of Barton, or of Gibson, 
 
 (212) 
 
DISLOCATIONS OF THE CLAVICLE. 213 
 
 (see Fractures of Lower Jaw,) and in nourishing the patient 
 for the following two or three weeks with liquid food. 
 
 SECTION II. 
 DISLOCATIONS OF THE BONES OF THE TRUNK. 
 
 If the vertebrae, the ribs, or the bones of the pelvis chance 
 to be separated from their articular connexions, the accident 
 is generally accompanied by other serious, if not fatal, in- 
 juries to the organs contained in the thoracic, abdominal and 
 pelvic cavities. The surgeon can do little or nothing towards 
 replacing the dislocated bones. Perfect rest should be en- 
 joined, with the use of such local and general antiphlogistic 
 remedies as may be requisite. The simple body-bandage for 
 the chest, or pelvis, will effect all that can be expected of 
 any mechanical contrivance ; or the bandages shown in figures 
 29, 31 and 76 may be employed, according to the region 
 injured. 
 
 SECTION III. 
 DISLOCATIONS OF THE CLAVICLE. 
 
 Either articular extremity of the clavicle may be luxated : 
 the modes of effecting reduction are very similar in all varie- 
 ties of the accident. The patient being seated, the surgeon 
 takes a position behind him, grasping each shoulder, and 
 having one knee placed against the spine between the shoul- 
 ders, so as to steady the patient, w T hile he draws the shoulders 
 backwards, and thus operates upon the clavicle. The natu- 
 ral distance between the , shoulders having been regained, 
 pressure must be made upon the extremity of the reduced 
 bone with the hand, until a suitable bandage can be applied. 
 
 After-treatment. — The retentive means employed to 
 maintain the reduction should accomplish two indications ; 
 viz., to prevent the shoulder from falling downwards, for- 
 wards, and inwards, and to exert a certain degree of pressure 
 
214 
 
 DISLOCATIONS OF THE CLAVICLE. 
 
 upon the dislocated extremity of the clavicle. If the humeral 
 end of the bone has been luxated, both of these indications 
 
 will be fulfilled by the appli- 
 Eig.92. cation of the figure-8 ban- 
 
 dage of both shoulders, a pad 
 being placed in the axilla of 
 the affected side and a- com- 
 press upon the end of the bone 
 (fig. 92), while the fore-arm 
 is supported in a sling upon 
 the front of the chest. If 
 the accident has occurred to 
 the sternal extremity of the 
 clavicle, the same bandage 
 should be employed, with the 
 addition of a compress upon 
 the injured articulation, to 
 be retained in this situation 
 by means of a few turns of a 
 roller made to encircle ob- 
 liquely the upper part of the chest, passing across the root 
 of the neck of the injured side, over the sternal extremity of 
 the clavicle, under the axilla of the sound side, and so around 
 the back to the starting-point. Dr. W. Poyntell Johnston, 
 some years ago lecturer on Surgery in this city, was in the 
 habit of recommending the use of the common hernia-truss in 
 the treatment of this accident, the pad being made to press 
 upon that extremity of the clavicle which had been dislocated ; 
 the truss can be easily secured in position by a few turns of 
 a roller, or by a handkerchief. 
 
CHAPTER II. 
 
 DISLOCATIONS OF THE BONES OF THE UPPER 
 EXTREMITY. 
 
 SECTION I. 
 
 DISLOCATIONS OF THE HUMERUS. 
 
 The head of the humerus is liable to three principal varie- 
 ties of displacement, viz., 1st, in the direction downwards into 
 the axilla; 2d, forwards, under the pect oralis major muscle; 
 3d, on the dorsum of the scapula. 
 
 In all of these, the principle of reduction is the same, vary- 
 ing only in the line in which the reducing force is made to 
 operate. There are, however, several methods by which the 
 restoration may be accomplished. 
 
 1. By the heel in the axilla. The patient should assume 
 the recumbent position on a bed, or on the floor; the surgeon 
 sits by his side, and places one heel in the axilla, in contact 
 with the head of the humerus, thus fixing the body; the 
 extending force is applied either to the arm above the elbow, 
 or to the wrist. By the former plan, the surgeon flexes the 
 patient's fore-arm so as to relax the biceps muscle, and secures 
 a double roller-towel upon the arm above the elbow, by means 
 of a wetted bandage ; he then passes the towel over his own 
 neck, and under the axilla of the side next the patient. 
 (Fig. 93.) It may be objected to this method, that the 
 triceps and biceps muscles may be stimulated to contraction 
 by the pressure exercised upon them, and thus oppose the 
 reduction. By the other mode, the surgeon grasps the pa- 
 tient's wrist either with the hand, or through the medium of 
 a bandage, or of a double towel arranged in the manner above 
 described. The last method is probably the best, as it does 
 not directly affect the muscles which pass from the scapula to 
 the lower part of the humerus and the fore-arm. By employ- 
 ing the double towel, in either mode of operating, the surgeon 
 may avail himself of the power of the muscles of the back, 
 
 (215) 
 
216 
 
 DISLOCATIONS OF THE HUMERUS. 
 
 as well as of those of the arms. The extension should be 
 made gradually and steadily in the direction assumed by the 
 
 Fig. 93. 
 
 humerus, and the head of the bone may be acted upon by the 
 heel of the surgeon also, so as to be dislodged from its position 
 in the axilla. 
 
 2. By relaxing the supra-spinatus muscle and the deltoid, 
 •which, according to Sir A. Cooper (op. cit. pp. 321, 2), are 
 
 Fig. 94. 
 
 the chief opponents of the reduction. The patient lies down, 
 as in the first method; the surgeon sits behind him, and 
 
DISLOCATIONS OF THE HUMERUS. 
 
 217 
 
 extends the dislocated arm with one hand, while with the 
 other he fixes the scapula. (Fig. 94.) If this simple manual 
 force is not sufficient, the scapula may be secured by means 
 of a double towel passed around it, crossing the axilla, and 
 confined to the bedstead, or to the floor, on the opposite side 
 of the patient ; while pulleys are employed to make the ne- 
 cessary extension, as will be explained directly ; or, again, 
 extension may be effected by means of the double towel 
 passed around the surgeon's back and shoulder, as already 
 described. 
 
 3. By the pulleys. It is necessary, in the employment of 
 the pulleys, to fix the scapula by some mechanical means. 
 This may be best accomplished by a broad piece of canvass, 
 or leather, in which a hole is made large enough to admit the 
 shoulder ; this band should pass in front of and behind the 
 chest, and be secured to a hook in the wall, or the floor, if the 
 patient is in the recumbent position. The annexed drawings 
 from Fergusson, illustrate the kind of pulleys which are used, 
 
 Fig. 95. 
 
 and the ring to which one of their hooks is attached during 
 the extension. (Fig. 95.) The other hook should be fas- 
 tened to a towel, which has been secured upon the arm above 
 the elbow, by means of a wetted roller. The cord of the 
 pulleys should be drawn, by an assistant, slowly and steadily, 
 and be relaxed as soon as the surgeon, who has his hands 
 upon the head of the bone and the shoulder, feels that the 
 former has been drawn out from beneath the glenoid cavity. 
 19 
 
218 DISLOCATIONS OF THE HUMERUS. 
 
 It may be of service sometimes, that the surgeon should place 
 his knee beneath the humerus near to its head, in order to 
 gain a fulcrum upon which, by depressing the elbow, the 
 head of the bone may be elevated towards the glenoid cavity. 
 (Fig. 96.) 
 
 Fig. 96. 
 
 The use of the pulleys is necessary in cases where, from 
 long-standing dislocations, or from the great muscular powers 
 of the individual, a very considerable, and a very steady and 
 long-sustained force is required to reduce the head of the 
 bone. In such instances, resort should be had to general de- 
 pressing means, as bleeding, the administration of nauseating 
 doses of tartar emetic, &c. 
 
 Any of the varieties of dislocation of the humerus may be re- 
 duced by these means, but the direction in which the extending 
 force should act, must be modified with each luxation. In 
 the dislocation downwards, the arm should be drawn down- 
 wards and a little outwards from the side, to correspond with 
 the direction of the axis of the humerus. In the luxation 
 forwards, the arm points outwards and backwards, and the 
 reducing force should operate in the same direction. When 
 
DISLOCATIONS OF THE HUMERUS. 219 
 
 the head of the bone is thrown upon the dorsum of the scapula, 
 the extension must be made forwards and outwards. 
 
 A complicated and expensive, though ingenious apparatus, 
 known in this country and in Europe as " Jarviss Adjuster" 
 was invented some years ago by Dr. Gr. 0. Jarvis, of Connec- 
 ticut. It consists of several pieces of iron, shaped to corre- 
 spond with the form of the different parts of the upper and 
 lower extremities ; these are to be secured upon the dislocated 
 member by means of straps and buckles. The extending 
 power, which accomplishes the reduction, is applied by means 
 of a rack-and-pinion-wheel. It is applicable both to disloca- 
 tions and to fractures. Those who are desirous of seeing 
 representations of the apparatus, and the manner in which it 
 is to be employed, we would refer to a series of lectures upon 
 the subject by its inventor, published in the London Lancet, 
 for 1846, Vol. I. _ 
 
 The apparatus is a very powerful one, unquestionably, and, 
 we dare say, can be made to accomplish what its maker 
 promises. But we believe, that with the ordinary pulleys, 
 aided by anaesthetic influence, the surgeon can exert as much 
 force as is necessary or safe, and can direct it perhaps better 
 than by the " Adjuster." Moreover, (and this we think a 
 very important consideration !) the surgeon knows how much 
 force he employs, if he uses the pulleys; whereas, if he 
 brings the apparatus in question to bear upon a dislocation or 
 fracture, he cannot judge of this so accurately, and he is 
 consequently much more likely to do mischief in his efforts 
 to benefit his patient. These considerations, together with 
 the costliness and complicated character of the machine, and 
 the fact that we can succeed very well with the means which 
 have been so long in use, render it hardly worth while to 
 burthen ourselves with "Jarvis s Adjuster." 
 
 After-treatment. — The fore-arm should be supported in 
 a sling, in the semi-flexed position, on the chest, a pad should 
 be secured in the axilla, and the arm bound, with a moderate 
 degree of pressure, to the side. Local antiphlogistic applica- 
 tions, as lead-water, cold poultices, or leeches, may be made 
 as required. The apparatus should be continued for ten days 
 or two weeks. 
 
220 DISLOCATIONS AT THE ELBOW-JOINT. 
 
 SECTION II. 
 DISLOCATIONS AT THE ELBOW-JOINT, 
 
 Of these there are six varieties : 1st, in which both bones 
 are thrown backwards, the olecranon process projecting very 
 much posteriorly ; 2d, in which both bones are drawn back- 
 wards and inwards ; 3d, when both are thrown backwards and 
 outwards; 4th, the ulna alone is forced backwards, the 
 orbicular ligament of the radius being ruptured, but this bone 
 itself remaining on the anterior face of the external condyle ; 
 5th, the radius forced forwards into the depression above the 
 external condyle, the ulna remaining in situ ; 6th, the radius 
 thrown backwards behind the external condyle of the humerus. 
 In all the varieties the reduction is generally easily effected. 
 In the first four species, the restoration may be accomplished 
 by placing the knee at the bend of the elbow, and flexing the 
 fore-arm upon it, the lower part of the upper arm and the 
 fore-arm being grasped by the hands of the surgeon. The 
 dislocations of the radius may be remedied by fixing the 
 humerus and making extension from the hand, while the bone 
 is thrown forwards ; if the luxation be backwards, the same 
 extension and counter-extension should be made, while at the 
 same time the fore-arm should be flexed, thus forcing the 
 biceps to draw the radius to its proper place. 
 
 Subsequent Treatment. — The fore-arm should be placed 
 in the semi-flexed position, and an angular splint should be 
 bandaged upon the front of the whole limb, compresses being 
 placed upon the head of the bones opposite the direction of 
 the luxation. This confinement must be maintained for two 
 or three weeks, passive motion being carefully instituted after 
 the first few days. 
 
DISLOCATIONS OF THE FORE-ARM. 221 
 
 SECTION III. 
 
 DISLOCATIONS OF THE LOWER EXTREMITY OF THE FORE-ARM. 
 
 These accidents are usually caused by falls upon the hand. 
 Both the radius and ulna may be thrown either backwards or 
 forwards upon the wrist, causing considerable projection in 
 these situations, or one of the bones only of the fore-arm may 
 be separated from its connexions and displaced anteriorly, pos- 
 teriorly, or laterally. The reduction is easily accomplished 
 by simply extending and counter-extending from the hand and 
 the fore-arm, and making moderate lateral pressure at the 
 same time, if the displacement be at the side of the wrist. 
 
 Subsequent treatment. — Place a straight splint on the 
 front, and another on the back of the fore-arm and hand, with 
 compresses on the anterior and posterior surfaces of the wrist, 
 and secure the whole by a roller. The fore-arm should be 
 supported in a sling. 
 
 SECTION IV. 
 DISLOCATIONS OF THE BONES OF THE HAND. 
 
 Instances have been met with, in which some one or more 
 of the carpal bones have been thrown from their natural posi- 
 tions, so as to form projections upon the back of the hand, 
 without a wound of the integuments. They may generally be 
 replaced by pressure : the reduction should be maintained, by 
 placing compresses upon the palmar and dorsal aspects of the 
 wrist, and upon these straight splints, the whole to be enve- 
 loped in the folds of a roller. The hand should be supported 
 in a sling. 
 
 The same treatment, conjoined with some degree of exten- 
 sion in the reduction, is applicable to dislocations of the meta- 
 carpal bones, should they occur without laceration of the in- 
 teguments. 
 19* 
 
222 
 
 DISLOCATIONS OF THE HAND. 
 
 Dislocations of the phalanges may ordinarily be reduced 
 •without much difficulty, if the accident is attended to soon 
 after its occurrence. Sometimes restoration may be accom- 
 plished by simply bending the displaced phalanx over the head 
 of the bone from which it has been dislocated, as represented 
 in the annexed drawing. (Fig. 97.) Frequently, however, con- 
 
 Fig. 97. 
 
 siderable extension and counter-extension are requisite. To 
 effect this, a piece of cord should be wound around the pha- 
 lanx, the skin being protected by a covering of wetted buck- 
 skin ; then, the hand being fixed, the surgeon should extend 
 the finger, at first in the axis of the bone, and gradually flex 
 it towards the palm, in order to relax the flexor muscles, if 
 the dislocation be posteriorly; or, if the phalanx has been 
 thrown upon the palmar face of the other bone, it should be 
 forced a little backwards, during the extension. (Fig. 98.) 
 
 Fig. 98. 
 
 The most convenient mode of securing the extending cord 
 or tape, is by making what is termed the " clove-hitch/ ' as 
 shown in the accompanying drawing, (fig. 99,) from Fer- 
 gusson. • 
 
DISLOCATIONS OF THE HAND. 
 
 223 
 
 Fig. 99. 
 
 Dislocation of the phalanges of the thumb is most difficult of 
 reduction. The following is the 
 method recommended by Sir A. 
 Cooper, p. 446 : " The extension 
 is to be made by bending the 
 thumb towards the palm of the 
 hand, to relax the flexor muscles 
 as much as possible, and the fol- 
 lowing is the mode of applying 
 the extending force : The hand 
 is to be first steeped in warm 
 water for a considerable time, to 
 relax the parts as much as pos- 
 sible ; then a piece of thin wetted 
 leather is to be put around the 
 phalanx, and as closely adapted to the thumb as possible : a 
 piece of tape about two yards in length is next to be applied 
 upon the surface of the leather, in the knot called the " clove- 
 hitch," for this becomes tighter as the extension proceeds. 
 An assistant places his middle and forefinger between the 
 thumb and forefinger of the patient, and makes the counter- 
 extension, whilst the surgeon, assisted by others, draws the 
 phalanx from the metacarpal bone, directing it a little inward 
 towards the palm of the hand." (Fig. 100.) 
 
 Fig. 100. 
 
 The quiescence of the joint after dislocation of the metacar- 
 pal, or phalangeal bones, is to be maintained by splints and 
 compresses placed upon the dorsal and palmar aspects of the 
 hand. 
 
CHAPTER III. 
 
 DISLOCATIONS OF THE BONES OF THE LOWER EXTREMITY. 
 
 SECTION I. 
 
 DISLOCATIONS OF THE HIP-JOINT. 
 
 Of these there are four chief varieties, named from the 
 false position which the head of the os femoris assumes ; they 
 are as follows : — 1st, upwards, or on the dorsum ilii ; 2d, 
 downwards, or into the foramen ovale; 3d, backwards and 
 upwards, or into the ischiatic notch ; 4th, forwards and up- 
 wards, or on the body of the pubis. 
 
 These require, on the part of the surgeon, the employment 
 of a greater degree of force in reduction than dislocations of 
 any other bone, owing to the much greater power of the 
 muscles concerned. In young children they may generally 
 be restored by simple manual extension and counter-extension, 
 as the luxations of the humerus ; but in adults, the pulleys 
 should always be employed, and it is almost always advisable 
 to have recourse also to depressing agencies, as bleedijig to 
 the amount of from twelve to twenty ounces, or the hot-bath 
 at 100°, or the administration of tartar emetic in doses of 
 half a grain every ten minutes, until nausea is produced, or, 
 still better, probably, by bringing the patient under the 
 anaesthetic influence of ether or chloroform. 
 
 As in other dislocations, the reducing forces should act 
 gradually and steadily, and in the line of the axis of the 
 dislocated bone, and during their operation, the patient's 
 mind should be interested, if possible, in some subject other 
 than his accident. 
 
 The treatment of the individual dislocations is as follows : — 
 
 1st. The dislocation upwards on the dorsum ilii. The 
 patient is placed upon a table covered with a mattrass, or 
 
 (224) 
 
DISLOCATIONS OF THE HIP-JOINT. 
 
 225 
 
 folded blankets. The pelvis is fixed by means of a sheet 
 folded longitudinally, passed under the perineum and over the 
 crista of the ilium, and secured to a staple so situated that 
 the sheet may be in a line with the axis of the thigh. The 
 extension is effected through the intervention of a wetted 
 roller secured upon the lower part of the thigh, and having 
 buckled around it a leathern band with a short strap on each 
 side terminating in a ring ; the two rings are to be attached 
 to the hook of the pulleys, and the latter secured to a staple 
 in such a position that the extending and counter-extending 
 forces may act parallelly to each other, from opposite points, 
 and to the axis of the bone. Instead of the leathern band, 
 a double towel may be confined to the thigh by the clove-hitch. 
 The knee of the dislocated limb should be bent nearly at 
 right angle and pointed across the thigh a little above the 
 knee of the other leg. After the muscles have been fatigued 
 by the continued action of the pulleys, the surgeon should 
 grasp the knee, and rotate the hip slightly and gently, or he 
 may pass a towel around the upper part of the thigh, and 
 raise thereby the head of the bone, when it will usually slip 
 into the acetabulum, (fig. 101). 
 
 Fig. 101. 
 
 The subsequent treatment consists in keeping the patient 
 in bed for two weeks or more, his knees tied to each other by 
 a strip of muslin, and a broad belt passed around his pelvis 
 pressing upon the trochanters. 
 
 2d. The dislocation downwards, or into the foramen ovale. 
 To reduce this luxation, the following course should be pur- 
 sued : The patient should be in the recumbent position, as in 
 
226 
 
 DISLOCATIONS OF THE HIP-JOINT. 
 
 Fig. 102. 
 
 the first case; a girth made of leather, or of a sheet, or 
 
 towel, should be passed 
 around the upper part of 
 the thigh and attached to 
 one of the hooks of the 
 pulleys, the other being 
 secured to a staple fixed 
 in the wall opposite the 
 dislocated hip ; another 
 girth should be made to 
 encircle the pelvis, so as 
 to steady the body, pass- 
 ing the noose formed by 
 the first girth, and at- 
 tached to a staple placed 
 opposite to the first, on 
 the sound side of the 
 patient. The cord of 
 the pulleys should now 
 be drawn until the head 
 of the femur begins to 
 leave its position in the 
 foramen ovale, when the 
 surgeon should pass his 
 hand behind the ankle 
 of the sound limb, and 
 grasp the other ankle, 
 which he draws steadily 
 towards him ; the effect 
 of this is, to throw the head of the bone outwards, the limb 
 being a lever with its fulcrum on the extending girth ; as soon 
 as the head of the femur is sufficiently disengaged from its 
 false position, the extending force should be suspended, when 
 the limb will be restored, (fig. 102.) 
 
 The after-treatment is as in the first case. 
 3d. To reduce the dislocation backwards, or into the 
 ischiatic notch : — Secure the extending and counter-extending 
 bands as in the first species of luxation ; then, the patient 
 reposing upon his sound side, the knee of the dislocated limb 
 should be pointed across the middle of the opposite thigh, 
 and the extension practised until the muscles are enfeebled ; 
 
DISLOCATIONS OF THE HIP-JOINT. 
 
 227 
 
 a round towel should now be passed under the upper part of 
 the thigh, and over the shoulders of an assistant, who should 
 be directed to press upon the pelvis with his hands, and at 
 the same time to raise his shoulders : thus the head of the 
 femur will be extricated from the ischiatic notch, and drawn 
 downwards into the acetabulum. (Fig. 103.) 
 
 Fig. 103. 
 
 The subsequent treatment does not differ from that advised 
 *or the other cases. 
 
 4th. To restore the luxation forwards and upwards, or on 
 the pubis : — The apparatus employed is the same as has been 
 already described, and its mode of application is as in the 
 ast-named variety of the accident. The patient should be 
 Dlaced upon his sound side, the knees widely separated from 
 each other, and the extension made in a line behind the axis 
 of the body. When the muscles have been sufficiently 
 fatigued, a round towel should be passed under the upper 
 part of the thigh, and around the shoulders of an assistant, 
 who elevates the head of the femur by raising his shoulders, 
 pressing at the same time upon the pelvis. (Fig. 104.) 
 
 After-treatment. — The same as in the other varieties. 
 
 A very good and simple substitute for the pulleys has been 
 recently recommended by Dr. Gilbert, Professor of Surgery 
 in the Pennsylvania Medical College. Its mode of applica- 
 tion is thus described in the American Journal of Medical 
 Sciences, vol. ix., N. S. : — "Place the patient and adjust the 
 extending and counter-extending bands as for the pulleys ; 
 then procure an ordinary bed-cord, or a wash-line; tie the 
 
228 DISLOCATIONS OF THE HIP-JOINT. 
 
 Fig. 104. 
 
 ends together, and again double it upon itself, pass it through 
 the extending tapes or towel, doubling the whole once more, 
 and fasten the distal end, consisting of four loops of rope, to 
 a window-sill, door-sill, or staple, so that the cords are drawn 
 moderately tight; finally, pass a stick through the centre of 
 the doubled rope, then by revolving the stick as an axis, or 
 double lever, the power is produced precisely as it should be 
 in such cases, viz. : slowly, steadily, and continuously." 
 (Fig. 105.) 
 
 Fig. 105. 
 
 Several instances of anomalous dislocations of the head 
 of the femur are recorded by Cooper and others. (Sir A. 
 Cooper, op. cit., pp. 83-97.) The means employed in the 
 
DISLOCATIONS OF THE PATELLA. 229 
 
 treatment of these are the same as in those varieties which 
 have been already described. Proper reflection upon such 
 cases will enable the surgeon to determine the probable posi- 
 tion of the head of the bone, and the line in which the ex- 
 tension and counter-extension should be made, together with 
 such other expedients as will assist in the dislodgement of 
 the head of the bone from its unnatural position. 
 
 SECTION II. 
 DISLOCATIONS OF THE PATELLA. 
 
 The patella is liable to displacement in two directions, 
 without rupture of its tendon or ligament, viz. : 
 
 1st. Dislocation outwards, the bone resting upon the exter- 
 nal condyle of the os femoris, causing great projection at this 
 point, and an inability to flex the knee. 
 
 2d. Dislocation inwards, producing the same difficulty in 
 bending the knee, with a marked prominence at the inner 
 condyle of the femur. 
 
 The restoration is generally easily accomplished, by re- 
 laxing the extensor muscles of the leg : for this purpose the 
 heel should be elevated upon the shoulder of an assistant, 
 while the surgeon presses down the edge of the patella 
 which is most removed from the centre of the knee-joint, 
 thus tilting up the other edge of the bone, when the mus- 
 cles, aided by a lateral pressure, will draw the patella to its 
 place. 
 
 The subsequent treatment consists in confining a straight 
 splint to the posterior surface of the limb, and in making 
 moderate pressure upon the knee by means of a roller, or a 
 laced bandage; local antiphlogistic applications are gene- 
 rally required, in addition. The patient should be confined 
 to bed for about two weeks. 
 
 20 
 
230 DISLOCATIONS OF HEAD OF FIBULA. 
 
 SECTION III. 
 DISLOCATIONS OF THE TIBIA AT THE KNEE. 
 
 . Of these there are four varieties, viz. : 
 
 1st. Displacement forwards, — the tibia being thrown upon 
 the anterior part of the thigh, of which the condyles are de- 
 pressed backwards, and somewhat to the side. (Cooper.) 
 
 2d. Backwards, — the tibia drawn upwards behind the con- 
 dyles of the femur, which project very much on the front of 
 the leg. 
 
 3d. Inwards, — the internal condyle of the thigh-bone rest- 
 ing upon the external semilunar cartilage. 
 
 4th. Outwards, — the inner semilunar cartilage being in con- 
 tact with the external condyle of the femur : the great lateral 
 projection of the head of the tibia in these cases renders the 
 diagnosis of the injury very easy. 
 
 These dislocations are readily reduced by making exten- 
 sion and counter-extension from the ankle and thigh, con- 
 joined with moderate pressure upon the head of the tibia. 
 After the restoration is accomplished, the limb should be 
 secured to a straight splint, and such local antiphlogistic 
 means should be employed as the circumstances of each case 
 may call for. The patient should be kept in bed for ten 
 days or two weeks, or longer, if there be continuance of pain 
 or of inflammation. 
 
 SECTION IV. 
 DISLOCATIONS OF THE HEAD OF THE FIBULA. 
 
 The head of the fibula is sometimes detached from its 
 connexions with the tibia, and drawn backwards by the 
 action of the biceps. It is easily restored to its place, by 
 flexing the leg so as to relax this muscle, and pressing the 
 bone forwards. 
 
 In order to retain it "in situ," the leg should be kept bent 
 over a pillow, or an inclined plane, with a compress bound 
 
DISLOCATIONS OF THE ANKLE. 281 
 
 against the posterior part of the head of the bone by means 
 of a roller. 
 
 SECTION V. 
 DISLOCATIONS OF THE ANKLE. 
 
 The astragalus may be separated from the bones of the 
 leg in four directions, viz. : forwards, backwards, outwards, 
 and inwards. The recognition of the accident is easy, and 
 the reduction not difficult. The limb should be flexed, so 
 as to relax the powerful muscles on the back of the leg ; 
 then, while extension and counter-extension are made from 
 the foot and the lower part of the thigh, the surgeon should 
 press firmly upon the dislocated bone, and thus force it to its 
 place. 
 
 After reduction, the leg and foot should be confined in 
 carved splints, or splints made of binders' board, soaked in 
 hot water and moulded to the shape of the limb, with a foot- 
 piece at right angles ; or a fracture-box will be found to 
 answer equally well. This confinement to bed and in splints 
 should continue for five or six weeks, and when the patient 
 is first allowed to walk, the ankle should be carefully sup- 
 ported by a roller bandage, or a firm laced gaiter. The time 
 requisite to perfect the cure of these accidents is, according to 
 Sir A. Cooper, ten or twelve w r eeks. 
 
 If the fibula alone is separated from the tibia, simple late- 
 ral pressure will restore it to its place, after which a roller 
 and compress should be employed for some weeks to retain the 
 bones in apposition ; rest is necessary, as in the last-described 
 injury. 
 
 The remarks made on the treatment of dislocations of the 
 bones of the hand and wrist are applicable to the same kinds 
 of injury of the foot ; the treatment to be pursued in the re- 
 duction, and subsequently, is similar, excepting that a greater 
 degree of force is required to reduce the luxation, and a longer 
 confinement afterwards, when the foot is involved than when 
 the hand is injured. 
 
CHAPTER IV. 
 
 COMPOUND DISLOCATIONS. 
 
 These accidents require the same sort of treatment as com- 
 pound fractures. Much experience, and careful examination 
 of all the circumstances connected with each case, are neces- 
 sary to enable the surgeon to determine when to attempt to 
 save a limb so injured, and when to amputate. This volume 
 does not pretend to lay down rules for such cases. The 
 reader will do well to consult the works of the Coopers, Vidal 
 (de Cassis), Boyer, Chelius, and others, with reference to this 
 important subject. 
 
 If an attempt to save the limb be decided on, the wound 
 should be carefully cleansed, all foreign bodies, spicula, or 
 small and detached fragments of bone, removed, hemorrhage 
 arrested, and the dislocated bone restored, if possible. Then 
 the edges of the wound should be apposed to each other, and 
 covered, as in the case of compound fractures of the patella, 
 &c, with a piece of lint dipped in blood, or in some aggluti- 
 native fluid, and every effort should be made to convert the 
 injury into a simple dislocation. The tendency to re-dis- 
 placement should be overcome by placing the limb in such a 
 position as shall relax the most powerful muscles connected 
 with the dislocated bone, and by the application of a bandage 
 to make moderate compression upon the seat of injury and 
 on the implicated muscles. The disposition to inflammation, 
 or this condition itself, should be combated by leeches, occa- 
 sionally by general bleeding, by irrigation with cold water, 
 by evaporating lotions, and by position. Warm applica- 
 tions should be avoided, so long as there is any prospect of 
 closing the wound by direct union. Perfect rest should be 
 maintained in bed, if one of the lower extremities be involved, 
 and such splints and other retentive and supporting appli- 
 ances should be employed as will most conduce to the objects 
 in view. 
 
 (232) 
 
APPARATUS FOR RELIEF OF ANCHYLOSIS. 233 
 
 APPARATUS FOR THE RELIEF OF PARTIAL ANCHYLOSIS. 
 
 It not unfrequently happens after fractures involving a 
 joint, dislocations, and other injuries or diseases, that the mo- 
 tion of the joint is very much impaired, and the usefulness of 
 the whole limb much diminished. The difficulty may often be 
 entirely relieved or lessened, by adapting to the limb some 
 instrument, whereby 
 
 constant and gradu- FlG - 106 - 
 
 ally increasing mo- 
 tion may be given to 
 the joint for a length 
 of time. The accom- 
 panying drawing (fig. 
 106) exhibits an ap- 
 paratus of this kind 
 for the arm, which is 
 recommended by Pro- 
 fessor Mutter, in his 
 edition of Mr. Lis- 
 ton's " Lectures on 
 
 the Operations of Surgery," &c, (p. 433, Am. edit., 1846.) 
 It consists of steel splints curved to the shape of the arm and 
 fore-arm, and well padded, two for the upper arm and two for 
 the fore-arm, for the anterior and posterior surfaces of the 
 limb. The anterior splints are connected by a steel or iron 
 bar, which is firmly secured to them on each side, and jointed 
 by a pivot at the centre, so as to move freely like a hinge. 
 A " Stromeyer's screw" is fastened to the centre of the same 
 splints in front, by moving which the apparatus may be made 
 straight or angular, at pleasure. The splints are now applied 
 to the limb, those for each division of the member being se- 
 cured to each other by means of straps and buckles, and thus 
 made to surround the arm above and below its bend, care be- 
 ing had that the joint of the side bars is opposite the centre 
 of motion of the elbow. When the apparatus is thus properly 
 applied, the screw should be turned until the patient com- 
 mences to experience slight uneasiness in the joint ; this pro- 
 cess should be repeated daily, now extending and now flexing 
 20* 
 
284 APPARATUS FOR RELIEF OF ANCHYLOSIS. 
 
 the limb, — avoiding the infliction of pain in the joint, — until 
 an adequate degree of motion is restored : the action of the 
 apparatus will be very much aided by frequently soaking the 
 joint in warm water. 
 
 When so elegant a splint as that employed by Dr. Mutter 
 cannot be obtained, the same effect may be had by attaching 
 the screw to simple splints of wood. The apparatus may be 
 adapted to the knee as well as to the elbow, and with equally 
 good results. 
 
PART V. 
 
 ON SOME OF THE MINOR SURGICAL OPERATIONS. 
 CHAPTER I. 
 
 ON INCISIONS. 
 
 We cannot attach much importance to, or advise any one 
 to comply with, set rules for the mode of holding and using 
 cutting instruments. We believe that each can judge 
 best for himself in such matters ; and that the most rational 
 proposition is that each one shall use his knife in such a 
 manner as will enable himself to gain, most readily and satis- 
 factorily, the object which he has in view. ^Nevertheless, a 
 few observations, offered as suggestions, may not be amiss 
 touching the simple incisions of Minor Surgery. 
 
 In the first place, the cutting edge of the instrument to be 
 used should be sharp. And it is important that the surgeon, 
 especially if he reside in the country, remote from his cutler, 
 shall be able to keep his knives in good order. For this end 
 he must have a proper hone; one of the " Water of Ayr''' 
 stones of Scotland, or an Arkansas or Missouri stone, will 
 answer the purpose. In making use of it, its surface should 
 be moistened with olive oil, and the knife passed lightly over 
 it from heel to point, the back being slightly raised from the 
 stone, and equally, of course, on both sides of the blade. 
 After the instrument has been honed until its cutting edge is 
 smooth and sharp, it may be strapped, or not, as seems re- 
 quisite ; but if the hone be sufficiently fine, strapping will not 
 be necessary. 
 
 Fancy has been very busy in contriving a variety of shapes 
 for the simple scalpel ; the one which we have before spoken 
 of, (fig. 2,) will be found as advantageous as any. It is 
 usually held between the thumb and the first two, sometimes 
 the first three, fingers of the right hand. If the incisions are 
 to be small in extent, and require to be delicately and care- 
 fully made, the knife may be held as indicated in fig. 107, 
 the hand being steadied, if necessary, bv the little finger or 
 
 (235) 
 
236 
 
 ON INCISIONS. 
 
 Fig. 107. 
 
 •wrist resting upon the part to be operated upon. If rapid 
 and extensive incisions are to be made, and if the operator 
 be practised, the instrument may be best held as shown in 
 fig. 108 ; but the position must be varied according to cir- 
 
 Fig. 108. 
 
 cumstances. For example, if the surgeon be about to sever 
 rugged and partially detached portions of a flap, or to pare 
 the edges of a lacerated wound, he will find it most conve- 
 nient, probably, to use the knife as illustrated in the accom- 
 panying drawing (fig. 109) ; if he wishes to open an abscess, 
 
 Fig. 109. 
 
ON INCISIONS. 
 
 237 
 
 be may employ " Lyme's abscess lancet," a curved blade, 
 with a sharp point and a double cutting edge, as delineated in 
 fig. 110, or he may plunge a common sharp-pointed bistoury 
 through the integuments, as in fig. 111. 
 
 Fig. 110. 
 
 The direction of the incision to-be made should depend 
 upon the object to be gained. If it be desired merely to 
 divide the parts, the cut is usually made in a straight line, the 
 knife being entered perpendicularly to the surface, the wrist 
 then depressed, and the edge of the instrument drawn along 
 in contact with the skin ; when the requisite extent of divi- 
 sion has been gained, the wrist should be elevated, and the 
 knife withdrawn perpendicular to the skin. Or if the parts 
 be loose enough, the integuments may be pinched up between 
 the thumb and fore-finger, and a sharp-pointed, narrow- 
 bladed bistoury, straight or curved, may be thrust through 
 the base of the fold, and made to cut its way upwards at the 
 same time. 
 
238 
 
 ON INCISIONS. 
 
 Fig. 112. 
 
 A semilunar incision is sometimes performed by sweep- 
 ing the edge of the knife through the skin in 
 a semicircular direction. 
 
 Sometimes it is advisable to make a crucial 
 division of the soft parts, two straight incisions 
 crossing each other at right angles. (Fig. 112.) 
 If it be desired to remove a portion of the in- 
 teguments, as in the extirpation of a considerable tumour, 
 where otherwise there would be a redundancy of covering, an 
 
 elliptical incision is made, by 
 FlG * 113 - uniting two semilunar cuts at 
 
 their extremities. (Fig. 113.) 
 Judgment must be used in per- 
 forming this division ; the con- 
 tractility of the parts is such 
 that, under ordinary circum- 
 stances, the resulting wound will gape much more widely than 
 the amount of tissue abstracted will account for. It is better, 
 therefore, to take away too little than too much ; in the 
 former event, time will diminish the difficulty, and pressure 
 carefully employed will generally obviate any unpleasant 
 effect ; in the latter case, the edges of the wound cannot be 
 brought together, excepting by so much straining as will be 
 painful, and endanger inflammation. 
 
 Other incisions are represented in figs. 114, 115, 116, and 
 117 ; names are applied to them corresponding to the letters 
 
 Fig. 114. 
 
 Fig. 115. 
 
 Fig. 116. 
 
 Fig. 117. 
 
 which in shape they resemble. They are designed to facili- 
 tate the exposure of the parts beneath the surface, the flaps 
 of the integument being elevated for the time, and then re- 
 placed, and their margins made to unite. 
 
 The direction of the incision should depend somewhat, too, 
 upon the situation of the part. Thus, on the face or neck, 
 especially of a female, it is desirable that no unsightly scar 
 should remain ; this end may be gained, to a certain extent, 
 
ON INCISIONS. 
 
 239 
 
 by dividing the skin in a line parallel to the direction of the 
 fibres of the subjacent muscle. If it be advisable that the 
 margins of the wound shall close readily, the skin must be 
 divided in the manner just indicated : if it be preferred that 
 the wound shall remain open, the incision should be more or 
 less directly transverse to the course of the muscular fibres. 
 
 It is often necessary to prolong an incision of the integu- 
 ments beyond the point at which the eye can direct the in- 
 strument. In such cases it is important to have a guide upon 
 which the knife may be glided. For this purpose, the finger 
 answers very well sometimes, as when the side of a hernial 
 stricture is to be divided, the fore-finger of the left hand 
 may be passed as high up as possible, and the bistoury slid in 
 upon it (fig. 118,) ; or, instead of a finger, a grooved director 
 
 Fig. US. 
 
 may be first introduced, and the bistoury then pushed along 
 its furrow, as is usually done when successive layers of tissue 
 are to be divided. 
 
 Subcutaneous wounds or incisions have, within a few years 
 past, come into merited esteem, because they enable the sur- 
 geon to effect even extensive division of parts without ex- 
 posing them to the air, and, as a consequence, union takes 
 place without inflammation and very promptly. These inci- 
 sions may be accomplished thus : if the object be to divide a 
 tendon, or to open a joint, a fine, sharp-pointed knife, such as 
 is represented in fig. 119, must be introduced through the in- 
 
 Fig. 119. 
 
240 ON INCISIONS. 
 
 tegument, obliquely, at a little distance from the deeper point 
 to be divided, and pushed on to the latter ; now the point of 
 the knife should be depressed and its edge a little turned 
 towards the surface to be cut, and the division of this effected 
 as by stealth, to use the expression of Mr. Miller. The in- 
 strument must be carefully withdrawn as it was entered, and 
 the external orifice immediately closed by adhesive plaster, or 
 covered with a piece of lint soaked in collodion, and perfect 
 quietude of the part enjoined. A narrow-bladed knife, like 
 that shown in the accompanying drawing, (fig. 120, taken 
 
 Fig. 120. 
 
 from Mr. Erichsen's book,) having only a part of the blade 
 sharp, the remainder rounded, will answer very well for such 
 sections. 
 
 Another method of making incisions of deep-seated parts, 
 so as to avoid access of air, is as follows : pinch up a fold of 
 the integuments covering the part to be operated upon, and 
 enter a sharp-pointed knife more or less perpendicularly at 
 the base of the fold; after the desired section has been made, 
 withdraw the blade carefully, and allow the integuments to 
 regain their proper position, then cover the opening in the 
 skin as above directed. This is a convenient mode of open- 
 ing chronic abscesses, when one does not wish to evacuate all 
 the matter at once. 
 
 For more detailed instructions upon these matters, which 
 we have not thought it necessary to furnish here, the reader 
 may consult any good work on Operative Surgery, as Mal- 
 gaigne's, Dr. Henry Smith's, or Mr. Fergusson's ; from the 
 latter, particularly, we have drawn most of the illustrations 
 and suggestions contained in this short chapter. 
 
CHAPTER II. 
 
 ON BLOODLETTING. 
 
 Blood may be drawn from a vein or artery of some size, 
 constituting what is termed " general bleeding," or from the 
 smallest vessels which ramify beneath the surface, by means 
 of cups and leeches, "local bleeding." The former method 
 of abstracting blood is practised when the amount to be drawn 
 is considerable, or when a general depressing effect upon the 
 System is desirable ; the latter, when a particular part only 
 of the economy is affected, — the system generally being little, 
 or not at all, involved. Sometimes, however, the indications 
 for resorting to both operations exist in the same case and at 
 the same time : under such circumstances, both general and 
 local bloodletting should be practised, the former from a vein, 
 usually, the latter from the vicinity of the suffering organ. 
 
 In cities, these operations are generally performed by a 
 class of persons who devote themselves to this duty as an oc- 
 cupation. In the country, the practitioner himself must 
 attend to them. Every medical man, however, should be 
 well acquainted with the methods of operating, and, whether 
 he live in the city, or in the country, should be skilled in the 
 practice of general bleeding, at least, since he will be often 
 compelled to resort to it. 
 
 SECTION I. 
 ON THE OPERATIONS FOR GENERAL BLEEDING. 
 
 These consist in the opening of a vein or an artery ; the 
 former is much the most commonly practised, and should 
 always be preferred, if a choice can be made. The incision 
 of a vein is termed phlebotomy; that of an artery, 
 arteriotomy. 
 
 Phlebotomy. — 1. One of the veins at the bend of the 
 21 (241) 
 
242 
 
 ON THE OPERATIONS 
 
 arm is usually selected for bleeding, because these vessels are 
 very superficial and convenient of access in this region, and 
 are of sufficient size to allow the requisite amount of blood to 
 escape freely and rapidly. The annexed drawings give a very 
 good view of the veins of this region, as they are generally 
 distributed, with their positions relatively to the artery and 
 the superficial nerves (figs. 121 and 122). In figure 121 are 
 
 Fig. 121. 
 
 displayed : " 1, the radial vein ; 2, the cephalic vein ; 3, the 
 anterior ulnar vein ; 4, the posterior ulnar vein ; 5, the trunk 
 formed by their union ; 6, the basilic vein, piercing the deep 
 fascia at 7 ; 8, the median vein ; 9, a communicating branch 
 between the deep veins of the fore-arm and the upper part 
 of the median vein; 10, the median cephalic vein; 11, the 
 median basilic ; 12, a slight convexity of the deep fascia, 
 formed by the brachial artery. This fascia is divided and 
 turned aside in fig. 122, to show the brachial artery ; 13, the 
 process of fascia, derived from the tendon of the biceps 
 muscle, and separating the median basilic vein from the bra- 
 
FOR GENERAL BLEEDING. 243 
 
 chial artery ; 14, the external cutaneous nerve, piercing the 
 deep fascia and dividing into two branches which pass behind 
 the median cephalic vein ; 15, the internal cutaneous nerve, 
 dividing into branches which pass in front of the median 
 basilic vein ; 16, the intereosto-humeral cutaneous nerve ; 17, 
 the spiral cutaneous nerve, a branch of the musculo-spiral." 
 Druitt, p. 494. 
 
 The median cephalic and the median basilic veins are those 
 in which the incision is generally practised in bleeding. The 
 median basilic is the larger of the two, and would seem there- 
 fore to be the most proper for the operation, and it is also 
 more superficial than the other ; but the brachial artery is 
 situated very near it, passing beneath it from the external 
 side, and separated from it only by the thin aponeurosis from 
 the tendon of the biceps muscle, so that an incision too deep 
 would probably penetrate the artery as well as the vein, as 
 has not unfrequently happened ; moreover, this vein is crossed 
 in front by several filaments of the internal cutaneous nerve, 
 which, as they are invisible to the operator, are liable to be 
 involved in his incision. Therefore it is safer to open the 
 median cephalic vein, as this is remote from the artery ; and 
 as regards the liability of wounding one of the nervous fila- 
 ments, the danger is rather less than in the other case, the 
 external cutaneous nerve passing beneath it; the superior 
 part of this vein, according to M. Lisfranc, is never crossed 
 by nervous twigs. With regard to injury of the nerves in 
 bleeding at the elbow, M. Velpeau says, that " all the veins 
 at this part of the arm are surrounded by nervous filaments, 
 and that with reference to this point, it would be ridiculous 
 to open one in preference to any other." (Op. cit., p. 298.) 
 Probably the best rule is, to bleed from the median cephalic 
 vein, provided it is sufiiciently large to allow the blood to flow 
 with freedom. If the median basilic be selected, the incision 
 should be made, if possible, either above or below the point 
 at which the vein crosses the artery, and not directly over 
 the latter, the artery becoming more deeply situated as it 
 leaves the vein. Sometimes the artery runs parallel with this 
 vein ; in such cases the fore-arm should be forced into a state 
 of pronation, so that the tendon of the biceps shall be made 
 to intervene between the two. 
 
 In all cases, the operator should carefully examine the part 
 
244 ON THE OPERATIONS 
 
 to see that there is no anomalous distribution of the arteries, 
 and to guard against danger from this cause. 
 
 It often occurs that in females and in children, the veins 
 are scarcely, if at all, visible, the adipose tissue being so 
 abundant. Sometimes they may be made apparent, by allow- 
 ing the ligature to compress the arm above the elbow for a 
 considerable time, by plunging the fore-arm in warm water, 
 by friction of the member, and by directing the patient to 
 call the muscles of the hand and fore-arm into action. Gene- 
 rally, however, if the veins cannot be seen, they may be felt 
 beneath the surface, like round elastic cords, not pulsating as 
 the artery, and losing their prominent corded form, and their 
 elasticity, when the compression is removed and the blood 
 permitted to flow along its channels, regaining these charac- 
 teristic marks when the pressure is resumed ; the tendon of 
 the biceps has been mistaken for a deep-seated vein, and has 
 been cut in attempts to bleed ; such an error ought never to 
 occur, as apart from the criteria above mentioned for distin- 
 guishing a vein, the tendon may be easily recognized by 
 flexing the fore-arm and marking the increased prominence 
 which it thereby acquires. 
 
 Before opening the vein, the surgeon should procure, and 
 have arranged in some convenient position, a narrow strip of 
 muslin, or linen, with which to arrest the circulation in the 
 veins of the fore-arm ; a lancet ; a vessel to receive the blood 
 as it flows from the incision ; a basin of water and a towel, to 
 cleanse the surface after the operation ; a small compress of 
 linen folded, to be placed over the wound, and a narrow ban- 
 dage of muslin, or linen, to retain this in place ; smelling- 
 salts, or some other restorative, should also be at hand. 
 
 The position of the patient during the operation is a matter 
 of some consequence. If it is desirable to abstract a large 
 quantity of blood, the recumbent posture should be assumed, 
 as syncope occurs less speedily in this than in any other 
 position ; when a rapidly prostrating or relaxing effect is re- 
 quired, as in cases of hernia or dislocation of the hip, the 
 patient should stand up while the blood is flowing ; when an 
 ordinary depletion only is indicated, and other circumstances 
 permit of it, the sitting posture will be found the most con- 
 venient. The size of the opening, too, should be varied in 
 different cases to meet particular views ; as, for example, 
 
FOE, GENERAL BLEEDING. 245 
 
 when a prompt effect is desired, the incision should be long, 
 to allow the blood to escape in a full current ; a small open- 
 ing should be made when a gradual influence is intended to 
 be produced. 
 
 The choice of the arm on which to practise the operation 
 may be left to the surgeon's discretion ; sometimes the veins 
 are larger in one arm than in the other, and their relative 
 position with regard to the artery may be more favourable in 
 one than in the other. If there be no reason of this kind for 
 selecting the right arm, it will be better to bleed from the 
 left, since, if any accident should happen, the injury is more 
 easily submitted to in the latter than in the former. 
 
 Either the thumb-lancet, or the spring-lancet, may be used 
 according to the habit or the fancy of the operator ; some 
 prefer one, some the other, and occasionally a patient is met 
 with who has strong objections against one or the other. 
 There seems to be great diversity of opinion concerning the 
 comparative safety of the two instruments. It is urged in 
 favour of the use of the spring-lancet, that the operation is 
 done more instantaneously with it than with the other, and 
 with less pain ; and that it is less frequently attended with 
 wound of the artery, in those cases in which the vein is 
 entered at a point directly over this vessel ; this last argument 
 derives strong support from the statement of Dr. Reese, the 
 American editor of Cooper's Surgical Dictionary, to the effect 
 that aneurism of the brachial artery at the bend of the arm 
 is much more commonly met with in the northern and eastern 
 sections of this country, where the thumb-lancet is in general 
 use, than in the southern and western and middle states, 
 where the spring-lancet is employed very generally, and in 
 many districts by very ignorant persons, as by the slaves on 
 the southern plantations. The thumb-lancet is the most sur- 
 gical instrument ; when of the proper shape and in perfectly 
 g >od order, as it always should be, the vein may be opened 
 with sufficient quickness, and with no more pain than when 
 the spring-lancet is employed ; the size of the incision can be 
 more nicely graduated with the former than with the latter, 
 and a deep-seated vein may be more certainly reached with 
 it: and as to the danger of penetrating the posterior wall of 
 the vein and wounding the subjacent artery, if the thumb- 
 lane t is used, the same amount of practice is as requisite to 
 21* 
 
246 ON THE OPERATIONS 
 
 enable the operator to determine just how far from, or how 
 near to, the skin it is necessary to hold the fleam of the 
 spring-lancet, in order that he may open the vein merely and 
 not penetrate entirely through it, will render him capable of 
 detecting, by the diminution in the resistance offered to the 
 point of the thumb-lancet, the moment at which the cavity of 
 the vessel has been entered by the instrument. It has occa- 
 sionally happened in bleeding with the spring-lancet, that the 
 fleam, or blade, of the instrument has been broken off, by the 
 force of the spring, and has remained in the cavity of the 
 vein, rendering it necessary in some instances to slit open the 
 vessel as far as the first valve, in order to remove the lancet. 
 This accident is of rare occurrence, but the possibility of such 
 an incident should be borne in mind. The spring-lancet will 
 be found the most convenient instrument in bleeding children, 
 in consequence of the struggles which they usually make, and 
 which interfere very much with the performance of the opera 
 tion when the thumb-lancet is used. 
 
 The shape of the blade varies very much according to the 
 fancy of the surgeon, or of his cutler; we would recommend 
 one rather more oval-shaped at the point than that repre- 
 sented in fig. 123. The point and the edges of the instru- 
 ment should be very sharp, and the blade as thin as is com- 
 patible with perfect strength and security. The lancet used 
 for bleeding should never be employed for any other pur- 
 pose, as cases have often occurred of inoculation of the 
 wound with irritating or poisonous matters which have ad- 
 hered to the blade. The instrument should be well cleansed 
 and wiped dry after it has been in requisition, and kept in a 
 suitable case. 
 
 Operation. — The operation is commenced by encircling 
 the arm, at a point an inch or two above the elbow, by a 
 piece of ribbon, or a strip of muslin, an inch and a half wide 
 and a yard and a half long. The arm should be bared 
 nearly to the shoulder, care being had that the sleeve of the 
 patient's dress exercises no constriction about the limb, im- 
 peding the flow of the blood through the artery ; then the 
 surgeon, having carefully examined the bend of the arm, in 
 order to ascertain the precise position of the brachial artery, 
 and whether there be any anomalous distribution of the ves- 
 sels, places the centre of the compressing bandage upon the 
 
FOR GENERAL BLEEDING. 247 
 
 middle of the arm, at the point already indicated, carrying 
 the tails around on each side successively, and bringing them 
 up over the anterior face of the arm, to tie them in a single 
 bow-knot on its outer side, the extremities of the band hang- 
 ing downwards. The bandage should be applied sufficiently 
 ti* T ht to arrest the course of the blood in the superficial veins, 
 but not to interfere with the circulation in the artery. If, as 
 is sometimes the case, the veins do not swell, the expedients 
 before adverted to should be tried, and if these are ineffectual, 
 the other arm should be taken, or a vein in some other part 
 of the body may be opened, if it should be impossible to find 
 a suitable vein in either arm. In such circumstances, M. Lis- 
 franc advises that the cephalic vein should be exposed, where 
 it occupies the interstice between the deltoid and pectoralis- 
 major muscles, and an incision made in it. But there are 
 few instances in which it is not possible to abstract the requi- 
 site amount of blood from one of the veins at the bend of the 
 arm. The vein having been selected for the operation, and 
 the exact situation of the artery with reference to it ascer- 
 tained, the next step is to make the incision. It is of great im- 
 portance that the patient's arm shall be well secured, in order 
 to avoid any accident which might ensue from a sudden 
 movement of the limb, as the instrument pierces the tissues ; 
 thi3 is of less moment when the spring-lancet is employed, 
 than if the thumb-lancet is used. When the latter instru- 
 ment is selected, the operator will find it of much advantage 
 to be equally skilful w T ith his right and left hands, as he can 
 secure the patient's arm, and perform the operation more 
 satisfactorily. Thus, the arm should be thrown out from the 
 body, and the surgeon should sit, or stand, between the limb 
 and the side of the patient : if the right arm is to be operated 
 upon, the elbow should be supported upon the outstretched 
 fingers of the surgeon's left hand, his thumb pressing upon 
 the vein, about an inch below the point of incision, in order 
 to steady the vessel, and to prevent a too great out-gush of 
 blood from soiling the clothes, while the patient's fore-arm 
 and hand are extended beneath the left fore-arm of the ope- 
 rator, and thus securely held ; the lancet is, of course, entered 
 with the right hand : if a vein of the left arm is to be opened, 
 the surgeon modifies his position, so as to secure the arm with 
 his own right hand and arm, and holds the instrument in his 
 
248 
 
 ON UHE operations 
 
 left hand. But if, as is the case with most persons, the ope- 
 rator cannot make the incision conveniently with his left hand, 
 he must place himself on the outer side of the patient's left 
 arm, securing the fore-arm with his own left, and open the 
 vein with his right hand. 
 
 The blade of the lancet should be exposed so as to form 
 
 a slightly obtuse angle 
 Tig. 123. with the handles, and 
 
 held as is represented 
 in the annexed drawing, 
 (fig. 123,) being grasped 
 near its head between 
 the extremities of the 
 surgeon's thumb and 
 fore-finger, the handle 
 resting against the lat- 
 ter. The operator places 
 his middle finger upon the patient's fore-arm, as in the figure, 
 so as to support the hand : the point of the lancet is entered 
 perpendicularly to the surface, if the vein is deep-seated, but 
 at a more obtuse angle if the vessel is more superficial ; the 
 mere straightening of the thumb and fore-finger serves to 
 force the point of the instrument through the integuments 
 and the anterior wall of the vein, when, so soon as the escape 
 of blood and the cessation of resistance to the entrance of 
 the blade make the surgeon aware that the point is within 
 the cavity of the vessel, he depresses the handle of the instru- 
 ment, and at the same time pushes it a little forwards by his 
 thumb and fore-finger, until the incision has been made suf- 
 ficiently long, when the blade is withdrawn ; or it is perhaps 
 safer to force the blade to cut its way out of the vein, so soon 
 as the latter has been entered, by depressing the handle 
 more and more, thus bringing the cutting edge in contact 
 with the anterior wall of the vessel and with the integuments, 
 successively : in this way there can be but little danger of 
 penetrating the posterior coats of the vein with the point of 
 the lancet. The incision should generally be somewhat oblique 
 with regard to the axis of the vein, especially if the vessel 
 be of small calibre, as otherwise the blood will escape more 
 slowly. 
 
 If the spring-lancet is used, it should be held more or less 
 
FOR GENERAL BLEEDING. 249 
 
 obliquely to the course of the vein, according as the vessel is 
 of small or large calibre : when the vein to be opened is su- 
 perficial, the point of the blade should be held a little above 
 the skin, so that it shall simply enter the vessel, and not pierce 
 entirely through it ; if, on the contrary, the vein is more deeply 
 seated, the point of the fleam should rest upon the surface. 
 In bleeding from a vein which is directly over the artery, the 
 incision should be made upon the side of the vessel, instead of 
 its anterior face, as being less liable to penetrate to the ar- 
 tery itself. 
 
 If, after the incision has been made, the blood does not flow 
 freely, the patient may be directed to grasp something in his 
 hand, as a cane, closing and relaxing his fingers upon it al- 
 ternately, thus compressing, by the contraction of the mus- 
 cles, the deep veins, and forcing the blood into the more su- 
 perficial channels; the current through the vein is sometimes 
 impeded by a constriction of the artery, arising from the too 
 tight application of the bandage, which should of course be 
 loosened : again, it may occasionally happen that a shred of 
 adipose tissue may obtrude itself across the incision, and thus 
 obstruct the escape of the blood ; the remedy for this difficulty 
 will at once suggest itself to the operator. Syncope, accom- 
 panied by cessation of the flow, is at times produced by the 
 dread of the operation which some persons experience, or by 
 the sensation of the incision itself, or by the sight of the blood, 
 in very sensitive patients ; in such instances, smelling-salts 
 should be applied to the nostrils, cold water be dashed upon 
 the face, and the individual be placed in the recumbent posi- 
 tion, until the faintness shall have passed off, when the blood 
 will flow again, generally. 
 
 It is of little consequence what kind of vessel is employed 
 to receive the blood as it escapes from the vein ; a common 
 bowl answers the purpose as well as any other: however, if it 
 be desirable to fix precisely the amount to be abstracted, the 
 44 bleeding-cup" proper should be used, — a vessel having lines 
 upon its inner side graduated to show the number of fluid- 
 ounces which it may contain : such bowls may be had of most 
 of the druggists. 
 
 After the required amount of blood has been drawn, the 
 bandage should be removed from the arm ; the edges of the in- 
 cision approximated by the thumb and forefinger of the sur- 
 
250 ON THE OPERATIONS 
 
 geon's left hand; the surface cleansed; the compress placed 
 upon the wound, and retained in this position by the crossed 
 bandage, as shown in figure 18. In applying the bandage, 
 care should be had that it does not compress the arm above 
 the opening in the vein more than below this point, otherwise 
 the blood may again flow from the incision. After the lapse 
 of twenty-four hours, during which time the patient should 
 keep the elbow flexed, and avoid using the arm, — the bandage 
 may be removed, as in most cases the orifice will have become 
 sufficiently closed to prevent the escape of the blood. 
 
 If it be probable that it will be expedient to repeat the 
 bleeding in the course of twenty-four hours, the necessity of 
 opening another vein may be avoided by anointing the com- 
 press with fresh lard, so that the orifice made in the vein will 
 close less speedily than when a dry compress is applied. It 
 is requisite merely to remove the bandage and encircle the 
 arm, just above the elbow, with a band, as in the first bleed- 
 ing : if the blood does not escape, on the vein becoming tur- 
 gid, the hand should be passed upwards along the vessel, when 
 the fluid will generally burst through the imperfectly closed 
 incision ; if it do not, a fine probe may be used to re-open the 
 wound. 
 
 2. Bleeding from the hand. 
 
 Operation. — Compress the fore-arm by a circular bandage 
 applied just above the wrist, in order to render turgid the 
 veins upon the back of the hand, and make an incision with 
 a thumb-lancet into the largest of these vessels, in the same 
 way as has been directed above with respect to the veins at 
 the bend of the arm. The cephalic vein, formed by roots com- 
 ing from about the thumb and fore-finger, and the vena salva- 
 tella, from the other fingers, are the largest trunks. Care is 
 necessary that the incision be not made so deep as to perfo- 
 rate the vein and wound the subjacent tendons. 
 
 The wound, after the bleeding, should be covered as in the 
 last-described operation. 
 
 3. Bleeding from the ankle. 
 
 Operation. — Plunge the foot in a basin of warm water, 
 and allow it to remain until the veins running along the ankle 
 shall have become swollen ; then remove the foot from the 
 water, dry it, pass a circular bandage around the leg just 
 above the malleoli, and open the internal saphena vein near 
 
FOR GENERAL BLEEDING. 251 
 
 the inner ankle, the vessel being fixed by the thumb of the 
 left hand, placed just below the point of the intended incision. 
 The opening should be oblique, and rather longer than is re- 
 quired for the veins of the fore-arm, so that the blood may 
 have every facility for its free escape. After the incision, if 
 the current do not flow readily, the foot should be again placed 
 in the water, in which case the amount drawn must be judged 
 of by the discoloration of the water, or by the effect produced 
 upon the patient. 
 
 The operator should be careful to regulate the force w T ith 
 which he makes the incision according to the volume of the 
 vein ; otherwise, by penetrating too deeply, he incurs the lia- 
 bility of breaking the point of his lancet against the bone. 
 The thumb-lancet should be used. The external saphena vein 
 is sometimes opened at the outer ankle, but it is rarely so 
 large as the other. The operation is performed as on the in- 
 ternal saphena. 
 
 The requisite amount of blood having been removed from 
 the vessel, a small compress should be placed upon the inci- 
 sion, the surface cleansed, and a figure-8 bandage applied to 
 retain the compress, circling around the leg and the foot, above 
 and below the ankles, leaving the heel exposed, and crossing 
 upon the instep. 
 
 4. Bleeding from the external jugular. 
 
 This operation is rarely performed, partly in consequence 
 of the more or less danger attending it, but chiefly because 
 the required amount of blood can generally be taken from a 
 vein at the elbow. It is sometimes advisable, however, to 
 practise this operation ; as, for instance, in convulsions occur- 
 ring in young children, in whom there is frequently much diffi- 
 culty in bleeding from the arm ; also in apoplectic seizures. 
 
 When it is determined to open the external jugular, the in- 
 cision is usually made between the lower third of the vein and 
 a point two inches above the clavicle. Below this point, there 
 may be danger that the air will enter through the orifice to 
 the heart, thus causing almost instant death. Above its lower 
 third, the vein is so surrounded by nervous filaments that the 
 incision of the former would, very probably, implicate the 
 latter. 
 
 Operation. — The patient is placed in a sitting, or in the 
 recumbent, posture ; a thick compress should be laid upon the 
 
252 
 
 ON THE OPERATIONS 
 
 vein in the supra-clavicular fossa, and retained in this position 
 by a strip of muslin, or a cravat, which crosses the chest ob- 
 liquely from this point to the axilla of the opposite side, where 
 its tails are united, as in the accompanying drawing (fig. 124.) 
 
 Fig. 124. 
 
 In opening the vein, the surgeon places the thumb of his left 
 hand upon the compress, and his forefinger upon the swollen 
 vein, just above the point selected for the incision, and opens 
 the vessel pretty freely in a line obliquely upwards and out- 
 wards, crossing the fibres of the platysma-myoid, so that the 
 lips of the wound may be w r ell separated. A tea-cup, or a 
 small bleeding-bowl, should be held against the skin at the 
 lower edge of the opening in the vein, to receive the blood as 
 
FOR GENERAL BLEEDING. 253 
 
 it escapes : or if the current do not jet from the orifice, a card 
 should be bent to the form of a gutter, or trough, to convey 
 the fluid into the cup. The compression should not be inter- 
 mitted until the operation is completed, and the opening in 
 the vein closed by another compress placed upon the wound : 
 this precaution is intended to prevent the ingress of air. The 
 compress may be retained in place by short strips of adhesive 
 plaster laid across it. or by the circular bandage of the neck, 
 described under the head of regional bandages. 
 
 The escape of the blood may be facilitated, if it do not 
 flow readily, by directing the patient to move the lower jaw, 
 as in masticating. After the operation, difficulty is occa- 
 sionally experienced in arresting the flow ; under such cir- 
 cumstances the recumbent posture should be maintained, all 
 compression from clothes carefully removed, and the patient 
 be directed to breathe freely and fully. M. Magistel closes 
 the wound, in such cases, with a fine suture. 
 
 ACCIDENTS ATTENDING PHLEBOTOMY. 
 
 Fortunately these are rare, when the frequency of the 
 operation is considered, and those which occur most frequently 
 are so slight in themselves and in their consequences, as 
 hardly to merit the appellation of accidents ; such are the 
 formation of what is termed a thrombus, and syncope partial 
 or complete. The proper remedies for the latter have been 
 mentioned, in treating of bleeding from the arm. A thrombus 
 is a tumour, or swelling, generally of small size, produced by 
 the infiltration of blood into the cellular tissue surrounding 
 the vein. It is owing, in most cases, to the external incision 
 not corresponding exactly in situation with the opening in the 
 vein, the correspondence having become destroyed by some 
 movement of the arm, or by a want of attention on the part 
 of the operator, while making the incision, to have the skin 
 tense and smooth ; any cause which will obstruct the ready 
 escape of the blood from the vein to the external surface may 
 develope a thrombus. Generally it is a matter of little con- 
 sequence, giving rise only to some swelling, discoloration, and 
 stiffness at the elbow, which inconveniences will disappear in 
 a few davs. Sometimes, however, if the effusion is large, the 
 22 
 
 i 
 
254 ON THE OPERATIONS 
 
 fluid is removed by suppuration instead of by absorption, and 
 there is danger that the vein will become involved in the 
 inflammation. 
 
 The simpler cases of this incident to bleeding require very 
 slight treatment ; the removal of the effusion will be hastened 
 by keeping the arm at rest and covering the affected part 
 with soap-plaster, or a wash of diluted spirits of camphor, or 
 of some similar resolvent. If inflammation and suppuration 
 occur in the tumour, a splint should be confined upon the 
 back of the arm and fore-arm, to maintain perfect repose of 
 the tissues about the elbow, and leeches, cold lotions, irriga- 
 tion, or poultices, should be made use of, according to the 
 condition of the tumour. 
 
 By carefully watching the escape of the blood during the 
 operation, the surgeon may often guard against, or arrest, the 
 formation of a thrombus, by maintaining the parallelism be- 
 tween the wound in the integuments and that in the vein, or 
 by restoring this condition if it has been deranged. If this 
 correspondence cannot be regained, and the tumour increases 
 in size, the external incision should be enlarged sufficiently 
 to permit of the blood reaching it, or another vein should be 
 opened. 
 
 Wound of a Nerve. — This accident may happen, and it 
 has occurred to the most skilful operators in bleeding, and it 
 cannot be considered as a subject of reproach. It will be re- 
 cognised by some disturbance in the functions of the part to 
 which the nerve is distributed. If the wounded nerve be a 
 nerve of sensation, pain will be experienced at the seat of the 
 incision, or at the terminal ramifications of the nerve, a sen- 
 sation of numbness or of tingling, or the skin will be deprived 
 of sensibility. If it be a motor nerve which has been impli- 
 cated in the incision, the muscle, or muscles, to which it gives 
 power will be more or less paralysed, or be the seat of irregu- 
 lar motor action, spasmodic twitches, tetanic rigidity, and the 
 like. 
 
 This accident is a much more serious one than those already 
 considered, and should be so regarded. The treatment con- 
 sists in the application of antiphlogistic or anodyne remedies 
 to the surface, according to the symptoms ; in securing the 
 limb to a splint in a semiflexed position, and in the adminis- 
 tration of opiates internally. The limb should be kept in a 
 
FOR GENERAL BLEEDING. 255 
 
 state of perfect rest on a splint, for two or three weeks, or so 
 long as there is any probability of the reunion of the cut 
 extremities of the nerve, experiments and observations having 
 shown that restoration of the functions of nerves simply 
 divided does take place. (Carpenter's Human Physiol. ; 
 Muller's Physiol, vol. i. p. 457, &c.) 
 
 Wound of an Artery. — The brachial artery is the one 
 most liable to be wounded in phlebotomy, and its accidental 
 puncture may be taken as a type of similar injuries of other 
 arteries. The signs usually mentioned as indicative of this 
 accident are, the flowing of the blood in jets from the external 
 opening, and the bright-red hue of the fluid. These appear- 
 ances, however, are fallacious, for venous blood is not always 
 of a dark blue colour ; in fact, in many persons and in some 
 diseases, its colour approaches very nearly to the hue of arte- 
 rial blood ; and if the vein which has been opened is seated 
 immediately upon the brachial artery, the pulsations of this 
 vessel will often agitate the vein, and communicate a jetting 
 motion to the current as it escapes from the latter. The 
 occurrence of the accident may be recognised pretty surely, 
 by observing whether the blood continues to flow from the 
 external wound, when the vein is compressed at the lower 
 edge of the incision ; if such is the case, the artery has pro- 
 bably been opened, the only circumstance likely to mislead 
 the observer arising from the communication of another vein 
 with the one in which the aperture has been made, opposite 
 the orifice ; this must be a very unusual incident. Additional 
 knowledge may be acquired as to the non-existence of injury 
 to the artery, by compressing this vessel at some point above 
 the wound, when, if the colour of the blood remain as before, 
 the inference from this fact, conjoined with the cessation of 
 the flow when the vein is compressed below the orifice, while 
 the artery still pulsates at the wrist, is, that only the vein has 
 been opened. Again, if the external wound be closed with 
 sufficient force to compress the vein merely without obliter- 
 ating the artery, a gradually increasing tumour will be devel- 
 oped in the tissues, if the artery has been punctured. The 
 existence of the injury having been ascertained, there can 
 still be no impropriety in permitting the blood to escape until 
 the amount originally intended to be drawn has been removed. 
 Then the surgeon must determine whether it is better, in the 
 
256 
 
 ON THE OPERATIONS 
 
 particular instance, to endeavour to remedy the accident by 
 the long-continued employment of a compress and bandage, 
 or to obliterate the artery at once by the application of a 
 ligature, or ligatures. M. Velpeau recommends that the first 
 method be tried for a week or two, unless some serious 
 appearance present itself. (Velpeau, op. cit. p. 312.) This 
 course having been determined upon, a graduated compress 
 should be formed, of a pyramidal shape, and applied with its 
 apex upon the wound, a figure-8 bandage being made to retain 
 it in place with a degree of compressive force considerably 
 greater than would be sufficient to obliterate the vein merely, 
 so that the pulsation at the wrist shall be arrested (fig. 125) ; 
 the limb, from the fingers to the axilla, should be enveloped 
 carefully in a roller-bandage, and maintained in a state of 
 perfect rest upon a splint, in the straight position ; the patient 
 should remain in bed, or his arm should be supported in a 
 sling. If, after compression has been employed, the forma- 
 tion of an aneurism be detected, the treatment necessary for 
 
 Fig. 125. 
 
 Plan of a Graduated Compress. — a, the artery wounded ; b, b, the 
 graduated compress arranged so that the apex of the cone is in immediate^ 
 contact with the arterial orifice, while its mass occupies the general wound, 
 and projects somewhat above the integumental level. 
 
 this affection must be adopted ; for this, and for the best 
 method of obliterating the artery by ligature, if the treatment 
 by compression be rejected at first, the reader is referred to 
 treatises on practical surgery. 
 
 Wounding of the Tendon of the Biceps, or of other 
 Muscles. — It happens occasionally that one of the tendons 
 is pricked by the point of the lancet, when it is seated beneath 
 the vein which has been opened ; or the operator may have 
 mistaken the tendon for the vein, and plunged his lancet 
 therein. Some degree of pain and difficulty in using the 
 
E R GENERAL BLEEDING. 257 
 
 muscle are generally experienced, after such an accident, but 
 the symptoms are rarely of a violent character. The treat- 
 ment consists in keeping the limb at rest upon a splint, the 
 muscle being relaxed, and in the application of anodyne and 
 emollient remedies. In irritable patients, it may be advisable 
 to abstract blood from the part, by leeches, and to administer 
 opiates. 
 
 ARTERIOTOMY. 
 
 The temporal artery is the only one upon which this ope- 
 ration is now practised, and very rarely is it considered 
 advisable, even on this vessel. The artery is superficial, is 
 favourably situated for compression after the operation, and 
 is generally large enough to allow of the abstraction of a 
 sufficient amount of blood. Although the incision of the 
 vessel is one of the simplest of operations, it is sometimes 
 followed by the development of an aneurism. 
 
 A strong lancet, or a bistoury, — a graduated compress, — a 
 narrow roller, two or three yards long, — warm water and a 
 towel, are all that are usually needed for the operation. 
 
 The trunk of the temporal artery itself, or its anterior 
 branch, may be opened ; if the former, the mode recom- 
 mended by M. Magistel may be resorted to, as follows : — 
 The position of the trunk is ascertained at the point where it 
 is most superficial, and where its pulsation is most forcible, 
 and there marked with ink in the direction of the intended 
 incision : this point will be found a little in advance of the 
 ear, and above the zygomatic arch. The patient may sit up, 
 or assume the recumbent position, his head resting upon a 
 pillow on the opposite temple ; the surgeon steadies the 
 artery by one finger placed upon the surface, on the outside 
 of the vessel, and about a quarter of an inch above the site 
 of the intended incision ; the bistoury is held as the lancet in 
 phlebotomy, and entered through the integuments on the 
 inner side of the artery, cutting its way obliquely through 
 the vessel and the integuments of the opposite side. The 
 blood is received directly in a cup, or it is guided to the 
 latter through a little gutter of paper, placed against the sur- 
 face beneath the opening : a plug of cotton should be inserted 
 into the chamber of the external ear, to prevent the blood 
 22* 
 
258 ON TOPICAL BLEEDING. 
 
 from entering it. When the proper amount has been drawn, 
 the flow is generally easily arrested by placing a small com- 
 press of folded linen upon the orifice, (its lips having been 
 placed in apposition,) and securing it thus by a few circular 
 turns of a roller. If this be insufficient to stop the bleeding, 
 a fine suture may be passed through the edges of the wound. 
 (Malgaigne, Med. Op£rat.) 
 
 If the blood do not flow freely, the patient, if he be con- 
 scious, should be requested to move his jaw, as in mastica- 
 tion, or a sponge filled with warm water may be laid upon the 
 vessel. 
 
 M. Velpeau advises that one of the branches of the artery 
 be selected for the operation, particularly the anterior 
 branch in its course towards the forehead, as it is very super- 
 ficial, and reposes so nearly upon the bone, that a firm com- 
 pression may be made upon it. The mode of performing the 
 operation is the same as for the trunk itself: the lancet may 
 be used as in opening a vein, or a bistoury may be employed, 
 and the integuments and vessel divided, from the former 
 towards the latter, and from the outer side of the artery 
 towards the operator. See fig. 124. 
 
 SECTION II. 
 ON TOPICAL BLEEDING. 
 
 1. On the application of the cupping apparatus. 
 
 In professional language, "a cup" is a small, bell-shaped 
 vessel, made of glass, or thin metal, intended for application 
 to the surface of the body, with the view either of removing 
 a certain amount of blood from the minute veins and arteries 
 which have been previously incised, or of merely producing a 
 congestion of the surface, or a certain degree of ecchymosis. 
 The first is termed "wet-cupping," or simply "cupping," the 
 latter " dry-cupping." 
 
 Dry cupping is effected by merely acting upon the air 
 within the cup, so that the integuments, on the surface of 
 which it is placed, shall be forced, by the pressure of the 
 atmosphere without, into the partial vacuum formed within 
 the vessel. This vacuum may be produced in several differ- 
 
ON TOPICAL BLEEDING. 259 
 
 ent ways, either by means of heat so applied as to rarefy the 
 air within the enclosure, or by the direct abstraction of a cer- 
 tain portion of it through the aid of a pump. The latter is 
 the most convenient and the most eligible mode. The pump 
 is made to fit upon the summit of the cup, which is perforated 
 with a small hole covered with a thin valve of oil-silk, or 
 of gum-elastic, to exclude the entrance of air from without ; 
 while, by the action of the pump, a very considerable ex- 
 haustion can be effected within the cup. The cup is best 
 made of glass, so that the degree of turgescence of the inte- 
 guments can be seen ; when this is deemed sufficient, the 
 glass is easily detached from the surface by slightly raising 
 the valve by means of a pin inserted beneath it, when the 
 pressure of the atmosphere within and without the cup will 
 become equalized. 
 
 If this complete cupping apparatus be not at command, the 
 operation may be sufficiently well performed by using a com- 
 mon wine-glass, or tumbler. The vessel may be immersed in 
 hot water, in order to heat its surface, and then, before it 
 becomes cooled, applied upon the skin ; thus the air which it 
 contains becomes rarefied by the heat of the material of 
 which the cupping vessel is composed, and retreats before the 
 ascent of the integuments, which are pressed upwards by the 
 weight of the air surrounding the cup ; or the inner surface of 
 the cup may be moistened with spirits of wine, which should 
 then be inflamed, and while the vessel is yet warm, it should 
 be placed upon the skin ; or, finally, small pellets of cotton,- 
 or strips of paper, may be moistened with the same fluid, then 
 lighted and introduced into the cup, which is used as above. 
 The vessel may be loosened from the surface after a proper 
 time, by pressing upon the integuments at its edge, so that 
 the air may rush into the cavity. 
 
 Dry cupping will be found of great benefit in the relief of 
 internal congestions, when it is not expedient to abstract 
 blood. It seems not to produce its good effect by revulsion 
 merely, or by the external irritation which it causes, but also 
 by rendering the vessels on the surface turgid, producing a 
 true ecchymosis, and thereby diminishing temporarily the 
 amount of fluid in circulation through the vessels. 
 
 Wet cupping requires that, in addition to the local tur- 
 gescence which the dry cupping occasions, the surface thus 
 
260 ON TOPICAL BLEEDING. 
 
 engorged shall be incised, its small vessels opened, and blood 
 be abstracted therefrom. To accomplish this object, the cup- 
 ping apparatus must be used as above described, and after 
 the integuments have become sufficiently full of blood, the 
 cup should be removed and a number of incisions made on 
 the surface, deep enough to open the subcutaneous vessels ; 
 then the cup is to be re-applied, and the air again exhausted 
 from it ; thus the blood will flow readily from the openings 
 made. After a sufficient amount has been obtained, the cup 
 is removed and the surface cleansed ; generally, no dressing 
 is called for, but if there be much smarting, cold or warm 
 water, or a piece of linen spread with simple cerate, may be 
 applied, as may be most agreeable to the patient. In direct- 
 ing the use of cups, it is generally considered that each one 
 will draw one ounce of blood ; this is not strictly correct, as 
 the amount will vary very much, according to the vascularity 
 of the part to which the application is made ; sometimes a 
 single cup will abstract several ounces if re-applied to the 
 same spot, and again but a very small proportion of this 
 amount can be taken. The flow of blood may be encouraged 
 by immersing the cup, before it is placed upon the skin, in 
 warm water, and by laying a sponge or towels dipped in warm 
 water upon the surface, while the cup is acting. The depth 
 of the incision must be regulated to suit the character of the 
 surface ; where the integuments are thick, containing much 
 adipose tissue, the incisions must be deeper than under oppo- 
 site circumstances. The proper instrument for making the 
 incisions in cupping is the "scarificator," — a metallic box of 
 about the same size as the cup, having its interior surface 
 pierced with a number of slits, through each of which a lancet- 
 blade is made to protrude by means of a spring, the frame 
 upon which the blades are secured being elevated or depressed, 
 so as to regulate the depth of the incisions, by the turning of 
 a screw arranged for the purpose. In the absence of this sca- 
 rificator, the necessary incisions may be made by a scalpel, or 
 a thumb-lancet ; they may be parallel to each other, or crossed, 
 or have an oblique direction. 
 
 The operation of cupping is sometimes a painful one, par- 
 ticularly upon surfaces not very well cushioned by integu- 
 ment, as on the chest of thin persons, and also when performed 
 over inflamed cavities, as upon the abdomen in gastritis, en- 
 
ON TOPICAL BLEEDING. 261 
 
 teritis, or peritonitis ; but even in these latter cases, the ope- 
 ration may be effected with comparatively little pain, by first 
 applying a poultice, or a fomentation, upon the surface ; thus 
 the sensibility of the part becomes lessened. This is a 
 matter of considerable consequence, as leeches cannot always 
 be obtained in all situations ; and by the simple precaution 
 just stated, cups may be very well used instead, in numerous 
 instances in which, otherwise, the advantages of local deple- 
 tion must be foregone. 
 
 It is of importance to bear in mind that the benefit of 
 cupping does not consist in the local abstraction of blood 
 merely, but also in the stimulation which it effects upon the 
 surface to which the cups are applied, and in the revulsive 
 action which is thereby occasioned. 
 
 2. On the employment of leeches. 
 
 There are many cases demanding local depletion, in which, 
 from peculiarity of situation, or excessive sensitiveness of 
 the surface, cups cannot be employed ; in such instances, 
 leeches may be used, as also in all other conditions requiring 
 the topical abstraction of blood. 
 
 Previous to the application of the leech, the surface on 
 which it is to be placed should be cleansed with warm water, 
 so as to remove, as far as possible, any matter which may 
 adhere to the skin, either as the result of medicinal applica- 
 tions, or as incident to the natural or diseased processes going 
 on in the part : if this precaution be not taken, much diffi- 
 culty and delay will be experienced in inducing the leech to 
 fasten upon the surface, and the animal itself may be injured 
 or killed, by the introduction into his system of such noxious 
 matter. If the surface to be leeched be covered at all thickly 
 with hair, as the pubis, the scalp, &c, it should be shaved 
 before the leech is applied to it. When a number of leeches 
 are to be applied to a circumscribed part, it is often found 
 difficult to confine them within a sufficiently restricted range, 
 if they are simply placed on the surface ; this may be over- 
 come by moistening the skin, at different points, w T ith blood 
 drawn from the tip of the finger, or with sugar and water ; 
 or the leeches, as many as are intended to be employed, may 
 be put into a tumbler, or wineglass, which should then be in- 
 verted upon the skin ; or, finally, the palm of the hand may 
 be covered with a napkin, and the leeches placed upon the 
 
262 ON TOPICAL BLEEDING. 
 
 latter, and thus held against tfe surface until they shall have 
 attached themselves. When blood is to be taken from the 
 mucous membrane lining a canal, it is necessary to place the 
 leech in a tube, which is then to be introduced into the canal, 
 its open extremity applied to the membrane at the proper 
 point, and there retained until the leech has fastened itself 
 upon the surface. Thus if the depletion is to be effected 
 from the neck of the uterus, the neck of the bladder, or from 
 any part of the vagina, in the female, — a speculum of polished 
 metal, made of a single piece, and having the upper end cut 
 obliquely, should be introduced into this passage to the proper 
 distance, the polished internal face of the speculum enabling 
 the operator to see each point of the vagina ; the leeches are 
 now to be placed in the speculum, and thrust up to the affected 
 spot by means of a quill, or a stick. For the rectum, a smaller 
 speculum is required. For the nostrils, a tube of glass slightly 
 curved at its upper extremity, and about a quarter of an inch 
 in diameter, gradually tapering downwards towards the curve, 
 may be used; this should be introduced, and the point of the 
 curvature carried opposite the spot upon which the leech is to 
 be attached ; the animal is then to be placed in the cavity, 
 and pushed upwards by means of a quill, or a pencil ; as soon 
 as it has fastened upon the membrane, the tube may be with- 
 drawn, and, if necessary, another leech introduced in the 
 same way. A similar plan should be adopted in the applica- 
 tion of leeches to the gums, or to the lining membrane of the 
 mouth at other points. 
 
 If, accidentally, one or more of these animals should 
 escape beyond the reach of the operator, as into the stomach 
 or rectum, it may be destroyed by injecting a solution of salt 
 into the cavity ; afterwards the leech will be discharged dead. 
 
 Repletion causes the leech to fall from the surface upon 
 which it had fastened ; but if it be expedient to detach it 
 before it has become filled, fine salt should be placed upon it ; 
 it should not be violently pulled from its hold upon the skin, 
 lest a portion of its mouth remain in the little wound which 
 it has made, causing more or less irritation and destroying 
 the animal. 
 
 The quantity of blood which a leech will draw varies very 
 much with the kind of leech used, and the degree of vascu- 
 larity of the surface. Six of the ordinary American leeches 
 
ON TOPICAL BLEEDING. 263 
 
 are allowed for each ounce of blood required ; these answer 
 very well for application to the external surface, in situations 
 possessing an average condition of the circulation, and offer- 
 ing space sufficient to allow of the application of the requi- 
 site number ; their bite is less irritating and less deep than 
 that of the European leech, and hence they should always be 
 employed upon children, and upon others w T hose skin is prone 
 to a morbid degree of inflammation or soreness, from slight 
 causes. An ounce of blood is generally allotted, as the 
 capacity of two or three Swedish, or Spanish, leeches. These 
 are used when the part to be depleted is endowed with little 
 vascularity, and upon internal surfaces of which the secre- 
 tions are naturally, or from disease, more or less acrid or 
 offensive to the animal, as the mucous membrane of the vagina, 
 that covering the neck of the uterus, the rectum, the gums; 
 and it is advisable always, before applying the leech to such 
 parts, to wash them with warm water. 
 
 After the animal has fallen off, the blood continues to flow 
 from the w r ound, but this ceases in the course of a few minutes, 
 if the bite be left exposed to the air, unless a small arterial 
 branch of notable size has been opened. If a sufficient de- 
 pletion has been had, and the bleeding does not cease of 
 itself, cold water should be laid upon the surface, or dry lint ; 
 and if anything more effectual is necessary, pressure with the 
 finger, a little fine lint intervening between its point and the 
 leech-bite, may be made upon the latter for a few minutes, 
 and then the finger gently withdrawn, leaving the lint behind ; 
 this will generally be sufficient to arrest the bleeding ; but if 
 this fail, a fine point of lunar-caustic should be thrust into 
 each bleeding wound, and quickly removed; finally, it is re- 
 commended, in obstinate cases of such hemorrhage, to pass a 
 fine needle transversely through the lips of the wound, and 
 to lay upon it a twisted suture ; this, however, must be very 
 seldom required. 
 
 If it be deemed expedient to encourage the flowing of the 
 blood, warm water should be laid upon the part, or a warm 
 poultice. 
 
 The preservation of the leech is a matter of great import- 
 ance. To insure this object, the habits of the animal should 
 be ascertained, in order that it may be placed in circumstan- 
 ces in which these habits and instincts may still be indulged. 
 
264 ON TOPICAL BLEEDING. 
 
 It should be kept in some suitable vessel, — an ordinary tub 
 will answer, — containing water, and pieces of turf, or, which 
 is still better, of peat, into which the animal may insinuate 
 itself, and, by the friction of its surface against the interlaced 
 roots of which the peat is composed, cleanse itself of the 
 slimy secretion which covers it, and which, if permitted to 
 remain long upon the exterior, prevents the proper perform- 
 ance of certain functions on which the health of the leech 
 depends. The water moreover should be changed as often as 
 once every w T eek, and the leeches should be washed, unless 
 they have the means, as above described, of performing this 
 office for themselves. The animal obtains its supply of oxygen 
 from the air entangled in the water, and not by rising to the 
 surface to breathe. 
 
 In this w T ay leeches may be preserved for an indefinite 
 length of time, until needed for application ; but after they 
 have been once employed in drawing blood, they never are so 
 efficacious again. If they have been applied to abstract blood 
 from persons suffering from some malignant or contagious 
 disease, they should not be used subsequently. 
 
 The natural food of the leech consists of smaller aquatic 
 animals which it meets with in its native haunts; and the 
 admirable apparatus with which it is provided, and which 
 adapts it so perfectly to the purpose to which it is made 
 subservient in the treatment of disease, would seem to be 
 contrived for the especial benefit of man, - — to be, in a mea- 
 sure, an appendix to the animal, and not called for in the 
 operations of its own economy. Hence, although the blood 
 with which it fills itself to distension, in the gratification of its 
 voracious thirst, does not putrefy in the animal's stomach, 
 notwithstanding the length of time during which it will be 
 retained in this cavity, unless it be evacuated artificially, — in 
 most cases, the animal will die unless the blood be removed 
 from it. (T. Rymer Jones's Comparative Anatomy.) To 
 accomplish this, it is requisite merely to place some fine salt, 
 or salt water, upon the leech, which will cause the animal to 
 eject the contents of its stomach by the mouth. The author 
 is informed by Mr. Moore, who is one of the best leechers in 
 this city, that he effects the removal of the blood by making 
 one or two small punctures on the back of the leech, on each 
 eide of the middle line ; the contents of the stomach and of 
 
ON TOPICAL BLEEDING. 265 
 
 the numerous sacciform appendages to this central cavity are 
 evacuated through these punctures, which soon close again 
 without having injured the animal at all. Mr. Moore prefers 
 this method to the use of salt, which he thinks is in some 
 measure hurtful to the leech. Leeches which have thus been 
 emptied of the blood that they have drawn, should be placed 
 in a vessel containing water and turf, as above mentioned, 
 and kept distinct from others for two or three weeks, after 
 which they may again be employed. 
 
 Within a few years past, " artificial leeches" as they are 
 called, have been introduced. These are small tube-shaped 
 cupping-glasses ; their diminutive size permits them to be 
 applied where the ordinary cupping-glass could not be placed. 
 They are not comparable to leeches as a means of abstracting 
 blood from certain parts ; but they may prove serviceable 
 under circumstances when leeches cannot be procured. 
 
 Simple scarification of the surface with a lancet or scalpel, 
 is sometimes resorted to as a means of local depletion. It 
 can only be employed on very vascular parts, as on the 
 tongue, the mucous membrane lining the interior of the 
 mouth, and that covering the fauces and the eyelids. 
 
 23 
 
CHAPTER III. 
 
 ON THE DIFFERENT MODES OF EFFECTING CUTANEOUS 
 IRRITATION. 
 
 It has long been an established principle in medicine, that 
 ■when a point of irritation exists in any part of the body, there 
 will be a corresponding accumulation at that point of organic 
 energy and of circulating blood ; and the physical and chemi- 
 cal changes which accompany every manifestation of organic 
 action will be proportionately more rapid and complete. To 
 admit of this concentration of vitality upon a particular part 
 of the body, the system elsewhere seems to suffer, as it were, 
 a transfer of some portion of the vital energy allotted to it. 
 Hence the resort to counter-irritation, or revulsion, in the 
 treatment of disease : an exaltation of life is artificially occa- 
 sioned in a particular part of the surface, with the view of 
 diminishing or annulling the same condition, as the result of 
 disease, in another and generally neighbouring organ. By 
 properly varying the means resorted to, the kind and degree 
 of action thus established may be suited to the different states 
 which it is the object of the surgeon to counteract. These 
 means are chiefly rubefacients, vesicatories, and such as pro- 
 duce suppuration. 
 
 SECTION I. 
 OF RUBEFACIENTS. 
 
 These are applications which excite an erythematous 
 inflammation of the skin, terminating in complete resolution, 
 and followed frequently by desquamation of the cuticle upon 
 which they were placed. Their local action is strictly counter- 
 irritant, not combined with any depletory influence ; but, in 
 addition to this, they produce a considerable degree of general 
 
 excitement. 
 
 (266) 
 
OF RUBEFACIENTS. 267 
 
 There are many applications which produce this effect: 
 water, sand contained in a suitable vessel, and heated to a 
 temperature somewhat above that of the surface of the body 
 (from 100° to 150°), will excite an erythema of the skin ; 
 the same result follows the application to the surface of the 
 aromatic oils and powders, of spirits of turpentine, dilute 
 aqua ammonise, the " linimentum cantharidis," and many 
 other substances. But the means most commonly employed 
 as rubefacients are sinapisms, or poultices made of ground 
 mustard-seed. In order to prepare the flour for application, it 
 should be mixed with water, and spread evenly upon a piece 
 of muslin, having the surface which is to be placed next the 
 skin covered with a piece of thin gauze or cambric. The 
 efficacy and rapidity of action of the sinapism may be in- 
 creased, by adding vinegar to the flour, instead of using water, 
 and also by incorporating it with a mixture of oil of turpen- 
 tine and water. This applies only to the white mustard-seed 
 powder. 
 
 The length of time during which a sinapism should be 
 allowed to remain in contact with the skin depends, in a mea- 
 sure, upon the sensitiveness of the surface, and the patient's 
 general sensibility. In the course of a few minutes after the 
 application has been made, a sensation of warmth is induced, 
 which becomes more and more powerful, so that after the 
 lapse of twenty minutes it cannot be tolerated, generally, with 
 any degree of comfort. It should now be removed, and re- 
 applied at intervals, upon the same part, or upon other regions, 
 as may be indicated. If it be suffered to vesicate the skin, a 
 very troublesome sore often results, and sometimes gangrene, 
 from excessive inflammation. Attention to the duration of 
 the application is particularly necessary when the patient is 
 unconscious, or only partially sensible, as the pain arising 
 from the action of the mustard, in ordinary circumstances, is 
 not complained of now, and great inflammation may be caused 
 before this effect is suspected. By combining some other 
 kind of meal with that of the mustard-seed, a poultice may 
 be made, which will excite erythema more slowly, and which 
 may be borne upon the skin for a much longer time. 
 
 The ordinary " spice poultice," — made by mixing together 
 the powders of several of the aromatics, as cinnamon, cloves, 
 red and black pepper, and mustard-seed, together with wheat 
 
268 OF VESICANTS. 
 
 or flaxseed meal, or bread-crumbs softened in milk or water, 
 — is an excellent and mild rubefacient application. From a 
 half teaspoonful to a teaspoonful of each of the aromatic 
 powders may be combined with a sufficient quantity of one 
 of the other substances, to make the poultice large enough for 
 the surface to be covered. 
 
 The general stimulant or excitant action of rubefacients 
 should be borne in mind when their application is directed, 
 as in many cases this influence will be sufficient to counteract 
 their revulsive effect. 
 
 SECTION II. 
 OF VESICANTS. 
 
 These are characterized by the effusion of serum beneath 
 the cuticle, caused by the inflammation arising from their ap- 
 plication. Hence, in addition to their derivative effect from 
 the diseased organ, and the general excitement which they 
 occasion, they act also as depletants : this last peculiarity 
 serves to counteract the injurious impression which would 
 otherwise be incident oftentimes to their stimulant action. 
 
 Vesication may be produced by a variety of applications. 
 If a very rapid effect is desired, probably the best mode is to 
 saturate a cloth, folded to the proper size, in boiling water, 
 and lay it upon the surface, taking care that the fluid does 
 not flow over a larger space than was intended. A piece of 
 metal, raised to a high temperature by being plunged in 
 boiling water, and then placed in contact with the skin ; — or, 
 according to the recommendation of Carlisle, metal heated to 
 redness and passed over the surface, a fold of wetted cloth 
 intervening ; — or a jet of steam from the nose of some con- 
 venient vessel ; — all these are at times resorted to for the 
 purpose of raising a blister speedily. But they cause a degree 
 of inflammation which often eventuates in gangrene, and are 
 always very painful remedial agents. 
 
 There are three remedies of this class which are simple in 
 their application and very manageable, and with which, 
 probably, the surgeon may accomplish all that he can hope to 
 
OF VESICANTS. 269 
 
 gain from the use of vesicating applications. These are the 
 Spanish fly, Croton oil, and aqua ammoniae. 
 
 1st. The cerate made of Spanish flies, — " ceratum cantha- 
 ridis" of the Pharmacopoeia, — is the preparation which is 
 most used. It may be spread on coarse brown paper, or on 
 soft leather, or, which is much the most convenient and most ele- 
 gant substance, upon a piece of adhesive plaster, as it is pre- 
 pared on sheets of linen for use. In covering either of these 
 substances with the cerate, a margin should be left all around 
 free from the salve. If the adhesive plaster is used, it will 
 be necessary merely to warm this margin, in order to make 
 the vesicating agent adhere to the skin on which it is placed : 
 if any other substance is employed on which to spread the 
 cerate, strips of adhesive plaster should be used to retain it 
 on the surface. 
 
 Before applying the vesicatory, the skin should be shaved, 
 if there be much hair upon it, and moistened with vinegar, 
 in order to increase the rapidity of action of the flies ; and 
 it is also advisable to cover the surface of the cerate with a 
 piece of fine tissue-paper moistened with vinegar, as by this 
 means none of the blistering matter will adhere to the skin 
 after the removal of the cerate. 
 
 The length of time during which the application should be 
 continued varies with the part to which it is confined, the age 
 of the patient, and the state of the general sensibility of the 
 individual : probably from two to twelve hours may be as- 
 sumed as the minimum and maximum duration. The scalp 
 being much more tardy in responding to the action of the 
 vesicant than any other part of the body, the application 
 should be retained longer upon it. It is not necessary to the 
 formation of the blister that serum should actually be effused 
 beneath the cuticle before the vesicating agent can be re- 
 moved. If the skin be rendered of a bright red colour by 
 the action of the flies, these may be withdrawn, and a piece 
 of linen covered with simple cerate, or a poultice, may be , 
 laid upon it, and in a short time the cuticle will be raised by 
 the serum poured out beneath it : excepting in some few cases, 
 where a very powerful impression is demanded, the desired 
 results will be obtained from this course as fully as though 
 the vesicatory had been retained upon the part for a much 
 longer time ; and this will be found to be the surest way of 
 23* 
 
270 OF VESICANTS. 
 
 preventing the occurrence of strangury, one of the most un- 
 pleasant incidents to the use of the Spanish fly as a blistering 
 application. In children this method should always be pur- 
 sued, the cerate being kept upon the skin for two or three 
 hours only, and then it will be rare that gangrene, or a very 
 high degree of inflammation, will endanger the life which the 
 blister has perhaps rescued from the grasp of some formidable 
 disease. 
 
 A very elegant and convenient preparation of cantharides 
 is the " cantharidal collodion," as it is called; it is made by 
 dissolving gun-cotton in an ethereal solution of cantharides. 
 It is applied upon the skin by means of a camel's-hair pencil. 
 It is prompt in its action, and the intensity of its effects may 
 be pretty well regulated by the manner in which it is used. 
 To produce a very speedy and comparatively severe vesica- 
 tion, a thick coating of the solution should be applied, and 
 then covered with oiled-silk. 
 
 The mode of dressing the blistered surface will depend 
 upon the effect which is desired. If it be not important to 
 encourage a continued secretion or discharge from the skin, 
 the cuticle should be simply punctured with a needle, or with 
 the point of a thumb-lancet, and the serum be suffered to 
 escape, and simple cerate, or a soft poultice, be subsequently 
 laid upon the surface ; in a day or two the irritation will have 
 subsided. But if a continuation of the secretion be desired, 
 the cuticle should be removed, having been first cut around 
 its adherent edge, and the exposed surface of the true skin 
 dressed with basilicon cerate, or with savine cerate. If, as is 
 sometimes the case, the surface be very painful and much in- 
 flamed, a soft poultice or cold water will be found the best 
 dressing. A sloughy condition of the part will be best com- 
 bated by the application of one of the acids sufficiently diluted, 
 or creasote, or decoction of oak-bark, or the solution of La- 
 barraque, together with the internal administration of suitable 
 tonics. When a blistered surface is tardy in healing, Dr. 
 Wood strongly recommends the application to it of "the 
 cerate of subacetate of lead diluted with an equal weight of 
 simple cerate. " 
 
 Blisters should always be dressed with great gentleness, as I 
 every one will feel who has had the misfortune to have been 
 
VESICANTS. ill 
 
 tered. The tearing off the cuticle, recommended by some, 
 
 is n. barbarity. 
 
 If strangury should occur, despite the precautions having 
 been taken to prevent it, as above recommended, the patient 
 may drink pretty freely of flaxseed tea. or if copious draughts 
 of liquids be objectionable from particular circumstances, 
 speedy relief will follow an enema of a scruple of camphor 
 and twenty or thirty drops of laudanum suspended in an 
 ounce or two of water or mucilage. 
 
 The affections strictly surgical, in which blistering by this 
 means is most efficacious, are, probably, periostitis — the blister 
 being produced directly over the seat of pain ; — fractures re- 
 maining long ununited — where the blister is created in order 
 to excite the vessels of the bone and surrounding soft parts 
 to an increased activity of function, with the hope of repair- 
 ing the injury: — erysipelas — in order to produce a more 
 healthy kind of inflammation, and thus to arrest the spread 
 of the disease; — and gangrene, — the object being the same 
 as in the last affection. Besides these, many others may be 
 enumerated as being "more or less benefited by the employ- 
 ment of vesicating remedies, such as caries, the various oph- 
 thalmic diseases, neuralgia, chronic articular inflammations, 
 indolent glandular and other swellings. 
 
 The general excitant effect of this class is one of the most 
 important therapeutic characteristics, more marked in this 
 than in the class last considered. 
 
 '2. Croton oil — the " Oleum Tiglii" of the Pharmacopoeia 
 — is a very mild and manageable Gaunter-irritant. It is more 
 adapted to chronic than to acute diseases ; its general stimu- 
 lating effect is much less than that of cantharides, and its 
 depleting action is comparatively slight ; as a local derivative. 
 however, it exerts a decided impression, and this may be 
 maintained for a long time wi:h less inconvenience to the 
 patient than by the employment of the Spanish fly. 
 
 The effect of Croton oil may be obtained either by fric- 
 tions, or by the incorporation of the oil with some Bort 
 plaster, so that the compound may be spread upon a suitable 
 substance, as leather, and worn upon the surface of the body. 
 The first is the method usually adopted, as vesication is occa- 
 sioned more speedily by this than by the plaster. The oil 
 should be diluted with one or two parts of olive oil, or it n 
 
272 OF VESICANTS. 
 
 be used in its concentrated strength, as the skin upon which 
 it is to be rubbed is more or less tender, and as a less or more 
 rapid action is desired. It is common to moisten a piece of 
 flannel with a few drops of the oil, and to rub it over the 
 surface until the skin is decidedly reddened and made to 
 smart ; this operation should be repeated after an interval of 
 six or eight hours, and a third time, if necessary ; two or 
 three applications will generally be sufficient, unless the oil 
 has been much diluted. The vesicles are numerous, some- 
 times coalescing, sometimes remaining distinct, each one being 
 surrounded by a red areola, which, if the vesicles are near 
 together, give the skin a uniform erythematous injection. 
 The fluid is at first clear, but soon becomes turbid and puru- 
 loid. The irritation subsides after a few days, when the ap- 
 plication may be renewed, if indicated. 
 
 If the other method of employing the oil be adopted, as 
 recommended by Dr. Graves, of Dublin, it may be incor- 
 porated with lead-plaster, in the proportion of 3j. of the oil, 
 to 3ij. or Kij. of the plaster, and spread upon kid; or Bur- 
 gundy-pitch may be substituted for the lead-plaster. This 
 application will produce a vesicular eruption after it has been 
 worn upon the surface for a day or two. 
 
 In using the Croton oil, it should be recollected that an 
 irritation of the skin will be produced wherever the oil shall 
 happen to come in contact with it, as on the eyelids and face 
 from accidentally touching these parts with the fingers on 
 which a little of the oil has remained ; the consequent burn- 
 ing sensation and swelling are soon relieved by the applica- 
 tion of cold water. 
 
 3. The strong water of ammonia — "Ammoniae liquor 
 fortior," — may be used when a very rapidly vesicating agent 
 is needed. It is applied by saturating with it a piece of linen 
 folded to the proper size, and laying it upon the surface to 
 be blistered, where it should be confined for two or three 
 minutes, care being had that the liquid does not flow upon the 
 surrounding skin. 
 
 The blistering lotion of Granville contains this preparation 
 of ammonia as its active agent. He directs two lotions of 
 different powers ; these are prepared thus : 
 
 Strongest water of Ammonia | and -| 
 
 Distilled spirit of Rosemary , i " f 
 
 Spirit of Camphor i " i 
 
SUPPURATIVE COUNTER-IRRITANTS. " 273 
 
 " The stronger lotion has been employed by Dr. Granville 
 only in cases of apoplexy and for the purpose of cauteriza- 
 tion. The first two ingredients are to be gradually mixed ; 
 whereupon the mixture becomes opalescent and gives out an 
 ethereal smell. Before the addition of the third ingredient, 
 the mixture should be rendered transparent by means of a 
 little alcohol. These lotions are stated to produce as full a 
 vesication in a space of time varying from three to ten 
 minutes, as can be produced by cantharides in as many hours. 
 They are applied by means of folds of linen impregnated 
 with them." (U. S. Dispensatory, art. " Ammon. Liq. fort.") 
 
 They are used chiefly to relieve violent neuralgic pains. 
 
 SECTION III. 
 OF SUPPURATIVE COUNTER-IRRITANTS. 
 
 The remedies of this class act less promptly than rube- 
 facients, or vesicants, but when the secretion of pus which is 
 excited by them has become established, they produce a more 
 depressing effect, inasmuch as the development and conti- 
 nuance of a suppurative discharge involve a greater expen- 
 diture of vital energy than is called for to produce an ery- 
 thema, or a vesication. Any application which will cause a 
 loss of substance of the surface on which it is made to act, 
 will occasion suppuration from the granulations by which the 
 reparation of the tissues is accomplished. Thus the strong 
 mineral acids, the actual cautery, even a vesicant if it pro- 
 duce a sufficiently high degree of inflammation, will give rise 
 to suppuration. The substances most employed with this 
 view, however, are, tartar emetic, caustic potassa, nitrate of 
 silver, the seton, the issue, and the moxa\ 
 
 1. Tartar emetic is most frequently used in the form of 
 the ointment made by incorporating the salt with lard, in 
 varying proportions according to the strength required ; one 
 part of tartar emetic to two parts of lard makes a powerful 
 ointment; a more common proportion is one of the former to 
 four, or even eight, of the latter. The strong ointment will 
 produce pustulation in the course of a few hours. 
 
 The mode of using this agent is, to rub a portion of the 
 
274 SUPPURATIVE COUNTER-IRRITANTS. 
 
 preparation upon the skin for some minutes, until pain and 
 redness are excited ; if a single application be not sufficient, 
 it should be repeated at intervals of a few hours. Suppu- 
 ration from the ulcers thus induced should be favoured by 
 dressings of some stimulating cerate, or by poultices. 
 
 A saturated solution of tartar emetic in warm water, to be 
 rubbed upon the skin by the aid of a piece of flannel, is a very 
 neat and cleanly method of producing pustular inflammation. 
 Another, and a very convenient mode of using this agent is, 
 to sprinkle a little of the powder upon the surface of a Bur- 
 gundy pitch, or other adhesive plaster, which is then laid 
 upon the skin, and there retained until pustules are deve- 
 loped. 
 
 2. Nitrate of silver, commonly called lunar caustic, pro- 
 duces an eschar much less deep than tartar emetic, and con- 
 sequently is a less powerful application than the other. It is 
 used by moistening a stick of the caustic and rubbing it upon 
 the skin. As a caustic, it is employed to cause a superficial 
 slough which, when it has become detached, leaves a healthy 
 granulating surface, as in the treatment of chancre, and old 
 ulcers. 
 
 3. Caustic potassa, prepared in the form of "sticks," is a 
 much more effectual pustulating application than the last. 
 With this, the tissues may be destroyed to almost any extent 
 and depth, and great care is therefore necessary in making 
 use of it. The best and safest plan is, to lay upon the skin a 
 piece of kid, in which a hole is cut corresponding in size and 
 situation with the portion of the skin on which the caustic is 
 intended to act ; then the potassa, slightly moistened, is to be 
 placed, or rubbed, upon the skin thus exposed, until a suffi- 
 ciently thick eschar is produced, after which it is advisable to 
 pour a little vinegar upon the part, in order to render inactive 
 any portion of the caustic which may still adhere to the tis- 
 sues. The separation of the slough, thus produced, should be 
 hastened by the application of warm poultices, and the granu- 
 lating surface, left exposed after the detachment of the eschar, 
 should be dressed with slightly stimulating lotions, or cerates, 
 to encourage the secretion of pus. 
 
 The "Vienna paste," recommended by surgeons on the 
 continent of Europe, is made by triturating together, with the 
 aid of a little alcohol, five parts of caustic potassa and six 
 
SUPPURATIVE COUNTER-IRRITANTS. 275 
 
 parts of quick-lime. The compound is used in the same man- 
 ner as the caustic potassa alone, and produces an eschar in a 
 few minutes, with less pain than the other. 
 
 A paste, made by incorporating chloride of zinc with wheat 
 flour and water, is recommended by many surgeons as a caus- 
 tic. ML Canquoin prepares it of different strengths, accord- 
 ing to the desired effect ; thus, he triturates one part of chlo- 
 ride of zinc with two, three, four, or five parts of flour, adding 
 fifteen drops of water for every ounce of the flour. The paste 
 thus formed is divided into cakes, varying in thickness from 
 one-twelfth to one-third of an inch, and applied to the part ; 
 the eschar which it causes may be from one line to an inch 
 and a half deep, according to the thickness of the portion of 
 caustic, the duration of its application, and the character of 
 the tissue to which it is applied. (U. S. Dispens.) 
 
 The white oxide of arsenic is now rarely used as a caustic : 
 its application is generally attended with great pain, and un- 
 pleasant constitutional effects have often followed it. 
 
 Iron heated to whiteness has been, in earlier times, much 
 resorted to as a means of producing a slough and subsequent 
 suppuration. It is now, however, seldom employed for this 
 purpose. When used thus, the iron is called ;i the actual 
 cautery," in contradistinction from the other caustics, to 
 which the term, potential cauteries, has been applied. 
 
 4. The moxa, as it is ordinarily used, consists of a cylinder 
 of carded cotton, about an inch long and from one to two 
 inches in diameter, the whole wrapped in a piece of linen and 
 impregnated with a saturated solution of nitrate of potassa, 
 or of chromate of potassa. To apply it, one of the extremi- 
 ties of the cylinder should be lighted in the flame of a lamp, 
 and the other placed upon the skin, the roll being beheld be- 
 tween the blades of a pair of dressing-forceps. The moxa is 
 maintained in a state of ignition by blowing upon it with the 
 mouth, through a blow-pipe, or with the lips merely, the object 
 being to secure a steady heat. The pain experienced from 
 this application becomes gradually more and more severe, 
 until the sensitive structure of the skin is destroyed, when it 
 ceases. A thick eschar is thus formed, which, by the con- 
 tinued application of emollients, becomes detached after some 
 days, leaving a granulating, suppurating surface, requiring 
 dressings suitable for such a condition. 
 
 i 
 
£76 SUPPURATIVE COUNTER-IRRITANTS. 
 
 The moxa is generally employed as a counter-irritant in 
 diseases of the bones, as caries of the spine, and is applied 
 near to the seat of the affection, — not so near, however, as 
 to involve the vessels and nerves in the slough which is 
 formed. 
 
 5. Issues are established by the introduction into the sub- 
 cutaneous tissue of some foreign body which acts as an irri- 
 tant, and thus perpetuates a suppurative secretion. The sub- 
 stance generally used for this purpose is made of cork, or pine 
 wood, or indeed of any similar material, cut to about the size 
 and shape of the common garden-pea. It is introduced into 
 the tissue either by an incision made with the knife, or it may 
 be confined by means of strips of adhesive plaster upon the 
 granulating surface, produced by the action of caustic potassa, 
 or a vesicating agent. 
 
 There is some choice as to the point at which the issue 
 should be established ; it may be directly over the seat of the 
 disease, or, if this be not important, at some remote point. 
 The arm and the back of the neck are the most convenient 
 situations for the formation of an issue ; in the former, the 
 pea should be introduced in the space between the biceps and 
 deltoid muscles, near the insertion of the latter. When the 
 neck is selected, any point may be taken which seems most 
 convenient ; it should generally be low down, so that the pa- 
 tient's dress may conceal it from view. 
 
 6. Setons are established by passing a piece of tape, or a 
 skein of silk, or other similar material, through a portion of 
 the integuments, and leaving it to excite suppuration. The 
 seton may be introduced by means of the instrument con- 
 trived by Boyer for the purpose, — a blade shaped somewhat 
 like that of the thumb-lancet, but stronger and curved also, 
 and having an eye cut in its heel, through which the seton- 
 tape, or silk, is passed (fig. 126); — or it maybe effected sim- 
 ply by using a common bistoury and an eyed-probe. In either 
 case, the first step of the operation is the same : a fold of the 
 integuments is pinched up between the thumb and fore-finger 
 of the left hand, and the blade of the instrument, previously 
 oiled, — be it the seton-needle, or the bistoury, — is thrust 
 through its base ; if the seton-needle is used, it should be 
 armed with the tape, or silk, and drawn through, its armature 
 following , if the bistoury is employed, the probe is armed in 
 
SUPPURATIVE COUNTER-IRRITANTS. 277 
 Fig. 126. 
 
 the same way, and passed along the base of the wound upon 
 the blade (fig. 127). After the needle or the probe has thus 
 
 Fig. 127. 
 
 cleared the incision, it is disconnected from the seton, and 
 the extremities of the latter are tied together, forming a loop 
 which encloses a portion of the integuments ; a poultice 
 should be laid upon the wound, and retained in place by a 
 proper bandage, for a few days, until suppuration has become 
 established, when simple cerate may be substituted as a dress- 
 ing, and confined by adhesive strips. The seton should be 
 drawn daily backwards and forwards across the wound, in 
 order to stimulate the latter slightly, and to sustain the dis- 
 charge ; and once or twice every week a clean seton should 
 be introduced, by attaching one end of it to one of the ex- 
 tremities of the tape already in use, and drawing it within the 
 wound. 
 
 Any part of the surface of the body may be selected for 
 the establishment of a seton, — the blood-vessels and nerves 
 being avoided, of course, — but the back of the neck, or the 
 24 
 
278 OF ACUPUNCTURE. 
 
 upper part of the arm, is usually chosen as being the most 
 convenient part. 
 
 Dr. Golding Bird has suggested and repeatedly practised 
 a mode of inducing a continued purulent discharge from the 
 surface, which is free from the objections generally enter- 
 tained by patients against the methods in common use. It 
 is an elegant adaptation of electricity to medical purposes. 
 
 He advises two small blisters to be applied to the surface 
 at the desired part, one a few inches from the other ; when 
 the cuticle has become raised by serum, " snip it, and apply 
 to the one from whence a permanent discharge is required a 
 piece of zinc-foil, and to the other a piece of silver ; connect 
 them by a copper-wire, and cover them with a common water- 
 dressing and oiled silk. If the zinc plate be raised in a few 
 hours, the surface of the skin will look white, as if rubbed 
 over with nitrate of silver. In forty-eight hours a decided 
 eschar will appear, which (still keeping on the plates,) will 
 begin to separate at the edges in four or five days. The 
 plates may then be removed, and the surface where the silver 
 was applied will be found to be completely healed. A com- 
 mon poultice may be placed upon the part to which the zinc 
 was applied, and a healthy granulating sore, with well-defined 
 edges, freely discharging pus, will be left. ,, 
 
 Dr. Bird's explanation of this interesting phenomenon is, 
 that the chloride of sodium contained in the fluid exuded be- 
 neath the cuticle is decomposed; — the chlorine being evolved 
 at the zinc plate, forms with the metal a chloride of zinc, 
 which is an escharotic. 
 
 This means will of course be applicable whenever, for any 
 purpose, it is desired to destroy a surface, whether of the skin 
 or of an ulcer. (London Medical Gazette, vol. iv., N. S. 
 1847, p. 981.) 
 
 ACUPUNCTURE. 
 
 For convenience-sake, the modes of practising acupuncture 
 and vaccination will be considered in connexion with this 
 chapter, although neither of these operations are performed 
 with a view of effecting cutaneous irritation merely. 
 
OF ACUPUNCTURE. 279 
 
 Acupuncture. — The instrument by which this is accom- 
 plished is a needle about two inches long, having a cylindri- 
 cal shaft tapering towards one extremity to a sharp point ; 
 the other end is received into a small handle of ivory or of 
 steel, or it is simply coated with sealing-wax. The needle is 
 made sometimes of steel, sometimes of one of the precious 
 metals. In introducing it, the instrument is held perpendi- 
 cularly upon the surface, and forced through the skin to the 
 requisite depth by a rotatory movement, combined with a 
 sufficient pressure upon the point. The punctures are made 
 in muscular, tendinous, or aponeurotic tissues, whichever may 
 be the seat of suffering, and the depth of the puncture must 
 of course depend upon the position of the tissue affected. It 
 is advisable to allow the needle to remain in the part for a 
 length of time, as for a half hour, an hour, or even longer, 
 since a more permanently beneficial effect is thus produced 
 than when the instrument is withdrawn at once. The needle 
 may be extricated by making slight pressure upon the sur- 
 face, and withdrawing the instrument with a rotatory move- 
 ment. 
 
 No accident follows the operation, generally ; rarely more 
 than a drop of blood appears at the puncture ; the chief ves- 
 sels and nerves are always avoided, and the puncture should 
 not penetrate any of the important cavities, or viscera. 
 
 Electro-puncture consists in passing through needles, intro- 
 duced as above described, a current of electricity collected in 
 a Leyden jar, or generated in a small voltaic pile, which is 
 connected with the needles by ^ metallic wire passing to each 
 pole of the battery. 
 
 Both these varieties of acupuncture are frequently of ser- 
 vice in the treatment of neuralgia, and of rheumatism un- 
 attended with inflammation ; in the treatment of indolent 
 tumours also, by promoting their removal by absorption ; 
 in the cure of local paralysis, &c, &c. Simple acupuncture 
 is very often resorted to in order to evacuate anasarcous col- 
 lections. 
 
 Local pain of a violent neuralgic character may be re- 
 lieved in many instances, and speedily, by rubbing upon the 
 surface thus punctured a solution of sulphate of morphia, con- 
 taining several grains in each ounce of water. 
 
280 OF VACCINATION. 
 
 VACCINATION. 
 
 The operation, as generally practised, consists in inserting 
 beneath the cuticle, at some convenient point, the matter of 
 the cow-pock. 
 
 Several methods have been adopted for the collection and 
 preservation of vaccine matter. If it were practicable, the 
 simplest method would be, to transfer the liquid vaccine 
 lymph from the arm of one child to that of another — upon 
 whom the operation is about to be performed. But since this 
 proceeding is not always convenient or possible, the virus 
 must be collected and preserved in the liquid state, or in the 
 form of the dry crust. In the liquid state, it may be pre- 
 served between two small plates of glass. Or capillary tubes, 
 having a bulb at one extremity, may be placed in contact, at 
 the open end, with the lymph of the fifth or sixth dry vesi- 
 cle, — the air in the bulb having been rarefied by the warmth 
 of the hand, or of the mouth, is again permitted to cool and 
 contract, when the fluid will enter ; so soon as a sufficient 
 quantity has collected in the bulb, the extremity of the tube 
 should be sealed in the flame of a spirit-lamp and blow-pipe. 
 But the most convenient method to be pursued in the pre- 
 servation of the virus is, to permit the lymph to dry, either 
 on points of ivory, or as a scab upon the surface at the site 
 of the vaccination. If the latter be adopted, the crust may 
 be very well kept by being enveloped in tin-foil, or between 
 two pieces of wax excavated to receive it. The author has 
 recently vaccinated several children with a scab which has 
 been thus preserved for two years ; the vesicle was developed 
 in each case, and passed through its customary phases with 
 perfect regularity. 
 
 The operation may be performed with a thumb-lancet, or 
 with a lancet made expressly for vaccinating ; this differs 
 from the thumb-lancet only in being smaller. The virus may 
 be introduced beneath the cuticle, by means of lateral punc- 
 tures made with the point of the lancet; or, the skin having 
 been rendered tense between the thumb and fore-finger of the 
 left hand, placed upon the part of the surface selected for the 
 seat of the operation (generally the arm above the elbow), 
 
OF VACCINATION. 281 
 
 the cuticle may be removed, over a minute space, by slight 
 scratches with the point of the lancet, crossing and recrossing 
 each other until the vascular surface is reached, (blood being 
 just made to appear,) and then the virus be applied thereon. 
 If the liquid lymph be used, it is simply requisite to moisten 
 the lancet therewith, and to apply the blade upon the exposed 
 surface ; if the points of ivory be employed, one of them may 
 be inserted beneath the cuticle, according to the first method 
 of operating, or placed in contact with the denuded surface, 
 if the second plan be adopted ; if the scab be selected, a small 
 particle of it should be reduced to powder and moistened with 
 a little water, being rubbed to a pulpy consistence by the aid 
 of the lancet-blade, which should now be wiped upon the 
 abraded skin, so that a sufficient portion of the vaccine mat- 
 ter shall come in contact with the absorbing surface. After 
 the operation is completed, the part should be left uncovered 
 until the surface has become perfectly dry; the subsequent 
 stages which the vaccine disease assumes, in the development 
 and maturation of the vesicle, should be carefully watched, in 
 order that a correct opinion may be had as to the efficacy of 
 the operation. 
 
 24 5 
 
CHAPTER IV. 
 
 ON THE METHODS OF ARRESTING HEMORRHAGE. 
 
 The occurrence of bleeding, as an accident, or in connexion 
 ■with an operation, always claims the prompt attention of the 
 surgeon, and often demands the manifestation of all his skill 
 and self-possession. 
 
 In the consideration of this subject we shall describe the 
 methods found most efficacious in arresting haemorrhage, and 
 state the circumstances to which each is most applicable. 
 
 1. By the action of cold. This is the simplest method of 
 arresting the flow of blood from a wound, and its efficacy is 
 exemplified daily, the mere evaporation which takes place at 
 the surface of the wound reducing the temperature of the part, 
 thereby favouring the coagulation of the blood and exercising 
 a degree of constriction upon the bleeding vessels. This effect 
 may be increased by exposing the divided tissues to a current 
 of air, naturally or artificially excited. Bleeding from super- 
 ficial wounds, or abrasions, when no vessel of notable size is 
 opened, may generally be checked by this simple mode. 
 
 The application of cold water, or of ice, to the bleeding sur- 
 face, or to its immediate vicinity, is still more effectual, and 
 will very often arrest haemorrhage from small arteries. Dr. 
 G. N. Burwell, of Buffalo, informed the author very recently, 
 that he had succeded in stopping profuse bleeding from a deep 
 transverse wound of the palm of the hand, by the constant ap- 
 plication of ice during twenty-four or thirty-six hours. The 
 ice may be placed in direct contact with the wound, or it may 
 be enclosed in linen, or in a bladder. If cold water is used, 
 it may be simply laid upon the surface in saturated lint, or it 
 may be employed by douche, or irrigation ; the latter is the 
 most efficacious. Evaporating lotions may be found effectual 
 sometimes, in the absence of ice. 
 
 2. By the application of astringents, and styptics. These 
 act, probably, in a twofold manner, — upon the organic proper- 
 
 (282) 
 
METHODS OF ARRESTING HEMORRHAGE, 283 
 
 ties of the bleeding vessels and surrounding tissues, and also 
 upon the blood itself; causing by the former, a constriction, 
 a greater or less degree of closure, of the vessels, — and by the 
 latter, favouring coagulation of the effused blood which me- 
 chanically prevents the escape of more. There are many sub- 
 stances which induce coagulation of blood, not by any chemi- 
 cal, or vital, agency which they exert, or develope, but simply 
 by opposing the flow at numerous points, so that it becomes 
 retarded, and then coagulates by its own inherent properties ; 
 such are cob- web, filaments of lint, powdered sugar, and other 
 similar domestic remedies. 
 
 The astringent and styptic applications which have been 
 found most serviceable for the purpose under consideration 
 are, powdered alum ; powdered galls ; sulphate of copper and 
 of zinc, also in powder; creasote, and the tincture of the mu- 
 riate of iron. Fluids act most rapidly because they come most 
 speedily in contact with the points from which the blood es- 
 capes ; they are applied usually by means of a brush of camel's 
 hair, or upon a feather, passed over the surface ; or by satu- 
 rating with them a piece of lint which is pressed lightly upon 
 the part. If a powder is used, it may be sprinkled over the 
 surface, or retained upon it by gentle pressure. The tincture 
 of the muriate of iron is probably the best of these means. 
 These agents will generally suffice to arrest bleeding from vas- 
 cular surfaces, no large vessel being opened, — for example, in 
 haemorrhage from the mucous membrane lining the nostrils, 
 in bleeding ulcers on the neck of the uterus, in bleeding he- 
 morrhoidal tumours. 
 
 Matico, a plant growing in South America, has been lately 
 recommended as possessed of particular efficacy in arresting 
 haemorrhage. Dr. Ruschenberger, of the U. S. Navy, has 
 employed it in a large number of cases, and bears strong testi- 
 mony to its value as a hemostatic agent. He used it success- 
 fully to arrest bleeding from a bubo which had been opened 
 by the knife, and from which the blood issued in full and free 
 jets, long-continued and well-applied pressure having failed to 
 arrest it ; it likewise caused the cessation of bleeding from hae- 
 morrhoids removed by incision, which had produced trouble- 
 some haemorrhage, resisting other applications of various kinds. 
 The mode which Dr. Ruschenberger advises for its employ- 
 ment is, to break the dried leaves into a coarse powder and to 
 
284 METHODS OF ARRESTING HEMORRHAGE, 
 
 form -with this, by the aid of water, a pultaceous mass, which 
 should then be placed upon the bleeding surface and retained 
 there by very light pressure, — a pressure which would not 
 prove sufficient, of itself, to arrest the bleeding. Dr. R. speaks 
 highly of the efficacy of matico, ta£en in infusion, for sponta- 
 neous haemorrhage, having proved its value in profuse monor- 
 rhagia, in hsemophthisis, and similar cases. 
 
 3. By cauterization. This produces an eschar, sealing up 
 the orifice, or orifices, from which the blood escapes. So long 
 as the eschar remains adherent to the vessel, it presents a me- 
 chanical impediment to the further escape of blood ; but when, 
 in the process of nature, the slough has become detached, the 
 haemorrhage will recur, unless the vessel has become perma- 
 nently obliterated from its open extremity as high up as the 
 first branch above it; hence the patient should be carefully 
 watched about the time at which the slough seems inclined to 
 separate, lest the bleeding should return unexpectedly. In 
 the choice of a cauterizing agent, therefore, some one must be 
 selected which shall produce an eschar sufficiently deep to re- 
 main adherent, until nature shall have accomplished the per- 
 manent closure of the vessel between the points mentioned. 
 The fact should be borne in mind that, the application of any 
 caustic will prevent the possibility of union of the wound by 
 the first intention. The actual, or the potential cautery, may 
 be used. 
 
 In employing the actual cautery, the metal, generally iron, 
 should be heated to whiteness and then applied upon the sur- 
 face for a few seconds only ; both of these precautions are ne- 
 cessary, for if the iron be of a lower temperature than that 
 which constitutes ' white heat,' the eschar occasioned by it is 
 less perfect and its action is more painful ; and if the cautery 
 be kept too long in contact with the tissues, it adheres to them, 
 and when it is withdrawn, it removes the eschar with it, 
 thereby destroying, of itself, the good which it had accom- 
 plished. 
 
 The form of the cautery should be adapted to the character 
 of the part to which it is to be applied : thus, if the wound be 
 narrow, and the bleeding vessel lay at the bottom of it, the 
 iron should be sufficiently long and small to reach to the ori- 
 fice of the vessel. The annexed drawing illustrates some of 
 the most common forms of the actual cautery. (Fig. 128.) 
 
METHODS OF ARRESTING HAEMORRHAGE. 285 
 
 Fig. 128. 
 
 - 
 .;i.SB3h.., ImMv. iftuki ,iL 
 
 The actual cautery is now rarely used to arrest haemorrhage, 
 this object being almost always effected by some other means 
 more simple, and less shocking in appearance. The cases in 
 which it is still recommended are, in operations upon the bones 
 of which the medullary membrane is excessively vascular ; in 
 the bleeding which sometimes follows the extraction of a tooth, 
 and in others similar. 
 
 Of the potential cauteries, those most used are, the nitrate 
 of silver, and concentrated sulphuric acid. The former may 
 be employed in the solid state, its extremity having be-en 
 previously more or less pointed, by friction upon the surface 
 of a wet rag, or in concentrated solution, as of 9j to a fluid- 
 ounce of water, applied, as is the acid, by means of a brush. 
 The efficacy of lunar-caustic, in stick, in arresting bleeding 
 from leech-bites, has already been mentioned. The solution 
 of the salt, or the sulphuric acid, is often of service in 
 haemorrhage from incised or ulcerated surfaces, which are too 
 much removed from sight to admit of nice inspection and 
 handling, and from those which present no apparent vessel, 
 or bleeding point : thus bleeding ulcers or wounds on the neck 
 of the uterus are sometimes treated, a speculum vaginas being 
 used to assist the surgeon in the application of the remedy. 
 
 4. By directly obliterating the vessel which gives out the 
 blood. This may be a temporary or a permanent effect, as 
 the means used are temporary or permanent in their action. 
 Transient obliteration may be best induced by simple pressure 
 upon the vessel ; permanent occlusion is produced by torsion, 
 and the use of the ligature. The former is applicable to all 
 
286 METHODS OF ARRESTING HEMORRHAGE. 
 
 varieties of accidental bleeding, whether it be arterial, venous, 
 or capillary ; the ligature and torsion are employed almost 
 exclusively in arterial haemorrhage. 
 
 Pressure. — The mode of making the requisite compression 
 varies according to circumstances. 
 
 If there be a wound bleeding moderately, or if the blood 
 be of a venous character, it very often happens that the 
 haemorrhage is arrested by the mere apposition of the edges 
 of the wound, if it be an incised wound ; or by the simple 
 pressure upon it of the dressings, if it be such as not to admit 
 of apposition of its lips. When the divided vessels are of a 
 larger calibre and bleed more freely, pressure should be made 
 W 7 ith the aid of a compress and adhesive plaster, or a roller 
 (as in fig. 125). Direct pressure upon a wound is objection- 
 able, particularly if it be a lacerated or contused wound, or 
 if much pressure be required to produce the desired effect, 
 because it will interfere with the reparation of the injury, and 
 may induce sloughing. When positive pressure is to be ex- 
 erted for the sake of the compression, the vicinity of the 
 wound should therefore be selected as the site of its applica- 
 tion, rather than the wound itself. 
 
 Pressure is employed also to prevent haemorrhage during 
 operations, as in amputations, and likewise in accidental 
 wounds, as a temporary expedient, until some more perma- 
 nent measure be adopted. For this purpose, the compressive 
 force may be applied at any point at which it can be most 
 effectually and conveniently exercised. The simplest method 
 of instituting this measure, is to press the fingers upon the 
 course of the vessel through which the circulation is to be 
 arrested. With this object, some point should be selected 
 where the vessel is readily felt pulsating ; and, if possible, 
 this point should be favourably situated with regard to some 
 bony support, so that the vessel can be pressed against the 
 latter, and thus be completely obliterated. For example, the 
 facial artery should be compressed against the edge of the 
 lower jaw, at the anterior margin of the masseter muscle ; 
 the temporal and occipital arteries, at any point of their 
 course, at which they can be felt ; the brachial artery, by 
 grasping the biceps muscle, at the middle of the arm, between 
 the fingers and thumb of the right hand, and at the samo 
 time pressing the artery against the bone with the points of 
 
METHODS OF ARRESTING HEMORRHAGE. 287 
 
 the fingers, on the inner side of the muscle, (fig. 129 :) the 
 axillary artery, by thrusting the fingers, — their points approx- 
 imated, — into the axilla, and forcing the artery against the 
 
 Fig. 130. 
 
 head of the humerus ; the subclavian artery, by pressing the 
 thumb down upon the vessel, behind the clavicle, upon the 
 point at which the artery crosses the first rib on the external 
 side of its tubercle ; generally, the artery cannot be suffi- 
 ciently well compressed by the thumb, and it is necessary, 
 therefore, to employ some instrument for the purpose, as a 
 common door-key, of which the ring should be wrapped with 
 a piece of linen, and then pressed upon the vessel, as above 
 advised ; the femoral artery, by placing one thumb upon the 
 vessel, at the point where it crosses the ilium to descend the 
 thigh, and making the requisite pressure by the other thumb 
 acting upon the first, (fig. 130 ;) the abdominal artery, by 
 causing the patient to occupy a position whereby his back and 
 thighs shall be flexed, and the abdominal parietes relaxed, and 
 then pressing the artery against the spinal column. 
 
288 METHODS OF ARRESTING HEMORRHAGE. 
 
 But, although it is not necessary in most cases, to exert 
 much force with the fingers, the muscles are very soon fa- 
 tigued, so that the pressure becomes unsteady and uncertain, 
 if it be maintained for any length of time ; and moreover, 
 the fingers are liable to become displaced by any sudden 
 movement of the patient ; hence the necessity of employing 
 some compressing force which shall not be liable to these 
 objections. The tourniquet offers such advantages. 
 
 The tourniquet, in its most common form, is very well 
 represented in the annexed drawing, (fig. 131.) It is so con- 
 trived, that when the strap is buckled around the limb, by 
 
 Fig. 131. 
 
 turning the screw the soft parts are compressed and the pad 
 forced upon the artery. Before applying the tourniquet, the 
 surgeon should examine it carefully, to see that it is in good 
 order, — the screw, strap and buckle strong, — so that it shall 
 not fail when most needed. A firm pad should be made, of 
 a cylindrical shape, for application over the artery, and the 
 strap secured around the limb. The screw should not be 
 turned too rapidly, and no more compression should be exer- 
 cised about the limb than may be necessary to prevent the 
 
METHODS OF ARRESTING HEMORRHAGE. 289 
 
 flow of blood below the point of pressure. A long-sustained 
 application of this instrument is productive of considerable 
 pain, and therefore it should be avoided. 
 
 The points upon which the tourniquet is applied to the 
 limbs are not fixed. Mr. Fergusson recommends those indi- 
 cated in the accompanying drawings (figs. 132, 133, 134), 
 
 Fig. 132. Fig. 133. 
 
290 METHODS OF ARRESTING HEMORRHAGE. 
 
 preferring compression of the artery in the popliteal region, 
 when the leg is to be amputated below the knee, rather than 
 of the femoral artery at the upper part of the thigh. 
 
 An ' impromptu' tourniquet, for use in emergencies, con- 
 sists of a cravat, in the middle of which a knot is formed ; the 
 cravat is made to encircle the limb, the knot corresponding in 
 situation with the artery : the two extremities are then tied 
 together, a piece of stick inserted between them and made to 
 revolve until the limb is sufficiently compressed. This is com- 
 monly called the field-tourniquet. (Fig. 135.) 
 
 Fig. 135. 
 
 Fig. 136. 
 
 An objection to the ordinary tourniquet is, that it con- 
 stricts the whole limb, preventing the circulation through the 
 veins as well as through the arteries, causing considerable 
 pain and swelling, if continued beyond a short time. To ob- 
 viate this difficulty, compressing instruments of various kinds 
 have been invented : they have not, as yet, arrived at such 
 perfection as to be, on the whole, preferable to the tourniquet 
 in common use. The compressor of Dupuytren " consists of 
 
METHODS OF ARRESTING HEMORRHAGE. 291 
 
 two steel-plates (fig. 136), half an inch broad, curved and 
 joined at the centre of the instrument in such a manner as to 
 allow of the curve being increased or diminished at will. To 
 these plates two others, which support pads, are attached : 
 one of the pads is movable, the other fixed; and in applying 
 the instrument, the movable one is placed over the artery, the 
 other rests upon the opposite side of the limb. The pressure 
 is made by the movable pad, and is regulated by a screw." 
 (Liston's and Miitter's Lectures on Surgery, p. 42.) 
 
 Dr. Dorsey (Elements of Surgery, vol. i., p. 57) mentions 
 a very simple and ingenious expedient by which the same 
 effect was attained. " The patient was a child, in whom 
 several unavailing attempts had been made to tie up the 
 divided vessel (an artery in the foot), and the wound was in a 
 state of great inflammation. A compress was applied over 
 the trunk of the anterior tibial, and another over that of the 
 posterior tibial artery, about two inches above the ankle; 
 over these a strip of sheet copper was passed around the leg, 
 and a tourniquet applied over the copper : when the tourni- 
 quet was tightened, the tibial arteries were compressed and 
 the bleeding ceased, the copper preventing the tourniquet 
 from compressing any other vessel, so that the circulation in 
 the foot w r as not interrupted. In a few days the wound healed 
 without any recurrence of haemorrhage." 
 
 Since the treatment of aneurism by compression has become 
 a standard measure, great improvements have been made in 
 the construction of tourniquets, and the great desideratum 
 seems to have been, to a considerable extent, gained, viz.: to 
 exercise a moderate, but sufficient compressive force upon 
 the artery, without interfering materially with the return of 
 the blood through the veins. The fact has become established, 
 that, to cure an aneurism, it is not essential absolutely to pre- 
 vent the arterial circulation, but merely to reduce it to a cer- 
 tain sluggish current. Several instruments have been con- 
 trived which produce this effect ; and they can, moreover, so 
 completely obliterate the artery, as to be adapted for use in 
 amputations, or in other cases where it is necessary that the 
 arterial flow should be stopped, for the time. The Dublin 
 Surgeons, particularly Drs. Bellingham, Carte and Tafnell, 
 deserve most of the credit for these improvements. 
 
 Fig. 137 represents an instrument of this kind, designed 
 
292 METHODS OF ARRESTING HEMORRHAGE. 
 
 for application to the middle of the thigh ; and fig. 138, one 
 for the groin. 
 
 Fig. 137 
 
 Fig. 138. 
 
METHODS OF ARRESTING HEMORRHAGE. 293 
 
 If employed simply for the purpose of arresting or prevent- 
 ing haemorrhage, only one tourniquet or compressor will be 
 required. But if applied for the cure of aneurism, it is con- 
 sidered better to use two, so that when the pressure caused by 
 one becomes disagreeable, the other can be brought into ser- 
 vice immediately. 
 
 Dr. Carte's compressor, as represented in fig. 139. possesses 
 
 Fig. 139. 
 
 this peculiar feature, that, in addition to the common screw 
 force, a certain degree of elasticity is gained by the introduc- 
 tion of bands of vulcanized India-rubber. 
 
 Plugging- of the divided vessel, or of a wound, is sometimes 
 resorted to for arresting the flow of blood when other means 
 have failed. It acts by compressing the vessel, or by me- 
 chanically stopping its orifice. It is rarely done now, except- 
 ing occasionally when blood continues obstinately to flow from 
 the cut extremity of the bones in amputation : here a piece 
 of lint, or of wood, having a ligature attached to it. is gently 
 pressed within the cavity of the bone, or within its reticulated 
 structure, and allowed to remain, the ligature hanging from 
 between the edges of the flap, so that the plug may be re- 
 moved when it has fulfilled its intention. 
 25* 
 
294 METHODS OF ARRESTING HEMORRHAGE. 
 
 Torsion is now but little resorted to. It consists in twist- 
 ing the vessel several times upon its axis, so as to rupture its 
 inner and middle coats, which then become more or less 
 inverted, as when cut by a ligature. Many methods of per- 
 forming this simple operation have been advised, of which the 
 simplest is probably as effectual as any. The artery should 
 be seized at its open extremity by a pair of serrated forceps 
 (fig. 140), with which it is drawn out from the wound, and 
 
 Fig. 140. 
 
 isolated from its connexions with the surrounding tissues ; it 
 is then held in the grasp of a pair of catch-forceps placed 
 across its axis, at the distance of half an inch from its open 
 end, and twisted several times in the direction of its axis by 
 means of the first forceps (fig. 141) : the torsion having been 
 
 Fig. 341. 
 
 thus accomplished, the vessel is returned into the wound. 
 This is not generally trusted to as a safe and certain means 
 of arresting haemorrhage, excepting in the instance of small 
 arteries. If the vessel can be thus seized and twisted, a liga- 
 ture can certainly be applied to it as well, and will scarcely 
 give rise to more irritation than the portion of the artery thus 
 violently crushed and reduced to the condition of a foreign 
 body in the wound. 
 
 The ligature offers the most safe and permanent means 
 
METHODS OF ARRESTING HEMORRHAGE. 295 
 
 of obliterating an artery of a size sufficient to admit of its 
 application. 
 
 The object had in view in the employment of the ligature 
 is, the division of the internal and middle coats of the artery ; 
 these retract within the canal, giving the latter the appear- 
 ance of a cone, of which the apex points towards the ligature. 
 The cavity of the vessel, from the ligature to the first branch 
 above it, becomes filled with a coagulum of blood, and the 
 same coagulating process takes place in the blood which has 
 been effused outside of the vessel; soon, however, a perma- 
 nent obliteration occurs, from a vital process, some degree of 
 inflammation and exudation of plastic matter being occasioned 
 by the irritation of the ligature, and a complete consolidation 
 of the tube ensuing from union of the internal tunic of the 
 artery w T ith the organizable mass within it. 
 
 Many substances have been recommended as materials for 
 the ligature. It has been supposed that leaden ligatures 
 excite less irritation in the midst of the tissues than those of 
 any other material ; ligatures made of animal fibre, as of the 
 sinew of the deer, have been supposed to be removed by 
 absorption at the point at which they are tied ; but these are 
 probably mistaken ideas ; no one now thinks it advisable to 
 incur the trouble of preparing ligatures of such materials, for 
 the sake of any advantage which fancy may attribute to them 
 over the ordinary ligature, made of saddler's silk, or of com- 
 mon flaxen thread. 
 
 A single strand of strong saddler's silk, or of good home- 
 spun thread, will answer for application to small arteries ; 
 but when the vessel is larger, the ligature should be corre- 
 spondingly more thick, as of from two to four strands. These 
 
 Pig. 142. 
 
 should be well waxed, and twisted firmly and roundly, in 
 order to cut the coats of the artery, as before mentioned, a 
 flattened ligature not effecting this object. Hence also in 
 
296 METHODS OF ARRESTING HEMORRHAGE.' 
 
 Fig. 143. 
 
 applying the ligature, the knot must be drawn tightly. For 
 the purpose of seizing the artery, in order to isolate and tie 
 it, the forceps figured on p. 295 (see fig. 142), having a toothed 
 extremity and a spring-catch to keep this closed, is a very 
 convenient instrument, less so, however, than the tenaculum 
 (fig. 143) — a hook with a long curve sharp at 
 the point — which is inserted into the mouth of 
 the vessel, and by which the latter is drawn out. 
 The artery being thus brought within reach, it 
 should be separated from its connexions with the 
 surrounding tissues, vessels, and nerves, for the 
 space of a few lines, and the ligature applied 
 around it, behind the tenaculum, or forceps. It 
 is sometimes proper to include a portion of the 
 surrounding tissues in the knot, as when the 
 coats of the artery are supposed to be weakened 
 from inflammation or other cause, or when the 
 mouth of the vessel which bleeds cannot itself 
 be seen, and yet the surgeon is assured that it 
 is within the mass which he has raised upon his 
 tenaculum, or by his forceps. If an artery of 
 considerable size has been divided, it is advisable 
 to tie both extremities, as otherwise the bleeding 
 may be renewed from that portion of the vessel 
 which was not at first emitting blood, but into 
 which an anastomosing current has afterwards 
 discharged itself: this precaution is particularly necessary in 
 
 situations where the anastomosis 
 of arteries is known to be com- 
 mon, as in the palm of the hand 
 and on the foot. 
 
 " The sailor's knot," as it is 
 called, is the one best calculated 
 to secure the artery firmly ; it 
 forms, when tightly drawn, a flat 
 knot which will not slip. The 
 accompanying drawing illustrates 
 it better than a verbal description. (Fig. 144.) 
 
 The vessel having been tied, one division of the ligature 
 should be cut off close to the knot, while the other is left 
 hanging from the wound. When many vessels have been 
 
 Fig. 144. 
 
METHODS OF ARRESTING HEMORRHAGE. 297 
 
 tied, the ligatures thus cut should be grouped together and 
 allowed to project at one extremity of the wound, of which 
 the edges should then be approximated : when one of the 
 vessels tied is of large size, as the main artery of a limb, the 
 ligature which is attached to it should be indicated by a knot 
 made at its free extremity. 
 
 The length of time during which the ligature remains con- 
 nected with the artery, varies according to the size of the 
 latter ; generally, from five to twenty days may be considered 
 as elapsing before the external coat of the vessel becomes 
 severed at its point of constriction; then the ligature i3 
 loosened and falls from the wound, or may be readily drawn 
 from it. After the usual time has passed, the ligature may 
 be gently twisted and drawn upon, in order to favour its 
 release, as sometimes it is retained by the granulations in 
 which it is imbedded, after its attachment to the vessel has 
 ceased. The ligature appertaining to the largest vessel 
 should be handled more carefully than the others. The 
 patient should be carefully watched about the period at which 
 the ligatures become detached, particularly when large ves- 
 sels have been tied, lest an unexpected haemorrhage occur. 
 Secondary bleeding requires the same treatment as the 
 primary. 
 
 The forceps and tenaculum are the only instruments re- 
 quired for tying a vessel which presents itself at the surface 
 of a wound. But it often happens that the bleeding artery 
 cannot be seen, it having retreated within the substance of 
 the tissues : it then becomes necessary either to slit open the 
 tissues from the point at which the haemorrhage appears, or 
 to cut down upon the course of the vessel above the wound, 
 and pass a ligature around it at this point ; the former is a 
 very uncertain and disagreeable operation, the latter is speedy, 
 simple, and sure. The incision having been made at the 
 point at which the vessel is most accessible, the object is to 
 inclose the latter in the loop of a ligature without including 
 the accompanying vein or nerve. To enable the surgeon to 
 effect this, several instruments have been contrived, to which 
 the term aneurism-needles has been applied. The simplest, 
 and one which answers very well almost always, is shown in 
 the following drawing (fig. 145) ; it needs no farther descrip- 
 tion. When the sheath of the vessels has been opened, the 
 
298 METHODS OF ARRESTING HEMORRHAGE. 
 
 extremity of this needle, armed with a ligature, is carried 
 under the artery and brought out on the opposite side, when 
 one division of the ligature is seized between the fingers, or 
 
 Fig. 145. 
 
 by a forceps, and drawn out upon one side, while the other 
 portion follows the needle as it is removed at the other side 
 of the wound: the vessel is then tied, as above advised. 
 Professor Gibson has invented an admirable instrument for 
 passing a ligature beneath deep-seated arteries. It consists 
 of a flattened canula of silver sufficiently strong, curved 
 rather more than the common aneurism-needle figured above, 
 and fitted to a handle ; through the interior of the needle, of 
 which one extremity of the cavity opens near the handle on 
 the back of the needle, and the other at the point, a piece of 
 watch-spring passes, having an eye at the extremity nearest 
 the handle, and terminating at the other end in a head of 
 silver ; the ligature is placed in the eye of the spring, and 
 the needle is passed beneath the artery; then the spring, 
 which is considerably longer than the needle, is pushed 
 through the cavity of the instrument and appears upon the 
 opposite side of the vessel, carrying the ligature with it. 
 Belloc's instrument, illustrated by fig. 148, would answer 
 very well in many cases where the artery is deeply located. 
 But in the majority of instances, a ligature can be readily 
 passed around a vessel by means of the grooved director and 
 the eyed-probe, which are in every one's pocket-case. The 
 director is introduced beneath the vessel, and carried com- 
 pletely across the wound, so as to rest upon the edges of the 
 latter, the artery being raised upon it ; then the probe, armed 
 with the ligature, is slid along the groove of the director, 
 beneath the artery, and drawn out upon the opposite side 
 with the ligature. In some instances, the bleeding artery is 
 
METHODS OF ARRESTING HEMORRHAGE. 299 
 
 concealed behind a 'projecting bone, as, for example, the 
 internal pudic behind the rami of the ischium and pubis ; in 
 order to secure this vessel, Dr. Physick's forceps, having a 
 curved needle inserted between its blades, and furnished with 
 a hook to compress its handles, will be found the most conve- 
 nient instrument. (Fig. 146.) 
 
 Fig. 146. 
 
 The surgeon is sometimes called upon to arrest haemorrhage 
 from one of the natural canals, or cavities, particularly from 
 the nostrils and rectum. 
 
 Epistaxis occurring in individuals of a hemorrhagic dia- 
 thesis, frequently induces a dangerous degree of prostration. 
 If it resists the use of cold water, or ice, applied upon the 
 face and forehead, or on the back of the neck, and if astrin- 
 gent powders blown into the nostrils, or injections of astrin- 
 gent solutions, fail to arrest it, the nostrils must be plugged. 
 Stopping the anterior orifices of these cavities will not suffice, 
 as the blood will continue to escape through the posterior 
 nares ; both must be stopped therefore. To effect this, a 
 piece of thin wire may be doubled upon itself, and the folded 
 end introduced along the floor of the nostril, from before 
 backwards, until it has traversed the passage and appears at 
 the back part of the mouth ; the surgeon then seizes this 
 looped extremity with his fingers, or forceps, introduced into 
 the mouth, draws it forwards, — the body of the wire still 
 resting on the floor of the nostril, — and passes a cord through 
 it, the centre of the cord corresponding with that of the loop, 
 while the ends are loose ; the wire is now drawn out of the 
 nose in the direction by which it was introduced, one of the 
 divisions of the ligature emerging with it, the other remain- 
 ing in the surgeon's hand ; to the middle of this portion of 
 the cord a piece of lint is attached, to serve as the plug, 
 which is drawn into the posterior nares by the first division 
 of the ligature ; the anterior nares are next to be plugged, 
 by inserting lint, and the haemorrhage is thus effectually 
 
300 METHODS OF ARRESTING HEMORRHAGE. 
 
 Fig. 147. * 
 
 arrested. At the end of two or three days, the plugs may 
 be removed, the posterior being drawn out by means of the 
 extremity of the cord which has been left hanging from the 
 mouth. (Fig. 147.) See Liston and Mutter, p. 185. 
 
 A very elegant and useful instrument for plugging the pos- 
 terior nares has been invented by M. Belloc. It is a canula 
 of silver, A, curved very much like a catheter, but smaller. 
 Through this canal a straight stem of silver, B, is introduced, 
 to which is attached a piece of watch-spring, C, terminating 
 in a rounded head which has a hole drilled in it for the in- 
 sertion of a ligature. The free extremity of the straight 
 rod, B, has a button attached to it, to prevent it from being 
 draw r n out of the canal ; a ring is soldered to the inferior 
 surface of the canula, to aid in holding the instrument. (Fig. 
 148.) In introducing this, draw the watch-spring entirely 
 
METHODS OF ARRESTING HEMORRHAGE. 301 
 
 within the tube so that the head shall form a smooth convex 
 extremity to the instrument ; then the tube is passed along 
 the floor of the nostril, the curve presenting downwards, until 
 its head reaches the extremity of the naso-palatine septum, 
 when the watch-spring is pushed out, its curved form causing 
 it to find its way directly into the mouth ; the head is now 
 drawn forwards, and a ligature, with a plug of lint attached, 
 is passed through the eye ; the remainder of the operation is 
 managed precisely as with the wire above spoken of. 
 
 In hemorrhage from the rectum, if the bleeding vessel 
 cannot be tied, or if the blood comes from the venous plexus, 
 astringent powders should be introduced ; if these fail, a 
 piece of bladder, or a portion of the intestine of some animal, 
 filled with pounded ice, should be inserted within the sphincter 
 ani as high up as may be necessary. But the presence of 
 these foreign matters, as well as of the effused blood, after a 
 time excites the expulsive efforts of the muscles and they are 
 discharged. In a case of this kind which occurred some 
 years ago at the Pennsylvania Hospital, during the attend- 
 ance of Dr. Thomas Harris, lately chief of the Naval Bureau 
 of Medicine at Washington, all these and other methods of 
 arresting the bleeding failed ; it w T as stopped by pressure 
 upon the bleeding point, effected by means of a finger intro- 
 duced into the rectum and held there for many hours, so long 
 as any disposition to recurrence of bleeding was manifested ; 
 — so soon as one individual became fatigued he was relieved 
 oy another. 
 
 26 
 
CHAPTER V. 
 
 ON THE DRESSING OF WOUNDS. 
 
 The exposure of the wound for inspection constitutes the 
 first step in its treatment. This should be accomplished very 
 carefully, after the manner recommended to be pursued with 
 regard to the examination of fractures. The arrest of 
 haemorrhage should next engage attention ; this will be 
 effected by some of the means already adverted to. It should 
 be borne in mind that, if it be probable that the wound may 
 be made to close by direct union of its edges, this will be 
 prevented by the application of styptics or escharotics to 
 check the bleeding, and therefore if the simple pressure pro- 
 duced by the apposition of the edges of the wound, and the 
 means used to secure this, be not sufficient to stop the flow 
 of blood, the ligature should be applied to such arteries as 
 bleed. In a simple incised wound, all the vessels of sufficient 
 size to require a ligature are seen pouring out blood; but in 
 wounds accompanied by severe contusions and lacerations, 
 such as are caused, by the bursting of fire-arms, or by 
 machinery ; it is not at all uncommon to see the arteries of 
 the largest calibre projecting an inch or more from the midst 
 of the torn muscles, and vibrating with every beat of the 
 heart, yet not emitting a drop of blood ; in such cases, liga- 
 tures should still be applied to these arteries, and at a point 
 w T here their coats seem to be uninjured ; otherwise, after the 
 wound has been dressed, and the vitality of the injured 
 parts has become restored by warmth and rest, profuse bleed- 
 ing will occur and render it necessary to reopen the wound. 
 It is neither important nor advisable to tie very small arte- 
 ries, as a short exposure to the air and moderate pressure 
 will generally prevent these from bleeding, and an unneces- 
 sary number of ligatures will interfere very much with the 
 healing of the wound. 
 
 All foreign substances, such as dirt, sand and gravel, splin- 
 
 (302) 
 
DRESSING OP WOUNDS. 303 
 
 ters of wood, fragments of clothes, shot, &c, should be care- 
 fully removed from the wound by the aid of forceps, or with 
 the fingers, or by allowing a stream of warm water to flow 
 gently over it. Coagulated blood should not be permitted to 
 remain upon the injured surface, but should be regarded as a 
 foreign body, as much as any of the substances enumerated. 
 These preliminary measures having been attended to, the pro- 
 per mode of dressing the wound must be determined upon ; 
 and in the selection of the pieces of the dressing, it should be 
 borne in mind that lightness and cleanliness are of great im- 
 portance in inducing a rapid cure. 
 
 If the wound must heal by granulations, the surgeon should 
 not attempt to confine its edges in apposition, as a consider- 
 able degree of compression must be exercised to effect this, 
 causing pain without any adequate good. He should be con- 
 tented with simply placing the limb, or other part, in the 
 most favorable position to ensure ease and rest, and cover the 
 wound with a suitable dressing, — cold water or a poultice, 
 generally, at first, to allay pain and to combat inflammation, 
 followed, when these symptoms have subsided, by the appli- 
 cation of an appropriate cerate, or lotion ; these dressings 
 should be retained upon the surface by strips of adhesive 
 plaster, or by a light bandage. In severe contused and lace- 
 rated wounds, the best primary application is cold water, in 
 the form of irrigation. (See Part I.) 
 
 When the wound is of such a character as to afford fair 
 reason to expect reparation by the first intention, its surfaces 
 should be placed in apposition along their whole extent, from 
 the bottom to the top, and not along its edges merely ; other- 
 wise, though the latter may adhere to each other, granulations 
 will form beneath the external lips, or summit of the wound, 
 and a collection of matter be the result, which will eventually 
 burst through the adhesion formed above it, and then the sur- 
 face will necessarily be disfigured by a cicatrix which might 
 have been avoided. The proper apposition of the walls of the 
 wound may be secured by the use of adhesive plaster, by su- 
 ture, and by suitable bandages, — by one or all of these means. 
 Before resorting to any of these, however, the part, particu- 
 larly if the wound be deep, should be placed in such a posi- 
 tion as shall most relax the muscles involved : thus, for exam- 
 pie, if there be an incised wound cutting across the muscles 
 
304 DRESSING OF WOUNDS. 
 
 on the front of the thigh, the limb should be raised upon an 
 inclined plane, and the back elevated in like manner; with- 
 out this simple precaution, the sides of the wound can be 
 but imperfectly retained in apposition by any compressive 
 means. 
 
 1. The mode of applying strips of the common adhesive 
 plaster, and of isinglass plaster, has been already described 
 (see Part I.) : aided by a proper position of the injured part, 
 the strips will be found adequate to secure the adhesion of 
 most wounds. When the extent of surface upon which the 
 strips can be applied is not sufficiently great to ensure firm 
 support, their power may be much increased by placing a 
 narrow strip of plaster near to, and parallel with, each edge 
 of the wound, and crossing the main strips upon them. 
 Again, if the strips are subjected to much strain, it will be 
 found of importance to make moderate pressure upon the 
 muscles by means of a roller, or bandage of Scultetus. In 
 removing this dressing, the precautions advised in the first 
 part of this volume should be attended to. 
 
 From his own experience, the author ventures to think that 
 the reports with regard to the irritation caused by the ordi- 
 nary adhesive plaster of good quality, and the liability of 
 erysipelas being occasioned by it, are very much exaggerated. 
 
 Recently it has been ascertained that "collodion" a solu- 
 tion in ether of the " gun-cotton," as commonly prepared, is 
 possessed of very strong adhesive properties; it may be spread 
 upon linen or silk, and then applied to the surface ; and it 
 offers this advantage over other adhesive matter, viz.: that, 
 being insoluble in water, the parts surrounding the wound 
 may be washed without disturbing the wound itself, by re- 
 moving the plaster which covers it. To separate the plaster 
 from the surface, it is necessary to moisten the application 
 with ether. (See p. 38.) 
 
 Gun-cotton is made by saturating carded cotton in a mix- 
 ture of equal parts of strong nitric and sulphuric acids, then 
 washing the cotton in water, and drying it at a temperature 
 of 150°, or less. 
 
 2. Several kinds of suture have been invented for the pur- 
 pose of securing perfect apposition of the surfaces of incised 
 wounds. They are passed directly through the skin at the 
 edges of the wound, or through strips of adhesive plaster pre- 
 
DRESSING OF WOUNDS. 305 
 
 viously applied near to its margins : to the former, the term 
 "wet suture" has been given, the latter is called "the dry 
 suture.'' Of the first there are four varieties in common use: 
 the interrupted, the continued, the quilled, and the twisted 
 suture. 
 
 The interrupted suture is made, by passing a needle armed 
 with a single strand of saddlers' silk, or of some other equally 
 strong material, through the skin from without inwards, en- 
 tering at the distance of two or three lines from the edge of 
 wound, crossing the latter, and re-entering the skin at the 
 opposite margin of the wound, to re-appear a few lines from 
 the edge : the two portions of the thread are then tied toge- 
 ther in the sailors' knot, as shown in fig. 144. The number 
 of sutures thus made varies with the length of the wound and 
 the strain which must fall upon each knot ; generally, their 
 number should not be greater than may be necessary to re- 
 tain the lips of the wound in close apposition. In order to 
 diminish the number of sutures, by supporting each one, strips 
 of adhesive plaster may be laid across the wound, between 
 each two sutures, leaving space enough between the latter 
 and the edges of the plaster, to allow of the escape of fluids 
 from beneath. Additional aid is sometimes given to the 
 stitch by a roller, or a bandage of Scultetus, passed around 
 the wounded part ; but this should be avoided whenever it is 
 practicable to do so, as the dressing is thereby rendered less 
 light and cool. 
 
 In most cases, the surfaces of the wound will have become 
 sufficiently adherent, after the lapse of forty-eight hours, to 
 admit of the withdrawal of the sutures ; this may be effected 
 by passing the sharp point of a pair of narrow T -bladed scissors 
 beneath the thread and cutting it, after which it may be 
 gently drawn out. If allowed to remain longer than two or 
 three days in the skin, the suture excites inflammation and 
 slight ulceration around itself, thereby deforming the appear- 
 ance of the cicatrix. The strips of adhesive plaster and, if 
 necessary, the bandage also, should be retained, in order to 
 give security to the recently formed adhesions, after the re- 
 moval of the suture. The following drawing illustrates 
 the application of the interrupted suture. (Fig. 149.) 
 
 The continued suture is less used than the last. It is the 
 one employed in wounds of the intestines, and also in closing 
 26* 
 
306 
 
 DRESSING OF WOUNDS. 
 
 Fig. 149. 
 
 the incisions made in conducting post-mortem examinations. 
 
 It is the stitch commonly used in 
 sewing, and is otherwise called 
 the glover s stitch. The needle 
 is first entered as in making the 
 interrupted suture ; it then crosses 
 the wound obliquely from the op- 
 posite side to the margin first 
 penetrated, and is again inserted 
 at a point below the first, thus 
 crossing and recrossing the wound 
 obliquely until a sufficient num- 
 ber of stitches have been laid, 
 when the ends of the thread are 
 1 1 % secured, at each extremity of the 
 
 wound, by being tied around the 
 first and last stitch respectively. The distance between the 
 stitches must depend upon the length of the wound and the 
 resistance which they are expected to overcome ; they may 
 be aided in their retentive action by the application of a roller, 
 or a bandage of Scultetus. 
 
 The quilled suture is now but little used : Mr. Liston says 
 of it, " it is only employed in one operation — that for lace- 
 rated perineum. I have used it two or three times in cases 
 of this kind." It is effected by entering the needle, armed as 
 before, at about four lines from the edge of the wound, and 
 carrying it downwards to reappear at the bottom of the 
 wound ; then ascending just exterior to the opposite lip, it 
 emerges at about four lines from the edge, opposite the point 
 at which it first entered ; if the wound be very deep, it will 
 be more convenient to carry the needle from above downwards, 
 on both sides, rather than from the bottom of the wound to- 
 wards the surface. A portion of the thread should be left 
 extending from each side of the incision, and when a sufficient 
 number of stitches have been introduced to support the wound, 
 a piece of a gum-elastic bougie, or a quill, of the same length 
 as the latter, is placed parallel with the incision on each side, 
 between each two strands, which are then tied upon the tube I 
 with force sufficient to retain the entire surfaces of the w 7 ound I 
 in apposition, after they have been approximated by the hands. 
 (Fig. 150.) 
 
DRESSING OP WOUNDS. 
 
 30T 
 
 The advantages of FlG - 15 °- 
 
 this suture are, that 
 it forces the sides of 
 the wound together 
 throughout its entire 
 depth, instead of the 
 edges merely, and 
 that, by the interven- 
 tion of the quills, or pieces of bougie, there is less danger of 
 the skin being torn by the threads at the points of puncture. 
 A bandage may be employed as an additional support. 
 
 The needle used in these varieties of suture is commonly 
 called the surgeon s needle: it is more or less curved, accord 
 ing to the fancy of the operator, and has a double cutting 
 edge extending about half of its length from the point, which 
 should be very sharp ; the 
 
 eve should be lar^e. The Fig. m. 
 
 accompanying drawing re- 
 presents two forms of the 
 surgeon's needle, of which 
 the straigtatest will gene- 
 rally be found to be the 
 most convenient (fig. 151): 
 the size should correspond 
 with the thickness of the 
 
 thread to be used, and the part or character of the wound, 
 For which it is to be employed. 
 
 The twisted suture is chiefly used to promote adhesion be- 
 tween the edges of incised wounds upon the face, especially 
 after the operation for the relief of hare-lip. A well-silvered 
 pin, very sharp at the point, is passed, with a rotatory motion, 
 through the skin, at a point two or three lines distant from 
 the edge of the incision, and brought out on the opposite side, 
 at the same distance, the extremities of the pin extending be- 
 yond the incision ; then the centre of a single strand of 
 thread or silk, is thrown over one end of the pin, and crossing 
 the wound — of which the lips are now in contact, — is turned 
 around the other extremity of the pin, in the form of the 
 figure 8 ; thus the threads cross and recross until several turns 
 are made. Generally, two pins are introduced, sometimes 
 
308 
 
 DRESSING OF WOUNDS. 
 
 §§S5pF<£^ 
 
 Fig. 152. more, and thread twisted upon each, as 
 
 above. (Fig. 152.) When the suture is 
 thus made, the extremities of the pins are 
 cut off by means of a pair of small cutting- 
 pliers. The pins themselves should be 
 carefully drawn out at the expiration of two, 
 or at most, three days, otherwise ulceration 
 will be excited around them, and an un- 
 pleasant scar will be the result ; the threads should not be 
 disturbed for some days longer. When used in an operation 
 upon the upper lip, the invaginated bandage, shown in fig. 25, 
 will be found a convenient support, if any should be needed. 
 
 Mr. Fergusson is in the 
 habit of employing the 
 instrument represented in 
 fig. 153, for this purpose. 
 It consists of a semi- 
 circular spring, padded at 
 both extremities, which 
 passes around the base 
 of the cranium, so that 
 the pads cause the mar- 
 gins of the wound to ap- 
 proximate, and thus re- 
 move any strain from the 
 sutures. The instrument 
 is held in position by 
 straps. 
 
 A particular kind of 
 needle or pin, made of 
 silver, with a steel point 
 which may be detached, 
 has been contrived for 
 this suture, but the common pin of good quality answers just 
 as well, and is much more convenient. 
 
 The dry suture, as before hinted, is made by surrounding 
 the part — a limb generally — with a strip of adhesive plaster 
 placed close to each margin of the wound, and passing from 
 one to the other as many stitches of the interrupted suture as 
 may be required to retain the edges in apposition. 
 
 M. Baudens, chief surgeon to the " Val de Grace" hospital, 
 
 ^fc*c 
 
DRESSING OF WOUNDS. 309 
 
 recommends the following kind of dry suture, to approximate 
 the edges of the flap after amputation ; he surrounds the limb, 
 above its cut extremity, with a circular bandage, through 
 which he passes pins in front and behind, leaving the extremi- 
 ties of the pins projecting ; then, while the flaps are brought 
 together accurately by an assistant, the surgeon passes from 
 one pin to the opposite, pieces of thread, wrapping them 
 around the pins with sufficient tightness to retain the flaps in 
 apposition. 
 
 M. Vidal (de Cassis) has invented an ingenious little con- 
 trivance for retaining the margins of incised wounds in appo- 
 sition. He calls it the "Serve-fine" and the Institute of 
 France awarded him a prize for it. It is made of fine silver- 
 wire, twisted so as to bear a remote resemblance, in shape and 
 size, to the "eye' which ladies use in hooking their dresses; 
 the end of each leg is bent at a right-angle, and is toothed, 
 so as to be capable of piercing and remaining fixed in the 
 skin ; and the spring is so arranged that when the " serre- 
 fine" is left to itself, after having been properly set in the 
 margins of the incision, it approximates these. 
 
 M. Vidal has described and represented this little invention 
 in the last edition of his " Traite de Pathologie Externe" 
 
 We think it rather ingenious and pretty, than useful. 
 
 The bandages used to promote union of incised wounds are 
 the common roller, the bandage of Scultetus, and the invagi- 
 nated bandage. The first two are employed to give support 
 merely to adhesive strips and sutures. The invaginated 
 bandage acts directly by approximating the edges of the in- 
 cision ; its composition and mode of application vary, as the 
 wound is longitudinal or transverse. These bandages are 
 applied to the extremities generally. 
 
 The invagijiated bandage for longitudinal wounds is thus 
 prepared : A linen roller is taken, of a width corresponding 
 with the length of the wound, and sufficiently long to make 
 several turns around the limb : at the free extremity of this 
 roller several slits are made, each about an inch broad and 
 six or eight inches long ; and beyond these, at the distance 
 of a few inches, fenestrae are cut, in number corresponding 
 with the slits, (fig. 154.) Thus prepared, the centre of the 
 undivided portion of the bandage is placed directly opposite 
 the wound, by the margins of which graduated compresses 
 
810 
 
 DRESSING OF WOUNDS. 
 
 (a, tf ? fig. 155) have been arranged, one on each side : the 
 slits, b, ?>, 5, are passed through the corresponding fenestra, 
 e, £, e, and these two portions of the roller drawn in opposite 
 directions until the edges of the wound are in apposition; 
 (fig. 155.) Then the slits are laid flatly upon the surface. 
 
 Fig. 154. 
 
 Fig. 155. 
 
 and the bandage is completed by circular turns of the roller. 
 The efficacy of this uniting bandage is much increased by the 
 employment of the compresses, which act very much as the 
 quilled suture, by pressing together the entire depth of the 
 sides of the wound. It will be found an advantageous mode 
 of approximating the surfaces of deep incisions of the thighs, 
 particularly. 
 
 The invaginated bandage for transverse zvounds. 
 
 Composition. — A piece of linen from two to three feet 
 long, corresponding in breadth with the length of the wound, 
 and divided at one extremity into two or more slits, each 
 about an inch wide and six inches or more in length, to cor- 
 respond with the same number of fenestra made in a second 
 piece of linen of the same dimensions as the first ; two rollers, 
 each six yards long and two and a half inches wide ; together 
 with two graduated compresses. 
 
 Application. — The limb having been placed in a position 
 most favourable for relaxing the divided muscles, the surgeon 
 makes a few turns of one roller, &, around the limb below the 
 wound, and upon these lays the fenestrated bandage, so that 
 the divided portion stretches upon and across the incision, 
 while the other part rests upon the limb below the wound. 
 
DRESSING OF WOUNDS, 
 
 ill 
 
 Fig. 156. 
 
 The extremity of this portion is reflected upwards over the 
 turns of the roller, which is now resumed and made to secure 
 the bandage in position. 
 The other band is now 
 confined upon the limb 
 above the wound, in the 
 same manner, by means 
 of the second roller," 
 the slits corresponding 
 in position with the 
 wound : next the com- 
 presses, c, <?, are placed 
 parallel with the edges 
 of the incision, one above, and the other below : then the slits 
 of one band are passed through the fenestrse of the other, 
 (fig. 156.) The two bands are drawn in opposite directions, 
 so as to approximate the lips of the wound, and are firmly 
 fixed by turns of the rollers passing respectively above and 
 below the seat of the injury. 
 
CHAPTER VI. 
 
 OF THE INTRODUCTION OF THE CATHETER. 
 
 Fig. 157. 
 
 A catheter, in its most general signification, is an open 
 tube, made usually of silver, or of gum-elastic prepared in 
 a peculiar manner, to which such a form and firmness are 
 
 given as permit of its intro- 
 duction into the various canals 
 of the body. The passages 
 into which such an instrument 
 is usually inserted are the 
 lachrymal tube, the eustachian 
 tube, the oesophagus, the 
 urethra, and the large intestine. 
 1. Catheterism, or rather 
 dilatation, of the lachrymal 
 passages, is sometimes prac- 
 tised for the purpose of re- 
 moving obstructions to the 
 escape of the tears along their 
 proper excretory passages. 
 Before resorting to this opera- 
 tion, however, it is important 
 to determine if the difficulty may not be an Epiphora, an ex- 
 cessive secretion, rather than a Stillicidium. 
 
 It is also essential to bear in mind the natural direction of 
 the lachrymal passages, as represented in fig. 157, for it is 
 along these same tortuous channels that the dilating instru- 
 ment must pass. 
 
 If the puncta lachrymalia be occluded, their minute ori- 
 fices may first be opened by the point of a pin, and then one 
 of Anel's gold probes (fig. 158) may be introduced, or one of 
 the less expensive instruments of which we shall presently 
 speak; the size of the dilator should be gradually increased, 
 until a permanent cure of the stricture has been gained. 
 
 (312) 
 
INTRODUCTION OF THE CATHETER. 
 
 313 
 
 It may be that the lachrymal canals, leading from the 
 puncta to the sac, are narrowed, in 
 Fig. 158. ^nich case the same instrument should FlG - 159 - 
 be passed along these passages. To 
 dilate the superior canal, the probe must 
 be passed almost perpendicularly up- 
 wards, inclining a little outwards, then 
 obliquely inwards and downwards. In 
 operating on the lower canal, pass the 
 probe downwards, then obliquely inwards 
 and upwards. 
 
 The Nasal duct, running from the 
 lachrymal sac to the inferior meatus of 
 the nostril, opening below the inferior 
 turbinated bone, may be diminished in 
 its calibre, and thereby occasion stillici- 
 dium lachrymarum. To overcome this 
 obstruction, various methods have been 
 adopted ; the most feasible is probably that by dila- 
 tation. A series of silver probes should be prepared, 
 four or five inches Ions:, varving in size from that of 
 the No. 17 wire to No. 21, slightly bent, as the one 
 illustrated in fig. 159, or straight, if preferred ; one 
 extremity may be turned as in the figure, the other 
 should be slightly pointed, but not sharp, to enter the 
 puncture. In treating stricture of the nasal duct, it 
 is most convenient to pass the probe through the in- 
 ferior canal, in the manner already explained ; and 
 when it has reached the sac, the instrument should 
 be pointed almost vertically downwards until it has 
 gained the inferior meatus of the nose, which may be 
 ascertained readily by passing a probe into the ante- 
 rior naris of the side operated upon, and touching the one 
 which has been inserted from above. A small sized instru- 
 ment should be first used, and after having been introduced, 
 should be allowed to remain a few hours, unless much pain be 
 occasioned thereby ; and at intervals of four or five days, the 
 same or a larger probe should be passed, the size being gra- 
 dually increased until the stricture is cured. After each in- 
 troduction, it is well to apply warm water with laudanum, to 
 allay anv irritation which may have been caused. It is im- 
 27 
 
314 
 
 INTRODUCTION OF THE CATHETER, 
 
 portant to avoid any haste, both in the passage of the prolbe 
 at each sitting, and in increasing the size of the instrument, 
 in order to guard against the production of inflammation. 
 
 Mr. Morgan has recommended dilatation of the nasal duct 
 from below, by introducing a probe, such as is represented in 
 fig. 160, beneath the inferior turbinated bone into the lower 
 orifice of the duct. This method is less generally practised 
 than the other, though highly spoken of by Mr. Morgan. 
 (Lectures on the Diseases of the Eye.) 
 
 Fig. 160. 
 
 Anel advised the syringing of the duct with astringent 
 solutions. To accomplish this, a fine tube must first be passed 
 into the duct from the punctum lachrymale, and the nozzle of 
 the small syringe of Anel be fitted into its upper orifice ; 
 when the piston of the syringe is being depressed, the other 
 punctum must be closed by pressure of the finger, otherwise, 
 the fluid will pass out of it from the lachrymal sac. Not 
 much can be effected in this way, however, the tube 
 being too fine to permit any force of injection. Syringing 
 of the duct in this manner, after the use of the probe, may 
 assist the operation of the latter, and is useful also in freeing 
 the passage from mucus. 
 
 It should be borne in mind, that very much can be done 
 for the cure of stillicidium, by correcting any temporary con- 
 gestion or inflammation; frequently, indeed, this affection 
 may be cured without resorting to such mechanical means as 
 we have described. 
 
 For farther details concerning these operations, and espe- 
 cially for proper views concerning the pathology of stillici- 
 dium, we refer our readers to Treatises on Diseases of the 
 Eye, among the best of which is the American Edition of 
 Mr. Lawrence's book, by Dr. Hays. 
 
INTRODUCTION OF THE CATHETER. 
 
 315 
 
 2. CaTHETERISM OF THE EUSTACHIAN TUBE. 
 
 The catheter used in this operation is gene- 
 rally of silver, about six inches long, slightly 
 curved at the end which enters the tube, and 
 gradually increasing in size from this to the 
 other extremity. It is open at both ends, and 
 it is of very great importance, that the ex- 
 tremity which is intended to be passed into the 
 canal, shall be well rounded ; otherwise, con- 
 siderable irritation, and even excoriation of the 
 lining membrane of the tube, will be produced. 
 The catheter which Mr. Wilde, of Dublin, one 
 of the most dexterous operators and one of the 
 best authorities, prefers, is represented in fig. 
 161 ; it is here shown in its actual dimensions. 
 The ring at the larger extremity of the catheter 
 should be in the same plane as the beak of the 
 instrument, in order that while the latter is 
 being introduced, the operator, by looking at 
 the ring, may know the direction of the beak. 
 
 It will be recollected that the pharyngeal 
 orifice of the eustachian tube is, according to 
 Malgaigne, situated at the distance of two 
 inches and a few lines from the anterior orifice 
 of the nostril of the same side, on a line with 
 the external wall of the meatus inferior, and 
 about half way between the floor of the nostril 
 and the inferior spongy bone. 
 
 To reach this point with the catheter, the 
 following plan, recommended by M. Gairal, is 
 probably the best : — The patient being seated 
 on a chair, with his head thrown a little back- 
 wards and supported upon a pillow, the sur- 
 geon stands in front of him and glides the point 
 of the catheter, the instrument having been 
 oiled, along the floor of the nostril of the same 
 side, towards the soft palate : the convexity of 
 the instrument should be directed inwards and 
 upwards, its concavity downwards and out- 
 wards. When the point has reached the velum 
 Ipalati, which will be indicated by a movement 
 of deglutition, the shaft of the catheter should 
 
 Fig. 161. 
 
316 INTRODUCTION OF THE CATHETER. 
 
 be rotated through a quarter of a circle, so as to turn the 
 point outwards and upwards to the same extent, and at the 
 same time pushed backwards for a few lines, when it will 
 have entered the expanded orifice of the tube. (Malgaigne's 
 Operative Surgery, Brittan's translation, p. 314, 315 — 
 London, 1846.) 
 
 Some surgeons prefer a catheter made of gum-elastic, with 
 a stilet, so that, w r hen the point of the catheter has reached 
 the orifice of the tube, the stilet may be glided into the latter, 
 and the catheter itself slid in upon it. But this we cannot 
 but regard as an improper instrument; for the operator is much 
 more liable to injure the delicate lining membrane of the canal 
 with the stilet; and the withdrawal of the latter, as Mr. 
 Wilde remarks, is very apt to cause the catheter itself, if it 
 have entered the canal, to be disadjusted. 
 
 Generally, the simple opening of the tube by the entrance 
 of the instrument, is sufficient to remove any temporary ob- 
 struction which may have impeded the free access of air to 
 the tympanum. It is sometimes necessary, however, to resort 
 to injections of air through the catheter: this should be done 
 very gently and cautiously. To accomplish this object, it is 
 necessary to have a properly contrived air-press, from which 
 the air may be injected, and it is also essential that the catheter 
 shall be firmly secured to the head, lest it slip and thereby 
 mischief be done. The air introduced may be the ordinary 
 atmosphere, or it may be some medicated vapour, according 
 to the supposed condition of the lining membrane of the tube. 
 Eustachian catheterism, certainly, when associated with this 
 farther process, does not properly come under the domain of 
 Minor Surgery. It is a delicate operation, and should not be 
 carelessly or ignorantly undertaken. Before attempting it, 
 more minute instruction should be sought than we pretend to 
 give. We, therefore, refer our readers to the special treatises 
 on aural diseases, the best of which, we think, is Mr. Wilde's. 
 3. Catheterism of the (esophagus. — The object of this 
 operation is, to insert a tube into the stomach, for the pur- 
 pose of removing fluids from this organ, or of introducing 
 them into it. The catheter used is of gum-elastic, of a 
 diameter varying to suit the capacity of different gullets, from 
 two feet to two and a half feet long, and furnished with a 
 flexible stilet made of a thin strip of whalebone ; the extrem- 
 
INTRODUCTION OF THE CATHETER. 317 
 
 ity which enters the stomach is closed and rounded, but fluids 
 reach the interior of the tube, and escape from it, through 
 two large eyes, placed one on each side, near this end ; the 
 other extremity is open and is usually somewhat expanded, to 
 allow of the easy insertion of a syringe-pipe. 
 
 The following is the simplest and readiest mode of intro- 
 ducing the instrument : let the patient be seated, if possible, 
 his head thrown back and supported, and his mouth widely 
 opened, and kept open, if necessary, by a piece of wood, or 
 something similar ; then the surgeon, taking his position in 
 front of the patient, guides the stomach-end of the tube, pre- 
 viously oiled and having the stilet in its cavity, towards the 
 posterior wall of the pharynx ; the stilet should now be with- 
 drawn, in order to allow the tube to curve more readily as the 
 surgeon pushes it downwards through the pharynx and oeso- 
 phagus. If the patient be possessed of his faculties, and his 
 brain be in a condition to respond to impressions made upon 
 sentient surfaces, the tube will be drawn downwards to the 
 oesophagus by the contraction of the pharyngeal muscles, as 
 in swallowing, so soon as the point of the instrument comes 
 within the sphere of their action ; the surgeon therefore is as- 
 sisted in the performance of the operation, which is thus made 
 much easier. But it happens very often that the patient upon 
 whom the operation is being performed has stupified himself, 
 so that no reflex muscular action takes place. The entrance 
 of the tube into the larynx will be recognised by a spasmodic 
 cough, or by the rushing of the air through the canal thus in- 
 troduced ; the mistake should at once be rectified. 
 
 Fluids may be thrown into the stomach through the tube, 
 by means of a common syringe, or of the stomach-pump pre- 
 pared expressly for this purpose. The first is the most sim- 
 ple and is equally effectual. Care should be exercised that 
 the liquid injected be of a proper temperature. 
 
 If the object be to remove liquid matters from the stomach, 
 a certain amount of fluid should be first introduced, either 
 simple tepid water, or some other fluid capable of neutralizing 
 the noxious matter which may have been swallowed ; then the 
 whole should be withdrawn by means of the syringe, and the 
 stomach thoroughly cleansed by repeated injections of warm 
 water, or mucilage. 
 
 Patients who are unable to swallow, or who obstinately re- 
 27* 
 
318 INTRODUCTION OF THE CATHETER. 
 
 fuse to swallow, food, may be sustained by injections of nutri- 
 tious fluids into the stomach through the stomach-tube. 
 
 When it is desirable that the tube shall be allowed to re- 
 main in the stomach for any length of time, it is recommended 
 to be introduced by the nostril. For this purpose, a tube ra- 
 ther smaller is preferable than if the other method be selected ; 
 it is pushed backwards along the floor of the nostril, and when 
 it has reached the edge of the velum, the stilet is withdrawn, 
 and the flexion of the extremity of the tube aided, if neces- 
 sary, by the finger carried through the mouth. This method 
 is not quite so easy as the first. 
 
 4. Catheterism of the urethra. — Very often the uri- 
 nary-bladder, both of the male and female, becomes distended, 
 being deprived, from a variety of causes, of its natural expul- 
 sive power over its contents; in such circumstances, it becomes 
 necessary to resort to some artificial means of relief. In 
 many cases, the difficulty may be overcome by employing re- 
 medies which tend to relax spasmodic muscular action, such as 
 a full dose of opium administered by the mouth, or in the form 
 of a small enema ; — or an enema of camphor ; or, again, a hot 
 bath may be tried ; often, too, the operation of a full purgative 
 clyster will be attended wdth evacuation of the bladder. But 
 where these and similar means fail, it is requisite to introduce 
 the catheter through the urethra into the bladder itself. 
 
 Catheterism of the urethra of the male. — The in- 
 strument used for this operation is a cylindrical tube made of 
 silver, or of gum elastic ; it should be about nine inches long 
 and of a diameter suited to that of the urethra, which of course 
 varies in size according to the age of the individual and to 
 certain morbid conditions of the canal ; the extremity which 
 enters the bladder should be conical in shape, closed at its 
 point, but perforated just above the latter with two or more 
 well-opened eyes ; a moderate degree of curvature should also 
 be given to this part of the catheter, though a perfectly straight 
 instrument may be passed through a healthy urethra; the 
 other extremity of the tube is open, and generally has a small 
 ring attached to each side of it, for the purpose of affording 
 means of confining the instrument in the bladder, if occasion 
 require, (fig. 162.) The double catheter represented in fig. 
 3, will be found a very convenient instrument. When the 
 
INTRODUCTION OF THE CATHETER. 319 
 
 Fig. 162. 
 
 gum elastic catheter is used, the proper curve and firmness 
 are given to it, by bending the iron wire inserted in its cavity. 
 
 The following will be found the most convenient method of 
 introducing the catheter, in most cases : The patient should 
 lie upon his back, or be a little inclined towards the right side, 
 his thighs semi-flexed and separated, and his back slightly 
 raised in order to relax the muscles which would, otherwise, 
 somewhat constrict the canal ; the surgeon places himself on 
 the left side of the patient, and exposes the head of the penis 
 with the thumb and fore and middle fingers of the left hand, 
 at the same time making slight compression upon the glans 
 penis so as to open the extremity of the urethra : he holds the 
 open end of the catheter, previously warmed and oiled, in his 
 right hand, between the thumb and the fore and middle fin- 
 gers, the concavity of the instrument looking downwards, and 
 engages its point in the orifice of the canal, the direction of 
 the tube corresponding with the line of flexure of the groin ; 
 (fig. 163.) With a moderate degree of force, the instrument, 
 still in this line of direction, is pressed onwards through the 
 canal until its point reaches the membranous portion of the 
 urethra beneath the arch of the pubis, when the right hand of 
 the surgeon, and with it the catheter, is gradually raised and 
 at the same time carried towards the middle line of the abdo- 
 men, after which it should be thrown downwards more and 
 more between the thighs ; its passage through the circle of the 
 sphincter muscle at the neck of the bladder will be indicated, 
 generally, by a slight shiver, or tremor, or a sensation of nau- 
 sea, on the part of the patient, and its entrance into the blad- 
 der itself by the escape of urine through it ; this should be 
 prevented by the application of the thumb upon the open end 
 of the catheter. 
 
 With practice, the instrument may be introduced into the 
 bladder, if the urethra be in a healthy condition, without 
 
320 INTRODUCTION OV THE CATHETER. 
 
 Fig. 163. 
 
 touching the penis at all with the hand, after the point of 
 the catheter has entered the orifice of the canal ; and this 
 will be found to be the least painful method to the patient, 
 as well as the one perhaps least liable to obstacles, for the 
 instrument will glide along through the urethra without 
 being deviated by any forced position of the penis. In 
 either method, an instrument of as large a diameter as the 
 urethra will admit will be more easily introduced than a 
 small one. 
 
 Some of the French surgeons are fond of practising the 
 "tour de maitre," as it is called, and this will sometimes 
 answer when the more common method has failed. The 
 patient may either stand, or lie down, or occupy a sitting 
 posture ; the surgeon stations himself on the right side, and 
 carries the instrument down the urethra to the arch of the 
 pubis, w 7 ith the concavity looking downwards ; when it 
 has reached this point, he gives it a turn of a half circle, so 
 as to bring it parallel with the middle line of the body, the 
 
INTRODUCTION OF THE CATHETER. 321 
 
 concavity looking upwards ; this movement, conjoined with 
 a little pressure, generally causes the instrument to enter the 
 bladder. 
 
 Even in perfectly healthy urethras, the catheter often 
 meets with impediments to its course along the canal, but 
 these are readily obviated. Thus the point of the instru- 
 ment may come in contact with the front of the pubis, 
 owing generally to slight deviation of the position of the 
 penis, or to too great pressure against the superior surface 
 of the urethra from the point of the catheter. Again, when 
 the tube has come within the action of the muscles which 
 compress the membranous portion of the canal, and, still 
 more, when it has reached the neck of the bladder, its farther 
 advance will be often checked by the contraction of the mus- 
 cular fibres at these points ; but a little patience on the part 
 of the surgeon is all that is required to overcome this momen- 
 tary obstacle. 
 
 When the cause of the obstruction is an organic alteration 
 of the urethra, or of the parts connected with it, much more 
 difficulty is experienced in the introduction of the catheter. 
 The most common sources of embarrassment of this kind are 
 stricture and enlargement of the prostate gland. 
 
 If there be a stricture of the urethra, the size of the ca- 
 theter must be adapted to the diminished calibre of the canal ; 
 it is necessary, therefore, to have a number of catheters of 
 different sizes always at one's command. The resort to much 
 force in introducing the instrument should be avoided, parti- 
 cularly when the stricture is within the pubic portion of the 
 canal, as a false passage may be made more easily at this 
 portion than in advance of it. The operation maybe assisted 
 by drawing the urethra over the catheter ; by first using a 
 large instrument, until the stricture is reached, and then 
 drawing the penis over it, so as to make an entrance fully 
 into the strictured part, then taking a smaller instrument 
 with a resort to the same manipulation. The use of the 
 warm-bath, the application of warm fomentations to the peri- 
 naeum, or the administration of anodyne enemata, or inducing 
 anaesthesia by inhalations of ether or chloroform, will usually 
 assist the operation, by relaxing the muscles which directly 
 or indirectly constrict the urethra. In the London Lancet, 
 for 1851, Mr. Thomas Wakley describes a method of effecting 
 
322 
 
 INTRODUCTION OF THE CATHETER. 
 
 prompt dilatation of the urethra which may prove very ser- 
 viceable in affording relief to persons suffering from retention 
 of urine, with stricture. He employs a series of instruments. 
 He first introduces a very fine bougie, and upon this, as on a 
 director, a small catheter, and so on, gradually increasing the 
 size of the catheter, until one of sufficient dimensions has been 
 passed. 
 
 M. Amussat frequently resorts to forced injections of the 
 urethra, to relieve retention caused by stricture. He intro- 
 duces a catheter of gum-elastic, open at both ends, as far 
 as the stricture, and then, by means of a syringe, forces a 
 stream of warm water along the urethra ; this removes any 
 mucus which may have collected, and dilates the canal some- 
 what, so that the patient can generally pass a small quantity 
 of urine. 
 
 One of the most common causes of difficulty in the intro- 
 duction of the catheter, particularly in old men, is an abnor- 
 mal development of the prostate gland. The middle lobe 
 becomes enlarged, sometimes to a very great degree, and 
 encroaches, proportionally to its size, upon the canal at the 
 neck of the bladder, thereby opposing a mechanical obstacle 
 to the ingress of the instrument. (Fig. 164.) There are 
 
 Fig. 164. 
 
 several expedients by which this difficulty may generally be 
 remedied. If the gland be not very large, a silver catheter 
 may usually be passed, by pressing the external end of the 
 instrument well downwards, when the point -has reached the 
 
INTRODUCTION OF THE CATHETER. 323 
 
 prostate ; or a gum-elastic catheter may be introduced by 
 withdrawing the stilet a little, when the prostatic part of the 
 urethra has been attained, and pushing the tube onwards with 
 moderate force and cautiously ; the point of the instrument, 
 meeting with the obstacle, will yield to it in virtue of the 
 flexibility of the gum, and will be thrown upwards so as to 
 clear the obstruction. If these methods fail, the surgeon 
 should insert the forefinger of his left hand, previously oiled, 
 into the rectum, and press the point of the catheter upwards 
 towards the pubis : if the gland is very large, the patient 
 should assume the erect position, or he may bend his body 
 forwards, supporting his hands against the back of a chair or 
 a table, so that the mere weight of the prostate will open the 
 neck of the bladder to the passage of the instrument. In 
 cases of obstruction from this cause, the curve of the catheter 
 should be somewhat increased, especially near its point, so 
 that it will pass over, and in advance of, the enlarged gland, 
 instead of impinging directly against it, as would probably be 
 the case were the degree of curvature smaller. 
 
 Many persons suffer very much from the performance of 
 this operation, even where there is no stricture ; others, again, 
 experience severe rigors, or fainting-fits. If these peculiari- 
 ties be known to exist, it is better, unless contra-indicated, to 
 put the patient under the influence of ether, or to diminish 
 their sensibility by opium ; and if such effects follow the ope- 
 ration, morphia should be given to allay them. And in all 
 difficult or protracted cases, the same expedients may be re- 
 sorted to with great advantage. 
 
 Where much difficulty is experienced in introducing the 
 catheter, or in the process of dilating a stricture, it is often 
 advisable to allow the instrument to remain in the bladder. A 
 silver catheter is borne with rather less comfort than a gum- 
 elastic, but the latter soon becomes corroded and roughened 
 by the action of the urine upon it ; hence if the gum catheter 
 is used, it should be removed at least once in every twenty- 
 four hours, and a new one substituted for it. 
 
 A very simple mode of securing the catheter in the blad- 
 der is the following : pass a ring made of ivory or of metal, 
 covered with linen, or of a cylinder of linen stuffed with 
 cotton, over the penis, and secure it against the pubis by 
 means of four tapes passing around the pelvis and between 
 
324 
 
 INTRODUCTION OF THE CATHETER. 
 
 Fig. 165. 
 
 the thighs, on each side ; attach the catheter to this ring by 
 tapes connected with the rings of the 
 instrument, or tied around its extremity, 
 if it be a gum-elastic tube. 
 
 M. Velpeau advises that a piece of 
 linen be passed around the penis, just 
 behind the corona glandis, and that four 
 tapes, secured to the rings of the instru- 
 ment, or tied around the extremity, be 
 twined about it. (Fig. 165.) The first 
 plan will be less likely to cause injury 
 to the penis, in case of erection of the 
 organ. 
 
 Catheterism of the female urethra is 
 attended with fewer difficulties than that 
 of the male, owing chiefly to the differ- 
 ence in the conformation of the two canals. 
 
 The instrument employed in the operation is made of silver, 
 generally ; its form and dimensions may be very well seen by 
 a reference to fig. 3, A and B, and to the text explanatory 
 of it. But a gum-elastic catheter, even without a stilet, may 
 easily be introduced. The only difficulty in the performance 
 of the operation, in most instances, consists in inserting the 
 point of the catheter into the orifice of the urethra, without 
 exposing the parts ; but a very little practice upon the subject 
 will enable the surgeon to acquire sufficient skill to operate 
 satisfactorily on the living female. 
 
 The simplest rule which can be given for ascertaining the 
 position of the orifice of the urethra in the female is this : 
 (the patient being on her back,) introduce the tip of the fore- 
 finger of the right hand within the labia and the orifice of the 
 vagina, and press its palmar surface against the summit of the 
 arch of the pubis, at the same time pushing the point of the 
 finger a little forwards ; it will now readily and immediately 
 feel itself entering the mouth of the canal, which is forced a 
 little open to admit its tip. 
 
 The catheter may be thus introduced : place the point of 
 the forefinger of the right hand at the orifice of the urethra, 
 as just directed, and with the left hand enter the catheter, 
 using the finger of the right hand as a guide ; or only one 
 hand need be employed, thus : lay the catheter upon the palm 
 
INTRODUCTION OF THE CATHETER. 325 
 
 of the right hand, the point of the instrument resting on the 
 top of the forefinger, the other extremity on the ball of the- 
 thumb, and supported in this position by the thumb and 
 middle-finger, both somewhat flexed ; now place the tip of the 
 forefinger at the orifice of the urethra, in the manner already 
 directed, and with the thumb and middle-finger cause the 
 catheter to glide along upon the fore-finger and enter the 
 canal. 
 
 When the uterus is higher up in the pelvis than usual, from 
 any cause, the orifice of the urethra is usually drawn behind 
 the arch of the pubis ; in such cases, the point of the finger 
 must be introduced a little farther than is otherwise neces- 
 sary, in ascertaining the position of the meatus, and rather 
 behind the pubis ; but the operation is scarcely rendered more 
 difficult on this account. 
 
 It sometimes happens that the urethra is much compressed 
 against the pubis by a tumour in the pelvis, as a child's head 
 during labour ; in such circumstances, if it is necessary to 
 remove the urine from the bladder, a gum-elastic catheter of 
 small size should be used, or, which is perhaps better, a flat- 
 tened silver catheter ; such an instrument can be had at the 
 shops of surgical instrument makers. 
 
 Should it be deemed advisable to allow the catheter to re- 
 main for any length of time in the bladder, it may be easily 
 secured by applying a double-T bandage around the pelvis, 
 and attaching the rings of the instrument to the strips which 
 pass between the thighs and over 'the perinaeum. 
 
 5. Catheterism of the large intestine is sometimes 
 resorted to, for the purpose of removing the gases which accu- 
 mulate so largely in some diseases. Thus, in peritonitis, the 
 bowels often become so much distended with flatus, as to 
 aggravate the patient's suffering in a high degree. In such 
 cases, relief is occasionally obtained from the introduction of 
 the common stomach-tube. The mode of performing the 
 operation is simple in the extreme ; and yet, from the tortuous 
 course of the intestinal canal, it is often exceedingly difficult 
 to pass the tube to any considerable distance above the rec- 
 tum. The most successful plan is to select a large-sized 
 stomach-tube, having within it a stilet of whalebone sufficiently 
 thick to impart to the tube a certain degree of firmness, yet 
 so flexible as to accommodate itself to the winding course of 
 28 
 
326 INTRODUCTION OF THE CATHETER. 
 
 the canal ; the tube should be oiled, and introduced with a 
 rotatory motion and slowly : the point of the catheter may 
 often be felt passing along the sigmoid flexure of the colon, 
 by the hand placed on the parietes of the abdomen. If the 
 operator fail in his first attempt, he should change the posi- 
 tion of the patient, and make another effort. It is sometimes 
 useful, when the farther advance of the tube seems to be pre- 
 vented, to throw a stream of tepid water through it from a 
 syringe inserted into its trumpet-shaped orifice. 
 
 6. Catheterism of the larynx and trachea is rarely 
 practised ; but in some cases of oedema of the glottis and 
 similar obstructions, it may perhaps be advisable to pass a 
 tube into the air-passages from the mouth. The operation is 
 more difficult of execution than catheterism of the oesophagus; 
 sometimes, indeed, it is impossible, as w r hen the rima glottidis 
 is spasmodically closed : the patient being seated, or recum- 
 bent, the head should be thrown back, the mouth widely 
 opened, and the base of the tongue depressed by means of a 
 spoon ; then the surgeon, taking a silver tube curved like the 
 ordinary catheter for the urethra, but rather larger and open 
 at both ends, or a stomach-tube curved by means of a stilet, 
 passes it through the mouth directly into the larynx, the pa- 
 tient being directed to prolong his inspiratory act : a momen- 
 tary cough may be excited by the entrance of the tube into 
 the larynx, but this may soon subside, so that the instrument 
 may be permitted to remain, having been secured by attach- 
 ing its external end to some conveniently-placed bandage, as 
 around the neck, for example. 
 
CHAPTER VII. 
 
 ON THE ADMINISTRATION OF INJECTIONS. 
 
 The term injections, or enemata, is applied to liquids in- 
 troduced into the canals or cavities of the body by means of 
 syringes contrived for the purpose. 
 
 The matter of the injection consists of water, holding in 
 solution, or suspension, certain medicinal substances, intended 
 to produce some special effect, — or of water alone. 
 
 The syringes used in the administration of enemata vary in 
 form and size, according to the amount of fluid to be injected, 
 and the canal into which it is to be introduced. The rectum, 
 the vagina, the urethra, and the lachrymal duct are the pas- 
 sages which are most frequently acted upon in this manner. 
 
 1. Injections by the rectum. 
 
 The syringes for the rectum are made of different sizes, to 
 contain from two fluid ounces to a pint, or more. In select- 
 ing them, those instruments should be chosen of which the 
 beaks are large and well-rounded at the extremity, so that 
 there shall be less probability of inflicting any injury upon 
 the mucous membrane of the rectum during their intro- 
 duction. 
 
 Before using the syringe, the beak should be warmed and 
 anointed with oil, or lard ; and when it is being introduced 
 into the rectum, great gentleness and caution should be 
 observed, otherwise, as has happened at times, the intestine 
 may be torn, or even perforated, particularly when its coats 
 are not in a perfectly healthy condition. Its entrance into 
 the anus may be facilitated by first passing in the forefinger 
 of the left hand, well oiled, and then sliding in the beak upon 
 it. While the piston is being forced down with the right 
 hand, the head of the syringe should be firmly held by the 
 fingers of the left, so that the instrument shall not be pushed 
 further into the bowel. The fluid should be forced from the 
 tube gradually ; and after all has been ejected, the beak of 
 
 (327) 
 
 i 
 
828 ADMINISTRATION OF INJECTIONS, 
 
 the instrument should be retained a few moments in the 
 rectum, lest, during its removal, the injection pass out with it. 
 
 The above remarks are of general applicability : there are 
 some modifications of the process, however, which should be 
 borne in mind. Thus, it is frequently advisable that a large 
 quantity of fluid shall be thrown into the bowel, a larger quan- 
 tity than can be contained in the syringe usually employed. 
 In such cases, the instrument must be carefully and slowly 
 withdrawn from the anus, refilled, and again introduced and 
 emptied, until the requisite amount shall have been injected ; 
 or, the self-injecting syringe may be more conveniently used 
 — an instrument made like the common forcing pump, having 
 connected with it one tube, through which the fluid enters the 
 syringe from the vessel which contains it, and a second, which 
 is inserted into the rectum, and through which the injection 
 finds its way into the bowel. With this very convenient ap- 
 paratus, any quantity of fluid may be thrown into'the large 
 intestine, until it is filled, either by the patient's self or by an 
 attendant. Again, it sometimes happens that an obstruction 
 of the lower part of the bowel prevents the introduction of the 
 matter of the injection beyond a certain point, if the ordinary 
 method be adopted. In such cases, it is customary to pass a 
 stomach tube, in the manner recommended in the last chap- 
 ter, as far into the canal as may be practicable, and to inject 
 the fluid through it. This method will be found effectual, 
 oftentimes, in overcoming the constipation which attends some 
 cases of colic. 
 
 The composition of the enema must be adapted to answer 
 the particular indication for which it is given. When it is 
 employed merely to distend the bowel by its quantity, simple 
 warm water, or warm mucilage, may be used. The ordinary 
 purgative injection consists of a tablespbonful of common salt 
 and the same; bulk of molasses, dissolved in a pint of warm 
 water, to which a small piece of soap may be added with ad- 
 vantage. The anodyne enema consists merely of half an ounce 
 or an ounce of mucilage, holding in suspension or solution the 
 anodyne element, — as, for example, thirty-five or forty drops 
 of laudanum. This small quantity of fluid is preferred, as 
 being less likely to induce contraction of the expulsive mus- 
 cles by its mere presence, than if a^larger amount were intro- 
 duced; and this fact should be recollected in giving any injec- 
 
ADMINISTRATION OF INJECTIONS. 329 
 
 tion which is intended to be retained in the rectum, to pro- 
 duce some general impression upon the economy. 
 
 "Suppositories" are sometimes used as substitutes for ene~ 
 mata : they may be so formed as either to induce an evacua- 
 tion of the lower bowel, from the irritation of their presence 
 in the rectum, — or, in consequence of the absorption of the 
 medicated materials of which they are composed, they may be 
 retained for a considerable length of time in the gut, and pro- 
 duce the peculiar effect of the medicine upon the system. 
 
 The suppository intended to produce catharsis is ordinarily 
 made of a piece of castile soap cut to correspond with the 
 form and size of the rectum; it should be oiled, and then in- 
 serted gently w r ithin the sphincter muscle. 
 
 Any medicine may be administered in the form of a sup- 
 pository, by combining it, in the state of powder, with liquo- 
 rice, cocoa-butter, or some other soft adhesive substance ; then, 
 having reduced the mass to the proper dimensions and figure, 
 let it be oiled and introduced into the low T er extremity of the 
 rectum. As a general rule, the quantity of the medicine used 
 in the suppository may be three or four times greater than 
 the proportion of the same medicine, when given by the 
 mouth. 
 
 It should be borne in mind that a very frequent resort to 
 the employment of suppositories, or to the administration of 
 injections, produces irritation of the mucous membrane lining 
 the lower part of the rectum, and is apparently an exciting 
 cause of the development of haemorrhoids and other organic 
 alterations of this portion of the intestinal canal. 
 2. Injections by the vagina. 
 
 The vaginal syringe is usually about four inches long and 
 an inch in diameter, terminating in a rounded head w r hich is 
 pierced with a number of holes, like a sieve. 
 
 No especial directions are required to enable one to intro- 
 duce this instrument, farther than that it should be oiled be- 
 fore so doing. 
 
 The cavity of the uterus itself may be washed, by passing 
 a gum-elastic catheter through the os uteri, and injecting the 
 interior of the organ w T ith tepid water or mucilage, by means 
 of an ordinary syringe, of which the beak is inserted into the 
 open extremity of the catheter. 
 8. Injections by the urethra. 
 28* 
 
330 ADMINISTRATION OF INJECTIONS. 
 
 A small glass syringe capable of containing about half an 
 ounce, and having a beak well rounded at the tip, is the best 
 instrument for injecting the urethra. The piston should ter- 
 minate, at its free extremity, in a ring large enough to receive 
 the thumb, so that the fluid may be forced from the syringe 
 and the syringe itself held by the right hand, while the left 
 supports the penis. The beak of the instrument should be 
 oiled and inserted very carefully into the orifice of the ure- 
 thra, lest the lining membrane be injured. 
 
 It is generally recommended that pressure be made upon 
 the perinseum opposite the neck of the bladder, in order to 
 prevent the fluid of the injection from entering the cavity of 
 this organ; but this precaution is scarcely necessary, if the 
 piston of the syringe is forced down with a proper degree only 
 of rapidity, and if only sufficient fluid be expelled to fill the 
 canal, — the sphincter muscle preventing the fluid from reach- 
 ing the bladder itself. 
 
 The interior of the bladder may be acted upon by fluid in- 
 jected through the urethra, a catheter having been first intro- 
 duced, and the beak of an ordinary syringe, or a gum-elastic 
 bag, then inserted into the mouth of the tube. But it is much 
 more convenient to use a catheter having two passages, as in 
 fig. 166. In the drawing the division of the tube is indicated 
 by the dotted line and the star; at a the nozzle of the syringe 
 (a) is received; the fluid from the latter passes along to the 
 bladder through the eye marked by one of the arrows, and is 
 returned from the bladder through that marked by the other, 
 to escape from the catheter by d. The stilet c is for the pur- 
 pose of removing any obstruction which may occur in the ca- 
 theter; it is made of steel, so thin and flexible as to be capable 
 of being readily pushed into the chambers of the instrument, 
 as indicated by the dotted curved line. (See Mr. Fergusson's 
 book, p. 588.) 
 
 Care should be taken, that the fluid thus introduced into 
 the bladder has been freed from all solid matter which, if re- 
 tained, would serve as the nucleus for calculous formations; 
 it should, moreover, be tepid in temperature, and of a slightly 
 mucilaginous character. 
 
 In injecting the urethra of the female, a catheter should 
 first be inserted within the orifice of the canal, the beak of the 
 
ADMINISTRATION OF INJECTIONS. 331 
 
 Fig. 166. 
 
 syringe adapted to it, and then the fluid forced through the 
 tube into the urethra. 
 
 4. Injection by the lachrymal duct. 
 
 The instrument by means of which this is accomplished, is 
 known by the name of " Anel's syringe ;" it is a small syringe 
 having a number of very fine tubes appertaining to it, one of 
 which, when the duct is to be injected, is attached to the beak 
 of the syringe and then inserted into the inferior puncture 
 lachrymal. The method of using the instrument is thus de- 
 scribed by Malgaigne : " Seat the patient opposite the light. 
 If you operate on the left eye, stand before him, and with 
 the thumb or fingers of your left hand draw the lower lid out- 
 wards and a little downwards, so as to direct the lachrymal 
 puncture forwards and outwards. Then, having filled the 
 syringe and applied one of the small tubes to the beak, hold 
 the instrument as a pen in your right hand, which you rest 
 on the cheek, and carefully insert the end of the tube in the 
 puncture ; first, obliquely downwards and inwards, then, after 
 having entered one line, directly inwards. At the distance 
 of three and a half lines you may stop, but it is advisable to 
 penetrate as far as four and a half lines, in order to reach the 
 
332 ADMINISTRATION OF INJECTIONS. 
 
 sac; then inject slowly, at first." On the right eye the ope- 
 ration may be performed also with the right hand, by stand- 
 ing behind the patient, and resting the hand upon the exter- 
 nal orbital process of the frontal bone. If the duct is pervi- 
 ous, the fluid thus injected will pass through it and appear 
 externally by the nostril ; and if it be not pervious at first, 
 the obstruction may oftentimes be removed by repeated use 
 of the syringe. The first injection should consist of tepid 
 water or mucilage ; subsequently, the fluid may be rendered 
 somewhat astringent, or be otherwise medicated. If the in- 
 jection cannot be passed through the duct, a fine silver probe, 
 of which the point is round and smooth, may be introduced 
 as directed for the syringe. 
 
CHAPTER VIII. 
 
 ON THE REMOVAL OF FOREIGN BODIES FROM THE NATURAL 
 CANALS AND PASSAGES. 
 
 1. The globe of the eye, from its exposed position, is very 
 liable to have foreign bodies, as particles of dust, cinders, and 
 minute insects, come in contact with it ; not unfrequently, 
 also, sharp splinters of iron or steel are driven forcibly against 
 it and imbed themselves. The pain in such instances is con- 
 siderable, sometimes excruciating ; more or less profuse 
 lachrymation takes place, and the patient is unable for a time 
 to make use of the eye without discomfort. 
 
 Frequently, the profuse secretion and escape of tears are 
 sufficient to wash away the offending substance, aided by the 
 friction which the patient almost unwillingly exercises. When 
 not thus removed, the lids should be well opened and the globe 
 carefully examined, while the patient rolls the eye-ball in 
 various directions ; if the object be thus brought into view, it 
 may be removed by the point of a camel's-hair pencil, by the 
 corner of a pocket handkerchief, the end of a tooth-pick or 
 probe ; or it may be necessary to throw a fine stream of tepid 
 water gently between the lids ; or, finally, if a particle of 
 metal or such body be adherent to the structure, it must be 
 removed by a pair of delicate forceps, or by the point of a 
 cataract needle ; in such cases a magnet would hardly accom- 
 plish the removal. 
 
 Very generally the offending object will not be detected by 
 the examination to which we have alluded ; it will then be 
 necessary to scrutinize the inner surface of the eye-lids. 
 The lining membrane of the lower lid may be readily seen by 
 depressing the lid, at the same time that the patient rolls the 
 eye upwards ; to expose the conjunctiva of the upper lid, the 
 surgeon should seize the lashes, and by these draw the lid a 
 little off from the globe, place a probe, a tooth-pick, or some 
 similar instrument, across the lid just above the superior 
 border of the cartilage and parallel thereto, and, while the 
 patient looks downwards as much as possible, throw the lid 
 
 (333) 
 
334 REMOVAL OF FOREIGN BODIES 
 
 over the probe, thus turning it " inside out;" all these steps 
 are done at once. If the object be seen, it may be removed 
 by any of the means above indicated. 
 
 It must be recollected that the sense of itching, pain, &c, 
 occasioned by the pressure of the irritating substance, usually 
 remains some time after the cause has been removed. This 
 disturbance, however, will commonly be relieved by the ap- 
 plication upon the closed lids of tepid or cold water, as is 
 most agreeable to the patient. 
 
 2. Removal of foreign substances from the Nostril. 
 — Children are not inapt to thrust beans, coffee grains, but- 
 tons, and such small bodies, into their own or others' nostrils, 
 in fun or malice ; or they may be drawn up into the nose by 
 smelling them strongly. Careless or ignorant manipulation, 
 instead of dislodging them, only forces them farther towards 
 the summit of the nasal chamber. The lining membrane of 
 the nose becomes swollen, in consequence of the pressure of 
 the irritant and of the efforts made to remove it, blood flows 
 more or less freely from the ruptured vessels, and the cavities 
 become additionally occluded by clots of blood. When the 
 surgeon is sent for he finds the inside, and perhaps also the 
 exterior, of the organ swollen, and is unable to see the offending 
 substance. In such a case, it is best to syringe the nose with 
 tepid water, to dislodge coagula of blood, and inspissated mucus 
 which obscure the cavity ; perhaps the same means will likewise 
 loosen and wash down the foreign body ; if not, let the sur- 
 geon pass a flattened probe, slightly curved, into the nose 
 beyond the object, and endeavour to drag it downwards ; the 
 spoon-shaped extremity of the silver director will answer this 
 purpose very well; or the substance may sometimes be caught 
 in the noose of a wire-armed canula. Either of these instru- 
 ments will be more likely to succeed in engaging the object 
 sought than the forceps, for the latter cannot usually be 
 worked with advantage, and even if the foreign substance be 
 grasped, it will slip from the blades repeatedly. 
 
 If it be not thrust high up in the nose, and only loosely 
 fixed, it may be dislodged by exciting violent sneezing, the 
 other nostril being closed the while. 
 
 Occasionally, children are so much frightened by the acci- 
 dent and the efforts made to relieve them, as to be entirely 
 unmanageable, and thereby expose themselves to injury from 
 
FROM THE NATURAL CANALS. 
 
 335 
 
 Fig. 167 
 
 attempts at extraction of the foreign body. It is better, 
 under these circumstances, to quiet the patient by inhalations 
 of ether, and then resume the operation under more favour- 
 able auspices, or to wait until the dread shall have passed off. 
 There is usually, however, no such difficulty. 
 
 Soothing applications should be made after the operation, 
 if the local symptoms seem to require any interference. 
 
 3. Extraction of foreign bodies from the external 
 meatus of the Ear. — The lining membrane of the external 
 auditory passage, especially near the mem- 
 brana tympani, is so exquisitely sensitive, 
 that great pain and irritation, sometimes 
 convulsions, are produced by the entrance 
 of foreign substances. Insects, the most 
 common of which is the "ear-wig," splin- 
 ters, small pebbles, &c, &c, are not un- 
 frequently introduced, or insinuate them- 
 selves into the external ear. Attempts to 
 remove them should be made with great 
 delicacy, as very unpleasant consequences 
 have often followed carelessness and rude- 
 ness. 
 
 The passage should be examined by the 
 aid of the speculum, such as is represented in 
 fig. 167, a conical silver tube carefully smoothed, and brightly 
 polished on the inner surface, or the little gorget-like instru- 
 ment shown in fig. 168 ; and if the object be seen, it may, 
 
 Fig. 168. 
 
 perhaps, be removed by a flattened silver probe, slightly 
 curved, or the scoop-shaped end of a director, or the little 
 curvette, or the delicate forceps, used by Mr. Wilde. (Fig. 
 169.) In consequence of the straightness of the passage, 
 however, the surgeon may not be able to manipulate conve- 
 niently with, or guide, any of the instruments to which we 
 
336 REMOVAL OF FOREIGN BODIES 
 
 Fig. 169. 
 
 have alluded, his hand being in the way of his vision ; he will 
 then find the forceps illustrated in fig. 170, more manageable. 
 
 Fig. 170. 
 
 But in most cases, more can be done, perhaps, by means of a 
 syringe and tepid water, than by any other instrument, and 
 W T ith less danger of injuring the patient ; this is particularly 
 true if an insect have found its way into the meatus, or if 
 wax have became impacted therein. 
 
 It is necessary to guard against inflammation, both before 
 and after the removal of foreign bodies from this situation. 
 (See Wilde's Aural Surgery.) 
 
 4. Foreign bodies occasionally become lodged in the 
 Pharynx and (Esophagus. Small objects, such as pins, but- 
 tons, fish bones, are apt to become arrested in the folds and 
 pouches at the base of the tongue and palate, causing con- 
 siderable uneasiness and constant coughing and hawking, 
 rather than actual strangling ; while bodies of larger size are 
 caught at the narrowest part of the pharynx, and by their 
 pressure upon the larynx, or the spasmodic irritation which 
 they produce in it, endanger suffocation. 
 
 The exact point of lodgement should first be ascertained, 
 by careful exploration with the fore-finger of the right hand, 
 as well as by the eye, of the surgeon — the patient's mouth 
 
FROM THE NATURAL CANALS. 
 
 337 
 
 being widely opened. The situation having been determined, 
 the surgeon may best remove the offending object by his finger- 
 nail, or by a pair of dressing-forceps, if it be not too low 
 down. 
 
 If the substance in question be impacted in the oesophagus, 
 its situation must be ascertained by sounding with the pro- 
 bang, (fig. 171,) a flexible rod of smooth whalebone, tipped 
 
 Fig. 171. 
 
 with a sponge, or rounded block of ivory ; if it be low down, 
 near the stomach, probably the best course to pursue is to 
 push it still onward into this cavity, by means of the pro- 
 bang ; if it be nearer to the pharynx and accessible to instru- 
 ments, the effort should be made to seize it with the gullet- 
 forceps, as represented in fig. 172 ; or, instead of the forceps. 
 
 Fig. 172. 
 
 29 
 
 i 
 
338 REMOVAL OF FOREIGN BODIES 
 
 a hook attached to a whalebone, as is exhibited in fig. 173, 
 
 Fig. 173. 
 
 Fig. 174. 
 
 may be passed between the body and the wall of the oesopha- 
 gus, and then, when it is beyond the former, drawn up again ; 
 the instrument being provided with a hinge, which 
 permits its blades to close as it is pressed between 
 the gullet and the foreign body, while they open 
 again when the pressure is removed, and thus en- 
 tangle the latter. 
 
 But a much more simple and effectual hook is 
 that contrived by Dr. Bond, of this city (fig. 174) ; 
 it is so simple that many may be inclined to think 
 little of it. It is longer than the common gullet- 
 hook, and sets out rather more from the stem at its 
 extremity, while at its commencement it forms quite 
 an acute angle with the shaft, and is thus capable 
 of engaging objects so small as a pin or a needle. It 
 is made upon a piece of copper wire, silvered, or 
 upon a piece of silver wire, long enough to reach 
 even to the stomach, and sufficiently flexible to be moulded to 
 any shape. It will be found to be a most efficient instru- 
 ment ; indeed, one can accomplish more with it than with any 
 other means. 
 
 It is very well to have two pair of gullet-forceps, opening 
 in opposite directions, as those figured by Professor Miller, 
 (fig. 175) ; in these, it will be observed, the inner face of each 
 blade is flat, and toothed near the extremity. Dr. Bond has 
 also contrived a gullet-forceps, (see fig. 176), the inner face 
 of whose blades are levelled off towards each other, and 
 toothed ; and they are so set that they do not come together 
 closely ; consequently, there is but little probability of catch- 
 ing the lining membrane of the oesophagus between them. 
 
FROM THE NATURAL CANALS. 339 
 Fig. 175. Fig. 176. 
 
 These forceps are in general use in this city, and are prefer- 
 able, we think, to all others. (See an interesting paper by 
 Dr. Bond, in the North American Med. and Surg. Journal, 
 vol. vi., in which he describes both the forceps and the hook.) 
 Sometimes, though happily very rarely, it is impossible 
 either to draw the body upwards, or to force it into the sto- 
 
340 REMOVAL OF FOREIGN BODIES 
 
 mach ; then, if the symptoms be urgent, it remains only to 
 make an incision upon it at the side of the neck, and remove 
 it from without. 
 
 If the foreign substance be withdrawn from the gullet, it 
 is advisable always that the patient should make use of some 
 mucilaginous article, as slippery-elm bark, or gum arabic, to 
 lubricate the lining membrane and to protect it, while so re- 
 cently irritated, from farther annoyance during the passage 
 of alimentary substances. And if the offending object have 
 been pressed down into the stomach, especially if it be irrita- 
 ting, unless it be chemically so, rather than give purgative 
 medicines to promote its evacuation per anum, demulcients 
 and mucilages should be taken freely by the patient, in the 
 hope that it may become more or less ensheathed, and thus 
 be rendered harmless : if it be likely to do mischief by chemi- 
 cal action, the proper antidote should be promptly and suf- 
 ficiently administered. 
 
 5. Extraction of foreign bodies from the Larynx and 
 Trachea. — During the act of inspiration, the glottis is opened 
 widely for the ingress of air, w^hile but a narrow chink re- 
 mains during expiration. Hence, during a fit of crying, 
 laughing, coughing, yawning, or the like, the unusual inward 
 rush of air often suffices to suck in, so to speak, bodies of 
 considerable size. Among the articles which have been thus 
 drawn into the trachea, are pieces of money, (a half sovereign, 
 for example,) cherry and plum stones, small pebbles, grains 
 of coffee and corn, teeth, (in one instance, a large molar with 
 its fangs,) pieces of grass, fragments of bone. The object 
 once in, escape is difficult, from the diminished size of the 
 orifice, but especially from the spasmodic closure of the glottis, 
 which the presence of an irritant almost necessarily induces. 
 
 The symptoms produced by this accident vary according 
 to the position occupied by the intruder. If it be fixed in 
 the rima glottidis, asphyxia is rapidly produced, and speedy 
 loss of consciousness and death, unless relief is procured by 
 surgical interference. If it be moveable in the larynx and 
 trachea, and if it change its position from time to time, these 
 alterations of site may occasion violent spasmodic cough, con- 
 tinuing until complete exhaustion is produced, when a tem- 
 porary cessation occurs, to be followed, upon revival, by the 
 same phenomena. In other cases, the cough is only occa- 
 
FROM THE NATURAL CANALS. 341 
 
 sional and much less violent, resembling more the paroxysms 
 of hooping-cough ; again, it is more like that which attends 
 an ordinary catarrh, or a pneumonia, so as to be mistaken for 
 one of these ; the nature of the expectoration is also similar 
 to that of these affections. Auscultation will aid the recog- 
 nition both of the cause of these aberrations, if the history 
 have been unknown, and of the portion of the body, es- 
 pecially if it be impacted anywhere, because such a condition 
 almost always occasions local pneumonia, or collapse of that 
 portion of the pulmonary structure which is connected with 
 the bronchial tube thus occluded. Frequently, too, the exist- 
 ence of the foreign body in the trachea and larynx, may be 
 recognised by feeling it with the fingers placed on the outside 
 of the passage, and its motions up and down in the tube may 
 thus be followed. Besides the local symptoms enumerated, 
 the general condition of the patient suffers, he becomes ema- 
 ciated, feverish, kc. ; in fact, many persons who have acci- 
 dentally had a foreign body lodged in the trachea, have been 
 supposed to labour under tuberculous diseases of the lungs. 
 
 The cause of all these troubles may remain entangled in 
 the ventricles and folds of the larynx, or be impacted in its 
 general cavity, or in that of the trachea ; it may have passed 
 into one of the bronchia, the right most probably, because of 
 the size and direction of the latter ; it may even slip farther 
 down into one of the smaller subdivisions of the bronchial 
 tubes ; or it may, as we before hinted, be arrested at the chink 
 of the glottis, either at its first descent, or subsequently 
 during expiration. 
 
 Before resorting to mechanical interference, the surgeon 
 should satisfy himself by careful investigation into the history, 
 as well as the present phenomena, of the case, that a foreign 
 body has passed into the respiratory canal, and that the symp- 
 toms are not due to inflammation, nor to impaction in the 
 oesophagus or pharynx. 
 
 Clearly, the attempt at removal of the object in question, 
 by forceps passed into the larynx and trachea, is out of the 
 question. The surgeon must decide between performing tra- 
 cheotomy and laryngotomy ; and removing the body through 
 the wound, on the one hand, and trusting to the expulsive 
 efforts of the patient, aided by the surgeon. The first of 
 29* 
 
342 REMOVAL OF FOREIGN BODIES 
 
 these proceedings does not concern us in this treatise ; we 
 refer our readers to works on practical surgery. 
 
 As regards the second course, it is very encouraging to find 
 that Nature does often accomplish the extrication of the 
 patient from circumstances of great peril ; but the surgeon 
 should be prepared to step in at any moment and perform 
 the operation, if suffocation be imminent, or if there seem to 
 be a probability that the longer sojourn of the foreign body 
 in its abnormal situation will cause the death of the patient 
 by the irritation, inflammation and exhaustion, which it 
 occasions. 
 
 If violent spasmodic cough be induced at any time, with- 
 out tending to cause the extrusion of the foreign body, but 
 serving only to wear out the patient's strength, it may be well 
 to try the effect of anaesthetic inhalation, to diminish the sen- 
 sibility of the air-passages, unless the substance be supposed 
 to be impacted at the glottis ; and even then, the inhalation 
 might have the effect of extricating it from its present position 
 by relaxing the muscular spasm. Again, if a violent fit of 
 coughing be induced, the patient should be inverted, and at 
 the same time struck smartly between his shoulders ; by these 
 simple means the air-passages have been relieved of their 
 troublesome occupant. 
 
 In the well known case of Mr. Brunei, the engineer of the 
 Thames tunnel, an apparatus was constructed, with a hinge 
 in its centre, upon which he was extended ; so that one end 
 being elevated, the other was depressed, and thus the patient 
 was inverted with as little suffering and fatigue to himself as 
 possible. Tracheotomy was performed by Sir B. Brodie, but 
 all efforts to remove the foreign body (a half sovereign), by 
 forceps introduced through the wound, were unsuccessful; 
 the wound, however, was kept open, and on the 16th day after 
 the operation, the patient being extended upon his platform, 
 by dint of striking his back sharply, the coin quitted the 
 trachea and fell into the mouth. 
 
 In conclusion, we may say with Mr. Fergusson, that such 
 examples as this, of which there are several on record, 
 " clearly indicate the propriety of trying the effect of change 
 of attitude in such cases ; for when we reflect how often per- 
 sons have died in consequence of the pressure of foreign 
 bodies in the air-passages, and how, too, occasionally such 
 
FROM THE NATURAL CANALS. 343 
 
 bodies have been spit up after months or years of almost con- 
 tinued coughing and suffering, it is not unreasonable to sup- 
 pose that such a change of attitude, and some such additional 
 measures as were resorted to by the gentlemen who conducted 
 the treatment of the instances above referred to, might have 
 saved many lives." 
 
 For farther details on this important subject, we refer to 
 Dr. Stokes's book on Diseases of the Chest ; to an interest- 
 ing paper by Dr. Davis, in the New York "American 
 Monthly," August, 1854; to Brodie's case, London Medical 
 Gazette, July, 1843 ; and to Mr. Porter's treatise on the 
 Larynx and Trachea. 
 
 6. Removal of foreign bodies from the Urethra. — 
 The urethra of both sexes is liable to be blocked up, more or 
 less effectually, by the lodgement therein of fragments of 
 calculi, portions of catheters or bougies which have been 
 broken during operations, or by foreign substances introduced 
 from malicious or otherwise improper motives. The seat of 
 the obstruction varies — it may exist at any point. The symp- 
 toms are, more or less complete retention of urine, local in- 
 flammation and pain. The precise point of obstruction can be 
 ascertained sometimes by manipulation of the exterior of the 
 canal ; more certainly by the introduction of a catheter or 
 bougie. 
 
 To remove the foreig§ body, it will be necessary sometimes 
 to resort to many expedients. The simplest is to introduce 
 the largest sized bougie or catheter down to the substance, 
 hoping that by this great dilatation of the canal in advance 
 of the latter, it may be disengaged and forced out by the 
 pressure of the urine from behind ; or the ingenious little in- 
 strument of Leroy d'Etiolles, should be passed behind the 
 impediment, then its arm thrown down, and both withdrawn ; 
 or, again, a long slender urethral forceps, such as is shown in 
 fig. 177, may be passed up to the obstacle, and efforts made 
 to grasp the latter with it, and if necessary the body may be 
 
 Fig. 177. 
 
344 
 
 REMOVAL OF FOREIGN BODIES 
 
 drilled or crushed at the same time. If the impediment be 
 located near the orifice of the urethra, it may perhaps be 
 seized with a pair of delicate dressing-forceps, or a loop of 
 wire, or be drawn out by means of a bent probe ; or the 
 canal may be dilated by the aid of Arnott's fluid dilator, or 
 Weiss' metallic dilator. (Fig. 178.) 
 
 Fig. 178. 
 
 If none of these experiments be # successful, nothing re- 
 mains save to cut down upon the foreign body and extract it 
 through the wound. This proceeding, however, will rarely 
 be necessary in the case of the female urethra, foreign bodies 
 being extricated from it with comparative facility, owing to 
 its straightness, shortness and capacity for dilatation. 
 
 7. Removal of foreign bodies from the Vagina, can 
 generally be accomplished without difficulty, if patience and 
 gentleness be used, together with a sufficiency of olive oil. 
 The passage is susceptible of very considerable dilatation, 
 and consequently it can rarely be necessary to divide its walls 
 with a cutting instrument ; the forceps and lever employed in 
 obstetric operations, may also be resorted to advantageously 
 in the case in consideration. 
 
 8. Removal of foreign bodies from the Rectum. — 
 Indigestible substances occasionally pass down from the upper 
 part of the alimentary canal, and become arrested in the 
 
FROM THE NATURAL CANALS. 345 
 
 rectum ; or from morbid sensibility of the mucous membrane, 
 and a resulting spasmodic stricture of the orifice of the gut, 
 feces accumulate in large masses, so as not only to exercise 
 a prejudicial influence upon digestion, but likewise to encroach 
 upon the other organs contained in the pelvis ; or, finally, 
 bodies, various in kind and size, may be introduced into the 
 canal from without. 
 
 To ascertain the nature, dimensions and situation of the 
 abnormal contents of the rectum, the fore-finger, well oiled, 
 should be passed into the bowel, or if this be not sufficiently 
 long, a metallic or gum-elastic bougie may be introduced. 
 
 If the intestine be occluded by a mass of hardened fecal 
 matter, it may be removed by throwing up an abundance of 
 tepid water from a syringe or gum-elastic bag, which will 
 soften the accumulation and wash it down little by little ; or 
 a scoop, a tea-spoon, or some similar instrument may be care- 
 fully employed to break up the concretion. 
 
 If the substance be solid, its removal may be effected by 
 means of a pair of lithotomy forceps, or a small lever, such as 
 obstetricians make use of. but reduced in size, or the scoop 
 employed to clear the bladder of fragments of sand after the 
 operation of lithotomy, (fig. 179.) or a loop of wire, intro- 
 duced beyond the foreign body and then drawn out. 
 
 Fl<J. 1 
 
 If the object be very large, it may be drilled to fragments 
 or crushed, as was done by Dr. Parker, of Canton, in the 
 case of the large glass goblet introduced into the rectum of a 
 Chinaman, reported by Dr. Ruschenberger in the American 
 Medical Journal, April, 1849 ; or the sphincter ani muscle 
 may be divided, and thus extraction be facilitated. 
 
346 TO DIMINISH PAIN DURING OPERATIONS, 
 
 OF THE MEANS OF DIMINISHING PAIN DURING 
 OPERATIONS. 
 
 Pain is at all times an inconvenience, and often a positive 
 evil both to the surgeon* and to the patient who is undergoing 
 an operation, since it interferes with the quiescence which is 
 essential to the performance of some operations and of im- 
 portance in all ; and, moreover, if it be very violent and pro- 
 tracted, it may produce such an impression upon the patient, 
 as shall impair the success of the operation, during its per- 
 formance and subsequently. Hence the very general custom 
 of administering to patients who are about to submit to surgi- 
 cal operations " some sweet, oblivious antidote,'' for the pur- 
 pose of calming their apprehensions of suffering and danger, 
 and to obtund, in a measure, their sensibility to pain, so that 
 the operation may be performed with less discomfort to them- 
 selves and with more facility to the surgeon, than might 
 otherwise be possible. 
 
 With this view, it has been usual to give a dose of one of 
 the preparations of opium, a short time previous to the opera- 
 tion, so that, when this is being performed, the patient may 
 be under the influence of the anodyne, not to such a degree 
 as shall completely stupify him, but so far as to be calmed 
 and tranquillized by it. The precise amount of opium neces- 
 sary to induce this condition, cannot be determined accurately 
 and for all cases, since different individuals are susceptible of 
 pain and of the influence of narcotics in very different degrees. 
 In ordinary cases, from forty to fifty drops of laudanum may 
 be administered to an adult, fifteen or twenty minutes before 
 the commencement of the operation, and this interval should 
 be passed as quietly as possible. 
 
 It has long been known that nitrous oxidje gas and the 
 vapours of many vegetable narcotics produce, when inhaled, 
 a degree of insensibility to physical suffering, and operations 
 have been performed upon persons thus affected; similar 
 results have been attained by the influence of animal mag- 
 netism. But the importance of these agents is slight, as 
 compared with that of more recent discoveries, — the influ- 
 ence of inhalations of the vapour of sulphuric ether and of 
 chloroform. 
 
TO DIMINISH PAIN DURING OPERATIONS. 347 
 
 The applicability of the vapour of Sulphuric Ether to the 
 purpose now under consideration, was first established by 
 Dr. W. T. Gr. Morton, of Boston, on the 30th September, 
 18-46. (See Report of the Mass. Gen. Hospital, Jan. 26th, 
 1848 — noticed in Am. Journ. of Med. Sc, April, 1848.) 
 The influence of Chloroform in producing similar effects, was 
 first determined by Professor Simpson, of Edinburgh. (See 
 Am. Journal of Pharmacy, Jan., 1848.) 
 
 Since their effects became generally known, these agents 
 have been employed to relieve pain in all sorts of operations, 
 and in very many diseases ; they have been administered, 
 too, by the ignorant as well as by the learned, and without 
 any discrimination of cases. It is not at all surprising, there- 
 fore, that in many instances injurious, and sometimes fatal, 
 consequences have ensued. It would be out of place to dis- 
 cuss fully, in this volume, all the circumstances connected 
 with the use of these agents. From the post-mortem exami- 
 nations which have been had of persons who have died appa- 
 rently in consequence of the inhalation of these vapours, it 
 would seem that they produce death by asphyxia, — the lungs, 
 the heart, the brain, having been found, in these cases, to be 
 much congested, and the blood dark-coloured and more fluid 
 than usual. The legitimate inference from these facts is, that 
 these vapours should not be resorted to in persons suffering 
 from congestion of these organs, or in whom any important 
 disease of these organs exists. And although it may be 
 admitted that a sufficient amount of testimony has been accu- 
 mulated to show that the inhalation of these substances is 
 not, under proper regulations and in well-discriminated cases, 
 attended with material danger, and that it is even a valuable 
 aid to the surgeon in many operations, it must also be 
 acknowledged, on the other hand, that we have facts sufficient 
 to prove that, without these precautions, and where the 
 amount of pain to be experienced is not very great, these 
 agents should not be used. It should be recollected that the 
 mere performance of an operation, with comparative freedom 
 from suffering to the patient and with satisfaction to the sur- 
 geon, is but one step towards the cure of the affection for 
 which the operation is performed : the treatment of the patient 
 subsequently is a matter of equal importance ; and with refer- 
 ence to this part of the surgeon's duty, any cause which dis- 
 
348 TO DIMINISH PAIN DURING OPERATIONS. 
 
 turbs the healthy play of important functions, whether it be 
 the impression of too intense pain, or of too powerful narcotic 
 agents, is to be regarded as an evil. 
 
 The vapour of chloroform is probably less safe than that 
 of sulphuric ether, although it acts more promptly and in 
 smaller quantity, — six or eight inspirations being sometimes 
 sufficient. No precise rule can be laid down as to the quan- 
 tity of the fluid, or the period of inhalation, necessary in 
 either case to produce insensibility to pain, children and per- 
 sons debilitated by disease, or other causes, being affected 
 much more speedily than those in opposite circumstances. 
 The vapour should be inhaled until the patient becomes insen- 
 sible to pain, unless some unpleasant effect be produced before 
 this condition is attained ; and this insensibility should be 
 prolonged, as may be necessary, by re-application of the 
 apparatus to the mouth, from time to time, as the influence 
 of previous inhalations passes off. 
 
 Many varieties of inhalers have been contrived for the 
 administration of these vapours, some of them complicated 
 and expensive ; the object of all, however, is the same, — to 
 allow atmospheric air to enter the lungs, loaded with the 
 vapour of ether, or of chloroform. This end may be secured 
 by using either of the inhalers illustrated by the accompany- 
 ing wood-cuts, as perfectly as by the more complex apparatus. 
 (Figs. 180 and 181.) " Figure 180 represents a double-necked 
 
 Fig. 180. 
 
 Fig. 181. 
 
TO DIMINISH PAIN DURING OPERATIONS. 349 
 
 bottle into which the liquid is introduced; through one neck 
 of the bottle, a glass tube passes, reaching below the level of 
 the liquid ; into the other a bent tube is inserted, through 
 which the patient breathes. The tubes must be tightly fixed 
 in the necks of the bottle, and the inspirations of the patient 
 must be made through the bent tube, his lips firmly compress- 
 ing the glass, the air expired from the lungs passing out 
 through the nostrils. Figure 181 shows a common wide- 
 mouthed bottle, having tightly fixed in the orifice a cork 
 through which the tubes enter the bottle as in the other case. 
 But it is not necessary to use any apparatus, — a sponge, or a 
 piece of linen, wet with the liquid and applied to the mouth, 
 being fully as efiicacious and more safe, inasmuch as a suffi- 
 cient supply of atmospheric air is more certainly secured. 
 The purest preparations only of ether and chloroform should 
 be employed. Before commencing the inhalation of the 
 vapour, the patient should be placed in the position most 
 convenient for the performance of the operation, whatever it 
 may be. 
 
 If any individual to whom these agents have been adminis- 
 tered should not revive spontaneously, stimulating applica- 
 tions should be made to the surface, among the best of which 
 is boiling water ; this should be placed in a cup covered with 
 a towel, and then the cup inverted upon the chest. (Amer. 
 Jour. Med. Sc, p. 556, April, 1848.) Artificial inspiration 
 should be resorted to, if other means fail. 
 
 The reader will find details as to the mode of preparing 
 ether and chloroform in the Am. Journ. of Pharmacy, for 
 Oct., 1847, and January and April, 1848. Numerous articles 
 relating to their employment are contained in the Am. Journ. 
 of Med. Sc. for 1847-8, to which reference should be made 
 by those who may be disposed to test the action of these 
 agents. Besides these publications, the author would recom- 
 mend attention to the report of Dr. Isaac Parrish, of this 
 city, to the College of Physicians, published in the " Transac- 
 tions" of that body; to the essays of Dr. Warren, Dr. Simp- 
 son, and Mr. Miller ; that of the latter being appended to the 
 last edition of his Principles of Surgery. 
 
 30 
 
APPENDIX OF FORMULA. 
 
 The following list of formulae will be found to contain 
 many which have been proved to be valuable in answering 
 the indications for which they are directed. 
 
 LOTIONS. 
 
 I. ASTRINGENT LOTIONS. 
 
 1. Wash for secondary venereal ulcers, particularly of the throat — 
 
 R. Cupri sulphatis, 9ij, 
 Pulv. cinchonae, §ss, 
 Aquae fluvialis, f^viij. 
 M. ft. lot.— Dr. Physick. 
 
 2. R. Tinct. myrrhae, fjj — f§ss, 
 Aquae fluvial., f^viij. 
 M. ft. lot. 
 
 3. R. Creasotae, gtts. xx — gtts. 1, 
 
 Aquae fluvial., f^vj. 
 M. ft. lot. 
 
 4. R. Tannin 9j, 
 
 Spt. vini gallici., f§ss, 
 Mist. Camphorae, fgvss. 
 M. ft. lot. — For salivation, spongy gums, &c. 
 
 5. R. Sodii chlorid., (sol.) 
 
 Tinct. myrrhae, aa f^ss, 
 Aquae fluvial., fgiv. 
 M. ft. lot. — Uses the same as the last. 
 
 (350) 
 
APPENDIX. 351 
 
 II. STIMULATING LOTIONS. 
 
 6. R. Acidi nitrici, f3J — f3ij> 
 
 Aquas fluvial., f 3 viij, 
 Aquas rosae, f§j. 
 M. ft. lot. 
 
 7. R. Ammoniae muriat., 3j — Jij ; 
 
 Aquae fluvial., f 3 viij, 
 Tinct. opii, f3J. 
 M. ft. lot. — For painful indolent ulcers. 
 
 8. R. Acid, cyanhydrici, fjj? 
 
 Mucilag. acacias, f 3 viij, 
 M. ft. lot. — To relieve the itching in prurigo. 
 
 9. R. Hydrarg. chlorid. mit., 3ij, 
 
 Liquoris calcis, g viij . 
 M. ft. lot. — " The black wash." 
 
 10. R. Hydrarg. bi-chlorid., grs. x — 9j, 
 
 Liquoris calcis, g viij . 
 M. ft. lot. 
 
 11. R. Spt. vini rectificati, 
 
 Tinct. camphoras, aa f^iijss, 
 
 Liquor, plumbi, fgj. 
 M. ft. lot. — To be rubbed upon the part several times daily, oc- 
 casionally suspending it. For indolent fibrous tumours of the 
 breast. — Brodie. 
 
 12. R. Iodini9j, 
 
 Potassii iodid., 3ss, 
 Aquae fluvial, f § viij 
 M. ft. lot. — For application to scrofulous and other indolent 
 tumours. 
 
 III. EVAPORATING AND REFRIGERANT LOTIONS. 
 
 13. R. Ammoniae mur., Jj, 
 Potassae nitrat., 3ij; 
 
352 APPENDIX. 
 
 Vinegar, fgj, 
 Aquae fluvial., fgx. 
 M. ft. lot. — Schmucker's frigorific mixture. 
 
 14. R. Athens sulphuric. 
 
 Alcohol, 
 
 Aquae plumbi, aa f^j. 
 M. ft. lot. 
 
 15. R. Sodii chloridi, 
 
 Potassae nitratis, 
 Ammoniae muriat, aa 3ij> 
 Aquae fluvial., q. s. ad mist, solvend. 
 M. ft. lot.— Druitt. 
 
 16. R. Spt. viiii rectif., f g j, 
 
 Aquae fluvial., f^vij. 
 M. ft. lot. 
 
 CERATES. 
 
 17. R. Resinae, gj, 
 
 Cer. flav., §ij, 
 Adipis, §v. 
 M. ft. cerat. — For burns. — Physick. 
 
 18. R. Cerat. plumbi, s'acet., 
 
 Cerat. simplicis, aa gss, 
 Hydrarg. chlor. mit., 
 Pulv. opii, aa 3J» 
 M. ft. cerat. — For burns, painful ulcers, &c. 
 
 19. R. Unguent, hydrarg. nit., 3j, 
 
 Cerat. simplicis, 3 n j — ^ss. 
 M. ft. cerat. — For sore nipples, &c. 
 
 20. R. Pulv. camphorae, 9j — 3j, 
 
 Cerat. simpl., §j. 
 M. ft. cerat. — A stimulating salve. 
 
 21. R. Hydrarg. chlorid. mit., grs. vj, 
 
 Pulv. opii, grs. x, 
 Cerat. simpl., 3ij. 
 M. ft. cerat. — For indurated chancres. 
 
APPENDIX, 353 
 
 22. R. Acid, hydrocyanic, gtts. xx, 
 
 Cerat. sirnpl., gij. 
 M. ft. cerat. — For papular eruptions attended with itching. 
 
 23. R. Creosotae, gtts. xx, 
 
 Cerat. simpl., gij, 
 Zinci oxid., jj. 
 M. ft. cerat. — For scaly eruptions. 
 
 OINTMENTS. 
 
 24. R. Potassae carb., gss, 
 
 Aquae rosae, fgj, 
 Hydrarg. sulph. rubr., gjj 
 01. bergam., f^ss, 
 Fl. sulphuris, 
 Adipis, aa §ix. 
 M. ft. unguent. — Batenian's aromatic sulphur ointment, for 
 itch, &c. 
 
 25. R. Picis liquid, f|j, 
 
 Salt butter, gij, 
 Melt together, and add of 
 Common potashes, 3j, 
 Grafe's itch ointment. 
 
 26. R. Unguent, hydrarg. fort., §j, 
 
 Antimon. et potass, tart., 3j, 
 Iodini, grs. x — xv. 
 M. ft. unguent. — To be rubbed upon the part daily, until it pus- 
 tulates. For chronic glandular tumours, old indurated buboes, &c. — 
 H. Johnson. 
 
 27. R. Morphise acetat. grs., vj, 
 
 Pulv. gallae, 3j, 
 Unguent, stramonii, gj. 
 M. ft. unguent. — For haemorrhoids. — Harlan. 
 
 28. R. Sodae bi-carb., 3j, 
 
 Adipis, gj, 
 Pulv. opii, 9j. 
 M. ft. unguent. — For lichen, prurigo, &c. 
 30* 
 
354 APPENDIX. 
 
 LINIMENTS. 
 
 29. R. 01. tiglii., fjss, 
 
 01. cinnamomi, f3J, 
 01. olivae, fgj, 
 Lin. cantharid, f§ij. 
 M. ft. liniment. — ^for neuralgia. — JPro£ Jackson. 
 
 30. R. 01. olivaa, 
 
 Alcohol aa, fgj, 
 Tr. camphorae, fgss, 
 Aquae ammonias, f^j. 
 M. ft. liniment. — For indurated breasts. 
 
 31. R. 01. terebinth, 
 
 01. lini aa Oss, 
 01. succini, 
 01. juniperi aa f^iv, 
 Petrol. Barbadensis, § iij, 
 Petrol. American, gj> 
 M.— "The British Oil." To be used diluted with olive oil, or 
 lard, as a stimulating liniment, or ointment. 
 
INDEX. 
 
 Abdomen, "bandage for, 93. 
 Acids, counter irritation by, 273. 
 
 cauterization by, 285. 
 Actual cautery, 284. 
 Acupuncture, 278. 
 Adhesive plasters, 34. 
 .Ether 347. 
 
 Air-passages, catheterism of, 326. 
 Ammonia, as a counter-irritant, 272. 
 Anaesthetics, 342. 
 Anchylosis, relief of partial, 233. 
 Aneurism-needles, 297. 
 Apparatus for treatment of fractures, 108. 
 
 dislocations, 210. 
 
 the immovable, of Dieffenbach, 115. 
 Laugier, 114. 
 Larrey, 112. 
 Seutin, 113. 
 Velpeau, 114. 
 
 of dressings, 29. 
 
 of instruments, 26. 
 Arteries, cauterization of, 284. 
 
 compression of, 286. 
 
 ligature of, 294. 
 
 plugging of, 293. 
 
 torsion of, 204. 
 Arteriotomy, 257. 
 Artery, wound of, in bleeding, 255. 
 
 Bandages, and their application, 65, 
 Bandages, compound, 72. 
 
 Bandage, the simple, or the roller^ 65. 
 
 winding of the, 66. 
 
 application of the, 66. 
 
 the circular, 67. 
 
 the compressing, 70. 
 
 the crossed, 69. 
 
 the dividing, 70. 
 
 the expelling, 71. 
 
 the invaginated, 72. 
 
 the knotted, 71. 
 
 the laced, 74. 
 
 the recurrent, 70. 
 
 the retaining, 71. 
 
 the spica, 70. 
 
 the spiral, 67. 
 
 the spiral reversed, 68. 
 
 the split, or tailed, 73. 
 
 the sheath, 74. 
 
 the suspensory, 74. 
 Bandaging, Mayor's system of, 75. 
 Barton's bandage for lower jaw, 123. 
 
 bran-dressing, 206. 
 
 fracture of the radius, 151. 
 Baynton's treatment of ulcers, 36. 
 Bathing, 57. 
 
 Bauden's dry suture, 308. 
 Bell's inclined plane, 166. 
 Belloc's instrument for epistaxis, 300. 
 Bleeding, operations for general, 241. 
 for topical, 258. 
 
 from the ankle, 250. 
 
 from the arm, 242. 
 
 (355) 
 
356 
 
 INDEX. 
 
 Bleeding, from the external jugular, 251. 
 
 from the hand, 250. 
 
 from the temporal artery, 257. 
 
 accidents attending, 253. 
 Blisters, 268. 
 
 Boyer's apparatus for fracture of thigh, 180. 
 Bond's splint for fractured radius, 154. 
 
 gullet-forceps, 338. 
 
 gullet-hook, 338. 
 Bran-dressing, 206. 
 Breast, handages for the, 90, 91. 
 Brown's bandage for fracture of clavicle, 131. 
 
 Canquoin's caustic, 275. 
 Carpus, bandages for the, 102. 
 
 dislocations of the, 221. 
 
 fractures of, 159. 
 Catheterism of the air passages, 326. 
 
 of the eustachian tube, 315. 
 
 of the lachrymal passages, 312. 
 
 of the large intestine, 325. 
 
 of the oesophagus, 316. 
 
 of the urethra of the female, 324. 
 of the male, 318. 
 Cerates, 47, 352. 
 Charpie, 29. 
 
 Chest, bandages for the, 88. 
 Chin, bandages for the, 81. 
 Chlorides of lime and soda, 62. 
 Chloride of zinc, 275. 
 Chloroform, 347. 
 Clavicle, dislocations of the, 213. 
 
 fractures of the, 128. 
 Clinical frame, 119. 
 Clove-hitch, 222. 
 Collodion, 38. 
 
 Colles' fracture of the radius, 151. 
 Compresses, 32. 
 Condyles of humerus, fracture of, 142. 
 
 os femoris, fracture of, 186. 
 Coronoid process of ulna, fracture of, 155. 
 Cotton, 31. 
 Croton oil, 271. 
 Cupping, 258. 
 Cutaneous irritation, 266. 
 by rubefacients, 266. 
 by suppurative agents, 273. 
 
 by vesicants, 268. 
 
 Demi-gauntlet, 102. 
 
 Desault's apparatus for fracture of olecranon, 
 158. 
 of patella, 192. 
 
 Desault's apparatus for fractures of the thigh, 
 
 172. 
 Disinfecting agents, 62. 
 Dislocations of bones of the foot, 231. 
 
 hand, 221. 
 
 lower extremity, 224. 
 
 trunk, 213. 
 
 upper extremity, 215. 
 
 clavicle, 213. 
 
 lower jaw, 212. 
 
 compound, 232. 
 Douche, 54. 
 Dressing, general rules for, 49. 
 
 apparatus of, 29. 
 
 instruments, 25. 
 
 Eighteen-tailed bandage, 104. 
 Electric-moxa, 278. 
 Electro-puncture, 279. 
 Epididymitis, Fricke's treatment of, 37. 
 Eustachian tube, catheterism of, 315. 
 Extending band, adhesive strips for, 177. 
 
 gaiter for, 174. 
 
 handkerchief for, 177. 
 
 Face, bandages for, 81. 
 Femur, fractures of, 163. 
 Fibula, dislocations of, 230. 
 
 fractures of, 204. 
 Fingers, bandages for, 102. 
 
 dislocations of, 221. 
 
 fractures of, 160. 
 Fore-arm, bandages for, 100. 
 
 dislocations of, 218. 
 
 fractures of, 148. 
 Foreign bodies, removal of, 333. 
 
 from eye, 333. 
 
 from nose, 334. 
 
 from ear, 335. 
 
 from pharynx and oesophagus, 336. 
 
 from larynx and trachea, 340. 
 
 from urethra, 343. 
 
 from vagina, 344. 
 
 from rectum, 344. 
 Fox's clavicle apparatus, 129. 
 Fractures, general considerations on, 108. 
 
 immovable apparatus for, 112. 
 
 hyponarthecia for, 115. 
 
 Jenk's apparatus for, 120. 
 
 of the bones of the face, 121. 
 of the foot, 208. 
 of the fore-arm, 148. 
 of the hand, 159. 
 
INDEX. 
 
 357 
 
 Fractures of the bones of the head, 121. 
 
 of the leg, 197. 
 
 of the pelvis, 126. 
 
 of the shoulder, 128. 
 
 of the trunk, 124. 
 
 of the vertebral column, 124. 
 of the clavicle, 128. 
 of the fibula, 204. 
 of the humerus, 138. 
 of the lower jaw, 121. 
 of the os calcis, 208. 
 of the os femoris, 163. 
 of the patella, 190. 
 of the radius, 151. 
 of the ribs, 125. 
 of the scapula, 133. 
 of the sternum, 125. 
 
 of the tibia, 204. 
 
 of the ulna, 155. 
 Fracture-bed, 117. 
 Fracture-box, 198. 
 Fumigations, 61. 
 
 Gaiter, laced, 107. 
 
 for extension in fracture of thigh, 174. 
 Gauntlet, 102. 
 
 Gerdy's bandage for fracture of patella, 192. 
 Gibson's bandage for fracture of lower jaw, 
 
 122. 
 Gibson's modification of Hagedorn's splint, 
 
 183. 
 Good's splint, 155. 
 Granville's lotions, 272. 
 Groin, bandages for the, 94. 
 Guillou's novel method of treating fracture 
 
 of clavicle, 132. 
 Gun-cotton, a solution of, for adhesive strips, 
 
 304. 
 
 Hand, bandages for, 102. 
 
 dislocations of bones of, 221. 
 
 fractures of bones of, 159. 
 Hare-lip, twisted suture for, 307. 
 Head, bandages for, 77. 
 
 fractures of bones of, 121. 
 Haemorrhage, arrest of, 282. 
 
 by astringents, 282. 
 
 by cauterization, 284. 
 
 by cold applications, 282. 
 
 by the ligature, 294. 
 
 by matico, 283. 
 
 by plugging, 293. 
 
 Haemorrhage, arrest of, by pressure with the 
 
 hand, 286. 
 Haemorrhage, arrest of, by torsion, 294. 
 
 by the tourniquet, 288. 
 
 from the nose, 299. 
 
 from the rectum, 301. 
 Hip-joint, dislocations of, 224. 
 Humerus, dislocations of, 215. 
 
 fractures of, 138. 
 
 Immovable apparatus for fractures, 112. 
 Inclined plane for fractures of the thigh, 
 166. 
 
 for fractures of the leg, 202. 
 Injections, modes of administering, 327. 
 
 of lachrymal duct, 331. 
 
 by the rectum, 327. 
 
 of the urethra, 329. 
 
 of the uterus, 329. 
 
 of the vagina, 329. 
 Instruments for the pocket-case, 25. 
 Invaginated bandage for the lip, 84. 
 
 for longitudinal wounds, 309. 
 
 for transverse wounds, 310. 
 Irrigation, 52. 
 Isinglass-plaster, 38. 
 Issues, 276. 
 
 Jarvis's Adjustor, 219. 
 Jaw, bandages for, 79. 
 
 dislocations of lower, 212. 
 
 fractures of lower, 121. 
 Jenks's apparatus, 120. 
 Jorg's apparatus for wry-neck, 87. 
 Jugular vein, bleeding from, 251. 
 Junks, treatment of fractures of the leg with, 
 
 197. 
 Junk-bags for fracture of thigh, 174, 
 
 Knee, bandages for the, 105. 
 dislocations of the, 230. 
 fractures of the, 190. 
 
 Lachrymal duct, injection of, 331. 
 Lancets for bleeding, 245. 
 Leeches, artificial, 265. 
 Leeches, preservation of, 263. 
 Leeching, 261. 
 Leg, bandages for, 106. 
 
 dislocations of, 229. 
 
 fractures of, 197. 
 
358 
 
 INDEX. 
 
 Ligature for the arrest of hemorrhage, 294. 
 Liniments, 47, 354. 
 Lint, preparation and uses of, 29. 
 Lotions, 46, 350. 
 
 M. Le Doyen's disinfectant, 63. 
 Mayor and Sauter, clinical frame of, 119. 
 hyponarthecia for the arm of, 150. 
 for the leg of, 206. 
 Moxa, preparation and application of the, 
 275. 
 
 Neck and axilla, bandages for the, 86, 90, 99. 
 Nitrate of silver, 274. 
 Nose, bandages for the, 82. 
 
 fracture of the bones of the, 121. 
 Nostrils, arrest of bleeding from the, 299. 
 
 Ointments, 47, 353. 
 
 Patella, dislocations of the, 229. 
 fractures of the, 190. 
 
 Penis, bandages for the, 98, 324. 
 
 Pennsylvania Hospital, treatment of frac- 
 tures of clavicle in the, 130. 
 
 Pennsylvania Hospital, treatment of frac- 
 tures of thigh in the, 173. 
 
 Pennsylvania Hospital, treatment of frac- 
 ture of leg in the, 197. 
 
 Pelvis, bandages for, 94. 
 dislocations of, 213. 
 fractures of, 126. 
 
 Phlebotomy, 241. 
 
 Physick's splints for fracture of thigh, 173. 
 
 Plasters 38. 
 
 Potassa, 274. 
 
 Poultices, 39. 
 
 Pulleys for reduction of dislocations, 217. 
 
 Purse of Pibrac for the tongue, 84. 
 
 Radius, dislocations of the, 220. 
 
 fractures of the, 151. 
 Ribs, dislocations of the, 213. 
 
 fractures of the, 125. 
 Roller, the, 65. 
 
 Sailor's knot, 296. 
 
 Scapula, fractures of the, 133. 
 
 Scultetus's bandage, 73. 
 Setons, 276. 
 Seton-needle, 276. 
 Sinapisms, 267. 
 Spanish windlass, 290. 
 Splints of Amesbury, 169, 184. 
 
 Bache, 179. 
 
 Barton, 152. 
 
 Bond, 154. 
 
 Boyer, 180. 
 
 Desault, 158, 173, 192. 
 
 Dupuytren, 151, 205. 
 
 Fergusson, 201. 
 
 Gibson, 183. 
 
 Good, 155. 
 
 Hagedorn, 183. 
 
 Hays, 155. 
 
 Hutchinson, 201. 
 
 Kimball, 182. 
 
 Liston, 181, 203. 
 
 Lonsdale, 124, 140, 149, 193. 
 
 Mayo, 146. 
 
 Mutter, 233. 
 
 Nelaton, 153. 
 
 Neville, 198. 
 
 Physick, 173. 
 
 Smith, N. R., 171. 
 Sponge, preparation and uses of the, 47. 
 Sponge-tent, 34. 
 Spongio-Piline, 45. 
 Sternum, fractures of the, 125. 
 Stomach, catheterism of the, 316. 
 Suture, the continued, 305. 
 
 the dry, 308. 
 
 the interrupted, 305. 
 
 the quilled, 306. 
 
 the twisted, 307. 
 
 Tarsus, dislocations of the bones of, 231. 
 
 fractures of the bones of, 208. 
 Tartar emetic, 273. 
 Torsion, 294. 
 Tourniquet, 288. 
 Tow, 31. 
 
 Urethra, catheterism of the, 318. 
 injections of the, 329. 
 
 Vaccination, 280. 
 
INDEX. 
 
 359 
 
 Vaccine virus, preservation of, 280. 
 Vagina, injections by the, 329. 
 Vaponrs of ether and chloroform, 346. 
 Venesection, 241. 
 
 Veins of the arm, anatomy of the, 242. 
 Vertebrae, fractures of the, 124. 
 
 dislocations of the, 213. 
 Vesicants, 268. 
 Vidal's spring-suture, 309. 
 
 Vienna paste, 274. 
 
 Wounds, means of promoting the closure of, 
 
 303. 
 dressing of, 302. 
 Water, applications of, to surgical purposes, 
 
 52. 
 
 Appendix of formulae, 350. 
 
 THE END. 
 
347 7 
 

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