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Title: The essentials of bandaging
        including the management of fractures and dislocations, with directions for using other surgical apparatus

Author: Berkeley Hill

Release date: March 21, 2023 [eBook #70330]

Language: English

Original publication: United Kingdom: James Walton

Credits: Bob Taylor, deaurider and the Online Distributed Proofreading Team at https://www.pgdp.net (This file was produced from images generously made available by The Internet Archive)


*** START OF THE PROJECT GUTENBERG EBOOK THE ESSENTIALS OF BANDAGING ***





  Transcriber’s Note
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  THE

  ESSENTIALS OF BANDAGING;

  INCLUDING THE

  MANAGEMENT OF FRACTURES AND
  DISLOCATIONS,

  WITH DIRECTIONS FOR USING OTHER SURGICAL
  APPARATUS.

  ILLUSTRATED BY 122 ENGRAVINGS ON WOOD.

  BY

  BERKELEY HILL, M.B. LOND., F.R.C.S.,

  Instructor in Bandaging, &c., in University College, Assistant
  Surgeon to University College Hospital, and Surgeon to Out-patients
  at the Lock Hospital.

  _SECOND EDITION, REVISED AND ENLARGED._

  LONDON:

  JAMES WALTON,

  BOOKSELLER AND PUBLISHER TO UNIVERSITY COLLEGE,
  137, GOWER STREET.

  1869.




  LONDON:
  BRADBURY, EVANS, AND CO., PRINTERS, WHITEFRIARS.




PREFACE TO THE SECOND EDITION.


In laying a Second Edition before the public, I have decided not
to alter the scope of this little work, but simply to endeavour
to increase its usefulness, by remedying omissions, and by adding
new instructions where such appeared desirable. I have ventured to
insert, as an Appendix, lists of the preparations requisite for the
sick room and for the operating room before the ordinary operations
of surgery are performed; also, lists of the instruments and
appliances requisite, or possibly useful, in performing forty-nine
different operations on the human body. It is hoped that, by giving
the surgeon a list, such as most operators draw up in manuscript for
their private use, whereby they may check their preparations before
proceeding to operate, some trouble may be saved.

  14, WEYMOUTH STREET, W.
  _November, 1869_.




PREFACE TO THE FIRST EDITION.


The descriptions and directions for using surgical apparatus in the
following pages, are those originally prepared for oral delivery in
a short course of practical lessons in bandaging and the application
of surgical apparatus, given by me in University College Hospital. No
attempt is made to include all efficient modes of treating surgical
injuries: it is merely proposed to supply the student or practitioner
with instructions by which he may refresh his memory when about to
employ the ordinary surgical appliances.

The drawings are by Mr. R. W. Sherwin, who has taken much pains to
furnish exact representations of the apparatus, as it was applied by
myself for his delineation. The directions for giving chloroform have
had the advantage of Mr. Clover’s revision before publication.

  14, WEYMOUTH STREET, W.
  _October, 1867_.




CONTENTS.


  CHAPTER I.

  BANDAGING.

                                                                  PAGE

  _General rules._—Different materials of bandages.—Position of
  the operator.—Mode of holding the bandage.—Varieties
  of turns; the simple spiral; the reverse; the figure of 8.       1-3

  _Bandaging the head._—The common roller.—The knotted
  bandage.—The Capelline bandage.—The shawl cap.—The
  four-tail bandage.—Fastening ice bladders to the head.—Compressing
  the jugular vein                                                 3-8

  _Bandaging the trunk._—The breast.—The groin.—After operation
  for hernia.—For tapping the belly.—The T-bandage.—The
  strait jacket.—Manacles for delirious patients.—To
  suspend the testicles                                           8-13

  _Bandaging the upper extremity._—The fingers.—The thumb.—The
  hand.—The fore-arm.—The elbow.—The shoulder.—The
  axilla.—Wound of the palmar arch.—Bleeding at
  the elbow                                                      14-20

  _Bandaging the lower extremity._—The foot.—The leg.—The
  thigh.—The heel.—The toe.—The knee.—A stump.—Extending
  a stump.—The many-tailed bandage.—Elastic
  socks                                                          21-24


  CHAPTER II.

  STRAPPING.

  _General rules._—Strapping the breast.—The testes.—Joints.—Ulcerated
  legs.—Scott’s mercurial dressing                               25-29


  CHAPTER III.

  TREATMENT OF FRACTURES.

  _The head and trunk._—Of the lower jaw; by the external splint
  and bandage; by interdental splints, Morell Lavallée’s
  plan; fitting a cap to the teeth.—Of the ribs; by
  plaster; by a body roller.—Of the pelvis                       30-37

  _The upper extremity._—Of metacarpal bones; by a gutta-percha
  glove; by a ball of tow.—Of phalanges.—Of the lower
  end of the radius; by the pistol splint; by the gutta-percha
  gauntlet.—Of both bones of the forearm.—Of the
  olecranon; by figures of 8 and an inside splint; by
  Hamilton’s plan.—Of the humerus near the elbow; by
  lateral hollowed splints; by a gutta-percha =L=-shaped
  splint.—Of the shaft of the humerus.—Of the anatomical
  or surgical neck, and of the great tuberosity of the humerus,
  by a cap for the shoulder.—Of the acromion.—Of the
  clavicle; by an axillary pad and elevation of the elbow; by
  a figure of 8 behind the back; the American ring pad           37-59

  _The lower extremity._—Rupture of the tendo Achillis.—Separation
  of the epiphysis of the os calcis.—Fracture of the
  fibula, by Dupuytren’s splint.—Of the tibia, by
  McIntyre’s splint; slinging the splint; elevating it on a
  block.—Transverse fracture of the tibia, by lateral
  splints; in the flexed position.—Of the patella; by back
  splint and figures of 8; by Malgaigne’s hooks; by strapping
  plaster and stick.—Of the shaft of the femur; by
  Liston’s method of using the long splint; by using elastic
  extension; Coxeter’s elastic perineal band; elastic stirrup.
  By continuous extension with the limb bent; tendency to
  angular union; double incline planes; slinging the
  double incline planes in fracture of the neck of the femur;
  by continuous extension of weight and pulley                   59-80

  The starch bandage.—The plaster of paris bandage.—Plaster
  of paris splint.—Gum and chalk and other stiffening mixtures.
  —Sand-bags.—Cradles; Salter’s swing cradle                     81-90

  Leather splints; Splint for the hip                            90-94


  CHAPTER IV.

  DISLOCATIONS.

  _General rules._—Of the lower jaw.—Of the clavicle.—Of the
  shoulder; signs of dislocation into the axilla; when beneath
  the clavicle; when behind the scapula. Modes of reduction;
  by the heel in the axilla; by simple extension. The
  clove-hitch knot.—Of the elbow, signs when both bones
  go backwards; distinctions between dislocation and
  fracture near the elbow; the mode of reduction by the
  knee inside the fore-arm; by extension at the wrist.—Of
  the radius, only, by extension at the wrist.—Of the thumb
  and fingers; handle for commanding the phalanx.—At
  the hip; signs of dislocation backwards, reduction by
  extension; by manipulation or leverage; signs of dislocation
  downwards, mode of reduction; signs of dislocation
  on to the pubes, mode of reduction.—Of the knee;
  incomplete, lateral, and posterior; mode of reduction.—Of
  the patella, mode of reduction.—Of the foot, mode of
  reduction                                                     94-110

  Scarpa’s shoes.—Varieties of talipes; equinus, varus, valgus;
  points to be attended to in fitting the shoe.—Casting in
  plaster of paris                                             111-114


  CHAPTER V.

  MISCELLANEOUS.

  The Hair suture.—The eye douche, drops for the eye.—Syringing
  the ears.—Epistaxis; Ice-cold injection; Plugging
  the nares; Belloc’s sound.—Drawing teeth; varieties
  of forceps; extracting incisors and canines, bicuspids,
  upper molars, lower molars, wisdom molars, roots; the
  elevator.—Stopping bleeding after extraction.—Sore nipples;
  nipple shields.—Plugging the vagina; Kite’s tail
  plug for vagina.—Injecting the urethra. Catheters,
  silver; different kinds of flexible catheters and bougies;
  conformation of the urethra.—Passing catheters and
  bougies; difficulties in doing so; passing the female
  catheter.—Washing out the bladder.—Tying in catheters.—Position
  for lithotomy.—Bed-sores, applications to
  prevent the formation of bed-sores; the floating bed; the
  water-cushion.—The stomach-pump, when used to empty
  the stomach or to inject food.—Transfusion of blood;
  precautions; mode of using the apparatus.—Tourniquets;
  the Ring; Petit’s; Signoroni’s; Carte’s; Lister’s; the
  make-shift.—Mercurial fumigation; general; local.—Hot
  air baths.—Vapour baths.—Sick carriage.—Cupping.—Junod’s
  boot.—Leeches.—Stopping leech bites.—Tents.—Setons.—Drainage
  tubes.—Issues.—Trusses, requirements
  of, inguinal, femoral, umbilical, Salmon and Ody’s.—Cauteries,
  iron; gas; galvanic. Caustics.—Vesicants,
  mustard, cantharides, iodine.—Corrigan’s hammer.—Poultices
  and fomentations.—Lister’s mode of dressing
  with carbolic acid.—Irrigation; Esmarch’s irrigator.—Administration
  of chloroform, precautions; dangers;
  methods; Clover’s inhaler.—Artificial respiration.—Local
  anæsthesia.—Ether spray, pulverised fluids.—Chloroform
  vapour to the uterus.—Subcutaneous injection.—Collodion.
  —Vaccination                                                 116-192

  LIST OF APPLIANCES FOR THE OPERATING ROOM AND THE SICK
  ROOM.—LIST OF SEDATIVES AND RESTORATIVES.—FOR
  THE ARREST OF HÆMORRHAGE                                     195-197

  LIST OF INSTRUMENTS EMPLOYED IN OPERATIONS—

  ON THE HEAD AND NECK.

  Trephining the skull.—Operations on the eye.—Hare-lip.—Resection
  of the jaw.—Excision of the tongue.—Cleft
  palate.—Excision of tonsils.—Laryngotomy.—Tracheotomy        198-202


  ON THE TRUNK.

  Removal of breast or tumours.—Nævus.—Tapping the pleura.—Tapping
  the belly.—Colotomy.—Ovariotomy.—Cæsarian
  section.—Strangulated hernia.—Radical cure of
  hernia.—Hæmorrhoids.—Fistula in ano.—Cleft perinæum.—Extirpation
  of the cervix uteri.—Amputation of
  the penis.—Circumcision.—Excision of testis.—Tapping
  a hydrocele.—Vesico-vaginal fistula.—Retention of urine.—External
  urethrotomy.—Lithotomy.—Lithotrity.—For
  removing foreign bodies from the urethra and bladder         203-210


  ON THE LIMBS.

  Ligature of the larger arteries.—Resections: of the head of the
  humerus, the elbow, the hip, the knee.—Removal of
  necrosed bone.—Amputations: at the shoulder-joint;
  arm; fore-arm and wrist; metacarpus; hip; thigh
  and leg; Syme and Chopart’s operation; metatarsus and
  toes                                                         211-215




THE

ESSENTIALS OF BANDAGING,

&c.




CHAPTER I.

BANDAGING.


GENERAL RULES.—Ordinary bandages are strips of unbleached calico
6 or 8 yards long, having a breadth of ¾ inch for the fingers and
toes, 2¼ inches for the head and upper limb, 3 inches for the lower
limb, and 6 inches for the body. These, when tightly rolled for use,
are termed rollers. Besides these rollers for general use there are
special bandages, such as rollers of muslin for using with plaster
of paris, of stocking-webbing when elasticity is needed; four- and
many-tailed bandages for particular fractures, &c. Messrs. J. & J.
Cash, the cambric frilling makers of Coventry, now make a very firm
light bandage of unbleached cambric woven in the necessary widths
and lengths for use; these are very cool and pleasant, and a decided
improvement on the ordinary calico strips generally used.

_Position of the Operator._—He should place himself opposite his
patient, not at the side of the limb to be bandaged; the limb too
should be bent to the position it will occupy when the bandage is
completed.

Before applying any kind of apparatus, the surgeon should see that
the limb is carefully washed and dried.

_How to hold a Roller._—When applying a roller it is best to begin
by placing the outer surface of the roller next the skin (see fig.
1, page 3), for it then unwinds more readily, and the first turns
are more easily secured; moreover the bandage should be carried from
the inner side of the limb _by the front_ to the outer side, for
the muscles are thus more firmly and pleasantly confined than by
turns passing in the opposite direction; of course this observation
supposes the hand and forearm to be in their usual position of
semi-pronation.

_Varieties of Turns._—In carrying a bandage up a limb, it is
necessary, in order to support the parts evenly, to employ a
combination of three different turns. The _simple spiral_, _reverse_,
and the _figure of 8_.

The _simple spiral_ turn is used only where the circumference of the
part increases slightly, as the wrist; but when the limb enlarges too
fast to allow the fresh turn to overlap the previous one regularly,
the turn must be interrupted, and the bandage brought back again by
reverse, or by figure of 8.

To _reverse_ the bandage, the thumb of the unoccupied hand is placed
on the lower border of the bandage while the roller is turned over in
the other, and then passed downwards to overlap and fix the previous
turn evenly. At the moment of reversing, the bandage should be held
_quite slack_, and not unrolled more than is necessary to make the
reverse. All the reverses must be carried one above the other along
the outer side of the limb, and only employed where really necessary.

_Figures of 8_ are made, as their name implies, by passing the roller
alternately upwards and downwards as it enwraps the limb (see fig.
1). They are adopted where the enlargement is too great and irregular
for reverses to sit evenly, over the ankle and elbow joint for
instance.

[Illustration: Fig. 1.—Figure of 8 turn.]


THE HEAD.

=Bandages for the Head.=—A roller is commonly applied in three
different ways to the head. 1st. For keeping simple dressings in
place.

_Apparatus._—1. A roller 2 inches wide, and of the usual length.

2. Some pins.

A turn is first carried round the head, over the brows and below
the occipital protuberance, and fastened by a pin; this being done,
the roller is carried across the dressing, and getting into the
line of the first turn, is passed round the head again, then across
the dressing, and round the head by horizontal and oblique turns
alternately, the former to fix the latter, and prevent their slipping
off the dressing (see fig. 2). In the figure the oblique turns have
been doubled, and would fix dressings on each side of the head.

=Knotted Bandage.=—This is used when pressure on the superficial
temporal artery is required.

_Apparatus._—1. A roller 8 yards long, 2 inches wide, one-third being
rolled into one head, the rest into another head.

2. Some lint.

3. A piece of a wine cork one-third of an inch thick.

4. Needle, thread, and pins.

[Illustration:

  Fig. 2.—Bandage for retaining dressings in position, showing two
  sets of oblique turns.
]

The cork is folded in a double thickness of lint; over this are
placed six or eight more folds of lint of gradually increasing size,
and the whole are kept in shape by a stitch passed through them and
through the cork. This forms a _graduated compress_, and is then laid
on the wound small end downwards.

One head of the roller is taken in each hand, its middle laid over
the compress on the injured temple, say the right; the ends are
carried round the head, one just above the eyebrows to the left
temple, and the other backwards below the occipital protuberance, to
the same point; the ends are then crossed and changed from one hand
to the other to be brought to the wounded temple. Here they are again
tightly crossed, one end being carried under the chin and by the left
side to the vertex, there meeting the other end, which has passed
over the head, in the opposite direction (see fig. 3); at the right
temple the ends are again crossed or “knotted,” but this time they
are passed horizontally round the head. Having done this the ends
are pinned and cut off, or if necessary the knots repeated before
fastening; the first pair, if tightly drawn, usually suffice as well
as several.

[Illustration: Fig. 3.—Knotted Bandage.]

=The Capelline Bandage= is rarely required, but is used when the
restlessness of the patient renders it difficult to keep dressings or
ice-bags in place.

_Apparatus._—1. A double-headed roller, 2 inches wide and 12 yards
long.

2. Some pins.

[Illustration: Fig. 4.—Capelline Bandage.]

The middle of the roller is laid against the forehead just above
the brows, and the ends passed behind the occiput, where they are
crossed, and while one continues the circular turns round the head,
the other head of the bandage is brought over the top along the
middle to the front, passing under the encircling turn, which fixes
it. It is then carried back to the occiput, on one side of the first
transverse band, when again fixed behind by the circular band it
is brought forward on the opposite side of the first, and fixed in
front. This arrangement is repeated until the head is covered in a
closely fitting cap (see fig. 4).

In beginning this bandage, it is necessary to keep the first circle
low down, close to the brows in front, and below the occipital
protuberance behind, or the cap will not fit firmly over the skull.

=A Shawl Cap= is readily improvised with a silk or cambric
handkerchief folded diagonally into a triangle; the base of the
triangle is then carried over the brow, the apex let fall behind the
occiput, where the ends cross, and catching in the apex, come round
to the front to be tied on the forehead.

[Illustration: Fig. 5.—Shawl Cap.]

=The Four-tail Bandage.=—Instead of applying the handkerchief in
the manner just described, it may be split from each end to within
six inches of the middle, and so converted into a broad four-tail
bandage; the middle is laid on the top of the head, the hinder ends
tied under the chin, and the forward ones behind the nape of the neck
(see fig. 6). Or a piece of calico, 1½ yards long and 4 or 6 inches
wide, is split from each end 3 inches short of the centre—one pair
of tails being rather wider than the other. If used on the face, the
middle is put against the point of the chin, the two narrow tails are
carried backwards to the nape, crossed, and pinned together on the
forehead above the brows. The two broader tails are carried upwards
in front of the ears, where they turn round the two narrow tails, to
be either tied or pinned at the vertex. Four-tail bandages are used
elsewhere, as in the axilla, to keep poultices in place, &c.

[Illustration: Fig. 6.—Four-tail Bandage.]

=To retain Ice Bladders on the Head.=—This is done by folding a thin
napkin over the bladder, which is then laid against the head or part
to be kept cool, and the ends of the napkin are pinned tightly down
to the pillow at each side. In this way the bag cannot slip, and its
weight is at the same time prevented from pressing on the head.

=To compress the Jugular Vein after bleeding.=—After venæsection of
the external jugular vein it is requisite to keep a compress of lint
on the wound. This is done by fastening the bandage on the neck with
two simple turns, then carrying it in a figure of 8 round the neck,
over the compress and under the axilla of the opposite side, then
round the neck again; if the figure of 8 is passed pretty firmly,
sufficient pressure is made in this way without interfering with the
circulation through the vessels, and the turns round the neck of
course must not be tight.


THE TRUNK.

=To bandage the Breast.=

_Apparatus._—1. A roller 3 inches wide and 8 yards long.

The roller is first carried once round the body below the breast,
beginning in front and passing towards the _sound_ side. When the
bandage is fixed, the roller ascends over the lower part of the
diseased breast, to the opposite shoulder, and comes back by the
arm-pit to the horizontal turn; it is then passed round the chest
to fix the oblique turn. Having done this, it again is carried up
over the breast and shoulder, and round the body in alternate turns
until the breast is fully compressed, each turn over the breast being
carried higher than the preceding one, and each turn round the body
overlapping the oblique turn to keep it in place (see fig. 7).

[Illustration: Fig. 7.—Bandage for a Breast.]

=To bandage both Breasts.=—This is readily done by first bandaging
one breast and then, carrying the roller over the shoulder of the
side already bandaged, bringing it across the sternum and under
the second breast on to the horizontal turns, which it follows
alternately with the oblique ones, as was done in bandaging the
first breast. The only difference is, that in compressing the first
breast the bandage was passed obliquely upwards, for the second it is
carried obliquely downwards over the breast.

=Spica Bandage.=

_Apparatus._—1. A roller or 2½ or 3 inches wide.

2. Some pins.

Lay the end on the groin to be bandaged, carry the roller between the
great trochanter and the crista ilii round the pelvis to the other
side, passing there also between the crista ilii and trochanter;
next take the roller downwards in front of the pubes to the injured
groin, then outwards round the thigh below the trochanter to the
gluteal fold, and pass it up between the thighs to the groin, where
the figure of 8 is completed. A second and a third are to be passed
in the same way, carrying them exactly one over the other, round the
body and below the buttock (see fig. 8); at the groin they should
overlap, each lying a little above the preceding turn. A pin, when
the necessary number of turns is completed, fastens down the end.

[Illustration: Fig. 8.—Spica for the Groin.]

=Hernia Spica.=—The spica bandage is usually required to keep
dressings and compresses in place over wounds after operation for
strangulated hernia, sinuses, &c., in the groin; when the figure of
8 has been put on the first time it may be cut across in front; and,
the dressings being changed, the ends may be fastened together by
pins. If additional strips are laid across and fastened to the figure
of 8 underneath, the required pressure is obtained, and much tedious
lifting of the patient is saved (see fig. 9.)

[Illustration: Fig. 9.—Hernia Spica.]

=Body bandage for tapping the Belly in Ascites.=—This is made of two
thicknesses of stout flannel, 2 feet wide in the middle, where it
forms a continuous sheet for 18 inches, but beyond that it is split
into 3 tails, 6 inches wide and 3 feet long. In the middle line, 4
inches below the centre, is a round hole 2 inches across, through
which the surgeon reaches the skin to insert the trocar.

When in use, the middle of the bandage is placed in front with the
hole in the mesial line of the body, and midway between the umbilicus
and pubes; the ends of the right side are passed behind the back to
the left, interlacing with those from the left side. When all is
ready, an assistant standing on each side of the bed pulls steadily
on the ends to keep up continuous pressure on the abdominal viscera
as the fluid escapes. After the fluid is evacuated the ends are
wound firmly round the body in front, while the puncture in the wall
of the belly is closed by a fold of lint attached with a strip of
plaster.

=The T Bandage= is used to apply dressings, compresses, &c., to the
anus or perinæum. A roller 3 inches wide is fastened by a couple of
turns round the pelvis, and then fixed by a pin at the middle line
in front. From this point the roller is carried tightly over the
dressings to the corresponding point behind, and returned once or
twice more until sufficient pressure is gained, when it is fastened
off.

=The Strait Jacket= is made of jean or stout canvas. It is cut long
enough to reach below the waist, around which a strong tape is
carried to be drawn tight and tied after the jacket is put on. The
sleeves are several inches longer than the arms, and their ends can
be drawn close by a tape which runs in the gathers; a similar tape
confines the garment round the neck, and it is tied behind by tapes
down the sides. When the jacket is to be put on a patient it is first
turned inside out, then one of the nurses or assistants thrusts his
own arms through the sleeves, and facing the patient, invites him to
shake hands; having thus obtained possession of the patient’s hands
he holds them fast while a second assistant, standing behind the
patient, pulls the jacket off the first assistant on to the patient,
whose hands are thus drawn through the sleeves before he perceives
the object of the manœuvre; the jacket is next tied round the neck
and behind, the tapes of the sleeves are carried round the body,
drawn tight till the arms are folded across the chest, and fastened
to the bed on each side, or tied round the body.

_Manacles for Delirious Patients._—Instead of the strait jacket
a double leathern muff is now generally used to restrain unruly
patients. It irritates them less, and is far more easily applied.

[Illustration: Fig. 10.—Manacles for confining the arms of delirious
patients.]

In wearing it the arms are crossed in front, and a strap drawn
tight round both wrists. Each hand is thrust into a stout leathern
glove, or muff, connected with the wrist-strap, and capable of being
tightened over the fingers by a strap and buckle across the glove.

=To suspend the Testicles.=—Suspensories are made specially for this
purpose. The best are fastened round the neck by a loop of elastic
tape, but a very efficient one can be improvised with a pocket
handkerchief and a piece of bandage. The bandage is tied tightly
round the hips for a girdle, the handkerchief is folded three-corner
wise, and its longest side slipped behind the testes, the ends being
passed over the girdle (see fig. 11), and tied again behind the
scrotum. The loose apex of the handkerchief is drawn up in front over
the girdle and pinned to it, which is all that is required (see fig.
12).

[Illustration:

  Fig. 11.—Shawl Suspensory for the Testes, in the first stage of
  application.
]

[Illustration: Fig. 12.—Suspensory for Testes completed.]

When the patient is recumbent, the testes may be supported by a
strip of diachylon plaster 2 feet long and 4 inches wide, passed
across from hip to hip underneath the scrotum and testes, which lie
supported on a shelf.

Another way of raising the testes is to place a soft pincushion
between the thighs, and allow the swollen gland to rest on the
cushion.


UPPER EXTREMITY.

=Bandage for the Fingers and Thumb.=

_Apparatus._—A ¾-inch wide roller.

_The fingers_ are bandaged to prevent œdema when splints are tightly
attached to the fore or upper arm. A roller ¾ inch wide is passed
once round the wrist and then carried over the back of the hand to
the little finger; then wound in spirals round it to the tip and
returned up the finger, completed by a figure of 8 round the wrist
and the root of the finger, and returned to the wrist before being
brought across the back of the hand to the next finger, to which it
is applied in the same manner till the four fingers are covered.
It is a good precaution to place a shred of cotton wool between
each finger before carrying the figure of 8 turn round the root; it
prevents the bandages from chafing the tender skin.

_The thumb_ is bandaged rather differently: the roller is commenced
in the same way round the wrist, but the first turn is carried at
once beyond the last joint, turned once or twice round the last
phalanx, and continued by reverses to the metacarpo-phalangeal joint;
the ball of the thumb is then covered by figures of 8 round the thumb
and wrist. This is called the _spica for the thumb_.

[Illustration: Fig. 13.—Spica for the Thumb.]

This plan is sometimes employed to compress bleeding wounds of the
ball of the thumb, and is applied without previously covering the
phalanges, as in fig. 13.

=The Hand and Arm.=

_Apparatus._—1. A roller 2¼ inches wide for an adult, but narrower
for a child.

2. Some cotton wool.

A little cotton wool should fill the palm before applying the roller.
The bandage commences with figures of 8 carried round the hand and
wrist. The roller is first passed across the back of the hand from
the radial border of the thumb to the root of the little finger (see
fig. 14), and then across the palm, reaching the back of the hand
between the thumb and forefinger.

[Illustration: Fig. 14.—Commencing to bandage the hand.]

When the hand is covered by these figures of 8 the bandage is passed
up the _forearm_ by reverses placed over the extensor muscles till
the elbow is nearly reached. Before going further a dossil of cotton
wool is placed in the bend of the elbow, and on the inner condyle;
the joint is bent to the degree that will be required by the splint,
and the patient told to grasp some part of his dress, or the sleeve
of the other arm, that he may not unconsciously extend the joint
again while the bandage is being rolled round it.

_The elbow_ is covered by first carrying the roller round the joint,
so that the point of the olecranon rests on the centre of the turn
(see dotted lines, fig. 15). The bandage is then continued in figures
of 8, passing above and below the first turn until the elbow is
covered in and the bandage of the forearm is completed.

[Illustration:

  Fig. 15.—Bandage covering the elbow. The first turn over the point
  of the elbow is shown by the dotted lines.
]

[Illustration: Fig. 16.—Spica Bandage for the shoulder.]

_The arm_ is covered by spirals and reverses till the armpit is
reached. Before bandaging _the shoulder_ the armpit is protected by
cotton wool or a double fold of soft blanket; the roller is then
carried in front of and over the shoulder, across the back to the
opposite axilla, where also some wool should be placed, then across
the chest to the top of the shoulder again, and under the armpit to
the front (see fig. 16). These figures of 8 are repeated as often as
necessary to complete the covering. The bandage is applied in this
method for dressings; but when pressure is needed the first turn may
be carried at once to the root of the neck, and each succeeding turn
made to overlap below the last, until the point of the shoulder is
gained, as in fig. 37, p. 55. These are called _the spica for the
shoulder_.

=Wound of the Palmar arch.=—Bleeding from this wound can usually
be stopped by pressure on the bleeding point, when this fails an
attempt should be made to tie the vessel at the wound, and if this be
impracticable the arteries of the forearm must be deligated.

_For compression_ the following is necessary:—

_Apparatus._—1. Petit’s tourniquet.

2. Straight wooden splint.

3. Rollers 2 inches wide, and ¾ inch wide for fingers.

4. Pad and cotton wool.

5. Lint.

6. A slip of a wine cork.

7. Scissors and needle and thread.

8. Lunar caustic.

Step 1. First apply the tourniquet to the brachial artery, to control
the hæmorrhage while the apparatus is being adjusted.

Step 2. Make a graduated compress by folding a sixpence or slip of a
cork in two or three thicknesses of lint, trim the lint into circular
disks and prepare a dozen similar disks of increasing size; lay these
one on each other to form a round cone about one inch high with the
piece of cork at the apex, and fasten them together by a thread.

Step 3. Clean and dry the wound, then rub its surface carefully with
nitrate of silver, to lessen the suppuration.

Step 4. Bandage the fingers and thumb, and prepare the splint, which
should be straight, as broad as the forearm, and long enough to
reach from the elbow to the tips of the fingers; it should be lightly
padded.

Step 5. Envelope the wrist with a little wool; next lay the graduated
compress on the wound, the small end downwards, and press it firmly
in with the left thumb, while the splint is applied to the back of
the hand and forearm. These are then fixed by a roller carried in
figures of 8 round the hand and wrist across the compress until that
is tightly pressed into the wound and the splint fixed to the limb.
The roller is then carried along the forearm, a fold of wool laid in
front of the elbow, the tourniquet removed and the roller carried to
the axilla while the forearm is raised, flexed across the chest, and
fastened to the side.

This apparatus is worn without being disturbed for three or four days
if bleeding do not return; but at the end of this time it should
be examined; if painful or if discharge ooze out at the wound, the
bandage should be removed and readjusted less firmly than before, a
piece of wet lint replacing the graduated compress.

=Venæsection.=—Bandage and bleeding at the _bend of the elbow_.

_Apparatus._—1. Lancet.

2. Tape.

3. Pledget of lint.

4. Dish.

5. Staff.

In opening a vein at the bend of the elbow, the median basilic is
selected, simply because it is usually the largest, but any branch
that is superficial, and well filled with blood, may be opened.

The patient should sit or stand, in which positions, syncope, one of
the objects of bleeding, is attained by the abstraction of a less
amount of blood than in the horizontal posture.

The surgeon places a graduated bleeding dish on a chair or stool
within his reach, and a pledget of lint in his waistcoat pocket; he
next gives the patient a heavy book, or staff to grasp in his hand.
The arm being bare to the shoulder, a tape, ¾ inch broad and 1¼ yard
long, is tied round the arm tight enough to impede the venous, but
not the arterial flow.

The surgeon standing opposite his patient and grasping the arm to
be bled with his left hand, so that his thumb controls and steadies
the swollen vein, takes his lancet between the right forefinger and
thumb; then going through skin and vein at one stroke, carries the
lancet upwards for about ¼ inch along the vein. The puncture of the
lancet should be quite vertical, and the extraction also made quite
vertically, that the slit in the vein may correspond to the slit in
the skin.

This being done, the operator lays aside his lancet, and takes up the
dish, holding it so that the blood shall flow into it: when the dish
is placed, he lifts his left thumb from the vein cautiously or the
sudden spirt of blood will fall outside the dish and be lost. When
the desired amount is drawn, the operator compresses the vein again
with the left thumb, and setting down the dish, puts the pledget of
lint over the wound. He keeps the pledget in place with his left
thumb, while he releases the tape round the arm and places its middle
obliquely across the pledget. His left thumb presses the pledget on
the wound, while the right hand takes the end of the tape which is
farthest from his left, and passes it under the forearm below the
elbow to his left fingers, which grasp it tightly. He then takes the
other end with his right hand (see fig. 17), and bringing it round
the arm above the elbow, carries it across the pledget: as he does
this, he replaces his left thumb on the compress with his right
forefinger, which he keeps there while he brings up the end of the
tape he has already in his left fingers, and throws it over the arm
_above_ his right forefinger, then passing his left hand _below_ the
right forefinger, he catches the same end of the tape again and draws
it back. The two ends thus locked in a loop over the compress, are
secured by tying them in a bow outside the elbow and the operation is
finished (see fig. 18).

[Illustration: Fig. 17.—Adjusting the tape after bleeding.]

[Illustration: Fig. 18.—The bandage completed.]


THE LOWER EXTREMITY.

For adults the most useful width for the rollers is 3 inches, and the
length the ordinary one of 8 yards.

=The Foot= is usually bandaged without covering the heel, and the
bandage is begun as follows:—

The roller being held in the right hand for the right foot, or in
the left hand for the left foot; the unoccupied hand takes the end,
and passing it under the sole, brings it up on the back of the foot
just behind the toes, where it is made fast by carrying the roller
outwards over the back. When one turn is completed, the bandaging is
continued by reverses until the metatarsus is covered, then one or
two figures of 8 round the foot and ankle carry the bandage to the
leg, where it proceeds upwards by spiral turns round the small of the
leg, and by reverses up the calf. The reverses lie at equal distance
up the leg, on the muscles, not over the bone, that the skin be not
pinched between the crease of the bandage and the bone. When the calf
is passed, the roller is continued by figures of 8 above and below
the knee, until that joint is covered in, then by reverses up the
thigh to the groin, where the bandage terminates by a spica round the
body (see page 9). This is the ordinary bandage for the lower limb.
There are some varieties for particular parts, these are:—

=To cover the Heel.=—Holding the roller as for the foot, pass the end
behind the heel, bring it out by the outside over the front of the
ankle-joint, and complete the turn with the roller. In doing this,
the point of the heel must catch the middle of the bandage. If the
foot is a long one, the roller should be three inches broad; but a
narrower bandage is more easily fitted on a small foot. After the
first turn, the bandaging is continued by carrying the roller in
figures of 8 round the foot and ankle, passing alternately above and
below the first turn until the ankle is covered as in fig. 19.

[Illustration: Fig. 19.—Covering the Heel.]

=To bandage a Toe.=—Take two turns round the foot, with a bandage one
inch wide, then go round the toe to be raised, and back again round
the foot. This figure of 8 lifts a toe above the rest if taken from
the dorsal, and depresses it if taken from the plantar surface.

=The Knee is bandaged= by beginning with a simple turn round the leg
above the calf, then carrying the roller across the patella to the
thigh above the knee: and next entwining it in a circular turn round
the thigh before descending over the patella to the leg below the
knee, where this is repeated until the knee is covered.

=To bandage a Stump.=—The flaps are first supported by two or more
strips of plaster, one inch wide and ten or twelve long, carried from
the under surface of the limb over the face of the stump, and a slip
of wet lint and oilskin is applied to the wound. The muscles and soft
parts are next confined by a bandage. This is first fixed by simple
turns below the nearest joint, and brought downwards in figures of 8
round the limb till the end of the stump is reached, which is next
covered in by oblique and circular turns carried alternately over
the face of the stump and round the limb, as is shown in fig. 2 for
bandaging the head. Or, if a double-headed roller be used, in the
manner directed for the capelline bandage on page 5.

=Extending a Stump.=—When the soft parts fall away from the bone
they may be drawn down by attaching a weight by cord and pulley, as
described for extending the hip-joint (see fig. 80). The stump should
be lightly bandaged and the cord fastened to its upper and under
surface. The weight is very small at first, and should be increased
from time to time as required.

=Many-tail, or 18-tail Bandage=, or bandage of Scultetus.—A roller is
cut into short lengths long enough to encircle the limb and to let
the ends overlap 2 or 3 inches; these are applied separately, the
lowest first, the next overlapping it, and the next overlapping the
second until the requisite number are applied. Sometimes the tails
are attached to each other before they are applied. To do this, the
tails are laid out on a table, so that the second overlaps one-third
of the width of the first strip, and the third strip overlaps the
second, and so on. When all the tails are arranged, a strip is laid
across their middle and fastened to each tail by a stitch; but this
is not a necessary part of the bandage, and it prevents single tails
from being removed. This bandage is used in compound fractures and
other wounds, as the soiled strips can be replaced without raising
the limb to pass the roller under it.

=Elastic Socks and Stockings= are made to support varicose veins of
the legs. They are woven of india-rubber webbing with silk or cotton.
The latter are the lowest priced and often even the most comfortable
to wear. The stockings should fit carefully everywhere, especially at
the small of the leg, where they generally are too slack, while they
cut at the upper end below the knee.




CHAPTER II.

STRAPPING.


Strapping is a method of supporting weak or swollen joints and other
parts. Sheets of calico, wash-leather, or white buckskin, spread with
lead or soap plaster, are prepared for this purpose. A sheet should
be rubbed with a dry cloth before using, to remove adherent dust,
&c. It is then cut into strips varying in width between ¾ inch and
2 inches, according to the evenness of the surface to be covered:
narrow strips fit best over joints and irregular surfaces. When
applied to a limb, the strips should be about one-third longer than
its circumference. Each strip or strap is first warmed by holding it
to a fire, or by applying its _unplastered side_ to a can of boiling
water; when hot, the strip is then drawn tightly and evenly over the
part. If the surface to be strapped be irregular, it is best to dip
each strip of plaster in hot water before applying it, being thus
quite supple the strap fits the limb more exactly. When the limb is
thickly beset with hairs, it is a good plan to shave the part where
the plaster will lie before putting on the straps.

=Strapping the Breast.=—Strapping is put on the breast in the same
way as the bandage (page 8). The straps should be not more than 2
inches wide, and long enough to pass forward under the axilla and
breast from the lower angle of the scapula on the same side as the
injured breast, across the chest as far as the spine of the other
scapula. The strips are then warmed and laid on alternately over the
breast and across the chest, until the former is fairly supported.

Strapping has this advantage over a bandage—its circular strips do
not pass round the chest completely and thereby hamper the breathing
as the roller does.


=To strap the Testicle.=

_Apparatus._—1. Strips of soap plaster spread on calico, or better,
on wash-leather, ½ inch wide and 12 inches long.

2. A can of boiling water.

3. Razor and soap.

[Illustration: Fig. 20.—Strapping the Testis.]

First, shave the scrotum; then tighten the skin over the testis
with the left thumb and forefinger passed above it; take a strip of
plaster 6 inches long and ½ inch wide, and encircle the cord tightly
with it; next pass another strap of the same width, 9 or 10 inches
long, from the back of this ring, over the testicle to the front,
drawing it tight also (see fig. 20). The strapping is continued by
laying fresh straps over each other until the whole testis is covered
in. Lastly, take a strip 15 or 20 inches long, and, beginning at
the ring above, wind it round and round the testicle until all the
vertical strips are confined in place by this spiral strip.

The strapping should be re-applied the second or third day, as the
testicle by that time will have shrunk within its case.

[Illustration: Fig. 21.—Strapping an Ulcer.]

[Illustration: Fig. 22.—Strapping the Ankle.]

=Strapping Ulcers and Joints.=—Cut strips of plaster one-third
longer than the circumference of the part to be strapped; if that is
irregular, as the ankle or wrist, they must be narrow: commonly the
width varies between ¾ inch and 1½ inch. The strips are warmed, the
middle passed behind the limb, the ends crossed in front (see fig.
21) and drawn tight, but with sufficient obliquity for the margins of
the strip to lie evenly. The strapping is begun as low down the limb
as requisite, and continued upwards by laying on more strips, each
overlapping about two-thirds of the preceding strap. When the process
is finished, the ends should meet along the same line, and all the
uppermost ones be on the same side.

_The ankle_ is strapped differently. Strips are prepared about ¾ inch
wide; one is carried behind the heel and its ends brought forward
till they meet on the dorsum of the foot; a second, encircling the
foot at the toes, secures the first; a third is again carried behind
the heel above the first, and is fixed by a fourth round the foot.
This is continued until the foot and ankle are firmly supported (see
fig 22).

=Strapping a Joint with Mercurial Ointment.=

(_Scott’s Bandage._)

_Apparatus._—1. Mercurial ointment.

2. Diachylon plaster.

3. Lint.

4. Spirit of camphor.

5. Cotton wool.

6. Freshly scalded starch, or solution of gum.

7. Binder’s millboard.

Spread the ointment on a piece of lint large enough to cover the
joint, and to extend four or six inches above and below it; then
wash the joint with warm water and soap and dry it carefully; next
sponge it well with the spirit of camphor for five minutes. Tear the
lint into strips and wrap it round the joint; then strap the part
firmly from below upwards over the lint with strips of diachylon
plaster, each overlapping the preceding. Lastly, envelope the joint
in a thin layer of cotton wool, and roll a bandage soaked in starch
over all. If the patient wears no other kind of splint the bandage
may be strengthened by laying a piece of millboard well softened in
boiling water along each side of the joint before the starch bandage
is applied. As the enlargement of the joint shrinks, this application
must be renewed, usually every fortnight is often enough.




CHAPTER III.

FRACTURES.

HEAD AND TRUNK.


=Fracture of the lower Jaw.—The External Splint and Bandage.=—A
method requiring the lower jaw to be firmly fixed against the upper
one while the broken bone knits.

_Apparatus_.—1. One and a half yards of bandage four inches wide.

2. A piece of gutta-percha, sole leather, or binder’s millboard.

3. Dentists’ silk or wire.

4. Boiling hot, and cold water.

Step 1. The fracture is first reduced. While the apparatus is being
fitted, the recurrence of the displacement is prevented by the hands
of an assistant, or by lacing the teeth together with stout silk or
wire. It is well also to wet the patient’s chin with a sponge and
cold water, to prevent the gutta-percha from sticking to his beard
while it is soft.

Step 2. A piece of gutta-percha is prepared 2½ inches wide and long
enough to reach from one angle of the jaw to the other when passing
in front of the chin. This is softened thoroughly by immersion in
boiling water, and when quite pliable should be quickly removed
from the hot and plunged for a moment into cold water: if a towel be
previously laid in the hot basin, the gutta-percha can be lifted on
it without stretching. It should be laid on a table, and its surface
sponged with cold water to prevent it sticking to the skin, it is
then slit from each end into tails 1 inch and 1½ inch wide, leaving
2 inches uncut at the centre. So prepared, the splint is applied to
the jaw with the middle pressing against the chin, the narrower ends
being carried horizontally backwards to the angles of the jaw; the
broader part is next bent up beneath the chin, its ends overlapping
the horizontal ones. While the splint is still soft, the surgeon
presses it firmly upwards that the gutta-percha may mould itself
accurately to the chin. When set, the splint is removed, trimmed,
and punched with holes here and there for evaporation. A covering of
wash-leather may be added, if desired. When the splint is finished,
it is replaced on the chin. If sole leather or pasteboard be used
instead of gutta-percha, they must be prepared in the same way, but
allowed to remain on the chin twenty-four hours that they may set
before the final trimming and adjustment.

Step 3. A bandage, 4 inches wide and 1½ yard long, and slit from each
end to about 2 inches from the centre, is then applied to the splint,
and a small pad of folded flannel should be placed at the nape of
the neck to protect the skin from the crossed bandage. When all is
ready, the two upper ends are carried behind the neck, crossed,
drawn tight, and tied or pinned on the forehead; the lower ends are
carried upwards, taking a turn round the first pair at the temples,
and fastened at the vertex (see fig. 23).

[Illustration: Fig. 23.—Outside splint for fracture of the lower jaw.]

The ligatures that may have been used on the teeth can now be
removed, or if they cause no pain, they may be left for a week or two.

It is a useful precaution to place a piece of soap plaster spread on
soft leather, under the chin and along the throat, to protect the
skin from the chafing of the splint while it is worn.

Sometimes the jaws close too nearly to allow food to be taken
between them. It is then necessary to place a thin wedge of softened
gutta-percha, 1½ inch long, ½ inch wide, and about ⅓ inch thick,
between the molars on each side. The gutta-percha must not be
softened much, or when the bite is taken the teeth will pass through
it. These plugs should be omitted unless absolutely required, as the
fragments keep a better position without them.

On emergency, when gutta-percha, leather, or pasteboard are not at
hand, the jaw may be set, and then kept in position by a four-tail
bandage, made from a pocket-handkerchief, until more complicated
apparatus can be prepared.

The apparatus must be worn five weeks before it is laid aside and
mastication permitted.

=Interdental Splints.=—In cases of unusual difficulty, interdental
splints may be employed. To fashion some of these, the mechanical
skill of a dentist is requisite, unless _Morel Lavallée’s plan_ is
resorted to. He applied a mould or socket to the line of the teeth,
and kept it in place by pressure underneath the jaw. He first brought
the fragments into apposition by means of threads and wire. Then he
took a piece of gutta-percha, about ⅓ inch thick and ½ inch broad,
and long enough to extend, when bent along the lower jaw, from one
wisdom molar to the other. This was softened in water, and pressed on
the teeth; next a well-padded horse-shoe plate was placed under the
chin, reaching from one angle of the jaw to the other, and two wires
were passed through the side of this plate opposite the angle of the
mouth; these were drawn through the plate by a screw nut; their upper
ends being curved into hooks with sharpened points. The points catch
into the gutta-percha; by screwing up the nuts, the chinplate was
raised, and the teeth driven up and bedded into the splint.

This method, however, has its disadvantages. If the fracture take
place behind the first molar, the bearing on the upper fragment is
too slight to keep it down in its place.

In the _New York Medical Journal_ for September and October, 1866,
Mr. Gunning, of that city, has published a mode of applying caps
fitted to the teeth for fracture of the jaw-bone. External support is
abandoned wherever it is possible. In simple fractures, the caps or
interdental splints, being accurately fitted, require no fastening to
the teeth.

The jaw should be adjusted in its splint as quickly as possible
after the accident. The fragments are first brought into their true
position. Gaps through loss of teeth at the line of fracture, are
filled by plugs of hard wood, and the fragments kept in place by
wiring the teeth together tightly. Continued strain on the teeth
causes much pain; hence all means for keeping the fragments in place
while the splint is being fitted should be removed when that is
accomplished, though ligatures used solely to support loosened teeth
may be left, as there is no traction upon them. Stumps, and teeth
loose before the accident are best taken out, if they interfere with
the arrangement of the splint.

[Illustration:

  Fig. 24.—Vulcanite Interdental Splint to fit the arch of the teeth
  of the lower jaw, seen upside down. The holes marked a pass through
  to the upper surface, to allow water to be injected between the
  splint and the teeth, while it is worn, for cleaning.
]

The next thing is to take a mould of the lower jaw in wax softened by
heat, holding the wax in an ordinary dentist’s tray. From this mould
a plaster cast of the jaw is made. If the line of teeth be uneven in
the cast, it is to be sawn through, the pieces raised to the right
level, and cast again. In this cast a vulcanite plate is made exactly
fitting the teeth (see fig. 24). The margins of the mould or splint
should be carried down below the line of the gums, to grasp the jaw
beyond the alveolar border; and when the fracture takes place behind
the teeth, its outer side should be prolonged backwards as far as
the muscles will allow, to prevent the displacement of the anterior
fragment outwards which muscular action produces in these fractures.
Holes should be made in the top of the splint, to permit a stream
of water to be sent between the splint and the teeth daily, for
cleanliness. Also, in difficult cases, a hole should be cut opposite
a tooth in each fragment, for ascertaining from time to time that
each part continues in its proper position while the splint is worn.

Metal is used for the plate by English dentists, instead of
vulcanite. It can be made thinner, and is less brittle than the
latter.

The perfect fit thus secured suffices, in simple fracture, to keep
the parts in close apposition; while the movements of eating and
speaking are very little interfered with.

[Illustration:

  Fig. 25.—Showing the method for supporting externally the jaws in
  the splint, when the teeth are not fastened to it by screws, E.
  Upper wing; G. Lower wing; H. Mental band to keep the jaw up in the
  splint; I. Neck-strap to keep the band back; K. Balance-strap to
  hold skull-cap in place. The upper wings are of course dispensed
  with, when a single splint only is used.
]

When the displacement is considerable the fragments are held in place
by riveting one or more teeth to the cap, or, when circumstances
prevent support being obtained in this way, external support is
supplied to the splint by steel wings, fixed into the splint at the
angles of the mouth (see fig. 25), and carried outside the cheek
to the angles of the jaw. A piece of stout jean or canvas, cut to
fit under the chin, is then connected with these wings, and also
fastened by a tape behind the neck.

If the case require that a bearing be made on the upper jaw as well
as the lower one, as in fracture of both jaws in edentulous persons,
the two splints are articulated behind, so that they may open and
shut with the lower jaw. Each piece then carries a wing, the lower
one supporting a chin-piece, and the upper one being connected by
strings attached at the temples to a close-fitting skull-cap. The
skull-cap is prevented from slipping forward by connexion with a
strap fastened to both shoulders.

=A fractured Rib= is very well treated by strapping the injured side
alone, without enrolling the chest in a tight bandage, which harasses
the patient by impeding respiration.

_Apparatus._—1. Diachylon plaster.

2. Can of boiling water.

[Illustration: Fig. 26.—Strapping a broken Rib.]

Strips of plaster long enough to reach from the spinal column to the
sternum, and 2 inches wide, are to be firmly drawn round the injured
side. The first strip should be carried as high as can be managed
under the arm-pit. The next strip overlaps it about an inch (fig.
26), each succeeding strip overlapping and fixing the preceding one
until the lower ribs are covered in. The arm should then be bandaged
to the side, and supported in a sling.

A _second mode_ of treating fractured ribs, is to take a flannel
roller 6 inches wide, and 8 yards long, and carry it firmly round the
chest in successive spirals, beginning at the armpits, and passing
down till the waist is reached. The turns of the roller may be kept
from slipping down by throwing across the shoulders two strips of
bandage like a pair of braces, and stitching each turn to the brace
in front and behind. The arm should be confined to the side as in the
other method. This plan has the inconvenience before mentioned of
interfering with respiration.

=In Fracture of the Pelvis=, the fragments are kept in position by a
broad roller carried several times round the pelvis and fastened.


THE UPPER EXTREMITY.

=Fracture of the Metacarpal Bones.=

_Apparatus._—1. A piece of gutta-percha.

2. A roller 2 inches wide.

In treating this fracture it is important to keep the broken bone in
place without confining the wrist or fingers.

A pattern of the palm and dorsum of the hand is cut out of paper,
which is doubled round the radial side, letting the thumb out through
a hole of convenient size to clear it (see fig. 27). The piece of
paper is then laid on a sheet of gutta-percha ¼ inch thick, and the
requisite quantity cut off; a hole as big as a pea is next punched
in the gutta-percha in the middle, about 1 inch from the lower
border, or at a point corresponding to the hole in the paper for
the thumb. The fragments are then pushed into place and held so by
an assistant, while the surgeon softens the gutta-percha in boiling
water; when thoroughly soft, he draws the thumb through the little
hole punched in the gutta-percha, and moulds the splint to the palm
and back of the hand, bringing the ends of the gutta-percha together
at the ulnar side of the hand; the fragments are held carefully in
position till the splint is set. The splint is afterwards removed
and trimmed. A few holes should be punched in it after it is moulded
to allow perspiration to escape. The splint may then be covered
with wash-leather, and a pair of straps with buckles stitched on to
keep it in place. It is worn for three or four weeks, or until the
fragments are united.

[Illustration: Fig. 27.—Gutta-percha Glove for fractured Metacarpal
Bone.]

Should gutta-percha not be at hand, another plan is effectual.

_Apparatus._—1. A firm ball of tow large enough to fill the palm,
stitched in old linen.

2. A roller 2 inches wide.

The broken bone is first replaced; then the hand and fingers bound
on to the ball by carrying the roller around them until they are all
immoveably confined.

This plan has the disadvantage of confining the whole hand for the
fracture of one metacarpal bone; the gutta-percha allows free use of
all but the metacarpal bones.

=Broken phalanges= are treated by bandaging them on to a slip of
wood long enough to reach into the palm; the slip must be well
padded, that the somewhat concave anterior surface of the digit may
accommodate itself on the flat splint. If more than one finger be
injured, and the fracture be compound, the splint should then reach
up the palmar aspect of the forearm and hand. Fingers should be cut
in it to correspond with the fingers to be fastened to the splint.

=Fracture of the lower end of the Radius.=—_Colles’ Fracture._—The
displacement in this fracture is mainly due to the lower end of
the radius and the carpus being carried backwards while the shaft
projects in front.

_Apparatus._—1. A straight splint of wood. A second splint, curved at
its lower end.

2. Pads and cotton wool.

3. A roller 2 inches wide.

4. A sling.

5. A strip of plaster.

The objects to be attained in treating this fracture are to press
the lower fragment forwards and to draw (adduct) the hand towards
the ulnar side of the limb. For this purpose a straight and a curved
splint are used.

No bandage should be placed under the splints in treating any
fracture of the shaft of the radius or ulna, lest the broken ends be
pressed into the interosseous space.

Step 1. Prepare the splints. The straight splint should reach, when
the arm is bent, to a right angle with the thumb upwards, from a
little below the inner condyle to the lower end of the upper fragment
or shaft; the curved or pistol splint extends from the outer condyle
to the joint of the first and second phalanges. The width of both
splints should slightly exceed that of the forearm. The bend of the
lower end of the pistol splint should be abrupt, and directed towards
the ulnar border opposite the wrist, where the margin of the splint
should make an obtuse angle of about 1½ right angles (see fig. 28).

[Illustration: Fig. 28.—Pistol Splint for fracture of the Radius near
the lower end.]

Pads used with these and other wooden splints are made of layers of
cotton wool, carded sheep’s wool, tow, or folds of old blanket. These
materials should be stitched in old linen or calico, and covered
outside with oiled silk where likely to be stained with the discharge
from wounds.

The pads must be thicker below than above, to keep the splints
parallel along the forearm; and that of the pistol splint is thickest
opposite the carpus, to push the lower fragment forwards.

Fixed deformity opposite the wrist is usually present from impaction
of the fragments; moderate extension may be employed to remove this,
but forcible or continued efforts give great pain and do harm,
by further straining the already wrenched ligaments. After these
preparations the splints are applied.

Step 2. Put a very little cotton wool in the palm and across the
root of the thumb, before the roller is begun, lest it chafe the
carpus in front. The curved splint, with the barrel or longer part
inclined downwards below the forearm, is next attached to the back of
the hand by a roller carried in figures of 8 round the hand and root
of the thumb, but not above the wrist (see fig. 29). This is made
fast by a pin.

[Illustration: Fig. 29.—Fracture of the Radius.]

Step 3. Raise the straight part of the outside splint till parallel
to the forearm, thus adducting the hand to the ulnar side; and fix
the splint by a strap of plaster an inch wide carried round it and
the forearm below the elbow.

Step 4. Apply the inside straight splint next, keeping the front of
the carpus and of the lower fragment exposed. Draw the two splints
together by simple spiral turns of a roller, begun just below the
elbow and carried down to the lower end of the inside splint, there
fasten it off.

Step 5. Put a narrow sling under the forearm between the elbow and
the wrist to support the limb comfortably.

When the apparatus is finished the position of the broken fragments
should be visible (see fig. 29) and not concealed by bandage. The
hand should also be quite free of the sling, lest it be drawn from
its proper adducted position. The fragments are in good position
when the hollow on the anterior aspect of the wrist and the
prominence on the corresponding posterior surface are removed.

=The Gutta-percha Gauntlet= is another plan of treating fracture
of the lower end of the radius that may often be adopted from the
first, and may always replace the wooden splints and bandage when
the swelling has subsided. It was contrived by Mr. Heather Bigg, and
permits the patient to use his hand to some extent while the bone is
uniting.

_Apparatus._—1. A piece of gutta-percha ¼ inch thick, wide enough
to enwrap the metacarpus and wrist, and long enough to reach up the
lower half of the forearm. Two thirds across the width, and about 1
inch from the lower end, a small round hole is punched. The sheet is
then softened in hot water, and applied to the hand, the thumb being
thrust through the hole punched to receive it, which rapidly enlarges
when soft. The gutta-percha is then adjusted to the hand and forearm,
its borders meeting at the ulnar side of the limb, rather nearer the
inner border of the arm than is depicted in fig. 30.

[Illustration: Fig. 30.—Gutta-percha Gauntlet for Colles’ Fracture.]

If the fracture is recent, it must be reduced while the splint is
soft by extending the hand and holding the parts in the required
position until the gutta-percha is set. Before removing the splints
superfluous edges should be marked, and, when the splint is off,
trimmed away with a knife. Holes must also be punched at frequent
intervals that the perspiration may escape. The splint is next lined
with wash-leather, and fitted with a pair of straps and buckles to
keep it in place.

By this plan the fingers are left free, and some motion allowed also
to the thumb. The only joints kept immoveable are those of the carpus
and wrist.

Apparatus of some kind must be worn three weeks continuously; then
for a fortnight longer, while it is removed every day to allow
passive motion of the fingers and gradually of the wrist also to be
practised. Care should be taken to warn the patient that pain and
stiffness last long in these fractures, lest he blame the surgeon
because he does not quickly recover full use of his arm.

=Fracture of the Shaft of one or both Bones of the Forearm.=

_Apparatus._—1. Two straight wooden splints.

2. Pads and wool.

3. 2-inch wide roller.

4. Sling.

The treatment is the same whether one or both bones are broken.
Caution has been already given against bandaging the forearm
underneath the splints.

Step 1. Prepare two straight wooden splints; one to go in front of,
and one behind the forearm. The posterior or outside reaches from the
external condyle to the end of the metacarpus; the anterior or inside
splint from a little below the internal condyle only as far as the
wrist, keeping clear of the ball of the thumb. The splints should be
slightly broader than the forearm, and well padded; towards the lower
end the padding should be thicker than above. The forearm is bent to
a right angle and the thumb put upwards.

Step 2. Reduce the fracture by gentle slow extension at the wrist;
this being effected, apply the splints to the forearm, and let an
assistant hold them while the bandage is rolled on.

Step 3. When a little wool has been wrapped round the hand and wrist,
fasten the dorsal splint by figures of 8 carried round those parts;
then draw the two splints together by simple spirals continued to the
elbow (see fig. 31).

[Illustration: Fig. 31.—Fracture of both Bones of the Forearm.]

Step 4. Support the forearm in a sling, to complete the apparatus.

The splints are worn three weeks; after this, passive motion may be
practised daily, and the splints finally abandoned ten days later.
But a sling is still required some ten days after the splints are
laid aside.

When the ulna alone is broken, an anterior splint reaching from the
inner condyle to the tips of the fingers often suffices without a
second one.

_When the shaft of the radius is broken high up_ (a rare accident)
the displacement is sometimes very difficult of reduction unless
the wrist be well supinated. To preserve this position it may be
necessary to use a wooden angular splint, and to fix the vertical
part to the arm behind the elbow, while the horizontal part is
carried along the back of the forearm.

=Fracture of the Olecranon.=—This fracture, if seen early before
effusion takes place, may be put up at once, but if delay till the
joint is swollen has occurred, the limb must be kept quiet on a
pillow, or on a splint in an easy position with evaporating lotions,
until the effusion is absorbed, before any means can be taken to
restore the position of the olecranon. Though the straight position
of the elbow is usually employed, it is not essential for even very
close union of the fragments.

In treating this fracture the following plan is useful.

_Apparatus._—1. Straight hollow splint.

2. 2-inch rollers and finger rollers.

3. Pad, wool, and lint.

4. Strapping plaster.

5. Pins.

Step 1. Bandage the fingers; wrap the hand in cotton wool and bandage
it. When the wrist is passed, fasten the bandage for a time by a pin,
and straighten the arm.

Step 2. Push the olecranon down as close as possible to the rest of
the ulna, and put a dossil of lint over it. Place the middle of a
strap of plaster an inch wide and 16 inches long, on the lint, and
carry its ends round the forearm in a figure of 8; to some extent
this alone fixes the fragment.

Step 3. Continue the bandage up the forearm by reverses, keeping the
elbow straight; and pass the joint by figures of 8 carried over the
compress of lint and the forearm, to draw down the olecranon (see
fig. 32). When this is secured, prolong the bandage to the deltoid,
to confine the action of the triceps muscle.

Step 4. Pad lightly a hollow splint about 2 inches wide, reaching
from the axilla nearly to the wrist, and apply it along the anterior
aspect of the limb, then fix it by a second roller. This completes
the apparatus.

[Illustration: Fig. 32.—Bringing down the Olecranon with Figures of
8.]

The splints and rollers should be removed on the fourth or fifth day,
that the positions of the fragments may be examined and the roller
again applied to draw them closer together. After ten or twelve
days, passive motion of the wrist and fingers, with pronation and
supination of the radius, should be adopted, but great care is to be
taken that the patient does not inadvertently bend the elbow joint
while free of the splint. The splint must be worn, with the frequent
removals directed above, for five weeks, by which time gentle flexion
of the elbow may be practised.

Hamilton notches his splint at each border about its middle so that
the notches shall be 3 inches below the tip of the olecranon (see
fig. 33). He begins the bandaging by fastening his splint on to the
hand and forearm, as high as the notches; here the roller is carried
above the olecranon and again down to the notches; this is repeated
again and again, each turn below the last, until the notches are all
covered, he then continues the bandage upwards by circular turns
until the top of the splint is reached.

[Illustration: Fig. 33.—Hamilton’s Splint for fracture of Olecranon.]

=Fractures of the Humerus near the Elbow.=—These resemble
dislocations of the ulna and radius backwards, but are distinguished
from them by the ease with which the bones slip into place and again
slip back from it when left to themselves; by crepitus; and, when
the fracture is above the condyles, the common accident, by those
projections retaining their natural relation to the olecranon. In
children and youths the articulating surface of the humerus may
separate from the shaft without carrying the rest of the lower
epiphysis with them. In this rare accident the main distinctions from
the usual fracture are, the projection of the olecranon behind the
condyles; from dislocation, the absence of the hollow of the sigmoid
notch, and facility of reduction.

In ordinary cases, where the deformity is reduced without much
difficulty, and the injury to the joint is not severe, lateral
rectangular splints of leather, hollowed wood, or wire gauze, answer
very well. These are placed both inside and outside the limb, and
reach from the axilla and shoulder to the wrist. They are applied in
the following manner:—

_Apparatus._—1. Lateral hollowed angular splints.

2. Pads and wool.

3. Rollers 2 inches wide for the arm, and 1 inch wide for the fingers.

4. Sling.

Step 1. The splints must be prepared.

Wooden and wire gauze splints are double. One, inside the arm,
reaches from the axilla to the wrist, the forearm being bent to a
right angle. The other extends, on the outside, from the deltoid
to the wrist. They are better if provided with hinges opposite the
elbow, so that their angle can be altered, if desired, in the later
stage of the treatment. Splints of wood or wire gauze must be evenly
and lightly padded before application.

Step 2. Bend the arm to a right angle with the thumb upwards. An
assistant next reduces the fracture, and holds it in position. Then
apply the splints. When adjusting the inside splint, care must be
taken that the internal condyle is eased from pressure by sufficient
padding above and below it. Next fasten on the splints by a roller
begun at their lower end, leaving the hand free, and carried up to
the elbow. Before turning round that joint a soft pad must be placed
in the hollow of the elbow to push the lower end of the humerus back,
and the length of the arm should be measured against the unbroken one
to make sure that the shortening is reduced. Extension is kept up
the whole time the splint is being fixed to the arm, which is done
by carrying the roller round the elbow with figures of 8 and simple
spirals up to the axilla, where it is finished off.

Step 3. Lastly, the forearm is supported in a sling under the wrist,
leaving the elbow free (as in fig. 35, page 52).

After three weeks of complete immobility, passive motion should be
applied to the elbow daily, during a fortnight or three weeks more in
which the splint is still worn.

If the displacement returns very easily, it is better to use an
L-shaped splint passing behind the arm and below the forearm. This
may be made of wood, or of leather, or of gutta-percha, in the mode
about to be described.

The =L-shaped splint= of gutta-percha, or leather, is made as
follows:—

_Apparatus._—1. Sheet gutta-percha ¼ inch thick.

2. A tray or wide wash-hand basin.

3. A basin of cold water.

4. A kettle of boiling water.

5. A towel.

6. A knife.

7. A sheet of newspaper.

Cut a pattern of paper reaching, while the elbow is bent and the
thumb upwards, from the arm-pit down the back of the arm and under
the elbow and forearm to the wrist. The sides must be brought forward
to the biceps and front of the forearm as seen in fig. 34. Next cut
from the sheet of gutta-percha a piece to match the pattern. Prepare
the tray with the hot water, lay in it the towel, and then soften
the gutta-percha by laying it in the tray and covering it with almost
boiling water, adding more water as the first cools; this may be done
by an assistant, while the surgeon directs another assistant to grasp
the forearm and reduce the fracture. The assistant keep extension
while the surgeon lifts the softened gutta-percha with the towel from
the hot and plunges it a moment into cold water, then lays it on the
limb, which the assistant keeps at a right angle, and the bone in
place, while the splint is setting to the limb. This done, the splint
is removed to be trimmed, perforated, and covered with wash-leather.
It is then ready for use.

[Illustration: Fig. 34.—Gutta-percha Splint for fracture at the lower
end of Humerus.]

_Leather_ takes so much time to set that it should not be used in
recent fractures. When the bone is partly set, leather is a useful
substitute for wood. It is prepared from a pattern in the same manner
as the gutta-percha, but is trimmed before soaking, not after it is
moulded, like gutta-percha. If possible it should have twenty-four
hours soaking in _water_ before being fitted to the limb; but when
this cannot be done, immersion in hot water, into which a teacupful
of vinegar has been thrown, will make the leather quite supple in a
quarter of an hour. The leather splint must be worn twenty-four hours
while it sets, and then be removed for covering (see Leather Splints).

=Fractured Shaft of the Humerus.=

_Apparatus._—1. Four straight hollow splints.

2. Rollers 2 inches wide, and 1 inch for the fingers, or straps and
buckles.

3. Pads and wool.

4. Sling.

When broken below the attachment of the deltoid and coraco-brachialis
muscles the displacement of the bone is commonly prevented with
ease; neither shoulder nor elbow-joint need be fixed, and it is not
necessary to apply the splints so tightly as to risk interference
with the venous circulation. If the pectoral muscles or deltoid be
connected with the lower fragment, the displacement is sometimes
obstinate; in such cases it is necessary to buckle the splints
lightly. For this to be done, the fingers, hand, and forearm must be
previously bandaged to prevent œdema; with this addition, the method
of treatment is the same in both varieties of fracture.

Step 1. Select the splints; they should be hollowed, of wood,
perforated sheet zinc, or wire gauze, about 2 inches broad, lightly
padded, and provided with straps and buckles.

The external one reaches from the acromion to the outer condyle; the
inner one from the axilla to the inner condyle; a third shorter one
is placed behind the arm, and if there is much projection forwards of
the lower fragment, a fourth very short one is added in front. The
patient should sit on a chair while the apparatus is being put on.

Step 2. The fingers and thumb are bandaged; then, the hand and
forearm, first padded with a little wool in the palm and over the
wrist, are evenly bandaged to the elbow, round which the roller is
carried while the joint is well flexed; this being covered in, the
roller is made fast.

The first step of bandaging the hand and forearm before applying the
splints is better omitted if the compression requisite to procure the
natural position of the bone does not interfere with the circulation.

Step 3. An assistant grasping the elbow in one hand, pulls down the
lower fragment, while he steadies the shoulder with the other. The
displacement thus reduced, the surgeon applies the splints, taking
care that the inside splint does not reach too high into the axilla,
lest it compress the axillary vein.

In simple cases, the splints should be drawn close by straps and
buckles; where the muscles are powerful, a roller should be wound
round the splints instead of straps.

[Illustration: Fig. 35.—Fractured Shaft of the Humerus.]

Step 4. A 2 inch wide roller is fastened to the arm above the elbow,
and then carried round the trunk to the arm again, to steady the
limb against the body.

Step 5. The hand and wrist are supported by a sling over the
shoulders, the elbow being allowed to hang (see fig. 35).

This apparatus is worn three weeks, when the bandages are removed
from the forearm, and the splints replaced less tightly than before.
They may be substituted by a sheath of gutta-percha moulded to the
arm from the acromion to the elbow, and buckled on to the limb. The
arm must be supported by splints for five weeks, but passive motion
of the elbow and wrist should be adopted after the third week. The
wrist especially should be set at liberty as soon as possible. In
treating this fracture great care is necessary that the bone be kept
in accurate and close position, as the humerus is specially prone to
remain un-united for many months.

=Fracture of the Anatomical or Surgical Neck of the Humerus=, of the
Great Tuberosity, and of the Neck of the Scapula. These fractures are
similarly treated.

_Apparatus._—1. Paper for pattern.

2. Gutta-percha, leather, or millboard.

3. Pads. A soft thin pad, 10 inches long, 5 inches wide (a double
fold of thick flannel or blanket answers very well), is wanted to
line the axilla. If the cap is of leather or gutta-percha, a lining
of wash-leather should be added after the splint is made.

4. Rollers, 2 inches and 1 inch wide for the fingers.

5. Scissors.

6. A tray, and kettle of hot water.

7. A towel, and basin of cold water.

8. Sling.

9. Cotton wool.

Step 1. Cut out a paper pattern of the splint on the limb to be
fitted. The pattern should reach along the clavicle to the root
of the neck, and over the scapula to its posterior border, and be
continued down the arm to the elbow, tapering as it goes, but having
its anterior and posterior margins brought sufficiently to the
inner side of the arm to give the splint a good grasp of the limb
in descending. The end should be left long enough to turn a couple
of inches round the point of the elbow (see fig. 36). A notch must
be cut at the upper end of the paper pattern to make it fit on the
shoulder between the clavicle and the spine of the scapula; this
should not be repeated in the gutta-percha, as that can be moulded on
without; and for that reason the cap is much more serviceable when
made of gutta-percha than of leather, where a notch must be cut and
stitched together when the leather is set. The gutta-percha, when cut
to pattern, must be softened in the manner described in making the
splint for the elbow at page 50, fig. 34; then accurately adjusted
to the shoulder as high as the root of the neck, and turned under
the point of the elbow a couple of inches (see fig. 36), while the
forearm is well raised across the chest.

[Illustration: Fig. 36.—Cap for fracture near the Shoulder.]

When set, the splint must be removed that it may be trimmed and
lined with wash-leather. If of gutta-percha, it must be perforated
with small holes; if of leather, the notch at the shoulder must be
stitched together. Next prepare a soft thin pad, 5 or 6 inches broad,
and 8 or 10 inches long, to fill the axilla.

Step 2. Bandage the fingers and thumb separately, then, putting a
little wool in the palm and round the wrist, bandage the hand and
forearm to the elbow, where the bandage is fastened.

Step 3. Apply the splint. First get on the cap; then put the soft
pad in the axilla, filling it out if the arm-pit is very hollow with
cotton wool, and bend the elbow till the hand lies on the breast
of the opposite side. Then, while an assistant holds the limb and
apparatus in position, fasten them all in place by continuing the
roller of the forearm in figures of 8 round the elbow until the
splint is well fixed to it; and carry the roller up the arm by
reverses to the axilla.

Step 4. A little wool or piece of flannel having been placed in the
opposite arm-pit to prevent chafing, a spica for the shoulder is then
applied (see page 16), beginning at the root of the neck and working
downwards. Careful extension is continued by the assistant all the
time this bandage is being put on, until the head of the bone is well
drawn into the cap.

[Illustration: Fig. 37.—Fracture at the upper end of Humerus. The
apparatus completed.]

Step 5. The arm is drawn to the side, and the forearm fixed against
the chest by a roller carried round the arm and trunk and over the
shoulder (see fig. 37).

After three weeks the forearm may be released, but the cap and
axillary pad must be continued to be worn two or three weeks longer
while the arm is well drawn to the side, and the wrist carried in a
sling.

=Fracture of the Great Tuberosity= of the humerus is difficult to
treat, on account of the tuberosity being carried backwards by the
muscles and the humerus being rotated forwards. Hence the parts must
be braced together with a firm cap of gutta-percha moulded on to
the shoulder while soft, and while the fractured parts are held in
apposition, which may be done by the fingers, or by putting on a wet
roller firmly over the shoulder as a spica before the splint is set.
When the splint is hard the bandage may be taken off, and the splint
removed and finished ready for application. In doing this, the steps
are the same as for fracture of the surgical neck of the humerus,
and the necessity for fixing the arm well to the side of the body as
great as in that fracture.

=Fracture of the Acromion= is treated very much like fracture of the
clavicle, that is, the arm is well raised by a sling under the elbow,
and then fastened to the side. It is not necessary to fill the axilla
with a pad, as in fracture of the clavicle, for in this case the
shoulder is not drawn inwards.

=Fracture of the Clavicle.=

_Apparatus._—1. Axillary pad.

2. Roller, 3 inches wide.

3. Sling.

4. Wool.

Fractures of the clavicle nearly always leave some deformity after
union; this is best avoided by keeping the patient on his back on a
flat couch with the head alone supported by a cushion, and the arm
fixed to the side until union has taken place. As most persons will
not submit to a fortnight or three weeks’ confinement in bed for
this accident, the fragments must be kept in position as nearly as
possible by apparatus while the patient goes about.

The displacement of the outer fragment is _inwards_, _downwards_, and
_forwards_. Many varieties of apparatus are employed to prevent this
displacement during union; the following mode is perhaps as effectual
as any other in accomplishing this object.

Step 1. Fix in the arm-pit a firm wedge-shaped pad of bedtick filled
with chaff; 5 inches broad, 6 inches long, and 1½ or 2 inches thick
at the thick end, or just enough to fill the axilla and throw out the
humerus without compressing the axillary vein, hence the thickness
varies with the hollowness of the axilla (see fig. 38). A band and
buckle are stitched to the thick end, which is uppermost. When in
use, this band is passed over the opposite shoulder and keeps the
pad in place. A little wool should be put under the band, where it
crosses the root of the neck, to prevent chafing.

[Illustration: Fig. 38.—Wedge-shape pad for broken Collar-bone,
attached to the American ring-pad.]

Step 2. The elbow is elevated by an assistant, who keeps the arm
vertical and lays the fingers on the breast bone. A roller attached
to the arm by a couple of turns is carried behind the back round the
trunk, and over the arm above the elbow, drawing that close to the
side.

Step 3. To support the elbow, the longest border or base of a
three-cornered handkerchief is carried under it, one end passes in
front, the other behind the body; both are then drawn tightly and
crossed over the opposite shoulder, where one end is taken under the
axilla, and tied in front. In giving this direction the ring-pads
shown in the figures are supposed not to be at hand. Lastly, the
loose corner at the wrist is folded neatly and pinned up (see fig.
39).

[Illustration: Fig. 39.—Apparatus for broken Clavicle finished.]

This apparatus must be watched from time to time, and re-adjusted if
any part slips. The sling and pad are to be worn for four weeks.

Union sometimes takes place in three weeks or less, in which case the
pad may be removed so much the earlier; but a sling should be worn
for a fortnight after the bandage and pad are laid aside. In children
the pad must be very much thinner and shorter than that described;
the sling should be replaced by a bandage carried alternately round
the body, and over the opposite shoulder. After it is put on the
turns should be well stitched together, and smeared over with stiff
starch. In bandaging children, great care must be taken to protect
with wool the parts likely to be chafed.

_Figure-of-8 bandage._—Many surgeons still employ a figure-of-8
bandage carried under each axilla and crossed behind the back.
Under any circumstances this is exceedingly irksome to the patient,
but is least so if two silk handkerchiefs be substituted for the
bandage, one being passed round each shoulder and the ends of both
braced tightly together behind the back. The wedge-shaped pad may be
dispensed with if the shoulders are braced back, but the elbow must
still be raised and drawn to the side.

The American surgeons have a very good plan for attaching the sling
to the sound shoulder. Instead of carrying the ends of the sling
round the shoulder and under the axilla, they pass over the shoulder
a loose but well-stuffed collar or ring-pad (see fig. 38), to which
they fasten the ends of the sling in front and behind; this prevents
all cutting or chafing under the armpit, and distributes the strain
evenly.


LOWER EXTREMITY.

=Ruptured tendo Achillis= is treated by extending the foot and
flexing the knee; for this purpose the patient wears a high-heeled
slipper. A band is sewn to the heel, drawn tight, and fastened to a
buckle and strap round the thigh, just above the knee. The patient
should not walk for a month unless he will use a wooden leg on which
he can kneel, with the knee bent.

=Separation of the Epiphysis of the Calcaneum=, which sometimes
occurs instead of rupture of the tendo Achillis, is treated in the
same way.

=Fracture of the Fibula.=—_Dupuytren’s Splint._—When the fibula only
is broken, it may be treated in several ways; this, however, is the
common plan:—

_Apparatus._—1. Straight wooden splint.

2. Pad and wool.

3. A roller.

Step 1. The splint should be about 3 inches broad, and long enough
to reach from the head of the tibia to 4 inches beyond the sole of
the foot. A notch 1½ or 2 inches deep is generally cut at the lower
end of the splint to catch the bandage in. The splint is then padded,
care being taken that the padding is sufficiently thick to prevent
galling at the upper end against the inner condyle of the tibia, and
that it becomes thicker as it descends along the leg, for that to
rest easily against the splint; lastly, the pad should end in a thick
boss or projection opposite the internal malleolus, beyond which it
should not reach, lest it interfere with the rotation and adduction
of the foot inwards.

Step 2. The splint, when thus prepared, is applied along the inner
side of the leg, taking care in doing this that the internal
malleolus is against the middle of the splint, and not allowed by the
assistant to slip towards the anterior or posterior border.

Step 3. A roller is then carried round the limb and splint, beginning
below the knee and continuing in simple spirals for three or four
turns, when it is fastened and cut off.

Step 4. A light layer of wool is wrapped round the outside of the
ankle, heel, and dorsum of the foot. Then a roller, beginning at
the splint, passes outwards in front of the ankle over the external
malleolus, behind the heel and the splint; then over the dorsum to
the outer margin of the foot, next under the sole through the notch
of the splint to the front of the ankle joint again, where it repeats
the same course three or four times. Each turn must be tightly
applied and made to draw the foot well inwards to the splint, and in
doing so to tilt outwards the broken part of the fibula (see fig. 40).

This splint is cumbersome, hence after two or three weeks, should
be replaced by a light starch or gum casing for the foot and leg,
leaving the knee free.

[Illustration: Fig. 40.—Dupuytren’s Splint for fracture of the
Fibula.]

=Fractures of the Tibia= with or without the fibula, and fractures at
the ankle joint.

These fractures are often from their obliquity difficult to keep in
good position; in such cases _McIntyre’s Splint_ is very generally
used in the early part of the treatment. For this splint the
following _apparatus_ is required:—

1. McIntyre’s splint.

2. Pads for the double incline plane and foot-piece.

3. Sock of flannel for the foot.

4. Rollers, 3 inches wide.

5. Wool, pins, needle and thread, strapping plaster.

6_a_. A sling-cradle, or

6_b_. Board, block, gimlet, screws and screw-driver.

The McIntyre’s Splint may be used either bent or straight, whichever
position of the knee most relaxes the tension of the muscles on the
fragments. As a general rule the straight position is best if the
fracture is high up, and the bent one, when near the ankle joint.

Step 1. A splint of suitable length is selected, by measuring the
sound leg. The joint of the splint should be put opposite the
patella, and space be left below the foot for the foot-piece to slide
along the slot when extension is made.

The splint is next padded, the hollow where the lower part of the
calf and small of the leg will come being well filled, that the leg
may be thoroughly supported; but the space behind the heel and tendo
Achillis must be left quite clear. A small pad is then fastened by a
strip of strapping or by needle and thread to the foot-piece.

Step 2. The limb having been first cleaned and dried, the dorsum of
the foot and ankle are wrapped in an even layer of cotton wool. A
sock or boot made of flannel is next put on the foot. This may be
readily extemporised by cutting off the foot of an angola stocking,
slitting it up along the back to the toes, and sewing on to the
sole, one inch in front of the heel, the middle of a piece of tape ¼
inch wide and 18 inches long. The foot is then wrapped in the sock,
the edges drawn together by a needle and thread, care being taken
that the sock fits closely round the ankle and dorsum of the foot.
A little wool having been wrapped round the knee, the limb is next
raised, while the splint is placed under it; the screw is turned
until the inclined planes are at an angle suited for the maintenance
of the fragments in position, and the foot-piece is pushed up to
the foot with its screw-pin loose, that it may be adjusted to the
amount of flexion or extension necessary for the foot; this being
ascertained, the screw is tightened to keep it so while the foot is
fastened to the foot-piece. For this the strings of the sock are
brought over the top of the foot-piece, and drawn tight before tying
them.

[Illustration: Fig. 41.—McIntyre’s Splint. The thigh fixed ready for
extension of the leg.]

The position of the heel is very important. It should not sink below
the splint, or it will rest on the bandage; neither should it be
drawn up too high, or the weight of the leg will hang on the sock,
instead of resting on the pad; both frequent causes of pain at the
heel. When the proper position is obtained, the strings are made fast
to the pin behind the foot-piece, and the foot is steadied by two or
three turns of a roller carried round it and the foot-piece (fig. 41).

Step 3. The thigh is next fastened to the thigh-piece by a roller
carried from the top of the splint downwards along the thigh to the
knee, or below that joint if the fracture is near the ankle.

In doing this the roller is passed inside the screw, should that be
placed underneath the splint, as in fig. 43 page 65, and not at the
side as in fig. 41, for the screw will be wanted free for further
adjustment.

[Illustration: Fig. 42.—McIntyre’s Splint slung in Salter’s Cradle.]

Step 4. An assistant grasps with both hands the foot and foot-piece,
and pulls them downwards until the shortening is removed. While doing
this, he tilts the foot up or down as the surgeon finds necessary
for adjusting the fragments, who also bends the knee and raises or
lowers the foot until a good position is attained. The general rule
is to keep the great toe in a line with the patella. This done, the
surgeon tightens up the screw-pin of the foot-piece, and completes
the attachment of the foot by continuing his roller with figures of 8
round the foot and ankle; these turns should not however pass above
the fracture, and be no more than sufficient to secure the position
of the foot and of the lower fragments (see fig. 42).

Step 5. The bandaging usually ceases with what has been already done;
but if the limb swell, a separate roller may be carried along the leg
to support the muscles and restrain œdema, otherwise the leg is best
left bare, that the position of the fragments may be watched, and
evaporating lotions applied.

[Illustration: Fig. 43.—McIntyre’s Splint raised on a Block.]

Step 6_a_. This consists in slinging the limb, for which Salter’s
Cradle is very convenient (see fig. 42), or an ordinary bed cradle
answers very well, from which the limb can be slung on pieces of
bandage carried underneath the splint at the knee and ankle.

_b._ Instead of elevating the limb by a sling, it is also customary
to raise and fix the splint on a block (fig. 43), 6, 8, 10, or even
12 inches high, as may be necessary; this block slides in a groove
on a board 3 feet square, put between the mattress and bedstead, to
afford a firm support for the block.

In ordinary cases the limb is kept on the splint three weeks, until
the irritation has subsided, and partial union is attained; the
splint may then be replaced by a starch bandage, and the patient may
leave his bed.

=Transverse Fracture= of the _tibia_ alone, or even of both bones,
when the displacement is small, is very well treated by a hollow
splint on each side. Both splints are cut away opposite the malleoli,
and the foot-piece of the inside one should not extend beyond the
tarsus; that of the outside passes to the toes. The splints reach on
each side to the head of the tibia, but ought not to extend above the
knee-joint (see fig. 44).

[Illustration: Fig. 44.—Outside lateral Splint for the Tibia.]

Step 1. They are padded lightly and evenly along their whole length,
and applied to the limb on each side.

Step 2. They should then be fastened by figure of 8 round the foot
and ankle until the foot is securely fixed in them. The bandage
should then be fastened off, and extension made by an assistant, who
grasps the foot and ankle with both hands while the surgeon fixes
the splints to the limb above the fracture, beginning his roller
at the top just below the knee, and continuing it downwards with
spiral turns until the fracture is reached, above which it should
terminate (fig. 45). After the apparatus is applied, the limb may
be either supported upright by sand-bags, or slung in a cradle, for
three weeks, after which the splints are advantageously replaced by a
starch bandage for three weeks longer.

[Illustration: Fig. 45.—Lateral Splints for simple transverse
fracture of the Tibia.]


_Flexing the Leg for Fracture of the Tibia._

Sometimes, when there is unusual difficulty in preventing
displacement of the fragments while the limb is nearly straight, the
bones can be readily kept in position if the patient lies on the same
side as the injured limb and the knee is well flexed. For such cases
these splints are very suitable; they should be applied after the
limb has been bent and the fragments brought into apposition. When
the splints have been put on, a roller may be carried round the leg
and thigh to keep the limb in its bent position.

=Fracture of the Patella.=—When this bone is broken there is usually
much swelling from effusion into the knee-joint; while this is
present, rest, with cold lotions, and elevation of the foot, are
alone applicable. When the effusion has subsided, the upper fragment
must be brought down to the lower one, by some means like the
following.

_Apparatus._—1. Straight wooden splint with a foot-piece.

2. Pads.

3. Diachylon plaster.

4. Roller.

5. Lint and wool.

6. Two hooks or screws, gimlet, and screw-driver.

Step 1. The splint is first fitted; it should reach from the buttock
to the heel, at which point a foot-piece rises for the foot to rest
against; at the back of the splint a line should be marked 3 inches
above, and another 3 inches below the knee-cap, into which a stout
screw or hook is inserted before the splint is put on. It is then
well padded, to support the calf and leg, while the heel is left
free, and a pad is put between the sole and the foot-piece. A firm
crescent-shaped pad is prepared to sit like a saddle above the upper
fragment.

Step 2. The limb is laid on the splint; an assistant draws the
patella as nearly as possible into its place, and the surgeon lays
the crescentic pad on the thigh above the patella, and takes a strap
of plaster 2 inches broad and 20 long, warms it, and lays the middle
across the compress, drawing each end tightly around the limb, and
then downwards and forwards in a figure of 8; a similar strap is then
fixed below the lower fragment. The knee, shin, ankle, and foot are
then protected by a layer of cotton wool, and the bandaging begins.

Step 3. The roller first fastens the foot against the foot-piece by
figures of 8, then passes up the leg by reverses until opposite the
lower hook, where it is fastened.

[Illustration: Fig. 46.—Fractured Patella, drawing down the upper
fragment.]

Step 4. A second roller is then begun at the top of the thigh and
brought down the limb till it reaches the compress over the patella;
from this point it passes below the lower screw at the back of the
splint and makes one circular turn round the limb; the roller is then
taken upwards across the compress (as shown in fig. 46) to the upper
screw, where it also makes a circular turn; having done this it again
descends to reach the lower screw, and is returned as before. Each
of these turns should be drawn tightly to bring the upper fragment
as near the lower one as possible; when this is done the bandage is
completed over the knee by figures of 8. It suffices to fix the lower
fragment, which cannot be drawn up to meet the upper one; the latter
must descend to it.

Step 5. The limb is lastly put into position by elevating the heel
and by raising the body with pillows till it is in a half-sitting
position.

The patient wears this splint four weeks, during the first fortnight
of which the bandage should be perseveringly re-applied every three
or four days until the upper fragment is brought into apposition
with the lower one. After this the splint may be changed for a light
starch or gutta-percha case, to be worn for six weeks more, and
then replaced by a back splint of leather and knee-cap, that must
not be laid aside for another period of three or four weeks. If the
patient can be persuaded not to bend his knee for four months, the
union of the fragments will be less likely to yield afterwards. He
should be also warned that much stiffness will result from the long
fixed position necessary to procure good union between the fragments;
but the stiffness will all subside in time, notwithstanding the
long-enforced rigidity.


_Strap and Spiral Bandage._

_E. K. Samborne’s Plan of drawing Patella Fragments together._—A
strip of diachylon plaster 4 feet long and 2½ in. wide is applied to
the front of the limb from 2 in. below the groin to the small of the
leg, leaving a free loop or doubling opposite the patella. Beneath
this loop a firm compress or horseshoe pad is placed above the upper
fragment. A roller is then carried round the limb to keep the strap
in place, but leaving the loop at the knee exposed. This done, the
body is propped up in a half-sitting position, and the limb elevated
on an incline. A stick, 6 inches long and ½ inch thick, is inserted
into the loop of plaster, and then twisted round and round till, by
shortening the loop, the loose tissues of the thigh, and with them
the upper fragment of the patella, are drawn down to the knee. The
stick is prevented from untwisting by a roller lightly carried round
the knee. As the plaster slackens, the stick may be tightened from
time to time and the fragment brought in a few days into its proper
place.

[Illustration: Fig. 47.—Malgaigne’s Hooks.]

_Malgaigne’s Hooks_ (fig. 47), for drawing closely and holding
together the fragments in transverse fracture of the patella, or of
the olecranon, often procure a closer union than any other method.
They should not be inserted until effusion is absorbed and the
soreness has subsided. To insert them, one pair of hooks should be
bedded in the ligamentum patellæ, and catch against the lower edge of
the bone; the skin is then drawn up the limb, while the upper pair
of hooks is passed through it and behind the upper fragment; the
two ends are then approximated by turning the screw. The fragments
usually do not come quite close the first day, but the next they can
be drawn so firmly together that if one is moved the other goes with
it. In applying the hooks care should be taken that the upper pair go
well through the skin and fascia behind the bone, or when they are
screwed up the upper fragment is apt to ride unevenly over the other,
and exact junction is lost. The pain of the insertion soon passes
off, and the hooks can commonly be worn without annoyance for five
or six weeks, until union is secured.

=Fracture of the Shaft of the Thigh-bone.=—_The long Splint._

_Apparatus._—1. A wooden splint.

2. Rollers, 3 inches wide.

3. Perineal band.

4. Strapping, needle, and thread.

5. Pad and wool.

The splint for an adult should be 2½ or 3 inches wide, and long
enough to reach from the nipple to 4 or 5 inches beyond the heel;
two round holes ¾ inch diameter are cut at its upper end, and at the
lower one two notches 2 inches deep.


_Liston’s Mode of applying the Long Splint._

Step 1. The end of a roller is split for a few inches, and tied in
the holes at the upper end. The roller itself is carried down the
inside of the splint and attached temporarily to the notches at the
other end; a pad is then fastened on, by drawing the margins together
with needle and thread across the outside of the splint, or by tying
strips of bandage round the pad and splint at short distances.

Step 2. The limb having been washed with soap and water, well dried,
and afterwards dusted with starch powder, especially at the perinæum,
the ankle and dorsum of the foot are wrapped in a layer of cotton
wool, and the splint applied along the outside of the body. The
bandage which was fastened to the splint is now released from the
notch; and, taking with it the end of the pad, is carried under the
sole, then over the ankle joint to the splint, and behind the ankle
round the internal malleolus to the dorsum of the foot, then through
the lower notch of the splint to the inside of the foot again. This
figure of 8 is carried four times over the dorsum of the foot, twice
through each notch of the splint, and is made fast by a pin or a
stitch. In doing this, care must be taken to keep the leg and splint
parallel, and that the splint does not ride over the back of the
foot; the external malleolus should be midway between the margins;
moreover, the bandage must fit firmly round the ankle and splint, not
spreading over the dorsum more than can be helped, to avoid straining
the front of the ankle. Means for more effectually preventing this
will be afterwards detailed.

Step 3. Next apply counter-extension; for this, the perineal band
is used. The band consists of a silk handkerchief or napkin folded
into a _flat_ ribbon, 1 inch wide and covered for about 1 foot of
its length with oiled silk. A piece of smooth brown paper, 1 foot
long and 4 inches wide, folded into a ribbon one inch wide, makes an
excellent foundation for the silk handkerchief to be folded upon. A
band thus prepared is too stiff to become a cord after it has been
worn a few days, which a simple handkerchief is apt to do. One end of
the band is passed in front in the groin, and one behind the buttock,
so that it bears on the tuber ischii in the perinæum; the ends are
then drawn separately through the holes in the splint. All being
ready for extension, an assistant, grasping the leg and splint above
the ankle, pulls out the shortening till the broken bone is in a good
position; the ends of the band are then tightened and made fast in a
knot.

Step 4. First protecting the bony points with cotton wool, the
muscles about the hip are confined by a spica carried round the body
and the splint, not merely a simple figure of 8 as depicted in the
figure, but a series of overlapping turns which ascend and cover in
the hips well. Afterwards the upper end of the splint is drawn close
to the body by a few turns of a broad roller carried round the chest
from _above downwards_ (see fig. 48).

[Illustration:

  Fig. 48.—The long splint, with elastic stirrup extension at the
  foot. Bandage carried up to the seat of fracture.
]

Step 5. It is customary to carry the bandage further than the ankle,
but this is not an essential part of the apparatus, which is simply
to keep up the extension in the direction of the axis of the limb.
This subsidiary bandage has the disadvantage of concealing the limb,
and the position of the broken ends of the bone; but it steadies the
limb on the splint, and confines the muscles, thereby preventing pain
and perhaps hindering rotation outwards of the upper fragment. Before
putting it on, some cotton wool is wrapped round the knee, and laid
along the shin; the application of the roller is then begun at the
ankle where it first terminated, and is carried up the leg, over the
knee, and along the thigh by reverses until the groin is reached,
where it finishes.

The perineal band must be changed whenever it gets soiled, and the
skin washed before a clean one is adjusted. After the first few days
the band need not be very tight; it suffices if not slack or loose.
Mr. Coxeter makes india-rubber tubes in the shape of a perineal band;
these are filled with water when in use (see fig. 49).

[Illustration: Fig. 49.—Coxeter’s elastic perineal band.]

_Stirrup extension_ is a mode of relieving the strain on the front of
the ankle, caused by the lower end of the splint being attached to
it. A 3-inch wide roller or bit of wood of the same breadth is laid
against the sole of the foot, and a stout india-rubber ring 2 inches
in diameter is slipped over it. A piece of strapping plaster, 2½ feet
long and 2 inches wide, is passed half-way through the ring, and its
ends carried up the leg inside and outside; the plaster is kept in
place by a roller or second strip laid on in spirals up the limb as
in fig. 50, and the india-rubber ring is hitched against a hook at
the end of the splint. By this means the strain is transferred to the
leg, and the ankle is quite free. It is perfectly successful, and
very easy to the patient.

The long splint is to be worn continuously for six weeks; or, what
is better, after the first three weeks it may be replaced by a starch
bandage, and the patient allowed to get about on crutches with his
leg slung from his neck.

[Illustration:

  Fig. 50.—Mode of fastening the stirrup to the leg, to avoid
  straining the ankle.
]

=Continuous Extension with the Limb flexed.=—The muscles attached
to the upper end of the femur sometimes cause so much flexion and
rotation outwards of the upper fragment that union of the bones in
this position produces a result approaching that in fig. 51, drawn
from a preparation in the museum of University College.

This crooked union is prevented by bending the thigh and relaxing the
muscles of the hip. This object is accomplished by using the _double
incline planes_ or the _double incline planes, slung_, shown in figs.
52 and 53.

[Illustration:

  Fig. 51.—Fracture below the trochanters; bone in angular union.
]

_Double incline planes_ are sometimes employed alone. The limb is
raised over a wooden frame about 8 inches broad, with a double slope
high enough at the apex for the leg and foot to hang unsupported down
the further side (fig. 52). It is well padded before being applied,
and the leg and thigh secured to it by a roller passed round the
limb and plane, or better, a trough of gutta-percha may be moulded to
the limb while it is on the plane, and when set, screwed down to the
wood at one or two points; in this the limb rests securely.

[Illustration: Fig. 52.—Double incline planes.]

=Slinging the double incline planes= was practised many years ago
by Mayor of Lausanne, and has been much used recently. It is an
apparatus very easy for the patient, and particularly well suited for
compound fractures of the thigh, for fractures near the trochanters
that require a flexed position, or for fractures of the neck of the
femur where the patient’s feebleness does not permit the constraint
of the long splint.

_Apparatus._—1. A bent wire frame (see fig. 53) with a separate
foot-piece.

2. Two pulleys, a rope with tent stretchers passing up to hooks in
the ceiling, or some suitable support.

3. One long and one short soft pad.

4. Strapping plaster, and some ends of bandage.

Step 1. The limb is washed and dried, and the short pad fitted to the
foot-piece, which is furnished with some hooks at its lower surface,
where ends of bandage or tape can be fastened, for fixing it to the
wire frame. The frame is next prepared by passing strips of bandage
across it from side to side at short intervals, to make a support
on which the limb is laid; if there is no wound, a soft pad may be
put on the frame first, but if one be present, the limb should rest
immediately on the strips of bandage, which can be changed whenever
soiled, and replaced by clean ones without disturbing the limb. These
strips should be tacked on with a needle and thread, that, when the
limb is placed on the apparatus, they can be shortened or lengthened
till the leg bears evenly on them (see fig. 53).

[Illustration: Fig. 53.—Double incline plane, slung.]

Step 2. The foot-piece is adjusted and fastened to the foot by straps
of plaster carried round it and up each side of the leg, as was done
for the stirrup extension in the “long splint” (p. 76).

Step 3. The limb is next placed in the cradle formed for it, to the
lower end of which the foot-piece is tied securely; the ropes are
rove through the pulleys and tightened till the limb swings easily.
The point of attachment of the ropes must not be just above the
limb, but beyond it, that the leg may be drawn away from the body
along its own axis. The weight of the body makes counter-extension
sufficient to remove all shortening in a few days. The relief from
the constraint attending the absolute immobility of the long splint,
renders this apparatus a particularly easy one for the patient; and
union is found to take place without any shortening of the limb.
Where there is no wound, the limb and frame may be kept together by
a roller bandage carried round them from the toes to the knee, after
the limb has been adjusted in the splint.

=Continuous Extension in the straight position= is employed for
fractures of the femur and in hip-disease. It is procured as follows.
A stirrup is fastened to the leg in the way described at page 76;
to this a cord and weight are attached below the sole of the foot,
and passed over a pulley fixed to a tripod frame (fig. 54), or any
convenient object below the bed, in a line with the axis of the
limb. The weight should balance the contraction of the muscles, and
usually varies between 2 and 6 lbs. A perineal band fastened behind
the patient’s head keeps the body from following the limb. The weight
may be a common scale weight, or a bag with a hole at the bottom
closed by a string, and filled with shot or sand, or a can with a tap
at the bottom filled with water: these arrangements allow increase or
lessening of the weight, without slackening the cord and moving the
limb. This apparatus requires no bandages, which are so difficult to
keep clean in children, and exerts a very even and continuous strain
on the limb.

[Illustration: Fig. 54.—Fracture of the femur. Extension by weight
and pulley.]

The perineal band may be often dispensed with, by laying the patient
on a flat mattress and raising the foot of the bedstead a few inches
higher than the head; the body then sinks towards the head of the bed
and resists the extension of the leg.

=Starch Bandage.=—The following mode of applying the starch bandage
and pasteboard splints may be used in all varieties of fracture;
the length of the splints and the number of joints that should be
included depend on the bone that is broken.

Some surgeons apply the starch apparatus immediately after the
fracture has happened, others wait until partial union is procured
and the irritability of the muscles has subsided.

_Apparatus._—1. Sheets of bookbinder’s millboard.

2. Rollers suitable for the size of the limb.

3. Cotton wool.

4. A basin of freshly scalded starch.

5. A long strip of plaster, to reach as high as the bandage will
extend up the limb.

6. If the fracture be recent, a wooden splint will generally be
necessary to keep up extension while the starch is drying.

As a general rule, the joint at the lower end of the fractured bone
should always be fixed, and that at the upper end also, if the
fracture is near that point. For an example of the mode of fitting,
let us suppose the femur is broken between the middle and lower
thirds as in fig. 56.

Step 1. The limb is first measured for the splints. The length from
the top of the sacrum to the heel, from the tuber ischii to the
inside of the foot, and from the iliac crest to the outside of the
foot, should be taken, and three strips of millboard prepared of
corresponding lengths; the posterior one being 3 inches wide above
and 2 inches, or, if the limb is small, 1½ inches wide at the heel.
The inner and outer strips of similar width must be cut with side
pieces for the foot, and these side-pieces stop short of the roots
of the toes. For a child’s thigh, the foot need not be included, it
suffices for the splints to reach the small of the leg, though to
prevent shortening in an adult it is usually necessary to include the
whole limb. The splints are readily cut, by first marking on the
sheet of millboard, the required width and length of the strips, then
bending the sheet over the edge of a table along these lines. The two
lateral splints may be first taken from the sheet in one wide strip,
after allowing for the foot-piece; the two strips are separated
through a diagonal line, so that the broad end of one splint is taken
from the other (see fig. 55).

[Illustration: Fig. 55.—Diagram showing the mode of cutting out
splints from a sheet of millboard.]

When the strips are cut they should be laid on a large tea-tray,
boiling water poured over them, and a minute or two later, some
boiling hot thin starch; this soon soaks into and softens the
millboard till it is thoroughly pliant. When somewhat softened, the
edges should be thinned by peeling off little strips along them,
after which some more boiling water may be poured on and allowed to
soak in while the limb is prepared.

Two or three rollers should then be unwound, and passed as they are
rolled up again through the basin of starch; these, thoroughly soaked
in starch, are used for the first layer, dry rollers serve very well
for the second layer.

Step 2. The limb is washed and dried; a strip of diachylon plaster
one inch wide is laid along the front to protect the skin when the
case is being cut open after it is dry; the limb is next wrapped
evenly in cotton wool, putting a scrap between each toe. This is
best done by unrolling a sheet of wadding, splitting the sheet into
a layer of suitable thickness, which is torn into strips about three
inches broad, that are then wound evenly round the limb as high as
the splints will reach.

Step 3. The splints are next adjusted and moulded to the limb, being
temporarily secured by a few ends of bandage tied round them. One
assistant grasps the splints and foot at the ankle and keeps up
extension, while another holds the thigh. The surgeon then proceeds
to roll the bandages, first round the foot and ankle, and then up the
leg, rubbing in the _warm_ starch as he proceeds. Each turn of the
roller should be made as tightly as possible, for when the case dries
it always grows loose by the evaporation of the water it holds. As
reverses are always difficult to cut through afterwards, they should
be avoided, and the bandage laid on in simple spiral or figure of
8 turns. When the perinæum is reached, the surgeon wraps round the
pelvis a broad strip of cotton wool, while an assistant on each side
of the patient supports his body on a folded sheet or jack-towel, and
a third holds the broken limb. The bandaging is then continued in a
well-fitting spica, and ended by a few circular turns round the body.
If the splint touches the crest of the ilium it should be shortened
till it clears that point, or it will gall the patient afterwards.
A fold of soft lint in addition to the cotton wool should line the
splint at the perinæum, or the sharp edge of the bandage, when it is
dry, will chafe there also. When the first bandage is complete, the
limb should be smeared again with starch, and a dry bandage rolled
over it from below upwards, which must be similarly saturated with
starch as it is laid on the limb, and when finished the whole is well
covered with starch.

If the fracture is recent, and no union has taken place, a long
splint should be put on outside the case, fastened to the foot and
extended by a perineal band, while the starch is drying, that the
limb may not shorten. With children it is best to apply the wooden
splint in all cases, as they are apt to wriggle about, or sit up in
bed and disarrange the case while it is in a pliant condition. If
the wood splint is not used, the limb should be supported in a good
position by sand-bags laid along its sides.

[Illustration: Fig. 56.—Starch Bandage.]

In three days the starch is quite dry, but the drying may be hastened
by hot-water bottles or hot sand-bags laid in the bed. It must then
be cut up along the front from bottom to top; it will often be
found loose, especially where swelling had existed before; this is
best remedied by paring the overlapping edges with scissors. If any
projecting part is chafed, an accident that ought not to happen,
the case may be lifted from the sore part by a little more wool laid
around, _not on_ the part pinched. The limb being in a satisfactory
position, and the case fitting properly, a roller is carried up over
the whole to keep it in place while it is worn (fig. 56).

The patient need not now be confined to bed; on the contrary, the
limb should be supported by a sling round his neck, while he gets
about with crutches, if his leg be the part injured.

The fracture should be examined from time to time, and at the end of
three weeks some of the joints previously confined in the splint may
be released by cutting off the part covering them; but if the part is
a dependent one, such as the leg, it should be supported by a bandage
after the splint has been removed. The limb may also be washed with
soap and water, and then anointed with simple ointment, if the skin
be roughened or irritated by long confinement.

In six weeks the starch splint may usually be discarded, and a roller
alone worn for a few weeks longer.

=Plaster of Paris Bandage.=

_Apparatus._—1. Freshly burned white plaster of Paris. If the plaster
have become stale by keeping in improperly closed vessels, and it
be impossible to obtain fresh plaster, the water the plaster has
absorbed from the atmosphere can be driven off by heating the powder
in a dry oven to about 200° F. to 260° F., but not higher, as greater
heat destroys the power of “setting.”

2. Rollers, about 2¼ inches wide, of muslin with a coarse open
texture.

3. A roller of Welsh flannel 3 inches wide and 6 yards long.

4. Basin of cold water, sponge, and a kitchen spoon.

5. Soft lard or spermaceti ointment.

Step 1. The muslin rollers are prepared by being loaded with dry
powder just before they are used. To do this the roller should be
gradually unrolled on a table while one person rubs in the powder,
and a second rolls the loaded bandage up again. When three or four
are loaded they should be plunged for a minute into cold water, and
then are ready for use. While this is being done the limb should be
thoroughly washed and dried, supported, if the fracture be recent, by
sand-bags.

[Illustration: Fig. 57.—Plaster of Paris Bandage, for simple fracture
of the tibia, and common bed cradle.]

Step 2. The surgeon carefully greases the limb wherever the plaster
will reach, and rolls a Welsh flannel roller round it for about
3 inches at the point where the plaster roller will cease. This
protects the skin from the rough edge of the plaster splint when the
apparatus is set and hard. Indeed, if the whole of the surface to be
covered with plaster be enveloped in a flannel roller, the apparatus
is more comfortable to the patient, and in this case the grease may
be dispensed with. When the limb is prepared the surgeon intrusts
it to assistants, who will maintain reduction while he lays on the
plaster rollers, wetting them freely as they are laid on, with a
sponge at hand in a basin of cold water. Usually two layers of roller
give sufficient rigidity to the apparatus; but if the limb is heavy,
the case should be strengthened, by smearing over it a coating of
plaster, prepared by shaking the powder into a basin of water kept
constantly stirred, till it has the consistence of cream. The surgeon
must watch that the fractured bones are kept in position till the
plaster is set, a process sufficiently advanced in five minutes, when
the bandage, supported by sand-bags, may be left to dry.

When the plaster is quite set the bone is immoveable and may be
carried about without risk of displacement. In deciding what joints
should be included in the bandage, the same rules obtain in this as
for the starch bandage; no more joints should be rendered immoveable
than are necessary to obtain command of the broken bone; when the
fracture is near a joint, that must be confined to prevent the bones
being moved with the movements of the joint; when the fracture is far
away from it, sufficient control can be exercised over the bone to
prevent the broken ends moving, and the joint may remain free.

If the plaster apparatus is applied over a wound, the latter
should be covered with greased lint, and its position noted before
the rollers are applied; when the apparatus is set, the plaster
must be dissolved around the wound by touching it with strong
nitro-hydrochloric acid; when this is carried completely round, the
isolated fragment of plaster may be removed, and the wound exposed.

For removal, the roller can be unwound again readily, or it can be
softened by acid along a line, and slit up with scissors, when the
apparatus comes off in a piece.

Should bandages of loose texture not be at hand, _common rollers_ can
be made to answer the purpose tolerably well in the following way.

Having washed and dried the limb, and reduced the fracture; the bones
are held in position by assistants, while the limb is greased and
enveloped in a dry roller by simple turns and figures of 8. A basin
of plaster is prepared by shaking the powder into water till a thin
cream is formed, which is laid on the bandage with a spoon, or the
hands. Then a second but wetted roller is put on in the same way
quickly before the plaster has set, and covered in its turn, until a
case of sufficient thickness is procured.

This bandage is much improved if the first roller be of flannel
instead of calico. The flannel roller may be unrolled and loaded with
dry plaster, like the muslin, and wetted before using; in this way
it contains nearly as much plaster as the loose webbing rollers of
muslin.

In the Army Medical Reports for 1865 (1867), Mr. Moffitt describes
a very ready method of employing the plaster splints for recent
fractures. Instead of bandaging the limb, an envelope of Welsh
flannel is fitted to the part to be supported.

The flannel should envelope the limb, except for a longitudinal
space about ½ inch in width between the edges of the flannel. The
dotted lines in the accompanying figure show the shape of the flannel
when fitted to the leg. The limb being thoroughly greased, the
flannel is well soaked in thin plaster cream, and laid on a table
while the creases are smoothed out of it.

When ready it is applied accurately to the limb, so as to fit
everywhere, but leaving a narrow open space along the whole length of
the limb. The flannel must be held steadily till the plaster is set,
which takes place in about five minutes, and the splint is complete.
If one layer is not stiff enough, a second may be laid over the first
in the same way. When the splints are fitted, they are kept in place
by a roller applied lightly over them. If instead of soaking the
second layer of flannel in plaster, it be thickly spread with strong
solution of British gum (dextrine), and the gummed side laid next
the first flannel, the splint is tough enough to stand any ordinary
strain without breaking.

[Illustration:

  Fig. 58.—Moffitt’s method of applying plaster of Paris splints.
  Copied from Army Medical Reports for 1865.
]

Gum thickened with powdered chalk, glue, silicate of soda, Hides’
leather felt and stiffening solution, paraffine, &c., are also
employed for stiffening bandages and flexible splints, after they
are moulded to a limb, but none of them are as readily procured or
have much advantage over starch and plaster of Paris. A detailed
description of the mode of using them is unnecessary.

=Sand-bags= are very useful, when laid along an injured limb, to prop
it up on either side. For this purpose they are better than pillows,
as their weight prevents their slipping from under the part they
support. They should be made of macintosh cloth about 4 or 6 inches
diameter, and in lengths varying from 1 to 4 feet, well closed that
the sand may not escape through the seams; the macintosh should be
covered with flannel, renewed from time to time. The sand should be
washed and well dried before the bags are filled, that it may not
rot the cloth containing it. Moreover, the bags should be only three
quarters full, or they will be too hard to adapt themselves to the
limb when in use.

=Cradles= are light arched frames of wire or cane to support the
bedclothes over an injured limb. On emergency an efficient cradle
can be constructed from a band-box, by knocking out the bottom and
putting the leg through it. If used to protect a foot, a notch may be
cut with strong scissors, _not_ a knife, for that splits the wood.

If the cradle is stout enough, it is useful to sling a broken limb in
its splint, and often great relief is thus given to the patient. Dr.
Salter’s Swing Cradle is specially contrived for the purpose, and is
shown, fig. 42, page 64.

=Leather Splints.=—For these sole leather, to be purchased at any
leather dealer’s, is used. In preparing them, the required length
should be first noted down, then a series of transverse measurements
taken at the widest and narrowest parts of the limb and over the
projections of joints, &c., or a pattern may be first cut in paper
and laid on the sheet of leather from which a corresponding piece
is cut. The splint should always be so arranged that _its edges_
do not bear on any bony point, the shin, or malleoli, for example,
but either fall short of or pass beyond them. The hair side of the
leather should go next the skin, as it is the smoothest and least
irritating. The edges of the splint must be thinned by bevelling off
the outside for about an inch all round, and no sharp corners should
be left. When the leather is prepared it should be soaked, if the
time can be spared, for twenty-four hours in cold water, but when
wanted quickly it can be softened in a few minutes by soaking it in
warm water to which a little vinegar is added—this, however, renders
the leather brittle when dry, and apt to curl at the edges. When the
leather is softened, a very thin even layer of cotton wadding or of
lint is laid on next the skin; the splint is then moulded to the
limb with the hands, and bandaged firmly; in twelve hours it will
be dry and rigid. The roller is then unwound, and any parts of the
splint pressing on bony projections are marked before removal. It is
then trimmed, and laid between two layers of wash-leather stitched
together round the edges. The splint is now finished, and can be
either fastened on by a roller or by two or more straps and buckles
stitched to it.

When support is required for a joint, the splint should be fitted
on the sides, where the leather may have the rigidity of its width
rather than only that of its thickness to prevent bending.

=Leather Splint for the Hip.=—This joint is by far the most difficult
to fit. The hip splint should obtain a good grasp of its fixed point,
the pelvis, and a stiff bearing on the front of the thigh where
its pressure is to be exerted. There are many plans of procuring a
satisfactory fit; the following is one of the best.

First cut a pattern on a sheet of paper from which to shape the
leather. If possible the patient should stand while the pattern is
fitting. Take a sheet of paper large enough to reach round the body,
and long enough to extend from the waist to the leg below the knee.
Lay it against the diseased hip, carry its vertical margin a little
beyond the middle line in front towards the sound side, and the other
part round the body behind, till the front is reached on the sound
side. Feel for the anterior iliac spine, and mark with a pencil the
point midway between it and the pubis; from this draw one horizontal
line inwards to the border of the paper, and a second obliquely to
the perinæum. Then seek for the junction of the sacrum and iliac bone
behind, which corresponds pretty nearly to the point first found in
front; from this mark the gluteal fold. Next carry a line vertically
from the upper border of the sheet of paper to the great trochanter;
and lastly, mark the level of the pelvis. Lay the sheet on a table
and slit it with scissors along the lines marked, apply it a second
time to the body and bend the thigh part round the thigh, making
its anterior margin reach well to the inside of the limb, while
the posterior part should almost meet it from behind. The splint
should also reach downwards to the back of the knee. The paper is
then trimmed down to these dimensions. The hip part is next trimmed
so that it clears the buttock on the sound side and passes round to
the anterior iliac spine of that side. The pattern being complete,
cut a piece of sole-leather to correspond, arranging that the hair
or _short_ side of the leather will lie next the skin; bevel off the
outer edge all round, and soak the leather till thoroughly soft in
water, wipe it dry, and bandage it carefully first to the trunk and
next to the thigh. When it is set, superfluous and overlapping edges
must be marked before removal; lastly, the sides of the vertical
notch, between the hip and trochanter, are stitched together, and the
splint is covered with wash-leather.

[Illustration: Fig. 59.—Leather splint for the hip.]

When extension of the hip is required (see page 80), it can be
applied to the leg below the splint without lessening the support
that affords.

The accompanying figure, 59, is drawn from a splint fitted by Mr.
Heather Bigg on the plan just described.

_Gutta-Percha_ may always be substituted for leather in these
splints, and the same plan of fitting is used, except that the
notching requisite in leather is not necessary in using gutta-percha;
for the directions to use this material see page 50.




CHAPTER IV.

DISLOCATIONS.


The main obstacles in reducing dislocations are entanglement
together of the displaced bones and contraction of the muscles; the
entanglement of the bones determines the direction in which extension
must be made, and also of the _counter extension_, or point at which
the body is fixed to resist the traction practised on the limb; this
should be exactly opposite the direction in which the limb will be
drawn. The muscles can always be relaxed by chloroform, hence it is
better when they are powerful, not to use the limb as a lever to
prize the head of the bone into its place. Steady extension instead
is better, to disengage the bone from the parts against which it is
caught, and to bring it opposite its socket, into which the hands of
the surgeon guide it with less risk of laceration of the soft parts
than attends forcible leverage.

=Lower Jaw.=—This bone is dislocated on one or both sides; when the
condyle has slipped forward from the glenoid fossa, the contracted
temporal muscle keeps the bone from regaining its proper position,
and causes the coronoid process to hitch against the malar bone.

_Treatment._—_Apparatus._—1. A towel.

2. A four-tail bandage.

[Illustration: Fig. 60.—Dislocation of the jaw.]

The patient should be seated in a high-backed chair, resting his head
against the back. The surgeon winds the towel round both thumbs, and
standing immediately in front of his patient, places a thumb on the
second molar of both sides, if the dislocation be double, or on one
side only, if that be alone displaced (see fig. 60). He then presses
steadily downwards until the condyle is released, when it slips back
to its place. The return of the bone may be aided by pushing up the
chin with the fingers _after_ the ramus of the jaw has been lowered.

When the jaw is replaced, a four-tail bandage or split handkerchief
should be tied over the nucha and vertex of the head, to keep the
jaw closed (see fig. 23, page 32). Biting or chewing should not be
attempted for ten days or a fortnight. The patient should be warned
also that when the jaw has been once dislocated it very readily slips
out of place again; he must thenceforth avoid gaping or opening the
jaw very widely.

=The Clavicle= is rarely dislocated, nevertheless both the inner and
the outer end may be displaced. The signs are obvious—the end of the
bone is felt in its new position. The treatment for all is the same.

_Apparatus._—1. Roller, 2¼ inches wide.

2. A piece of old blanket.

The blanket should be torn into strips about a foot square, and
folded thrice, thus making a long soft pad to line the axilla, one
for each armpit. The patient is next seated on a stool; an assistant
standing behind, draws back the shoulder while he presses on the
spine with his knee; the dislocation being reduced, the surgeon fixes
the bone by a figure of 8 carried round the shoulders and across
the back. The forearm is then bent and fastened to the body by a
few turns of the roller round it and the chest. This prevents the
pectorals from acting on the bone. The apparatus may be laid aside
at the end of a week, but the arm must be fixed to the trunk for a
fortnight longer.

This bone is often difficult to keep in place after dislocation, and
even the most accurately fitted apparatus sometimes fails to effect
its object, hence many varieties of collar and yoke have been devised
by different surgeons to accomplish this purpose.

=The Shoulder= is dislocated in three directions, downwards, inwards,
and backwards. These have subordinate varieties, but the signs depend
chiefly on the direction of the greatest displacement.

Signs of dislocation into the _axilla_. When the bone is displaced
below the glenoid fossa the acromion is prominent; underneath it,
the surgeon feels a hollow instead of the head of the humerus, which
the finger detects in the axilla. Movement of the shoulder is very
limited and painful If the elbow is rotated while the finger is in
the armpit, the head will be found to move with the rest of the bone.

If the head of the bone is carried more _inwards_ on to the ribs, it
can be seen and felt near the clavicle; the hollow is again readily
detected below the acromion, while the axis of the arm is altered,
being directed inside its proper position.

When the bone is carried _backwards_ the head is plainly felt on the
scapula below the spine.

For the reduction of these dislocations several plans are employed.
When recent the two first displacements can generally be restored
without chloroform, but if the patient is muscular it often saves
time and pain to produce anesthesia before attempting to replace the
bone.

[Illustration: Fig. 61.—Reducing a dislocated shoulder by the heel in
the armpit.]

_By the heel in the axilla_ (fig. 61).—The patient lies flat on a
couch; the surgeon pulling off his boot from the left foot if he
has to reduce a left dislocation, and _vice versâ_ the right boot,
seats himself on the couch facing the patient. Putting his unbooted
foot into the armpit, he grasps the forearm with both hands and
pulls steadily downwards. When the head of the bone is disengaged
the muscles draw it into the socket, and the movements of the limb
become at once easy and natural. The arm must then be fixed to the
side by a roller for a fortnight, and the shoulder is wetted with
an evaporating lotion to allay the pain and inflammation resulting
from the laceration of the soft parts. Should the surgeon’s strength
be insufficient for the requisite extension, a jack towel may be
attached in a _clove hitch_ round the wrist and held by an assistant,
who standing behind the surgeon draws steadily in the same direction.

_To make a clove hitch._—Grasp the towel in the left hand, the little
finger being downwards, then pronating the right hand till the little
finger is upmost, seize the towel below the left hand; if the wrists
are then rotated in opposite directions the towel will be drawn into
two loops, of which the ends cross above the connecting part between
the loops (see fig. 62); if one hand holds the loops and the other
pulls the ends, the loops will be found not to slip, however tight
the ends are pulled.

[Illustration: Fig. 62.—The Clove-hitch knot.]

_Reduction by simple extension._—The patient again lies flat on his
back, a jack towel is passed round his body and fastened behind
the opposite shoulder for counter-extension, while a second towel
is attached to the wrist by a clove hitch and intrusted to two or
three assistants, who are desired to pull quietly and steadily
directly away from the patient’s body. The surgeon meanwhile watches
the progress of the extension, altering its direction as he finds
the head more or less engaged against the scapula, and finally with
his hands thrusts the head into its socket. Sometimes there is much
difficulty in getting the head back to the glenoid fossa, even
when the humerus is completely disengaged from the scapula; this
difficulty is often overcome if an assistant rotates the humerus
backwards and forwards, while the extension at the wrist and the
pressure on the head of the humerus is steadily maintained. When the
limb is replaced it is fixed to the side as before directed.

[Illustration: Fig. 63.—Dislocation of the shoulder reduced by simple
extension.]

If the dislocation has existed more than a few hours, relaxation of
the muscles by chloroform and extension of the limb carried directly
away from the body are more sure of success than the heel in the
axilla, because they allow greater power to be exerted in a steadier
manner than is possible by the other mode.

=The Elbow.=—The signs of dislocation at this joint are tolerably
evident, but there is often coexistent fracture of the coronoid or
olecranon processes. Separation of the articulating surfaces of the
humerus from the shaft is sometimes mistaken for dislocation of the
forearm backwards.

In dislocation of _both bones backwards_ the olecranon is very
plainly felt behind the lower end of the humerus; the sigmoid notch
is generally to be made out, and the forearm is fixed at a right
angle. The altered relation of the olecranon to the condyles suffices
to distinguish dislocation from fracture of the humerus at its lower
end, where the olecranon also goes backwards, but _the condyles
go with it_. The immobility of the joint distinguishes it from
separation of the lower articular surfaces of the humerus from the
shaft, an accident, moreover, only met with in children.

Other subordinate distinctions between dislocation and fracture are,
the limited movement, the difficulty of restoring the bones to their
natural position, and the absence of crepitus; lastly, the peculiar
form of the articular surfaces can sometimes be made out.

In reducing the _backward dislocations_ the patient sits on a chair
on which the surgeon rests his foot, pressing his knee against the
forearm at the elbow for a fulcrum; then, grasping the wrist with
one hand, and steadying the arm with the other, he flexes the elbow
to dislodge the coronoid process from the fossa at the back of the
humerus; when this is done, the articulating surfaces slip into
place. This plan is commonly adopted when the olecranon is displaced,
but if it fails to reduce the dislocation, direct extension at the
wrist must be employed, as for the following dislocation.

When the _radius only_ is displaced, the body should be fixed by a
jack towel carried under the armpit of the injured side, and over
the shoulder of the sound side. A wetted bandage is rolled round the
forearm, and a second towel is attached by a clove-hitch (see fig.
62, page 99) to the wrist for extension, which is made in the axis of
the limb until the radius can be slipped into its place on the outer
condyle.

[Illustration: Fig. 64.—Reducing dislocation of the elbow round the
knee.]

In all dislocations of the elbow, when the bones are returned the
limb should be bent to a right angle and put on a lateral angular
splint for a week or ten days, after which time it should be worn in
a sling a fortnight longer.

[Illustration: Fig. 65.—Handle for obtaining grasp of the thumb in
dislocation.]

=The Thumb and Fingers.=—When the first phalanx is dislocated from
the head of the metacarpal bone it is sometimes very difficult of
reduction. The most effectual mode is steady extension, which is
procured by fastening the thumb to a piece of wood, which serves as a
handle to give command of the phalanx, and is contrived as follows:
the thumb is first bandaged with a narrow wetted roller over the
two phalanges, and a thick layer of cotton wool is rolled round
it; a piece of stiff wood, 1 inch wide, ½ inch thick, and 12 long,
is perforated at one end with three pairs of holes ½ inch distant
from each other and from the end; through these, three stout tapes,
½ inch wide and 2 feet long, are threaded, leaving three loops on
one side of the piece of wood (fig. 65). The wood is then applied
to the palmar aspect of the phalanges, the loops passed over the
thumb, their ends drawn tight, and tied, not in a bow as the figure
represents, but wound round the end of the stick. The stick thus
attached becomes a good handle for extending the digit, and also a
long lever for altering the direction of the phalanx if desired.
Langenbeck of Berlin employs a pair of forceps to seize the thumb,
instead of the wooden handle just described. But with the greatest
care and perseverance it is sometimes impossible to replace the bone
unless the constricting bands be divided with a tenotome.

=Hip-joint.=—There are three chief directions in which the hip is
dislocated. First _backwards_ on the dorsum ilii, or further on to
the sciatic notch. In this dislocation the limb is shortened, moved
with difficulty, drawn inwards over the other, and its great toe
touches some part of the back of the other foot. The hip itself is
altered, the great trochanter being nearer to the crista ilii, and
more prominent than on the uninjured side, and the head is often
plainly felt in its new position. Resistance to extension of the
limb, limited movement of the hip, with rotation inwards, are the
distinguishing points between this dislocation and fracture at the
neck of the femur.

_Treatment._—_Apparatus._—A complete apparatus for this purpose
is contrived and sold by instrument makers, but a sufficiently
serviceable one can be extemporised when the former is not at hand;
it consists of:—

1. A rope running in two pulley blocks.

2. Three jack towels.

3. Two stout hooks to screw into the wall, or some firm object, to
obtain fixed attachment.

4. A wetted roller 3 inches wide.

The complete apparatus is as follows:—

_Apparatus._—1. A set of multiplying pulleys.

2. A leathern padded girth, 2 inches wide and 3 feet long, having at
each end an iron ring.

3. A stout leathern belt about 6 inches broad, furnished with
buckles, straps, and rings to fasten on to the thigh above the knee;
a rope is run through the rings to connect the hook of the pulleys
with the thigh.

4. Two strong iron hooks to screw into the wall, for fixing the
apparatus.

5. Half-a-dozen yards of stout cord.

6. A hook, fitted with a buckle and strap, and hinged so that, by
turning a pin, it at once disengages itself. If this is interposed
between the pulleys and the hook fixed in the wall, the limb may be
instantaneously released if desired.

[Illustration: Fig. 66.—Dislocation of the dorsum ilii.]

_Treatment._—Step 1. The patient is laid on a flat couch, and put
under the influence of chloroform. When he is narcotised, a jack
towel, or if it be at hand the pelvic girdle, is carried across the
perinæum, arranging it to bear on the tuber ischii behind and the
pubes in front, its ends being attached to one of the hooks screwed
into the wall behind, and about six inches below the level of the
patient. This towel should be put slightly on the stretch, that the
pelvis may be kept in the position first assigned to it when the
pulleys begin to draw. A wet roller is put on the lower third of the
thigh, the jack towel slipped up the leg to the bandage, and fastened
in a clove hitch. Another jack towel is then doubled and passed up
the limb to the perinæum. The patient is next turned on to his sound
side, and the belt of the thigh connected by the disengaging hook to
the pulleys, which are drawn out from each other as far as their cord
will allow, and attached to a hook fixed a little above the level of
the patient, on a line carried from the hip across the junction of
the middle and lower thirds of the uninjured thigh (see fig. 66).

Step 2. The surgeon being ready, an assistant draws on the pulley
cord, getting gradual extension of the limb as required by the
surgeon, who, keeping his hands on the hip and great trochanter,
watches the progress of the head of the bone towards the acetabulum.

Step 3. When the bone has reached the edge of the acetabulum, a
second assistant slips the doubled jack-towel over his shoulders,
and by raising his body, lifts the femur away from the brim of the
acetabulum, while the surgeon, grasping the foot and knee, makes a
few movements of rotation backwards and forwards to ease the head
into its socket.

When a reduction is effected, the limb should be put in a long
splint or starch bandage for three weeks, and the patient not allowed
to exercise the limb freely or violently for a month afterwards.

_Reduction by Manipulation._—When the patient is not very muscular,
and the dislocation recent, the bone can often be speedily returned
by movements of flexion and rotation.

The patient is put fully under chloroform and brought to the foot
of the bed; the surgeon grasps the ankle in one hand, and the knee
in the other, bending that joint till the heel reaches the thigh;
he next flexes the thigh on the abdomen, in doing this he carries
the knee outwards away from the body, and then rotates the limb by
pushing the foot outwards, on which the head often slips into the
acetabulum. If this plan do not quickly succeed it is better to have
recourse to extension, by assistants if pulleys are not at hand, but
the irregularity of the force when assistants are employed renders
the traction of pulleys much preferable to manual strength.

=Dislocation downwards= into the ischiatic foramen. The limb is
lengthened, capable of little motion; the knee is bent; the toe
points forwards, and away from the other foot. Here the reduction
is best managed by extension; the apparatus required being the same
as that employed in dislocation backwards, but it is differently
arranged.

Step 1. The patient lies on his back, the pelvic girth, or towel, is
carried round the pelvis and fastened to the wall on a level with
his body, opposite the uninjured side. A jack towel is put round the
upper part of the dislocated thigh, and attached to the pulleys
outside, which are fastened to the wall opposite (see fig. 67).

[Illustration: Fig. 67.—Dislocation into the foramen ovale.]

Step 2. Extension is then made by an assistant, the surgeon grasps
the leg above the ankle, and rotating the limb inwards and outwards,
but without lifting it from the bed, guides the head into the
acetabulum.

Here, as after dislocation backwards, a long splint should be worn on
the limb for three weeks before the patient is allowed to move about
at all.

=Dislocation on to the Pubes.=—The limb is easily moved at the hip,
shortened, rotated outwards, and the head of the bone is felt in the
groin.

The same apparatus is used in this as in the dislocation on the
dorsum ilii. It is applied as follows:—

Step 1. The patient lies on his back (fig. 68), with his legs
separated. The pelvic band is passed over the perinæum and pubes,
and attached above the patient, in a line passing from the pelvis a
little to his sound side. A double jack towel is slipped up the limb
to the perinæum; the pulleys are fastened to the thigh above the knee
and fixed, in the manner directed on page 106, to the wall below and
external to the injured side of the body.

[Illustration: Fig. 68.—Dislocation on to the pubes.]

Step 2. Extension is then steadily made, while the surgeon watches
the head getting free from the pubes, over the edge of which a second
assistant slipping his neck through the doubled towel, raises the
bone a little outwards. The surgeon in the meantime encourages the
bone by rotation to enter the socket.

A splint is necessary here also after reduction.

=The Knee.=—These dislocations are rarely complete, and are easily
reduced; the lateral ones by flexing the thigh on the belly,
straightening the leg, and rotating it a little from side to side.

_Another Plan._—_Apparatus._—Two jack towels. This is more useful
when the tibia is carried backwards. Lay the patient on his back,
and slip a jack towel in a clove hitch up the leg to the ham, and
another round the small of the leg; the thigh is bent and retained in
a semiflexed position by an assistant holding the jack towel at the
ham, while a second pulls on the one at the ankle and so disengages
the bones from each other, when the surgeon readily slips them into
place.

After reduction is accomplished, the limb should be fixed in a
leathern back splint until the inflammation subsides.

=Dislocation of the Patella.=—The displacement of this bone on to the
outer or inner condyle is generally easily reduced if the knee is
straightened and the vasti relaxed by bending the thigh on the belly.
When the patella is turned on its own axis, the side, not the under
surface, is locked against the condyle, and reduction is sometimes
extremely difficult or impossible. The same movements must be adopted
as for simple lateral displacement, and the surgeon must endeavour to
release the bone by pressing its upper edge downwards with his thumbs.

After their reduction, all dislocations about the knee-joint must be
treated by rest, straight splints, and evaporating lotions.

=The Foot= is very rarely dislocated from the leg without fracture
of the malleoli. Its reduction requires simple extension of the foot
on the leg, with the knee bent; the surgeon grasps the heel in one
hand, the foot in the other, while an assistant fixes the thigh
in the half-bent position. The foot is first drawn downwards to
disengage it from the tibia, and then directed into its place.

After reduction the limb should be put in a McIntyre’s splint, in the
way described for fracture of the tibia near the ankle-joint.

=Scarpa’s Shoes= are instruments for restoring deformed feet to their
natural shape. The shoe (fig. 69) consists of a flat metal sole
broader and longer than the foot, furnished with a rest for the heel.
A rod, attached to the side of the sole beneath the ankle, reaches up
the limb, to which it is secured by one broad band and buckle below,
and by a second above the knee, opposite which joint the iron stem
moves on a free joint backwards and forwards. Opposite the malleoli
are set the centres of movement required for the restoration of the
deformity; they are moved by a key. The foot is fastened to the sole
by straps across the instep and ankle; the toes are restrained by a
strap passing round them and fixed to a horizontal toe-bar by the
side of the foot. In fitting one of these shoes, which of course must
always be made specially for the limb it is to control, the points to
be attended to are—1st, the centres of the joints must be so arranged
that, when traction is made, the foot shall revolve back again
round the same centres it has passed in reaching its distortion.
For example, if the heel is raised, as in talipes equinus, the fore
part of the sole of the shoe must be capable of elevation, by moving
a joint that rotates in a plane parallel to the rotation of the
astragalus on the tibia. In most cases of talipes, the bones of the
foot have been displaced round several centres; hence, the apparatus
must be furnished with power of traction along all of these, or
along the lines resulting from these different directions acting
simultaneously. 2nd. The heel must be got thoroughly into its place
at the back of the sole to ensure that the foot will follow the shoe
in all its movements.

The treatment of talipes frequently requires division of tendons
before extension is attempted, if they are too firmly contracted
to permit the bones to regain their proper position until they are
lengthened by division. Thus, in varus, the tibiales and tendo
achillis; in valgus, the peronci; in equinus, the tendo achillis; are
often divided.

The limb must not be very tightly braced into the shoe, slight
tension, if continuous, suffices to overcome the resistance; and in
children if the straps are drawn tight the skin almost invariably
inflames, and even sloughs where it is compressed. Before the
instrument is applied, the limb should be bandaged with a soft
cotton, or Domett’s flannel roller. The foot is first fixed to the
sole or shoe, and then the leg to the rod. Traction is increased
gradually with frequent small alterations, as the foot yields to the
tension and regains its natural position. The accompanying figure
(No. 69) represents an instrument made by Mr. Heather Bigg. It shows
the shoe restoring a much elevated heel to its proper position after
division of the tendo achillis.

There are three common varieties of talipes—equinus, or horse-heel,
where the heel is drawn up and the toes only touch the ground;
varus, club-foot proper, where the foot is twisted inwards; and
valgus, splay-foot, in which the foot is drawn outwards. Equinus is
often associated with varus, and sometimes also with valgus, and
consequently for such cases the instrument must provide the mechanism
proper to each direction of displacement.

In _Equinus_ the heel is raised by the extreme extension of the
ankle, and the sole of the foot is shortened by the metatarsus being
drawn backwards. In this kind of deformity the shoe must have a joint
to bring the astragalus forwards on the tibia, and the sole of the
shoe must be well padded beneath the scaphoid and metatarsal bones,
that, as the foot is released from its position of extreme extension
at the ankle-joint, the anterior parts of the foot may be thrust
upwards into their proper relation to the astragalus and os calcis.

[Illustration: Fig. 69—Shoe for reducing talipes equinus.]

In _Varus_, or rather _Equino-varus_, for varus without elevation
of the heel is rare, the displacement is compound, the ankle is
extended, the heel raised, the scaphoid and metatarsus are drawn
inwards and downwards, so that the scaphoid lies immediately
beneath, sometimes even in contact with the internal malleolus. The
astragalus and cuboid are drawn forwards so as to lie in front of
their natural position against the tibia and os calcis. To bring
down the heel the upright stem passes outside the limb, the toe of
the shoe can be raised by a circular joint on the stem opposite the
malleolus, which by its revolution raises the toes and depresses the
heel. A second joint working outwards and upwards elevates the outer
border of the foot, and restores the scaphoid to the front of the
head of the astragalus. Lastly, the metatarsus is drawn outwards by
a horizontal spring toe-bar along the outer border of the foot, to
which the toes are fastened.

In _Valgus_, the plantar arch is flattened or even rendered convex
downwards by the sinking of the scaphoid, and in extreme cases, by
rotation outwards and upwards of the tarsus. The shoe here has the
vertical rod inside the limb, and if necessary, an axis for rotation
below the inner malleolus, and an elastic arched pad under the
scaphoid to lift it into its natural position.

=Casting in Plaster of Paris.=—It is often convenient, when ordering
an apparatus for deformity, to send the instrument-maker a cast of
the deformed part. This is readily made in the following way:—

_Apparatus._—1. Two packets of freshly burned plaster of Paris.

2. Some pasteboard, an old bandbox, or several newspapers.

3. Olive oil.

4. A basin of cold water.

Step 1. The part to be modelled should be laid in an easy position,
thoroughly oiled, and a shell or trough of pasteboard roughly built
round it to contain the plaster till it sets.

Step 2. The plaster is then prepared by shaking the powder into cold
water, till a thick cream without lumps is formed; this is secured by
constantly stirring the water as the plaster is shaken in. The cream
is then poured into the trough, little by little, that it may make
its way into the inequalities and recesses under the limb, until the
limb is half immersed, leaving the projecting parts, such as joints,
half exposed, so that the halves of the mould may separate opposite
them. This first instalment is then allowed to set, and a fresh
supply of plaster is prepared.

Step 3. The surface of the hardened mould is oiled, that the fresh
cream may not stick to it, and the whole of the limb is then covered
by pouring the cream on a second time. Plenty of plaster should be
laid over the projecting parts that the mould may be strong enough
for use. It should be ¾ inch thick everywhere, and 1 inch thick
along the sides. When the second half is set, the trough or shell is
cleared away, and the two halves of the mould removed from the limb
separately.

For casting, the mould is well oiled inside and filled with cream,
which sets into the cast required. While the plaster is liquid, the
mould should be well shaken, that the air-bubbles may be all driven
from the surface of the cast.




CHAPTER V.

MISCELLANEOUS.


=Hair Suture.=—This is useful to bring the margins of small scalp
wounds together, where plasters are not employed. It consists in
taking a lock of hair ½ or ¾ of an inch on each side of the wound,
and tying them together over a double thickness of lint; by this
means the margins of the wound are kept together, and the dressing in
place. The slits left after the removal of small sebaceous tumours
are very conveniently treated in this way.

[Illustration: Fig 70.—Eye Douche.]

=The Eye Douche= is a small elastic bottle fitted with a nozzle and
flexible tube, ending in a rose, through which, by means of a valve,
the water is drawn from a vessel and driven in a fine spray over the
eye held open to receive it (see fig. 70). The syringe in fig. 70 is
very useful for a variety of purposes.

=Eye-Drops.=—Little bottles are sold by chemists for this purpose,
with a tubular stopper; at one end of the stopper is a fine jet, the
other is closed by a piece of indian rubber stretched over it; on
pressing this a drop escapes from the jet. In dropping astringents
into the eye the patient should put his head well back; while the
surgeon raises one lid from the eye, drops in the lotion, and then
raises the other and drops it in again, and tells the patient to
move his eyelids about a little to force the lotion over the whole
conjunctiva.

[Illustration: Fig. 71.—Syringe for sending a continuous current into
the nose or ear, &c.]

=Syringing the Ears= is best performed by a syringe having a long
nozzle to direct the current of soap and water down the meatus on
to the wax. Figure 71 consists of a syringe with double opening
and air chamber; when in action it supplies a continuous gentle
current, which breaks up the concretions more speedily and with
less discomfort to the patient than the intermitting jet of a
common syringe; but an important part of the apparatus is the long
slender nozzle to direct the stream well into the meatus. The
instrument-makers supply a little spout or shoot to hang under the
ear, to turn off the water into a basin clear of the neck. If time
permit, the patient should keep the ear charged with olive oil for a
few days before syringing, that the wax may be softened. After the
wax is removed, the irritation of the canal is best allayed by a
little glycerine or olive oil put into the meatus, and covered by a
pledget of cotton wool, large enough to fill the concha and too large
to enter the passage, where it may be lost sight of.

=Ice-Cold Injection.=—In obstinate epistaxis the nares are sometimes
plugged, but, before proceeding to this painful mode of treatment,
a simpler plan should first be tried; namely, the _injection of
ice-cold water_ into the nostril along which the blood flows. The
stream should be directed upwards that the water may first dislodge
the clots entangled in the meatuses, and then flow over the bleeding
surface. This is best done by employing a clyster or douche bottle
(see fig. 71), one tube of which lies in a vessel of ice-cold water
(containing solution of gallic acid or other styptic if desired,
though cold water alone usually suffices), the other tube, having a
long narrow nozzle, is passed up the nostril and directed upwards
among the spongy bones. With this apparatus the water is injected
steadily for half an hour, before being abandoned as unsuccessful.
The patient is kept still, sitting upright in a cool room. If these
means fail to check the flow of blood, the nares may then be plugged.

=Plugging the Nares.=

_Apparatus._—1. A flexible catheter, No. 7, or Belloc’s sound.

2. Whipcord.

3. Lint.

4. Scissors.

Step 1. Roll up a strip of lint tightly into a mass, 1 inch broad and
½ an inch thick, trim the ends away with scissors till the mass is of
a size to enter a posterior naris, then tie the wedge in the middle
of a yard of doubled whipcord. If blood trickle down both nostrils
both must be plugged, and two such plugs must be prepared; next, make
two similar rolls of lint, and tie these up with a short piece of
silk or twine to prevent their unrolling.

Step 2. Pass along the interior of the catheter a yard of twine,
and draw its end through the eye of the catheter a few inches, then
introduce the catheter through the naris directly backwards, not
upwards nor downwards, because, when the patient is upright, the
floor of the nose is nearly horizontal. When the catheter has reached
the pharynx, the finger, or a forceps, must be passed through the
mouth to catch the string hanging from the end of the catheter and
bring it out of the mouth, where it is held while the instrument is
withdrawn from the nose. The step is repeated in the other nostril if
required.

Step 3. Next wash out the nostrils with a few syringefuls of
ice-cold water, in which some tannin is suspended.

Step 4. Fasten the double string of the plug to the end of twine
hanging out of the mouth (see fig. 72), and then draw out the other
end through the nose; this will carry the plug to the pharynx, where
the finger guides it over the soft palate and thrusts one of its ends
into the naris, where the strings draw it tight. The plug for the
anterior nostril is then put in place, and the strings tied tightly
over it (see fig. 73). Thus the plug in front keeps the plug behind
in place and _vice versâ_. The end of string from the posterior
nares, left hanging out of the mouth, must next be tied to the string
of the anterior plug to keep it out of the patient’s way, till wanted
to withdraw the posterior plug, when that is to be removed. If blood
run from both sides, the other nares are stopped by a repetition of
this operation.

[Illustration: Fig. 72.—Plugging the nares. Belloc’s sound passed
through the nares, and projecting at the mouth.]

This apparatus is very painful, and, if borne so long as a couple
of days, should always be taken out then. If bleeding recur, which
is very unlikely, fresh plugs must be introduced. Sometimes the
posterior plugs are soaked in styptic solutions; this is bad, because
the bleeding part is not at the posterior nares, and the styptics
increase the soreness the plugs themselves produce.

[Illustration: Fig. 73.—Plugging the nares; the strings from the
posterior plug tied over the anterior plug.]

[Illustration: Fig. 74.—Belloc’s Sound, for drawing a thread from the
mouth along the nares.]

=Belloc’s Sound.=—Fig. 74 is a curved silver cannula like a female
catheter, furnished with a long spring stylet, that arches round in a
circle when thrust out of the cannula, and has a hole at the end to
carry a thread. The long stylet can be unscrewed into two parts, when
not in use. The figure represents the instrument with the stylet
ready for protrusion, and the same arching forwards after it is
protruded.

The cannula is passed along the nares till the end reaches the
pharynx, then the stylet is protruded and arches forward till it
reaches the teeth, when a thread is passed through the hole, and
the stylet being withdrawn, the thread is carried with it into the
pharynx and through the nostril, where it can be used to draw the
plug into its place at the posterior nares.

=Tooth Drawing.=—A surgeon is frequently required to draw a tooth on
emergency, and should be provided with instruments (see fig. 75).
Seven pairs of forceps and an elevator are sufficient for all he is
likely to deal with. They are differently shaped for the different
teeth, which vary much at the neck, the part grasped in the forceps.

[Illustration: Fig. 75.—Tooth Forceps.]

For the operation the patient should be seated in a high-backed
chair; the surgeon stands at his right side, holds the jaw with his
left hand, while with the right he thrusts the beaks of the forceps
between the gum and the tooth on its lingual and buccal aspects;
having reached the neck, he holds the tooth firmly, pushing it
inwards and outwards with a rotary motion of the wrist (except for
the molar teeth). Sudden tugs break the tooth and leave the fang
behind; when loosened by rotation and lateral motion, the forceps
readily lift the tooth out of its socket.

For the _upper incisors_ the beaks of the forceps are straight,
slightly hollowed inside, to give them hold of the teeth, and have
crescentic edges (see fig. 76).

The _upper incisors_ and _canines_ can be drawn by the same pair, as
the shape of these teeth at the neck varies to a small extent.

For the _lower incisors_ a very narrow forceps is necessary. The
beaks (fig. 77) should be curved at the joint sufficiently to form
an angle of 25° with the handles, that the latter may clear the
upper jaw. The edge of the beaks is crescentic, similar to that of
the upper incisors. These forceps are also very useful for removing
roots, as their fineness enables them to sink between the stump and
the alveolus with ease.

[Illustration: Fig. 76.—Upper incisor tooth and forceps.]

[Illustration: Fig. 77.—Lower central incisor and forceps.]

[Illustration: Fig. 78.—External aspect of upper bicuspid tooth, and
bicuspid forceps.]

For the _bicuspids_, beaks with crescentic edges also are used, but
the inside of the beak is more hollowed to fit the round neck of
these teeth (see fig. 78). All the bicuspids can be drawn with the
same pair, but it is convenient to have forceps bent at the joint to
clear the upper jaw when extracting a lower bicuspid (see fig. 79).

[Illustration: Fig. 79.—Lower bicuspid forceps.]

For the _upper molars_ two forceps are required, one for each side of
the jaw; the beaks of these are well hollowed to admit the crown of
the tooth. The inner beak terminates in a crescentic border to fit
the large internal fang (see figs. 80 & 81); the outer beak has two
smaller grooves separated by a point, that passes between the two
external fangs.

In drawing these teeth the forceps should be thrust as high as
possible and held firmly, while the fangs are loosened by moving the
tooth from side to side, but from the multiplicity of fangs, rotary
motion is not available.

[Illustration: Fig. 80.—Left upper molar tooth and forceps.]

[Illustration: Fig. 81.—Right upper molar forceps.]

The _wisdom molars_ are often difficult to seize from being almost
buried in the jaw; as they resemble a bicuspid in shape, bicuspid
forceps (fig. 78) should be employed; if this fails to penetrate
between the tooth and the alveolus, the narrow incisor forceps (fig.
77) can be driven up till it grasps the tooth. Not unfrequently the
fang of this tooth in the lower jaw is curved backwards and prevents
extraction when the tooth has been loosened; this difficulty may be
overcome by pushing the crown of the tooth a little backwards so as
to tilt the fang forwards out of place.

When the molars are closely set, or the tooth to be extracted is
overhung by its neighbour, it is often difficult to avoid tearing the
gum extensively and even carrying away more than one tooth; tearing
the gum is easily avoided by lancing it before applying the forceps,
and slow and steady movements of the wrist usually prevent the latter
accident, or the overhanging tooth may be filed away before the
forceps are applied.

The _inferior molars_ (fig. 82) have forceps, whose beaks are doubly
grooved and pointed, to enable them to seize the neck on each side
between the two fangs.

[Illustration: Fig. 82.—Inferior molar tooth and forceps.]

[Illustration: Fig. 83.—Elevator.]

In _raising stumps_, so much decayed that the forceps will not hold
them, the elevator must be employed; this instrument (fig. 83),
straight, pointed, and a little grooved at the point, is thrust
down between the alveolus and the tooth; the jaw being then the
fulcrum, the elevator is the lever to push _forwards_ the fang; when
thus loosened it is easily lifted out. In working with an elevator
there is some risk of thrusting the point through the alveolus, and
wounding the tongue or floor of the mouth, hence it should always be
guided and covered by the left forefinger. In removing the fangs of
incisors the narrow forceps are most useful, and should it not be
possible to penetrate between the fang and the alveolus, the alveolar
border may be included in the grasp of the forceps and brought away
with the tooth. The injury thus inflicted is very unimportant and
much pain is saved.

After the tooth is extracted the mouth should be well washed
with warm water a few times, the attending bleeding being of no
importance, except in individuals of hæmorrhagic diathesis, in whom
measures should be at once taken to arrest the flow.

_To stop a bleeding socket_ the alveolus must be well cleared of
clots, and fragments of sponge, soaked in a solution of perchloride
of iron, one part of the salt to three of water, packed into the
cavity. A plug of cork is placed between the jaws, and a four-tailed
bandage (see page 32) carried round the head to keep them firmly
closed. Should this plan fail, the socket must be cleared again, and
the wire of the galvanic cautery pushed well down to the bottom and
then heated till it has cauterised the cavity (see page 168).

=Nipple Shields and Artificial Nipples= made of flexible ivory,
vulcanized india-rubber, &c., are required when the nipple is chafed
and excoriated by the child’s sucking, especially if his mouth be
attacked by thrush, as is usually the case. When the nipple is sore
it should be well washed and dried after suckling, covered with
glycerine of starch or plastic collodion and protected by a shield.
If much inflamed it may be wrapped in lint dipped in alum water or
solution of sulphate of zinc (one grain to the ounce), and deep
chinks should be freely rubbed with lunar caustic. The breast should
be regularly emptied by the breast-pump if the child’s sucking gives
much pain, lest the accumulation of milk in the ducts cause milk
abscess.

=Plugging the Vagina= is employed in cases of rapid hæmorrhage from
the womb, &c.

_Apparatus._—1. A silk pocket-handkerchief.

2. A dry new fine sponge or pellets of cotton wool.

3. Silk thread.

4. A body roller or folded sheet.

The sponge should be cut into pieces the size of nuts; if the
sponge is compressed it answers better. When prepared, the vagina
should be cleared of coagula by a syringeful of ice-cold water; the
handkerchief, unfolded and thrown over the right hand, is passed up
the vagina till its centre reaches the os uteri, the borders and
ends then project from the vagina. The interior of the handkerchief
is next filled by firmly packing the sponge in bit by bit until the
vagina is distended by the mass; the ends of the handkerchief are
then tied together. The sponge swells as it absorbs the blood, and
compresses the bleeding vessels by its distention.

The abdomen and uterus are then supported by a body roller, or folded
sheet, wrapped tightly round the hips and waist, while the patient,
lightly clad, is kept quiet in a cool chamber.

When the plug has answered its purpose it is removed, by withdrawing
the sponge bit by bit, and the vagina is washed with tepid water.

_The kite’s-tail plug._—Masses of cotton wool the size of a hen’s
egg are tied at two inches distance from each other along a long
string. When about a dozen are tied on, a speculum is introduced, and
the first ball of wool is passed to the bleeding point and pushed
firmly against it, and then another, and so on, until the vagina is
firmly packed. An end of string is left hanging out of the vulva,
whereby the plug may be removed when necessary. Each mass comes away
successively with ease as the string is pulled out of the vagina.

=Injecting the Urethra= often fails from the inefficient mode in
which it is done. The syringe employed should be short enough to be
worked easily with one hand, and need not contain more than one or
two tea-spoonfuls, as the capacity of the urethra does not exceed
that amount. One of such a size is just 2 inches in length, and
easily worked by one hand. The opening through the nozzle should also
be wide, that a forcible stream may be injected into the urethra.

The patient should fill the syringe, then place on a chair or stool
before him a chamber pot, and, having just made water to clear out
the discharge collected in the urethra, he inserts the slightly
bulbous nozzle into the meatus urinarius. He then grasps the sides
of the glans with the left forefinger and thumb to close the mouth
of the passage. The right forefinger next presses down the piston
slowly, so that the whole of the injection passes into the canal and
distends it; keeping the meatus shut with his left finger and thumb,
the patient lays down the syringe and rubs the under part of the
penis backwards and forwards, that the injection may be forced into
any folds or follicles of the mucous membrane. Having thus occupied
about thirty seconds, he releases the mouth of the passage, when the
fluid is ejected sharply into the vessel placed ready to receive
it. This rapid ejection is a test of the proper performance of the
operation.

In counselling the use of astringent solutions, the surgeon should
always caution the patient not to employ one that produces severe
smarting, which lasts more than a few minutes after injection. If it
causes much pain, the solution is too strong.

=Catheters and Bougies.=—Silver catheters are made in sizes,
increasing from No. ¼ to No. 12, the first having a diameter of
0·64 inch, the latter 0·25 inch. Larger ones than these are seldom
employed.

[Illustration: Fig. 84.—Silver catheter.]

[Illustration: Fig. 85.—English Flexible catheter.]

The curve preferred by different surgeons varies much; that depicted
in fig. 84 is the one used by Sir Henry Thompson; it begins at 3¼
inches from the point, and ends when the point is at right angles
with the stem. Each catheter is fitted with a wire stylet.

The flexible catheters are of many kinds; the English gum-elastic
(fig. 85), the French black flexible (fig. 86), and the vulcanised
india-rubber (fig. 87), catheters, being the three varieties most
generally employed. English flexible catheters should be kept on
stylets well curved at the last 3 inches, that, when the stylet is
withdrawn, for the catheter to be passed, the latter may retain
sufficient curve to pass over the neck of the bladder easily.

[Illustration: Fig. 86.—French bulbous-ended catheter.]

[Illustration: Fig. 87.—Vulcanised india-rubber catheter.]

=Sounds= are solid, being of steel, plated or gilt. Their curve
varies, and is generally 20 or 30 degrees more obtuse than that of
the catheters.

=Bougies= are made of the same materials as the flexible catheters;
they are kept straight, and the more supple they are the better,
the black bulbous-ended bougies being the most useful variety for
dilating the urethra.

[Illustration: Fig. 88.—The Olive-headed bougie.]

=Olive-headed Bougies= (_Bougies olivaires_) are used for exploring
the urethra in cases of gleet, where the discharge is often kept
up by a stricture or a tender patch of chronic inflammation of the
mucous membrane. They are made of metal, or of black gum mounted
on a very flexible leaden wire; the latter kind are far preferable.
The stem of the instrument is slender, no bigger than a No. 3 or No.
4 bougie; the end terminates in a conical point about ¼ or ⅜ of an
inch long, expanding at its base to any required size. These bougies
are most useful from No. 4 to No. 16 of the English scale, or from
No. 10 to No. 24 of the millimetrical scale. The stem should be
marked with white rings an inch apart, so that when the instrument
is passing over a tender part, or is arrested by a stricture, the
distance of the impediment down the urethra can be at once estimated.
In withdrawing the instrument, the wide base of the olive shows
the exact position and length of those strictures which are not
too narrow for the olive-head to slip by, for it is nipped by the
stricture and released as soon as the narrowing is passed. By using
instruments large enough to fill the normal urethra, an induration
beneath the mucous membrane can be detected in its earliest stage
before it has produced symptoms diagnostic of stricture.

Rigid instruments have one advantage over flexible ones, in that
their points can be guided by the surgeon; the points of flexible
instruments cannot be directed, hence the introduction of the latter
into a stricture is less easily managed, consequently bougies with
various kinds of points should be kept. But flexible instruments
cause far less irritation than rigid ones, and should always be
employed instead of the latter when possible: with patience and
practice much of the difficulty attending their introduction is
overcome. The French bougies, with tapering ends and bulbous points,
slip more easily through a stricture than instruments having the
same diameter throughout, and bougies with fine tapering points can
sometimes be introduced where others fail.

_Passing Catheters._—In passing instruments along the urethra the
conformation of its interior should be borne in mind. From the
meatus to the triangular ligament, the normal urethra, when gently
stretched, becomes a straight tube; having, nevertheless, just within
the meatus, a pouch in the roof, the lacuna magna, where the point of
the instrument may catch if not turned downwards. At the bulbous part
the urethra enlarges in capacity by having a slight downward curve in
its floor, just before the triangular ligament is reached. In this
depression, the beak of the catheter is apt to sink below the level
of the passage through the ligament, which is always a fixed point.
Beyond the triangular ligament the urethra curves gently upwards,
has a floor beset with irregularities, in which the point of the
instrument easily catches, if not raised as it passes along the curve.

_A Silver Catheter_ is passed most easily while the patient is in a
horizontal position, with the shoulders low and the thighs separated.
The surgeon stands on the left side of the patient, and holds the
catheter, previously warmed and lubricated with oil or lard, lightly
between the thumb and two first fingers of the right hand, the beak
downwards and the stem across the patient’s left groin. Then taking
the penis between the middle and ring fingers of the left hand, the
palm being upwards, he pushes back the foreskin with the thumb and
forefinger, and steadies the meatus while introducing the beak of
the catheter. This done, he draws the penis gently along the catheter
as the point is lowered to the perinæum, but without raising his
right wrist until the instrument has travelled 5 or 6 inches along
the passage and reached the triangular ligament. The surgeon then
carries his right wrist to the middle line of the patient’s body,
and while pushing the point onwards, raises the hand round a curve
till it again sinks between the patient’s thighs. When the bladder
is reached he withdraws the stylet that the urine may escape. Three
points of difficulty are usual in passing catheters; the lacuna magna
just within the meatus, the triangular ligament, and the prostatic
part of the urethra just before the bladder is reached. The first is
escaped by keeping the beak along the floor of the urethra for the
first two inches; the second is best avoided by raising the wrist
as the instrument passes the triangular ligament, and directing the
beak against the upper surface of the urethra, lest, being in the
enlarged bulbous part, it sink below the opening in the ligament; the
third difficulty is overcome by depressing the hand well as the point
approaches the bladder.

_To pass the catheter in the upright position_, the patient is placed
against a wall or firm object, with his heels eight or ten inches
apart and five from the wall, that he may rest easily during the
operation. The surgeon sets himself opposite the patient and grasps
the penis with the two middle fingers of the left hand, the palm
upwards; he next exposes the meatus with the thumb and forefinger,
and his right hand holding the catheter by its middle obliquely
across the left side of the patient, he draws the penis on to the
instrument till the triangular ligament is gained. He then carries
the shaft of the catheter to the middle line and, holding it by its
end, brings the right hand downwards and forwards, to carry the point
upwards over the obstruction at the neck of the bladder.

The operation should be done slowly and with great gentleness, giving
the urethra time “to swallow the instrument,” as the French surgeons
express it. Hasty or forcible movements tend to thrust the point
against the wall of the urethra, where it hitches, if it does not
penetrate and make a false passage. However easy the introduction
may have been, the withdrawal of the catheter should be always done
slowly to avoid giving pain to the patient.

When the canal suddenly contracts, as from a stricture, the point
of the sound often stops at the obstruction; by withdrawing the
instrument a little, and diverting its point to another side or
along the upper part of the urethra, a part where the obstruction
is less abrupt will often be found to let the catheter glide into
the stricture. The floor of the urethra should always be avoided, as
false passages nearly always branch off from the floor close to the
stricture.

Difficult narrow strictures are most easily overcome by injecting
a drachm of warm olive oil into the urethra, and then passing fine
black gum or whalebone bougies (_bougies filiformes_) along the
urethra. These, from their fineness (their diameter is only ⅓ or ⅔
of a millimetre, about 1/100 inch), are very apt to catch in false
passages; if so, the bougie should be left engaged in the false
passage, and held in the left hand while another bougie is passed
along the urethra; if, in its turn, this one gets into a false
passage, it also should be left, and a third passed; and so on till
all the false routes are occupied, or a bougie enters the stricture
and reaches the bladder, which is known by the readiness with which
it will pass backwards and forwards. The other bougies should then be
withdrawn, and the bougie which has passed the stricture be tied in
for twenty-four hours, until the passage is sufficiently dilated to
allow a small catheter to replace it. If the patient is not suffering
from retention of urine, there need be no anxiety about evacuating
his bladder, as urine will find its way alongside the bougie when
he attempts to make water. In passing to relieve retention, No. ½
English flexible catheter should be used instead of bougies; but
when the stricture is too narrow for these, a bougie may still be
tried, as the urine will generally dribble alongside the bougie with
sufficient rapidity to relieve the patient.

_English flexible Catheters_ should be kept on stylets curved as
represented in fig. 85, that the first 3 inches of the instrument,
when the stylet is withdrawn, may retain sufficient curve to ride
over the impediment at the neck of the bladder. In warm weather,
after being oiled, they should be dipped in cold water just before
using, to render them a little stiffer, and less likely to lose their
curve while traversing the urethra.

They may also be passed while the patient lies or stands, and the
movements are the same as for the silver catheter.

_Bulbous-ended or probe-ended Catheters and Bougies_ (_Bougies à
boule_) are always straight; their suppleness, their tapering
ends, and their smooth rounded point enable them to glide along the
urethra, and to accommodate themselves readily to the windings of the
passage; for which reason they are the easiest to pass both for the
patient and the surgeon. In passing them they are slightly warmed, if
the weather is cold, to restore their flexibility, and gently pushed
along the canal till the bladder is reached.

_Vulcanised India-Rubber Catheters_ (fig. 87) are used when the
bladder is to be kept empty; their suppleness renders them very
unirritating, and as phosphates crust on them very slowly, they may
be worn for a week without being changed.

They are easily passed by threading them on a stylet with the
appropriate curve, and lubricating them with white of egg or water,
not with grease, which injures them. The stylet is withdrawn after
they are passed.

=To pass a Catheter in the Female.=—The patient may lie on one
side or on her back; if on her side the knees should be well drawn
up; if on her back, the thighs must be somewhat separated. Before
introducing the catheter, a wine bottle or narrow-necked bed urinal
should be placed in the bed ready to receive the urine. If the
ordinary slightly curved female catheter be not at hand, a No. 7 or 8
flexible one does just as well.

Having oiled the instrument, go to the patient’s back, and take the
catheter in the right hand if the patient lies on her right side, and
in the left hand if she lies on her left side; if she lies on her
back, go to either side and take the catheter in the hand nearest her
feet. Hold the stem of the catheter in the palm, so that the beak
lies against the tip of the forefinger, while the thumb and second
and third fingers grasp the stem. Then passing the hand under the
bed-clothes, seek the buttock; from that pass the forefinger to the
perinæum, and let it enter the vulva, keeping the back of the finger
against the posterior part, then pass it between the nymphæ to the
entry of the vagina. This is known by the tip of the forefinger being
lightly grasped, unless the vagina is very wide. Keeping the finger
just within the entry, feel for the arch of the pubes in front;
having found this, withdraw the tip of the finger slightly from the
vagina: in doing this, it will strike a small projection of mucous
membrane hanging just at the anterior margin of the entry. Keep the
finger steady against this, while the other hand pushes the catheter
gently onwards, which then rarely fails to enter the urethral opening
close above the projection of mucous membrane. Having penetrated the
urethra, arrange the catheter in the receptacle for the urine, and
push the instrument into the bladder.

=To Wash out the Bladder.=

_Apparatus._—1. A flexible catheter; Nos. 8 or 9 are convenient
sizes; but a smaller one can be employed.

2. A caoutchouc bottle, holding six ounces, and fitted with a
tapering nozzle and stop-cock. (Fig. 89.)

[Illustration: Fig. 89.—Elastic india-rubber bottle for injecting.]

During the operation the patient should stand, if possible, as the
mucus is thus more easily cleared from the bladder. The surgeon
first fills his bottle completely with tepid water, that no air
may remain; then directing his patient to stand against a wall or
some firm object, passes the catheter and draws off the urine. He
next inserts the nozzle into the catheter, and, turning the cock,
compresses the bottle slowly until two or three ounces of water have
run into the bladder; this he lets escape by removing the bottle
for a minute, and then repeats his operation till the water returns
clear, without exhausting the patient’s strength. Three or four small
injections wash the sediment and mucus from the bladder as quickly,
and with far less fatigue or risk of spasm than a prolonged flow
of water through a stiff double current catheter. In this way the
bladder may be washed twice or thrice daily to the great comfort of
the patient.

Injections of solutions of nitrate of silver, carbolic acid, alum,
&c., in the proportion of 1 part to 100, or to 50 of water, can be
used instead of water for this purpose.

=To Tie in a Silver Catheter.=

_Apparatus._—1. A few yards of tape ¼ inch wide.

2. A roller.

3. A spigot of wood; or,

4. A yard and a half of fine india-rubber tubing.

[Illustration: Fig. 90.—A silver catheter tied in the urethra.]

A narrow roller is tied round the hips; from this, on each side, a
tape is passed round the thigh at the groin, and fastened before and
behind to the roller round the hips (see fig. 90); a narrow tape run
through the rings of the catheter connects them with the loops in
the groins. The tapes are tied short enough to prevent the catheter
slipping out; a yard or two of narrow india-rubber tubing, fixed on
to the end of the catheter, conveys the urine to a pan under the bed,
and keeps the bed dry, or a spigot of wood fitted to the catheter may
be inserted, for the patient to draw out when he desires to void his
urine.

=To Tie in a Flexible Catheter.= (Fig. 91.)

_Apparatus._—1. A piece of soft twine, or Berlin wool, about 15
inches long.

[Illustration: Fig. 91.—A flexible catheter tied in the urethra;
the string fastened behind the corona glandis, and concealed by the
foreskin.]

A catheter is first passed into the bladder, and the urine runs off.
The catheter is then gently withdrawn, till the stream ceases, that
the end of the instrument may remain just without the neck of the
bladder. The string should be tied round the catheter ½ an inch from
the meatus, its ends gathered together and tied in a knot about 1
inch farther on. The foreskin is then drawn back, the ends passed
beneath the glans and tied round the penis behind the corona; the
superfluous string is snipped off, and the foreskin brought forward.
The catheter is cut off obliquely ½ an inch beyond the string and
then stopped with a spigot, direction being given to the patient to
withdraw the spigot, and push the catheter a little further in when
he wants to make water.

=To Tie a Patient in Position for Lithotomy.=

_Apparatus._

Two bandages, each 3 yards long and 2 inches wide, of calico or
saddle-girth, with tapes sewed on the ends.

[Illustration: Fig. 92.—Tying for lithotomy.]

The patient is laid on his back, a slip-knot made in the middle of
the bandage and passed over the wrist; the hand is then made to grasp
the foot, the thumb above, the fingers under the sole (fig. 92); one
end of the bandage is carried behind and inside the ankle to the
dorsum of the foot, where it meets the other end passing in front of
the ankle. The ends are then carried under the sole, brought up and
tied in a double bow over the back of the hand.

=Bedsores= are best treated by great cleanliness, and by washing
the skin exposed to the discharges with spirit of wine every day.
Brown-Sequard recommends cold and heat to be applied daily, by means
of an ice bag for ten minutes, followed by a warm poultice for an
hour. The pressure of the skin over the sacrum or trochanters is
prevented by a ring of soft thick felt, covered on one side with
adhesive plaster, and applied like a corn plaster _around_ the
prominent bone.

In addition to these local applications, the pressure of the body
should be evenly distributed over its under surface by placing the
patient on a water cushion, or, better, on Arnott’s water-bed.

[Illustration: Fig. 93.—Water-bed.]

_Arnott’s Floating Bed._—In the hydrostatic or floating bed of Dr.
Arnott, the patient floats on the surface of a trough of water,
into which he sinks until he has displaced his own weight of water;
his floating apparatus, or raft, so to speak, being a sheet of
waterproofing, and a thin mattress or folded blanket, on which he
lies. The bed consists of a trough running on large castors, about
8 feet long, 2 feet 8 inches wide, and 1 deep, with a tap at the
bottom for letting out the water, and a spout in one corner to fill
it by. Over the top a macintosh cloth is spread, its edges being
firmly nailed to the margin of the trough, but the cloth is left
slack enough to float easily on the surface of the water when the
trough is partly filled. This slackness is requisite to allow the
water displaced by the weight of the patient’s body to rise up
around him without tightening the cloth, or the floating principle
of the bed is not carried out, and the pressure of the patient’s
weight not evenly distributed over his body (see fig. 93). Three
or four blankets are laid evenly over the macintosh, and these
again protected from the moisture of the patient by a macintosh
under-sheet. If a mattress is used, it must be very thin, and supple
enough to let the surface of the water adjust itself to the patient’s
body and receive the pressure evenly. The water employed to fill the
bath should be about 50°.

[Illustration: Fig. 94.—Water-cushion.]

_Water Cushions_ are flat cushions of stout macintosh cloth, half
or two-thirds full of water, and laid on the mattress beneath
the blanket and sheet (see fig. 94). They are more portable than
the water-bed, but they are simply soft pillows, and do not
counter-balance the weight of the patient in the manner of the
floating bed.

=The Stomach-Pump= is used for emptying the stomach, or for injecting
fluid food when patients refuse to swallow.

It consists of a brass syringe holding 4 ounces, of which the nozzle
is connected with two tubes, one at the end, the other at the side.
The passage through these is directed by a valve which is governed
by a lever lying on the barrel (see fig. 95). When the lever is at
rest, the current passes in and out of the syringe by the lateral
tube; when depressed, by the direct tube. The elastic tubes with
smooth nozzles, about 2 feet long, are fitted to the syringe. There
is also a gag of hard wood, having a hole in the middle, through
which the tube passes on its way to the stomach, to protect it from
the patient’s teeth.

[Illustration: Fig. 95.—The stomach-pump.]

When the pump is employed to remove the contents of the stomach,
two washhand-basins are placed at hand, one empty, one full of
tepid water. The patient is seated in a high-backed chair to steady
his head; one assistant holds his hands, while a second screws the
small end of the gag between the teeth and forces open the mouth,
across which it is then easily fixed. The flexible tube, being well
oiled, is next passed across the pharynx and down the gullet slowly
and cautiously, without staying for any effort of vomiting it may
induce; when about 20 inches are passed through the gag the nozzle
has reached the stomach. First, two or three syringefuls of water
are injected into the stomach; then, removing the second tube from
the basin of water to the empty basin, the action of the syringe
is reversed, by pressing on the lever as the piston is raised, and
letting it fly up when the piston is depressed. Thus two syringefuls
may be withdrawn, then fresh water is again injected and withdrawn,
until the contents of the stomach are removed and the water returns
clear. Precaution must be always taken not to exhaust from the
stomach before water is injected, lest the coats of that organ be
injured by being sucked against the nozzle of the tube.

If desirable, antidotes may be dissolved or suspended in the water
injected. When the pump is used for feeding patients, one or two
pints of beef tea, eggs beaten with milk or wine, Liebig’s soup, &c.,
are the kinds of food suited for the purpose. Each time the pump is
used, it should be thoroughly cleaned by syringing through it plenty
of warm water, and the tubes must be unscrewed to wipe the joints
carefully.

=Transfusion of Blood.=—The points of greatest importance in
performing this operation are:—

1. That the supply of blood come from a vigorous adult.

2. That the transfer be made within two minutes of the blood’s escape
from the vein of the supplier.

3. That, to prevent coagulation, the blood should pass over as small
a surface, and suffer as little exposure as possible in transit.

4. Care must be taken to prevent air entering the vein with the blood.

The apparatus described below is that devised by Dr. Graily Hewitt,
and depicted in the Obstetrical Society’s Transactions for 1864,
page 137. It consists of a glass syringe holding two ounces (fig.
96), with a piston easily attached and removed; its nozzle is
curved and fits the mouth of a cannula of silver. The nozzle of the
syringe is provided with a little stopper attached by a chain; a
stylet likewise fills the cannula, to be withdrawn when the blood is
injected through the latter.

[Illustration: Fig. 96.—Graily Hewitt’s syringe for transfusion of
blood.]

The success of the operation depends in great measure on the rapidity
with which it is performed, and requires the aid of two assistants
that the various steps may follow each other as quickly as possible.

_Apparatus._—1. Syringe, cannula and stylet.

2. Lancet.

3. Scalpel.

4. Forceps.

5. Three yards of tape, one inch wide, and lint.

6. A silver wire suture.

7. A basin of cold water.

8. Brandy and Sal Volatile.

Step 1. See that the piston-rod works properly in the syringe, and
that the instrument is fit for use; then place it in the basin of
cold water with the cannula to lie till wanted.

Step 2. Place the person supplying the blood on a couch or easy
chair in the same chamber, but so that he cannot see the recipient,
lest he faint and his blood consequently flow feebly. Tie up the arm
as for venesection; lay ready the lancet, and direct the assistant,
in charge of the supplier of blood, to keep his thumb on the vein
when it is opened, that the flow may be checked when blood is not
required.

Step 3. Place a tape round the arm of the recipient, above the point
for injection, and another below it at a convenient distance, and
lay bare a vein (usually the median basilic) for an inch and a half
of its course; holding the vein by the forceps, make a slit with the
scalpel and introduce the cannula, which is then intrusted to the
second assistant. The stylet is withdrawn, and a minute drop of blood
escapes through the cannula, showing that the point has been properly
introduced into the vein. The assistant replaces the stylet and
slackens the ligature, while the surgeon proceeds to fill his syringe.

Step 4. The surgeon, going to the supplier of blood, makes a large
opening in the vein with a lancet, or if the first assistant be a
surgeon also, he may do this while the chief operator is preparing
the vein of the recipient. When the vein is open and the blood
flowing freely, the barrel of the syringe is inverted over it and
filled with blood; when full, the nozzle is stopped by the plug and
the piston attached while the syringe is carried to the recipient.

Step 5. This being reached, the plug is pulled out, the nozzle
inserted into the cannula, and the blood _slowly_ injected by
depressing the piston gently, but without quite emptying the syringe.
A minute should be spent in injecting one ounce and a half, and a
pause of five minutes ensue before a second supply is introduced.
This interval may be employed in cleaning the syringe, &c., and
procuring a fresh supply of blood; 3-4 ounces of blood are usually
sufficient, but 10 ounces have been injected on some occasions.
The perturbation of the supplier (generally a near friend of the
recipient), renders it necessary he should drink freely of brandy and
water, that the blood flow forcibly when required.

Step 6. When sufficient blood has been introduced, both patients’
wounds are dressed, as after venesection (see page 20), the long
incision of the recipient being closed by a point of suture under the
pad.

=Tourniquets.=—Tourniquets are of several kinds.

_The Ring Tourniquet_ (fig. 97) is used when pressure is desired
on the main artery of such a limb as the arm. It is less easily
displaced than the Signoroni, but, like that, soon becomes irksome by
its continual pressure.

[Illustration: Fig. 97.—Ring tourniquet.]

When hæmorrhage has to be temporarily arrested, that of _Petit_ (fig.
98) is generally used. It consists of a strap of stout webbing and
buckle, that can be rapidly tightened by a few turns of a screw. To
use this tourniquet, lay a roller over the artery and carry the end
once or twice round the limb to steady the roller, then pass the
strap over the roller, keeping the buckle about two inches away from
the screw and the screw on the anterior or outer aspect of the limb,
not over the pad, lest that be displaced when the screw is tightened.
The tourniquet should be screwed up as quickly as possible, that the
limb be not charged with blood by obstructing the venous, before the
arterial flow is checked.

[Illustration: Fig. 98.—Petit’s tourniquet applied to the popliteal
artery.]

[Illustration: Fig. 99.—The horse-shoe tourniquet.]

In _Signoroni’s Horse-shoe_ tourniquet (fig. 99) the extremities of
the shoe can be approximated to each other by a rack screw working a
hinge. The ends are furnished with pads, one broad and flat to bear
on the limb away from the artery, the other rounded to compress the
vessel itself. This tourniquet does not arrest the whole circulation
in the limb. It can therefore be applied for a longer time than
Petit’s. However, it easily slips out of place, and soon becomes very
irksome and painful.

[Illustration: Fig. 100.—Lister’s tourniquet for compressing the
aorta.]

_The Abdominal Tourniquet_ of Professor Lister is a very effectual
contrivance for compressing the aorta during amputation through the
hip joint, and operations where a tourniquet cannot be placed on the
limb. It consists (see fig. 100) of a semicircular bar, with a broad
pad to fit on the lumbar vertebræ behind, while in front it holds
a long screw-pin carrying a pad. This instrument passes round the
left side, and its pad is forced down into the abdomen, one inch to
the left of the umbilicus, until the aorta is compressed against the
spine.

[Illustration: Fig. 101.—Carte’s tourniquets for femoral aneurism.]

_Carte’s Tourniquets_ (fig. 101) are employed to control and diminish
the flow of blood through an aneurism. They are intended to be
worn for several days, and are fitted with many contrivances for
obtaining a continuous pressure on the artery without completely
arresting the flow of blood. They are always used in pairs; in the
figure, one presses the external iliac on the pubes, the other the
femoral artery. The first is fastened to the body round the hips,
the second round the thigh. They are constructed as follows: an arm
attached to a pad reaches round the limb to the artery, over which it
supports a ball and socket joint turning in any direction, but fixed
by a screw clamp. This joint has a long screw carrying the compress
down to the artery. There is a little play of the screw in the ball
of the joint, controlled by india-rubber bands, that the compress
may yield slightly before the arterial pulse. In the solidification
of an aneurism by this means, the flow of the blood is intended to
continue; hence the current through the vessel need not be completely
obstructed by the pressure of the tourniquet, and the elastic bands
prevent that pressure from becoming insupportable.

When the tourniquets are applied, the patient must lie on a flat hair
mattress, have his limb well washed and dried, lightly but evenly
bandaged, and somewhat raised. If the thigh is hairy it should be
shaved where the pads will press, and dusted with powdered French
chalk. The tourniquets are next adjusted, as seen in fig. 101; the
patient is taught to change the pressure when it grows irksome, by
screwing down the second pad, and then releasing the first.

_To improvise a Tourniquet._—A tourniquet may readily be formed on
emergency from a handkerchief, a stone, and a stick. Fold a stone the
size of an egg in the middle of a handkerchief, lay it over the main
artery, tie the ends of the handkerchief round the limb, slip the
stick underneath and twist it round, till the tightened handkerchief
draws the stone on to the artery and arrests the flow of blood (see
fig. 102).

[Illustration: Fig. 102.—An improvised tourniquet.]

=Fumigation.=—Mercurial vapour baths are contrived in various ways.
The following plan succeeds perfectly well when the whole surface of
the body is to be exposed to the vapour (fig. 103).

[Illustration: Fig. 103.—Mercurial fumigation.]

[Illustration: Fig. 104.—Lamp for fumigating.]

_Apparatus._—A Langston Parker’s lamp made by Savigny and other
instrument makers. In this a spirit lamp, holding the required amount
of spirit is protected in a cage, on the top of which is a receptacle
for the calomel, and a small saucer for water (fig. 104). The flame
beneath boils the water and volatilises the calomel. Water is added,
because the calomel vapour, when associated with steam, acts more
efficiently than with dry air.

The lamp is placed under a high wicker chair, on which the patient
sits undressed, and round his neck, a frame is tied, made of cane
hoops, with a calico cover sewn over them; this falls to the ground
and encloses his body in a chamber, where the vapour is confined
while absorbed into the skin. A blanket thrown over the frame
completes the preparation. If a hoop frame be not at hand a lady’s
wire-hooped petticoat answers the purpose quite as well.

[Illustration: Fig. 105.—Lamp for local fumigation.]

The patient, in four or five minutes, usually breaks into a violent
perspiration, his pulse quickens much, sometimes even syncope occurs;
hence, he should not be left alone until the bath is over. This, if
the flame is strong and the quantity of calomel not very great—one or
two scruples being a common dose—occupies a quarter of an hour. When
the bath is over the patient should at once get into bed, and lie
there a few hours; then he may rise and be well sponged with tepid
water. Moderate but tolerably speedy mercurialisation of the system
is thus induced.

=Local Fumigation= is employed when the disease is confined to a
few obstinate patches of eruption. For this purpose an earthenware
alembic (fig. 105) is fitted to the lamp used for general fumigation;
the calomel is thrown into the bottom of the alembic. The flame plays
over the outside, and heating it, sublimes the calomel; which reaches
the mouth of the alembic and condenses on any part to which it is
applied.

The _throat_ may be fumigated by inhaling the vapour as it escapes
from this alembic, or by sucking air through the spout of an
earthenware teapot in which the calomel has been placed, and heated
by a spirit lamp underneath.

=The Hot Air-Bath= is easily obtained by undressing the patient,
putting him to bed on a mattress, and fastening across the bed two
or three lengths of cane or stout wire, over which a blanket is next
thrown. The patient’s body is thus enclosed in a small chamber, the
air of which is then heated by putting inside, on an earthenware
plate, a spirit lamp, surrounded by a kitchen lemon-grater to protect
the bed clothes from its flame. Sheets should be dispensed with while
the lamp is alight, lest they catch fire. The temperature of the air
should be watched, lest it grow hot enough to scorch, but it must be
kept up till the patient breaks into a sharp perspiration, when the
lamp may be removed and the patient allowed to cool slowly down.

The action of the bath is greatly accelerated by sponging the patient
all over as he lies in bed with tepid water, when the air grows warm.

Lamps protected with wire gauze, and furnished with a cradle to keep
the bed clothes up, are sold at the instrument-makers, but the above
arrangement answers just as well as more elaborate apparatus.

=The Vapour Bath.=—The patient is put to bed as in the hot-air bath,
and a few feet of vulcanised india-rubber tubing, fastened to the
spout of a tea-kettle on the fire, bring a supply of vapour into the
bed.

The vapour bath may precede the hot-air bath, and will quicken the
action of the latter very greatly.

[Illustration: Fig. 106.—Dr. Horace Swete’s village ambulance or sick
carriage.]

=Carriage for transporting the Sick.=

The army ambulance and the carriage of the Invalid Carriage Society
are excellent means for transporting sick from their homes, or
wounded persons from the scene of injury to the hospital. As their
cost is somewhat considerable, a cheap carriage (see fig. 106) has
been devised by Dr. Horace Swete, of Weston-super-Mare, for the
use of the district in which he is residing, and which may be kept
for use at workhouses, hospitals, and in remote districts. It is
constructed of varnished wood and iron, and in the following manner.

The dimensions of the carriage are—length, 7 feet 6 inches; breadth,
3 feet 9 inches; height, 4 feet 9 inches. Its weight is under 3 cwt.,
and its total cost 21_l_.

The body is like a skeleton hearse, without fixed floor or sides.
The sides are closed by vulcanised india-rubber curtains, or by
glass sliding panels. The back, a wooden panel, opens like a door.
A wooden tray slides on three rollers at the bottom, and on this a
mattress covered with vulcanised india-rubber is placed to receive
the patient. For infectious cases straw should be used instead of the
mattress, as it may be burnt when the patient is removed. The tray is
narrow, and fitted with handles, that it may be carried up a narrow
staircase. The vehicle runs on four wheels, is fitted with lamp,
handle, shafts, and driving box, and is well hung on good springs.
The material of the carriage admits of being washed, and thus readily
purified, after conveying an infectious case.

=Cupping=—_Dry, and Bleeding Cupping._

_Apparatus._—1. A series or nest of exhausting glasses.

2. Different sized boxes of lancets for incising the skin, called
scarificators.

3. A spirit lamp (fig. 107).

The glasses are 6 oz., 4 oz., 2 oz., and 1 oz. in size, of rounded
shape, with thick smooth edges.

In _dry cupping_ the object is to relieve internal congestion by
drawing the blood into the subcutaneous cellular tissue. The back
and loins, where the skin is tolerably loose, are most suitable
places for this proceeding.

[Illustration: Fig. 107.—Cupping glasses, lamp, scarificator, and
spirit bottle.]

_The Operation._

Step 1. Light the spirit lamp, direct the patient to sit forwards,
and lay bare the back ready for the glasses, which should be placed
on the bed within reach of the operator’s right hand.

Step 2. Rarify the air in a glass by plunging the flame into it a few
moments, and then quickly clap the mouth of the glass on the skin;
leave it there while a second and third glass are heated and applied,
when the first should be removed and its vacuum restored before it is
replaced. In putting the glasses on again, their rims should not lie
exactly in the rings marked on the skin by previous applications, or
the bruises may inflame and slough afterwards at these parts. The
application and removal of the glasses should be done as lightly as
possible to prevent all unnecessary pain.

A few repetitions of this incomplete vacuum causes the skin to puff
up readily into the glasses, and much blood is thereby attracted into
the cellular tissue.

_Bleeding or Bloody Cupping._—When it is desired to take blood from
the body the skin is punctured or scarified by the scarificators,
half a dozen incisions being made at a blow by as many lancets
protruding from a box, when a spring it holds is touched; the glasses
are then laid over these incisions, and the necessary amount of blood
removed by their exhausting power.

[Illustration: Fig. 108.—Junod’s vacuum boot for attracting the blood
to the lower extremities.]

_Junod’s Boot_ is a tin case, shaped like a boot (see fig. 108),
but capacious enough to allow a limb when placed within it to swell
freely. It is sometimes employed to draw blood and serum into the
lower extremities during congestion of internal organs. When used,
the leg is passed into the boot, and the mouth of the boot closed
round the limb by a packing of india-rubber tied firmly round the
boot and limb, and well smeared with simple ointment. The air is
then exhausted from the inside of the boot by a small brass syringe,
which screws into a hole in the leg of the boot, as depicted in the
figure. The patient should wear the boot some two or three hours,
while the vacuum is kept up by an occasional exhaustion of the
syringe. Both limbs may be subjected to exhaustion, but the patient
must remain in bed for twenty-four hours after the operation; this is
generally necessary for other reasons, and he must wear a bandage for
a few days when he gets about.

=Leeches.=—Each leech should draw about 2 drachms of blood, and if
the bite is well fomented, another drachm will escape from the wound
afterwards.

Before the leeches are applied, the skin should be well washed with
soap and warm water, and carefully dried. The leeches should not
be taken from their box, but the box inverted over the part, when
they will quickly fasten themselves. If the leeches are applied in
a dependent position, a soft napkin may be pinned round the box to
support them as they grow heavy, and to enable them to suck as long
as possible. They should be allowed to drop off; if pulled off they
are apt to tear the wound, or leave part of their suckers in it,
which causes much irritation afterwards.

The leech is put in a little glass when applied to the gums or the
cervix uteri, and held against the part he is to suck.

If the leeches do not bite readily the part should be smeared with
blood or warm milk, and the leeches put into lukewarm water a few
minutes; immersion in small beer is also said to stimulate them to
bite.

If the bites bleed longer than is desired, they may be stopped by
pinching the skin between the finger and thumb, wiping the bite
thoroughly dry, and filling it with a little bit of amadou or fine
sponge, soaked in solution of perchloride of iron; a larger piece of
amadou is placed over the first, and the whole compressed with a turn
of a bandage or long strip of plaster. If this fails, a sewing needle
may be passed through the skin beneath the floor of the bite, and the
bleeding surface constricted by twisting a thread round it under the
needle.

Leech-bites should never be left bleeding, especially in children,
for a dangerous amount of blood may be lost from them in a few hours.

=Tents= are instruments made of some substance that enlarges as it
absorbs liquid; they are employed to dilate apertures of sinuses or
natural passages, as the cervix uteri, &c., and are generally short
rods 2 to 3 inches long, and 1/10 to ¼ inch in thickness, made of a
whalebone stem, wound round with compressed sponge, which is smeared
with wax to keep it in shape. Slips of gentian root, or of laminaria
digitata, which rapidly enlarge as they imbibe moisture, are also
employed for this purpose.

=Setons= are strips of varnished calico, 6 or 8 inches long and ⅓
broad; a thread is fastened to each end, which are tied together
while the seton is worn. It is employed to excite irritation either
along the course of a sinus, or in some superficial situation, as
the nape of the neck, to relieve congestion of internal parts. In
sinuses, a few threads of silk usually produce the required amount of
irritation.

=Chassaignac’s Drainage-tubes= are a form of seton; they are
india-rubber tubes of the calibre of a wheat straw, of any requisite
length, and perforated with holes at frequent intervals; they are
carried into the cavity to be drained, by hitching the prong of a
forked probe, made for the purpose, through one end of the tube and
thrusting it along the sinus, or across the abscess. The skin is then
incised over the further end of the sinus to bring the probe out, and
the ends of the tube are tied together.

The advantages of these tubes are, the small amount of irritation
they provoke, and the ready exit furnished for the matter along their
interior.

=Issues= are a contrivance for keeping up irritation of the surface.
A piece of diachylon plaster the size of a half-crown, with a hole
in the centre as large as a pea, is laid over the skin where the
issue is to be formed. A bit of potassa fusa is laid in the hole and
kept _in sitû_ by a second plaster, for an hour or till the skin is
destroyed under the hole. The plasters are then removed, the wound
washed, and a fresh piece of the same size put on, having at its
centre a slit ¼ inch long, under which a pea is slipped into the sore
and covered over by another smaller piece of plaster. The discharge
that soon sets up must be washed away twice daily, and the plaster
and pea renewed from time to time as they become soiled.

=Trusses= for ruptures. These are various, in shape, strength of
spring, &c.

Whatever variety of truss is employed, care should be taken that the
pressure is made in the right direction, and that it is sufficient,
but not too great for the strain it has to support.

In reducible hernia the pressure for _inguinal rupture_ should be
exerted on the inguinal canal and directly backwards (see fig. 109).
For _umbilical rupture_, the pressure should be also backwards, and
confined as much as possible to the aperture in the wall of the
belly. In _femoral_ rupture the pressure should be directed upwards
as well as backwards into the femoral ring (see fig. 110). The pad in
all should be large enough to well cover the passage through which
the rupture passes. The ease and comfort of a truss much depend on
the completeness with which it fulfils these conditions.

[Illustration: Fig. 109.—Inguinal truss.]

[Illustration: Fig. 110.—Femoral truss.]

The adequacy of a truss should always be tested by directing the
patient to separate his legs, lean forward over the back of a chair,
and cough or strain deeply. If the truss support the rupture during
this exertion it fits satisfactorily.

For _irreducible_ hernia large air-, or spring-padded trusses are
made, which prevent further descent of the viscera, but they are
exceedingly difficult to fit and often unsatisfactory in use.

In _inguinal hernia_ the truss consists of a _pad_, a _spring_, and a
_neck_, with _guide straps_.

The _pad_ is made of various materials, fine carded wool is among the
best when well stuffed into a proper shaped leather pad, and in most
cases a fixed pad is better than a moveable one.

The pad should compress the _canal_ and be convex if the patient is
stout. Its size ought to be sufficient to compress the canal and the
margins for a short distance on each side, but the pad should be as
small as will ensure fair compression. A very flaccid bellywall,
and a large gap or protrusion require a large surface on the pad.
The _spring_ should be supple and padded behind to rest on the two
sacro-iliac synchondroses, without bearing on the spine. The spring,
narrowing as it comes forward, embraces the pelvis; and opposite the
anterior iliac spine inclines downwards, because the hernia is a
little lower than the resting-place of the spring behind. When the
rupture is almost reached, the spring takes a slight elbow or bend
(the neck), that its pressure may be directed against the hernia more
fully. _Understraps_, generally not necessary, should be omitted if
possible.

In trusses for children when the testis is not descended, the pad
should have a notch at its lower border in which the testis may rest
uncompressed.

In the truss for _femoral hernia_, the _spring_ bears behind the body
and encircles the hips in the same manner as in the inguinal truss,
but when opposite the femoral artery it turns abruptly downwards to
reach the saphenous opening. The _pad_ should fit the hollow where
the rupture issues and be not oval, but rounded. The _under-strap_
should be attached to the stud at the lower end of the pad, and pass
round the perinæum and fold of the buttock, and be attached to the
neck of the spring close to the pad. It should be made of knitted
bandage that it may be changed and washed frequently.

_When measuring_ a patient for an inguinal truss, the circumference
of the body round the hips (between the crista ilii and the great
trochanter) should be first taken, and then that between the
symphysis pubis and the anterior iliac spine, half of which distance
denotes the position of the internal abdominal ring, which with the
inguinal canal has to be supported by the pad of the truss. For a
femoral hernia the same measurement should be taken round the body,
and also the distance of the saphenous opening from the symphysis
pubis and from the anterior superior iliac spine. This will enable
the maker to put the pad at the proper angle with the spring, so that
it compresses the saphenous opening, and clears the crest of the
pubes.

Every patient should, while he wears a truss, show himself from time
to time to the surgeon to see that any defect in his apparatus may be
quickly remedied. It is a useful precaution also to keep two trusses
at hand, so that if one breaks, the patient may at once apply the
other.

Salmon and Ody’s truss consists of a spring passing round the hip
from a circular pad _b_, which bears on the sacrum to a second oval
pad _a_. Both pads are attached to the spring by a ball and socket
joint. There is also a slide for shortening or lengthening the spring
if desired (fig. 111). This truss is worn round the _sound_ side of
the body and reaches beyond the middle line to the hernial opening,
with the object of directing the pressure of the spring outwards and
backwards, or exactly counter to the course of the hernia inwards.

[Illustration: Fig. 111.—Salmon & Ody’s truss.]

_Umbilical hernia._—Spring trusses are not adapted for restraining
umbilical hernia. The support consists of a broad belt fitted to
the belly, made in front of elastic webbing, and on each flank, of
white jean. Behind, the belt is fastened by straps and buckles, or by
lacing, the better plan. In the centre, the elastic part carries a
nearly flat air-cushion, measuring about 3 inches transversely and 2½
vertically. This cushion is placed against the aperture of the belly,
and presses back the protrusion. The size of the pad varies with the
size of the hernia, but it should always largely exceed the extent
of the gap in the abdominal wall. The pad, when the apparatus is
used for an infant, should not be too prominent, as it is then more
difficult to keep in place, and also by pressing into the aperture
hinders it from closing. The pad for an infant is best made of a disc
of ivory, 1½ inch broad and ½ an inch to 1 inch thick, stitched in
a little case in the centre of the girdle. The quantity of elastic
tissue should be much less in the infant’s belt than in those for
adults that the belt may be frequently washed. The difficulty of
keeping the belt in place is obviated by attaching two bands to the
upper border, to pass over the shoulders and cross behind before
fastening to the belt, like braces. Two similar ones may be fastened
to the lower border and carried under the thighs. These bands should
be of soft webbing, and several pairs kept in store, that they may be
frequently changed and washed.

=Cauteries.=

_Cautery irons._—These are masses of iron of different shapes; some
pointed, others rounded like buttons, &c., set in a stem a foot long,
fixed in a thick wooden handle. They are heated in a charcoal brazier
or common fire to bright redness if required to destroy deeply, but
short of redness if intended only to scorch the surface.

As these irons are inconvenient for many cases from their bulk, and
yet soon lose their heat if made small, other cauteries have been
devised to which the heat can be quickly renewed.

[Illustration: Fig. 112.—Gas cautery for large surfaces.]

_Gas Cautery._—The late Mr. Alexander Bruce perfected an instrument
which employs the gas flame as a source of heat (see figs. 112,
113). A blowpipe flame plays on platinum discs of various sizes, and
keeps them at a glowing heat. This hot solid point can be thrust into
the tissue wherever it is desired.

A larger form is also made for cauterising the pedicle in Ovariotomy,
&c. In this a large flame is blown on a wedge-shaped surface of
platinum, 1 inch long and ½ inch broad, and continued backwards for 2
inches by wire gauze to confine the flame against the platinum. The
flame behind these platinum discs quickly heats them again if cooled
by the blood. This cautery is very portable, and easily made ready
for use.

[Illustration:

  Fig. 113.—Gas cautery. A. Elastic gas reservoir. B. Gas jet. C.
  Tube for convoying air to the flame. 3. Platinum disc to be heated
  by the flame.
]

Mr. Clover has also devised a cautery, very useful for small growths.
A silver bead, the size of a pea, is set at each end of a horizontal
metal rod 4 inches long, which rotates on a vertical pivot half a
circle backwards and forwards, so that one or other bead is thrown
into the flame of a spirit lamp placed at a proper distance; when the
bead is heated, a touch of the finger causes the central pivot to
rotate, which brings the hot bead away from the lamp, and carries the
cold one into the flame, to be heated while the first is used.

_Galvanic Cautery._—The instrument consists of a platinum wire, made
to glow by passing through it a powerful galvanic current. The wire
should be thick (about 1/12 of an inch), and all the other conducting
surfaces sufficiently large to offer no impediment to the current
where heat is not desired. The battery best adapted for this purpose
is a Grove’s battery.

The main advantage of a galvanic cautery is that the wire can be
passed while cold exactly where it is required, and then heated
when it is in place. It is exceedingly useful in fistulæ between
the urethra and rectum, or in destroying vascular growths, nævi,
&c., where it is desirable not to destroy all the skin covering the
tumour. Again, by this means, an intense heat can be applied to a
very limited area, and more quickly renewed than by any other plan,
for the wire, even when plunged in the tissue, is never far below a
red heat.

Of _chemical caustics_ a host exist; those most commonly employed
are:—nitrate of silver, solid, or in saturated solutions (2 drachms
to the oz. of water, &c.); fuming nitric acid; solution of nitrate
of mercury in nitric acid; oil of vitriol made into a paste with
powdered charcoal; chloride of zinc mixed with dry starch, then
rolled into cakes and cut in slices; Vienna paste, that is, equal
parts of potassa fusa and quick lime worked into a paste with spirits
of wine; potassa fusa itself; solution of chromic acid. Some surgeons
prefer one, some another; as a rule, the liquid caustics are employed
where the surface to be destroyed is uneven and spongy, and solid
caustics where the surface is smooth, and a long continued action is
desired.

_Vesicants and irritants._—Of the commonest are _mustard poultices_,
made by mixing mustard flour in a basin with luke-warm water, _i.e._
about 100° F., to a paste and spreading it on muslin, which is again
folded over the exposed surface of the mustard. Boiling water and
vinegar should not be used, for they lessen the pungency of the
poultice. If the full effect be desired the poultice should remain
on the skin fifteen or twenty minutes. If only slight reddening is
wanted, the mustard flour should be diluted with its bulk of linseed
meal before mixing it with water.

A stronger vesicant is _Corrigan’s hammer_, a button of polished
steel with a flat surface, fixed to a handle; when used it should
be plunged for a couple of minutes in boiling water, or heated over
a spirit lamp, but care must be taken not to overheat it, or it
will bring the cuticle away with it. It is pressed on the skin for
ten or fifteen seconds; this is sufficient to cause reddening and
vesication.

_Blisters_ are raised by the emplastrum lyttæ, lin. cantharidis,
or _pâte epispastique_, which is milder in its effect than the two
preceding preparations of Spanish fly. Solution of iodine and iodide
of potash, in three times their bulk of spirit of wine, also produces
a blister when laid on freely.

_Poultices_ are made of linseed meal, bread, or starch, and are means
for applying warmth and moisture without absolutely wetting. Bread
poultices sodden the parts to which they are applied most, and starch
least, of the three kinds.

Before making a poultice all the materials should be at hand and
thoroughly warmed before a good fire. They are—boiling water, a
broad knife or spatula, soft old linen or muslin, oil silk, tapes,
strapping plaster, bandages, a piece of old blanket, flannel or
cotton wadding, safety pins, or needle and thread.

The linen on which the poultice is to be spread should be cut of the
intended size, and when for use about the neck or shoulder should
have some tapes sewn on to it to tie it on to the body. The oil silk
should be large enough to cover the poultice next which it is laid to
keep in the moisture. The flannel or wadding are used to wrap over
and keep in the heat of the poultice; the strapping or bandage to fix
every thing _in situ_ as required.

When poultices are continued long, their surfaces should be smeared
with lard before application; this protects the skin somewhat from
the irritation that arises; also when the poultice is to be laid
between folds of skin or on hairy situations, as the buttocks and
perinæum, it is better to cover the poultice with a thin cambric
handkerchief lest some of the meal stick to the parts.

_The Linseed Poultice_ is made as follows: pour boiling water into a
well-heated basin till the basin is half full, then scatter meal with
the left hand on the water while that is kept continually stirred
with a broad knife, adding more and more meal until the mass becomes
quite soft and gelatinous, but too stiff to cling to the knife; then
turn it out on the linen, also well heated at the fire, and spread it
in a layer about ½ an inch thick, turn up the edge of the linen for
½ an inch all round, and carry the poultice at once to the patient.
If it has to be carried far the poultice should be laid between two
very hot plates; apply it to the part to be poulticed, lay on the
oil silk, and cover that with the hot flannel or cotton wadding, and
fasten these in place with pins or a stitch. Wadding is put where the
part is irregular, as the neck or axilla; unless the wadding is well
placed and the poultice is fastened by strings, it will soon fall
into a narrow band leaving the part exposed that it should warm and
moisten.

_The Bread Poultice_ is made as follows: the materials being all at
hand, as detailed in the directions for making a linseed poultice,
crumble the inside of a moderately stale loaf until about half a
pint or a pint of crumbs are prepared; then pour boiling water into
a basin, and throw in crumbs gradually in the same manner as the
linseed meal, until a soft porous mass is prepared. The remaining
steps are the same as those for making the linseed poultice.

The poultice can be made to hold more water if it is turned into a
saucepan after mixing, and a little more water added while it simmers
for half an hour at a slow fire. Any superfluous water must be
drained off, and the poultice covered with muslin when it is made in
this way.

_The Starch Poultice_ is made as follows: rub a little starch in a
basin with cold water till it has the consistence of cream, then mix
in _boiling_ water till the starch is a thick jelly, and spread it on
the linen while hot. Starch poultices retain their heat a long time,
but yield very little moisture to the part. They are chiefly used as
emollients to inflamed affections of the skin, &c.

_Hot fomentations_ are a means for applying heat when moisture is
not desired. A ready mode is to take a piece of blanket or thick
flannel, soak it in boiling water and dry it by wringing in a folded
towel, and then wrap it over the part to be fomented with a piece
of oil silk or a hot dry flannel over it. Laudanum, turpentine, and
other applications are sprinkled over the flannel, when soothing or
counter-irritating effects are required in addition to the warmth.
A bag of bran makes a light warm fomentation if heated in a steam
kitchen, or steamer for boiling potatoes.

When absolutely _dry heat_ is desired, chamomile flowers, bran, or
sand, may be heated in an oven, and poured into hot flannel bags.

Dry heat is also very agreeably obtained by filling _india-rubber
bags_ and _cushions_ with hot water: they are rather heavy, but
retain their heat many hours.

_Lister’s Method of Dressing Wounds with Carbolic Acid._—The
properties of carbolic acid which concern the surgeon may be briefly
recapitulated as follow:—

It is highly volatile, and the putrefaction of organic fluids
is indefinitely postponed where its vapour is present. Carbolic
acid is soluble in different degrees in water, alcohol, ether,
glycerine, fixed oils, gutta percha, india-rubber, and shell-lac.
Its varying affinity for these substances enables the surgeon to
modify the application of carbolic acid in various ways; these
modifications are necessary to fully utilise its properties. Water
dissolves the crystallised acid but sparingly, 1 part in 20 being a
concentrated solution, and allows it to escape readily. The aqueous
solution is therefore useful where the effects of the acid are
required copiously, but only temporarily. Glycerine and the fixed
oils dissolve a far greater amount of the acid, and part with it
unwillingly. Their solutions are adapted for the continuous but
abundant application of the antiseptic. Shell-lac, and some other
substances, hold the carbolic acid still more tenaciously, and are
valuable as solid storehouses which yield up the antiseptic in small
quantity for a considerable period.

Carbolic acid stimulates raw surfaces, and when concentrated even
destroys animal tissues. It is a local anæsthetic; with moderate
doses, wounds lose their sensibility after the first smarting of
the application has passed off. When given in large quantities the
acid produces a peculiar kind of delirium, and temporary paralysis
of sense and motion: fatal results have followed its internal
application.

It is rapidly absorbed into the blood from wounded surfaces, and
through the skin, whence it is discharged from the body by the lungs
and kidneys. The urine of patients dressed with carbolic acid, though
of normal colour when passed, assumes a dark greenish-brown hue after
a few hours’ exposure to the air and light.

How much of the antiseptic must float in the atmosphere to prevent
fermentative changes has not yet been determined; Bucholtz found that
1 part of carbolic acid in 600 of milk almost entirely prevented
lactic fermentation, while 1 in 285 did so altogether. Alcoholic
fermentation in sugary fluids was arrested by a similar quantity.

When using the acid in dressing wounds, the watery solution, the
solid mixture, and the oily solution are necessary. The first to
neutralise the effects of exposure to the atmosphere and water before
the wound is closed; the second solid mixture in the form of plaster
to provide a very scanty but continuous supply of carbolic vapour
close to the wound: too scanty to irritate the raw surface, yet
enough to check putrifaction in the discharge oozing from it. The
third, or oily solution, is to supply the carbolic vapour abundantly
to the linen dressings, appointed to receive the discharge when it
has passed from the vicinity of the wound. The tin is used to afford
as close a cover as possible to the breach of surface; for this
purpose it must be as flexible as possible that it may fit the wound
exactly.

The carbolic plaster is made of 3 parts of shell-lac and 1 part of
carbolic acid crystals melted together and spread on calico. To
render the lac plaster non-adhesive that it may not stick to the
tender wound, it is painted with solution of gutta percha, which
dries and leaves a thin film of that substance covering the plaster.
This film is easily removed by rubbing the surface with a rough towel
should an adhesive quality be desired. In either state the carbolic
acid continues to volatilise slowly when the plaster is laid over the
wound.

When adopting this method of treating wounds the following materials
are necessary:—

1. Aqueous solution of crystallised carbolic acid (1 part in 20).

2. Carbolic oil: 1 part of carbolic acid in 5 of olive oil.

3. Lister’s shell-lac plaster.[1]

4. Sheet tin.

5. Lint; old linen.

6. Diachylon plaster.

7. Glass syringe.

8. Scissors.

9. Thin calico or muslin.

10. Bandage.

11. A wooden splint to rest the limb upon.

_To Dress recent Wounds._—When the apparatus is ready, the piece of
tin is cut and fitted to the wound, so that it shall overlap the
wound to a small extent on all sides; then a piece of lac plaster,
large enough to overlap the tin one or two inches all round; this
plaster may be cut and notched when the surface is irregular to make
it lie pretty closely; then strips of diachylon, about two inches
broad, are cut ready. The parts around the wound are well cleaned;
dirt and clots cleared from the wound with cold water, containing
about 1 of carbolic acid to 40 of water, and the interior of the
wound is freely syringed with water containing 1 of acid in 30 or
even 1 in 20 parts. The sides are brought together with sutures,
if necessary, in the ordinary way, and the tin laid on the wound;
the tin is freely wetted with carbolic water, and the lac plaster
laid over it and kept _in situ_ by strips of diachylon plaster. In
dressing recent wounds the most dependent side of the lac plaster is
left unattached, that the serous discharge, which is often copious,
may readily escape. To receive this discharge, a piece of calico,
soaked in carbolic oil, is laid over the wound now covered in,
and all kept in place by a folded towel or a roller bandage. This
oily cloth is to be changed from time to time as it gets soaked
with discharge: at first this change is necessary every night and
morning, but after three or four days once a day is often enough. The
shell-lac plaster and tin need not be removed for a week unless the
wound grow hot and painful, when they can be removed at any time if
the surface of the wound is immediately smeared with carbolic oil,
and kept well imbued with the antiseptic while it is being examined.
Should it contain pent-up discharge, the sutures must be loosened and
the discharge washed out by injecting the 1 in 30 aqueous solution.
The tin and lac plaster may be then replaced, and the dressing
renewed. The same precaution must be followed when the sutures have
to be removed. Usually there is very little swelling and no pain,
and the healing process goes on tranquilly if undisturbed. Should
bruised parts slough, they may be trimmed away with scissors dipped
in carbolic oil. When the wound has once been washed with carbolic
acid, the antiseptic should not enter the wound a second time, as its
irritant qualities excite inflammation in the wound.

_Chronic abscesses_, besides recent wounds, are treated with carbolic
acid. The surface to be punctured is covered with a piece of thin
muslin soaked in carbolic oil, and the knife to be used is dipped in
the oil also. Then, a second piece of muslin being ready, the surgeon
opens the abscess through the muslin, and as he withdraws the knife
an assistant lays on the second piece of muslin over the wound.
The matter drains away from under this curtain, and the access of
atmospheric air is prevented. When the matter ceases to flow, the lac
plaster is laid on, and the oily cloth outside, which can be changed
as often as is requisite. Abscesses so treated usually soon cease to
secrete matter, shrink, and fill up without delay. If the abscess has
burst or had communication with the external air, the interior must
be filled with watery solution 1 to 20 before it is dressed, that
fermentation in the cavity may be prevented; the further treatment is
the same as for a recent wound.

[Illustration: Fig. 114.—Irrigating a wound.]

=Irrigation.=—The continual flow of ice-cold water is used to prevent
inflammation of certain wounds. In using cold, it is particularly
necessary that the temperature of the water remain steady, for
alterations of temperature cause alterations in the capacity of the
blood vessels, and promote congestion rather than diminish it; hence
irrigation, badly attended to, becomes an evil instead of a benefit.
The simplest way (see fig. 114) of contriving irrigation is to lay
the limb in an easy position on pillows, protected by a sheet of
india-rubber cloth, weighted at one corner to draw the cloth into a
channel, down which the water trickles into a receiver under the bed;
over the limb a jar, wrapped in blanket, is suspended. This is filled
with water from time to time, and kept charged with lumps of ice. A
syphon is made by a few feet of fine india-rubber tubing reaching
from the bottom of the jar to the wound, the escape of water through
the tube being moderated by drawing the end more or less tightly
through a bit of cleft stick. It is sufficient that the wound should
be kept constantly and thoroughly wetted; more than that is waste of
cooling power.

_Esmarch’s Irrigator._—This is a simple contrivance for washing out
wounds and sinuses with a stream of water. It consists of a tall can
of block tin (see fig. 115), with an orifice at the lower end, to
which a couple of feet of india-rubber tubing are attached. The tube
is fitted with an ivory nozzle and a hook, so that when the stream is
not wanted the flow of water is stopped by hanging the nozzle on the
upper edge of the can. The stream can be made more or less forcible
by raising or lowering the can above the wound.

[Illustration: Fig. 115.—Esmarch’s Irrigator.]

=The Administration of Chloroform.=—In administering chloroform the
main points to be borne in mind are—1. If the patient is fit to
undergo an operation at all he may inhale chloroform. 2. The patient
should be fasting; this is the most effectual preventive of sickness.
3. He should be in an easy position, clad in a loose but warm
night-dress, which does not interfere with ordinary or artificial
respiration, should that be suddenly required. 4. The patient must
never inhale more than 4 per cent. of chloroform vapour in the air he
respires; on the other hand, the vapour may circulate in the blood
without harm for an indefinite time, provided it never pass beyond a
certain concentration. 5. Chloroform is a sedative and depressant;
the pulse gives the earliest indication of syncope, and the
respiration should be constantly watched the whole time chloroform
is inhaled. It should be noted that the pulse often fails suddenly
at the first flow of blood in an operation. Again, when the patient
is deeply narcotised, the jaw may gape and the tongue sink back till
it closes the glottis. From this cause respiration sometimes ceases,
and danger quickly arises if the chin is not drawn up to raise the
epiglottis. In beginning to inhale, the quantity of vapour should be
small, and gradually increased. The patient must be cautioned not
to talk, to avoid the irritation and coughing chloroform sometimes
excites while he is speaking. He should also shut his eyes lest the
vapour make them smart. After inhalation has been continued a few
minutes the patient is often quiet and inattentive, though easily
roused by pain. His condition at this stage should be tested by
asking him to give his hand, or by pinching him gently; if no notice
be taken of these, the conjunctiva should be touched, and the amount
of winking thus excited will enable the chloroformist to judge if
the patient will resist when the knife is applied. Patients vary
much in the time passed before recovering consciousness; if they
remain soundly asleep, breathing freely and with good pulse, it is
better to avoid rousing or moving them until they wake spontaneously;
such patients suffer less confusion and vomiting than those who are
quickly alive to what is going on around them.

_Signs of Danger._—Sudden failure or irregularity of the pulse, with
pallor and arrested breathing, are of great importance; if these
occur, the chloroform must be at once removed, a free supply of fresh
air ensured, the tongue drawn gently forward, and if the breathing
do not quickly begin, it must be set up artificially (see p. 183)
without loss of time, and continued, if necessary, for at least an
hour before recovery is despaired of. Stertorous breathing is not
alarming unless accompanied by feeble pulse, shallow respiration, and
dilatation of the pupils; with these it becomes a sign of a comatose
condition.

As subordinate adjuvants for faintness the following are
useful:—moistening the tongue and lips with brandy from time to time,
or letting the patient sip a small quantity from the spout of a
feeding cup. In complete syncope, galvanism to the epigastrium, a hot
iron or scalding water to the præcordia may be employed, but _should
never interfere with the maintenance of artificial respiration, which
is of far greater efficacy in restoring suspended animation than
anything else_.

Chloroform is safely given on a handkerchief, or in various ways, if
the administrator is careful to watch the pulse and respiration, and
to guard against the patient, by a sudden deep inspiration, taking
too large a dose of vapour at once. Exact measurement of the quantity
of liquid poured on the handkerchief at a time is of no value, as
it is no index of the concentration of the air respired by the
patient. Of far greater consequence is it to insure a free supply of
atmospheric air, by keeping the evaporating surface a few inches from
the mouth and nostrils.

[Illustration: Fig. 116.—Clover’s apparatus for administering
chloroform.]

The safest mode of giving chloroform is by _Clover’s Inhaler_ (fig.
116), now used in many London hospitals and elsewhere. It renders it
impossible to give the patient too strong a dose, by preparing an
atmosphere of known strength for him to breathe. Clover’s apparatus
consists of a bag of 8,000 or 10,000 cubic inches capacity, suspended
by a loop behind the chloroformist’s back, from this a flexible tube
brings the vaporised air to a mask, fitting over the nose and mouth
of the patient. This mask has a flexible metal border for adjusting
it to different faces; and a valve that opens and closes, to allow
more or less common air to be respired with that drawn from the
reservoir if desired.

The reservoir is supplied by injecting into it, from a bellows, 1,000
cubic inches of air, drawn through an evaporating box heated by
hot water, into which 32½ minims of chloroform are injected from a
graduated syringe each time the bellows are filled. By these means,
an atmosphere of known strength is prepared for the inhalation; that
is one containing about 4° of vapour. This apparatus is very easy
to use, and the most efficient in producing anæsthesia quickly and
pleasantly.

=Artificial Respiration.=—Many plans are employed; but the two most
efficient are those to be described.

[Illustration: Fig. 117.—Artificial Respiration. Marshall Hall’s
method. 1st position.]

_Marshall Hall’s Method._—Lay the patient on the floor, with the
clothing round his neck, chest, and abdomen loose; if wet, remove it,
and throw over his body a warm blanket. Clear out the mouth, and turn
the patient _on his face_, one arm being folded under his forehead
(see fig. 117), and the chest raised on a folded coat or firm
cushion. Next, turn the patient well on his side, while an assistant
supports the head and arm doubled underneath it (see fig. 118), and
confines his attention to keeping the head forward and the mouth
open during the movements to and fro. When two seconds have elapsed
turn the body again face downwards, and allow it to remain so for
two seconds, and then raise it as before. This series of movements,
occasionally varying the side, should be repeated about fifteen times
a minute, and continued until spontaneous respiration is restored,
or, until two hours have been thus spent in vain.

[Illustration: Fig. 118.—Artificial Respiration. Marshall Hall’s
method. 2nd position.]

[Illustration: Fig. 119.—Artificial Respiration. Silvester’s Method.
Expanding the Chest.]

[Illustration: Fig. 120.—Artificial Respiration. Silvester’s method.
Compressing the Chest.]

_Silvester’s Method._—Lay the patient on a flat surface, the head and
shoulders supported on his coat folded into a firm cushion. Loosen
all tight clothing, and if wet replace it by a warm dry blanket, his
arms being outside the blanket. Clear the mouth of dirt, blood, &c.,
draw the tongue forwards, and fasten it to the chin by a piece of
string or tape tied round it and the lower jaw. Next, standing at the
patient’s head, grasp the arms at the elbows, and draw them gently
and steadily upwards till the hands meet above the head (see fig.
119); keep them so stretched for two seconds. Then slowly replace
the elbows by the sides, and press gently inwards for two seconds
(see fig. 120). These movements are repeated without hurry about
fifteen times in a minute, until a spontaneous effort to breathe is
made, when exertion should be directed to restoring the circulation
by rubbing the limbs upwards towards the body, and by placing hot
bottles at the pit of the stomach, to the armpits, between the
thighs, and to the feet. Should natural breathing not commence,
artificial respiration should be continued for two hours before
success is despaired of.

[Illustration: Fig. 121.—The Spray-producer.]

=Richardson’s Ether Spray-Producer= (fig. 121) consists of a tube on
which two india-rubber bags are placed; one, protected by a silk net,
acts as a reservoir; the other, furnished with a valve, is the pump;
these drive a constant stream of air over the tip of a fine tube
projecting from a flask of ether; this sucks up the ether and throws
it in fine spray on the surface to be chilled by its evaporation. The
ether for this purpose must be very pure and dry, having a specific
gravity of ·720, or the evaporation will not be sufficiently rapid
to produce congelation. The first effect of the spray is a numbing
aching pain with reddening of the surface. This is succeeded by a
pricking pain. In ten seconds, if the ether be good, a dead white hue
spreads rapidly over the skin, and when this appears the surface is
quite insensible.

The bottle and elastic air-pump may be attached to the glass jet
seen in the corner of fig. 121, which then makes an apparatus for
injecting astringent solutions in spray over the nasal passages, the
throat, and air-tubes; but the tubes used for watery fluids are much
wider than that for pulverising ether into spray. Tannin in solution
of 3-10 grains to the ounce of water, sulphate of zinc, or alum in
similar quantity, may be thus inhaled with much benefit by persons
suffering from chronic congestion of the mucous membranes.

=Injecting Chloroform Vapour into the Uterus= is a ready means of
relieving pain in cancer of that organ; special apparatus is made
for the purpose, but an ordinary elastic clyster syringe will answer
the purpose, if the flask is unscrewed and a few drops of chloroform
are poured into it, from time to time, while air is pumped through
the delivery tube, which is passed up the vagina to the ulcerated
cervix-uteri.

=Subcutaneous Injection.=—The syringe for this operation (fig. 122)
consists of a graduated glass tube holding six minims. The piston
works in a silver continuation of the graduated tube, and is thus
kept clear of the solutions used for injection. To the nozzle of
the syringe fine sharp-pointed cannulæ are screwed on; they are of
different lengths, some of steel, others of steel gilt; the gilding
renders the points very blunt, and consequently much more painful to
insert. In filling the syringe, care should be taken not to draw the
fluid above the level of the graduation on the tube, that the exact
amount injected may be read off as the liquid sinks in the tube. The
finer the cannula, and the sharper its point, the less pain is caused
by its introduction.

[Illustration: Fig. 122.—Subcutaneous Injection.]

The solution of morphia should contain a grain in six drops and
be as little acid as possible. In injecting morphia, it should be
recollected that ⅙ grain is the usual dose to allay pain, and produce
sleep; doses even far smaller often suffice for this purpose, though
very much greater quantities can be administered by injection, where
long use has rendered the patient tolerant of the drug. Some persons
dread the puncture considerably; for them the pain may be entirely
prevented by numbing the surface with ether-spray (see page 186)
before inserting the syringe, though usually the prick is of so
little consequence that any precaution of this kind is unnecessary.

The cannula should be thrust completely through the skin into the
subcutaneous cellular tissue; if the fluid is injected into the
skin itself, inflammation and suppuration of the puncture sometimes
ensues. After the cannula is withdrawn, the finger should be placed
for a few seconds over the puncture, or much of the fluid will leak
out again. When large quantities of solution (one or two syringefuls)
are injected the cannula need not always be withdrawn, the nozzle
can be unscrewed and the syringe charged again; but more than ten or
twelve drops injected into one place generally causes much pain, even
where the cellular tissue is very loose.

The syringe and cannula should be carefully cleaned, by sending
plenty of cold water through them each time they are used, or the
cannula will rust and become unfit for use.

=Collodion= is much used in drawing the edges of small wounds
together, &c. Preston’s plastic collodion, or the flexible collodion
of the British Pharmacopœia, 1867, have advantages over the common
form by furnishing a tougher pellicle, yielding to the movements of
the skin beneath without cracking. Collodion should be kept for use
in a small wide-mouthed bottle, with stopper and brush, and when
employed should be laid on quickly in a thick mass, so that the
crust it leaves shall be of one layer. A tougher crust is obtained
if a piece of muslin is soaked in the collodion and then laid on the
wound, than if the collodion is used alone.

=Vaccination.=—The lymph of the vaccine vesicle, taken between the
seventh and tenth days, is preserved for use on lancet-shaped slips
of bone 1 inch long, called _points_. These are dipped in the lymph
as it exudes from the vesicle, and exposed to the air till dry; they
are then wrapped in paper ready for use. When used, the lymph should
be moistened, by holding them over a vessel of steaming water a few
seconds before inserting them in the wound made to receive the lymph.

The points often lose the virus in a few days, and should, if
possible, be used the same day they are charged.

The lymph may be much longer preserved if hermetically sealed in
_glass tubes_. These are about the thickness of a darning-needle, 3
inches long, and open at both ends. When the tube is to be charged,
one end is inserted in the lymph exuding from a punctured vesicle; a
drop then enters the tube by capillary attraction, but filling not
more than half its interior: a few shakes of the hand will send the
drop a little further in. The lymph end of the tube is then taken
in the thumb and forefinger, while the unoccupied part of the tube
is passed once or twice quickly through the flame of a candle. This
rarifies the air, and while it is warm the end is closed by melting
it at the edge of the flame. The second end is then closed in the
same way as the first. When the lymph is wanted for use, the ends
of the tube are broken, and the lymph blown out on the point of
a lancet. Lymph preserved in these tubes retains its efficacy an
indefinite time. The National Vaccine Institution, Russell Place,
Fitzroy Square, London, W., supplies to medical practitioners both
points and tubes gratis on application.

In performing the operation the common lancet does very well; but two
or three forms of narrow-grooved lancets are employed by surgeons
for this purpose. The operation is most successful when the lymph is
transferred direct from arm to arm; the lancet making the puncture is
then charged at the vesicle of a child vaccinated a week before, and
points are unnecessary. When making the puncture the surgeon grasps
the child’s arm in his left hand, puts the skin on the stretch over
the insertion of the deltoid with his left forefinger and thumb,
pushes the lancet downwards between the cutis and cuticle, about
1-10th of an inch, to raise the latter in a little pocket; he then
charges his lancet with lymph and inserts it in the pocket, or if
using points, inserts the moistened point for a minute, taking care
as he withdraws the point to press the skin down on the point with
his left thumb, that the lymph may be well wiped off the point and
left in the wound. This process is repeated four or five times and
the operation is complete. The corium should not be penetrated, or it
will bleed freely and the blood will wash away the lymph; one drop of
blood is of little consequence; indeed, it shows that an absorbing
surface has been reached.

The phenomena following the insertion of the vaccine virus in an
infant’s arm are as follows:—On the second day the puncture is
slightly elevated; on the third it begins to grow red; on the fifth
it is marked by a distinct vesicle with a depressed centre and red
areola; on the eighth the vesicle is perfect, of pearl-like aspect,
full of clear lymph; the areola, often little marked by the eighth
day, rapidly increases on the ninth and tenth days, and reaches an
inch or more in diameter. This bright-red inflammatory action in
the skin is essential to show the system is properly infected with
the vaccine disease; by the twelfth day the areola has lessened,
the lymph is yellow, and often escapes by rupture of the vesicle;
on the fourteenth day the vesicle has dried to a scab, that falls
on the twenty-first day, leaving a dotted cicatrix, the vestige of
the multilocular structure of the vesicle. The three important marks
diagnostic of the vaccination being satisfactory, are—1, the pearly
multilocular vesicle of the 8th-9th day; 2, the widely-spread areola
on the 9th-12th day; 3, the well-marked foveated cicatrix after the
scab has fallen.

Observation shows that the number of people who take small-pox after
vaccination is very small indeed, when more than three well-marked
scars exist; and this number at least should be secured by making
five insertions of lymph at the time of vaccination.


FOOTNOTES:

[1] Lister’s shell-lac plaster can be obtained of the Glasgow General
Apothecaries’ Company, and the sheet tin of Messrs. Compton & Co.,
148, Fenchurch Street, E.C.




  LIST OF THE INSTRUMENTS AND APPLIANCES REQUISITE, OR OCCASIONALLY
  USEFUL, IN MOST OF THE IMPORTANT AND ORDINARY OPERATIONS IN SURGERY.




PREPARATIONS AND REQUISITES FOR OPERATIONS IN GENERAL.


  THE OPERATING ROOM.
  THE SICK BED AND BED-ROOM.
  SEDATIVES AND RESTORATIVES.
  THE ARREST OF HÆMORRHAGE.


OPERATING ROOM.

_Having a good Light and Windows that open readily, and a Fire in
Winter._

  1. Firm table, 4 feet long, 2 feet wide, and 3½ feet high.
  2. Pillows.
  3. Blankets.
  4. Towels.
  5. Old linen.
  6. Mackintosh sheets.
  7. Old carpet, or old sheet to cover the floor.
  8. Tray of sawdust or sand.
  9. Bandages.
  10. Strapping plaister.
  11. Lint.
  12. Oiled silk.
  13. Cotton wool.
  14. Tow.
  15. Perchloride of iron.
  16. Basins, large and small.
  17. Hot and cold water, ice.
  18. Bucket and slop-jar.
  19. Sponges.
  20. Chloroform and inhaler.
  21. Oil.
  22. Pins.
  23. Scissors.
  24. Brandy.
  25. Ammonia.
  26. Fire for heating cauteries.


SICK ROOM AND BED.

  1. Iron bedstead.

  2. Wool and hair mattress.

  3. Several pillows, soft and of different sizes.

  4. Air and water cushions.

  5. Blankets, small single ones.

  6. Pieces of soft flannel.

  7. Six sets of sheets and pillowcases.

  8. Old soft linen.

  9. Cotton-wool.

  10. Towels.

  11. Soft pocket-handkerchiefs.

  12. Three pieces of Mackintosh, 2 feet 6 inches square.

  13. Bed cradle.

  14. Light bedgowns.

  15. Flannel jacket, and flannel Zouave drawers.

  16. Hot-water bottle.

  17. Bed-pan.

  18. Bed-urinal and bed-stool.

  19. Basins.

  20. Cold water.

  21. Condy’s fluid.

  22. Sir W. Burnett’s fluid.

  23. A bed-rest chair.

  24. Night lights.

  25. A fire, or in summer a lamp to burn in the fireplace, to create
  a draught of air.

  26. Enamelled saucepan.

  27. Two feeding cups.

  28. Spittoon.

  29. Tea-equipage.

  30. Tea-kettle.

  31. Medicine measure.

  32. Apparatus for keeping food warm, with lamp.

  33. Flowers.

Before a room is occupied by a patient who has been operated on, it
should be thoroughly cleaned; the walls and ceiling should be well
brushed, the carpet taken away and the floor thoroughly scrubbed
with soda. All curtains and chintz furniture should be removed, old
window-blinds replaced by new green ones, and the window made to
open readily at the top and bottom. A fire or oil-lamp should be
lighted in the fireplace to maintain a circulation of air. If the
season require a fire, the iron fender should be removed and replaced
by a wooden tray of sand or ashes, to prevent the noise of cinders
and fire-irons falling on the fender and hearth. It is well also
to flush all the drains, water-closets and sinks in the house with
disinfecting fluid one or two days before the operation, and a store
of Sir William Burnett’s, or similar disinfecting fluid, should be
made ready to clear away the fœtid odours of discharges as they arise.

When possible, it is a great advantage to have two beds of similar
height and size, that the patient may occupy them alternately. The
cool bed refreshes the patient greatly, and the vacated bed is easily
cleaned and aired without fatigue to the sick person.


SEDATIVES.

  1. Tincture of opium.

  2. Solution of morphia and hypodermic syringe.

  3. Morphia suppository.

  4. Ice.


RESTORATIVES.

  1. Brandy, champagne, sherry.
  2. Eau-de-cologne.
  3. Liquor ammoniæ.
  4. Smelling salts.
  5. Spirit of chloroform.
  6. A fan.
  7. A Rimmel’s perfume vaporiser.
  8. Beef-tea.
  9. Chicken-broth.
  10. Milk.
  11. Lime-water.
  12. Soda-water.
  13. Eggs.
  14. French bread.
  15. Biscuits.
  16. Arrow-root.
  17. Liebig’s extract of meat.


THE ARREST OF HÆMORRHAGE.

  1. Artery forceps.

  2. Torsion forceps.

  3. Tourniquet.

  4. Tenaculum.

  5. Hare-lip pins.

  6. Acupressure needles.

  7. Nævus needle.

  8. Wire nippers.

  9. Solution of perchloride of iron (equal parts of the salt and
  water).

  10. Solid perchloride of iron.

  11. Richardson’s styptic colloid.

  12. Ice, ice-cold water.

  13. Cautery irons.

  14. Galvanic cautery wire.

  15. Ligatures, silk, fine hemp, and whipcord.

  16. Lint.

  17. Amadou.

  18. Bandages.

  19. Compressed sponge.

  20. Scissors.

(See List for the Ligature of Arteries.)




INSTRUMENTS AND APPLIANCES FOR OPERATIONS ABOUT THE HEAD AND NECK.


  TREPHINING THE SKULL.
  OPERATIONS ON THE EYE.
  HARE-LIP.
  RESECTION OF THE JAW.
  EXCISION OF THE WHOLE TONGUE.
  CLEFT PALATE.
  EXCISION OF TONSILS.
  LARYNGOTOMY.
  TRACHEOTOMY.


TREPHINING THE SKULL.

  1. Scalpel.

  2. Trephines—several crowns.

  3. Hey’s saw.

  4. Elevator.

  5. Stout dissecting forceps.

  6. Brush to clean away the bone-dust.

  7. Probe.

  8. Quill, cut like a tooth-pick, to clear the groove of bone-dust.

  9. Lenticular knife.

  10. Small polypus forceps.

  11. Sponges.

  12. Lint.

  13. Ice.


OPERATIONS ON THE EYE.


_Strabismus._

  1. Chloroform, if used.

  2. Laurence’s, or other head-fixer.

  3. Specula of different sizes.

  4. Toothed forceps.

  5. Strabismus scissors and hooks.

  6. Fine curved needles, and _finest_ thread.

  7. Lint.

  8. Ice, or cold water.


_Extirpation of the Eyeball._

  1. Chloroform.

  2. Head-fixer.

  3. Speculum.

  4. Toothed forceps.

  5. Curved scissors.

  6. Strabismus hook.

  7. Small and large sponges.

  8. Dissecting forceps.

  9. Ice-cold water.

  10. Perchloride of iron.

  11. Fine curved needles, and _finest_ silk thread.

  12. Lint.

  13. Pulled lint.

  14. Basin.

  15. Bandage.

_Cataract_ (_Congenital_).

  1. Atropine drops.
  2. Chloroform.
  3. Head-fixer.
  4. Speculum.
  5. Lacerating needles.
  6. Toothed forceps, to fix eyeball.
  7. Lint.
  8. Cold water.
  9. Gelatine plaster.


_Cataract_ (_Senile_).

  1. Atropine drops.
  2. Chloroform.
  3. Head-fixer.
  4. Speculum.
  5. Lacerating needles.
  6. Toothed forceps.
  7. Cataract knives.
  8. Scoop.
  9. Platinum spatula, to adjust edges of wound.
  10. Small sponges.
  11. Basin and water.
  12. Gelatine plaster.
  13. Wool and bandage.
  14. Lint.


_Iridectomy._

  1. Chloroform, if used.
  2. Head-fixer.
  3. Specula.
  4. Toothed forceps.
  5. Right-angled knives.
  6. Iris forceps.
  7. Iris hooks.
  8. Capsule scissors, if required.
  9. Light curved scissors.
  10. Lint.
  11. Gelatine plaster.
  12. Wool and bandage.
  13. Atropine drops.
  14. Small sponges and basin.
  15. Hot and cold water.


HARE-LIP.

  1. Scalpel.

  2. Artery forceps, or sharp hook.

  3. Hare-lip pins.

  4. Wire nippers.

  5. Dentist’s silk twist.

  6. Strapping plaster.

  7. Silver suture.

  8. Collodion.

  9. Scissors.

  10. Cheek compressor.

  11. Sponges.

  12. Large towel to wrap the child in.

  13. Chloroform and inhaler.

When the bone has also to be bent back—

  14. Bone nippers.

  15. Sequestrum forceps.

  16. A knitting needle; and

  17. Spirit lamp to check deep hæmorrhage by the actual cautery.


RESECTION OF THE JAW, AND TUMOURS CONNECTED WITH IT.

  1. Scalpels.
  2. Artery forceps.
  3. Torsion forceps.
  4. Ligatures.
  5. Retractors.
  6. Tooth forceps.
  7. Narrow saw.
  8. Hey’s saw.
  9. Bone-cutting forceps.
  10. Lion’s-tooth forceps.
  11. Sequestrum forceps.
  12. Gouges.
  13. Chisel.
  14. Gag.
  15. Hare-lip pins.
  16. Wire nippers.
  17. Actual cautery.
  18. Perchloride of iron.
  19. Ice.
  20. Sutures, silk and wire.
  21. Solution of chloride of zinc.
  22. Lint.
  23. Bandages.
  24. Plaster.
  25. Collodion.
  26. Mackintosh sheet.
  27. Small sponges tied on sticks.
  28. Larger sponges.
  29. Chloroform and inhaler.


EXCISION ON THE WHOLE TONGUE.

  1. Scalpel.
  2. Torsion forceps.
  3. Artery forceps.
  4. Gag.
  5. Archimedian bone-drill.
  6. Cheek retractors.
  7. Incisor tooth forceps.
  8. Narrow saw.
  9. Nævus needle, and
  10. Half a yard of thick whipcord.
  11. Stout copper wire.
  12. Key for twisting the wire tight.
  13. Wire cutters.
  14. Stout acupressure needle.
  15. Hare-lip pins.
  16. Two ecraseurs.
  17. Needle for passing the chain.
  18. Sharp and blunt hooks.
  19. Stout silk.
  20. Metallic sutures.
  21. Ligatures.
  22. Ice.
  23. Perchloride of iron.
  24. Cautery iron.
  25. Solution of chloride of zinc.
  26. Collodion.
  27. Small sponges mounted on sticks.
  28. Brandy.
  29. Chloroform and inhaler.
  30. Lint.
  31. Mackintosh sheet.


CLEFT PALATE.

  1. Long-handled, narrow-bladed knife, for dividing the palatine
  muscles.

  2. Long-handled curved scissors.

  3. Slender hooked forceps, to seize soft palate.

  4. Long-handled small bistoury, for paring edges of fissure.

  5. Long-handled needles, with the eye at the point for passing
  sutures.

  6. Fine blue silk, or catgut.

  7. Blunt and sharp hooks.

  8. Scissors.

  9. Ice, ice-cold water.

  10. Mackintosh sheet.

  11. Sponges set on sticks.

  12. Glass syringe for washing the mouth.

  13. Smith’s gag.

  14. Chloroform and inhaler.


EXCISION OF TONSILS.

  1. Long vulsellum.

  2. Tonsil guillotines; or, probe-pointed bistoury, the posterior
  two-thirds of the blade covered with lint or plaster; or, tonsil
  excisors of various kinds.

  3. Ice, ice-cold water.


_To repress Hæmorrhage from the Tonsils._

  1. A small lump of ice held in a long vulsellum against the tonsil.

  2. Small sponge on the end of a stick, dipped in ice-cold solution
  of perchloride of iron, or other styptic.

  3. Long straight polypus or gullet forceps with padded ends, to
  compress the tonsil; one blade being passed within the mouth, the
  other outside against the neck.


LARYNGOTOMY IN THE CRICO-THYROID SPACE.

  1. Scalpel.
  2. Artery forceps and ligature silk.
  3. Torsion forceps.
  4. Silver tube, curved on the flat.
  5. Tapes.
  6. Sharp and blunt hooks.
  7. Two hooked forceps.
  8. Sponges.


TRACHEOTOMY.

  1. Scalpel.

  2. Dissecting forceps.

  3. Blunt hooks for veins.

  4. Sharp hook to draw forward trachea.

  5. Double silver tube and tapes.

  6. Torsion forceps.

  7. Artery forceps.

  8. Ligatures.

  9. Trachea-dilator, to assist introduction of tube.

  10. Sponges.

  11. Brandy.

  12. Ammonia.

  13. If a foreign body is lodged in the larynx, forceps of various
  kinds to extract with.

  14. Strapping plaister.

  15. Silver suture.




INSTRUMENTS, &c., FOR OPERATIONS ABOUT THE TRUNK.


  REMOVAL OF THE BREAST OR TUMOURS.
  NÆVUS.
  TAPPING THE PLEURA.
  TAPPING THE BELLY.
  COLOTOMY.
  OVARIOTOMY.
  CÆSARIAN SECTION.
  STRANGULATED HERNIA.
  RADICAL CURE OF HERNIA.
  HÆMORRHOIDS.
  FISTULA IN ANO.
  CLEFT PERINÆUM.
  EXTIRPATION OF THE CERVIX UTERI.
  AMPUTATION OF THE PENIS.
  CIRCUMCISION.
  EXCISION OF TESTIS.
  TAPPING A HYDROCELE.
  VESICO-VAGINAL FISTULA.
  RETENTION OF URINE.
  EXTERNAL URETHROTOMY.
  LITHOTOMY.
  LITHOTRITY.
  REMOVING FOREIGN BODIES FROM THE URETHRA AND BLADDER.


REMOVAL OF THE BREAST OR TUMOURS.

  1. Scalpel.
  2. Artery forceps.
  3. Torsion forceps.
  4. Dissecting forceps.
  5. Double hook.
  6. Blunt hooks.
  7. Tenaculum.
  8. Fine ligatures.
  9. Half-yard of stout whipcord, for irremovable glands.
  10. Wire or silk sutures.
  11. Lint.
  12. Diachylon plaster.
  13. Sponges.
  14. Scissors.
  15. Three-inch wide rollers.
  16. Folded towel compress.
  17. Chloroform and inhaler.
  18. Waterproof sheet.


NÆVUS.

_For Ligature._

  1. Nævus needles, straight and curved.
  2. Suture silk, stout compressed whipcord.
  3. Scalpel.
  4. Scissors.
  5. Lint.
  6. Chloroform and inhaler.
  7. Sponge and water.

_For Cauterising._

  1. Acupressure needles.
  2. Spirit lamp.
  3. Galvanic cautery.
  4. Gas cautery.


_For Excising._

  1. Scalpel.
  2. Dissecting forceps.
  3. Blunt hooks.
  4. Artery forceps.
  5. Sharp hooks.
  6. Ligature.
  7. Lint.
  8. Bandage.
  9. Sponge.
  10. Sutures.


_For Injecting._

  1. Subcutaneous injecting syringe.
  2. Solution of perchloride of iron.


_For Passing Setons._

  1. Small fine suture needles.
  2. Fine silk suture.


TAPPING THE PLEURA.

  1. Small scalpel.
  2. Trocar, fitted with india-rubber tube.
  3. Bucket.
  4. Lint.
  5. Collodion.
  6. Strapping.
  7. Scissors.
  8. Brandy.


TAPPING THE BELLY.

  1. Body bandage (see p. 10).
  2. Scalpel.
  3. Trocar.
  4. Suture.
  5. Collodion.
  6. Scissors.
  7. Lint.
  8. Bucket.
  9. Diachylon plaster.
  10. Brandy.


AMUSSAT’S OPERATION OF COLOTOMY AND GASTROTOMY.

  1. Scalpel.
  2. Probe-pointed bistoury.
  3. Director.
  4. Dissecting forceps.
  5. Nævus needle, threaded with thick whipcord.
  6. Silver sutures.
  7. Artery forceps.
  8. Fine ligatures.
  9. Retractors.
  10. Sponges.
  11. Large trocar.
  12. Tow.
  13. Sponges.
  14. Large syringe full of warm water.
  15. Chloroform and inhaler.


OVARIOTOMY.

  1. Room raised to temperature of 70° F.
  2. Scalpel.
  3. Clamp.
  4. Vulcanised india-rubber tubing, to fix on cannula.
  5. Torsion forceps.
  6. Artery forceps and ligatures.
  7. Fine ligatures.
  8. Broad retractors.
  9. Blunt hooks.
  10. Ovariotomy trocar.
  11. Nævus needles, threaded.
  12. Hare-lip pins.
  13. Wire nippers.
  14. Strong whipcord.
  15. Silk sutures and silver wire.
  16. Diachylon plaster.
  17. Catheter for emptying the bladder.
  18. Soft napkins.
  19. Bandage or laced napkin.
  20. Chloroform and inhaler.
  21. Cautery iron.
  22. Silver pins.
  23. Sponges.


CÆSARIAN SECTION.

  1. Room maintained at temperature of 70° F.

  2. Catheter to empty bladder.

  3. Large scalpel.

  4. Straight probe-pointed bistoury.

  5. Director.

  6. Large blunt hooks.

  7. Large syringe and vaginal tube, for washing out uterus per
  vaginam.

  8. Artery forceps.

  9. Ligatures, fine and stout whipcord.

  10. Torsion forceps.

  11. Hare-lip pins, stout and long.

  12. Suture silk.

  13. Fine sutures.

  14. Folded linen compress.

  15. Broad body roller.

  16. Flannel.

  17. Cotton wool.

  18. Warm flannels.

  19. Chloroform and inhaler.


STRANGULATED HERNIA.

  1. Scalpel.
  2. Straight bistoury.
  3. Probe-pointed bistoury.
  4. Hernia knife.
  5. Narrow director.
  6. Broad director.
  7. Dissecting forceps.
  8. Blunt hooks.
  9. Fine hook, in case the sac is very tense.
  10. Artery forceps.
  11. Torsion forceps.
  12. Ligatures.
  13. Sutures.
  14. Lint.
  15. Diachylon plaster.
  16. Three-inch wide roller.
  17. Compress.
  18. Razor.
  19. Sponges.
  20. Half grain of morphia suppository.
  21. Chloroform and inhaler.
  22. Scissors.


WOOD’S OPERATION FOR RADICAL CURE OF HERNIA.

  1. Razor, or scalpel, for shaving the groin.
  2. Tenotomy knife.
  3. Needle.
  4. Compressed whipcord, well waxed and soaped.
  5. Glass or box-wood compress.
  6. Two pads of lint.
  7. Lint.
  8. Bandage.
  9. Scissors.
  10. Suture.
  11. Collodion.


HÆMORRHOIDS.


_External,—Excision of._

  1. Vulsellum, or hook, or ringed forceps.
  2. Knife-edged scissors curved on the flat.
  3. Torsion forceps.
  4. Lint and T-bandage.
  5. Smith’s clamp.
  6. Cautery iron.


_Internal._

  1. Enema of warm water.

  2. Hook, vulsellum, or ring-forceps.

  3. Thin compressed whipcord.

  4. Nævus needles threaded, to transfix the base of the pile.

  5. Scissors.

  6. Smith’s clamp.

  7. Ice.

  8. Solid perchloride of iron.

  9. Lint and cotton wool.

  10. Opium suppository.


PROLAPSUS ANI.

The same.


FISTULA IN ANO.

  1. Probes of various sizes, some grooved.
  2. Grooved director.
  3. Probe-pointed curved bistoury.
  4. Straight sharp-pointed bistoury.
  5. Tenaculum.
  6. Threaded curved needle set in a handle.
  7. Torsion forceps.
  8. Artery forceps.
  9. Stout ligature.
  10. Cautery iron.
  11. Lint, cotton wool.
  12. Sponges.
  13. Compress.
  14. Three-inch wide roller.
  15. Oil.
  16. Chloroform and inhaler.


CLEFT PERINÆUM.

  1. Scalpel.
  2. Hook forceps.
  3. Curved nævus needles, threaded.
  4. Stout whipcord.
  5. Suture silk.
  6. Wire suture.
  7. Glass rods, or No. 12 bougies.
  8. Collodion.
  9. Lint.
  10. Sponges on handles.
  11. Oil.
  12. Chloroform and inhaler.


EXTIRPATION OF THE CERVIX UTERI.

  1. Two hooked forceps, or long vulsella.
  2. Specula (bivalve and duckbill).
  3. Ecraseur.
  4. Two wool holders.
  5. Small sponges on sticks.
  6. Scalpel.
  7. Straight probe-pointed bistoury.
  8. Bistoury curved on the flat.
  9. Long-handled straight scissors.
  10. Long-handled curved scissors.
  11. Artery forceps.
  12. Ligatures.
  13. Hare-lip pins.
  14. Dentists’ silk.
  15. Cautery irons.
  16. Perchloride of iron.
  17. Solution of chloride of zinc.
  18. Ice.
  19. Lint (if plugging necessary, see pp. 127, 128).
  20. Compressed sponge in pieces.
  21. Soft silk handkerchief.
  22. Cotton wool.
  23. Suppository.


AMPUTATION OF THE PENIS.

  1. Tape to tie round the root of penis.
  2. Straight bistoury.
  3. Scalpel.
  4. Artery forceps.
  5. Torsion forceps.
  6. Dissecting forceps.
  7. Scissors.
  8. Fine ligatures.
  9. Fine suture, to fix the flap of mucous membrane of the urethra.
  10. Flexible catheter.
  11. Lint.
  12. Tape.
  13. Ice.
  14. Chloroform and inhaler.


CIRCUMCISION.

  1. Small straight bistoury.
  2. Polypus forceps.
  3. Half-inch wide tape.
  4. Artery forceps.
  5. Fine ligatures.
  6. Silk suture.
  7. Torsion forceps.
  8. Scissors.
  9. Lint.
  10. Ice.
  11. Chloroform and inhaler.


EXCISION OF TESTIS.

  1. Scalpel.
  2. Large sharp hook.
  3. Blunt hooks.
  4. Stout whipcord.
  5. Fine ligature.
  6. Artery forceps.
  7. Sutures, silk or wire.
  8. Scissors.
  9. Chloroform and inhaler.
  10. Lint.


TAPPING AND INJECTING A HYDROCELE.

  1. Trocar.
  2. Vulcanite syringe, with nozzle to fit cannula.
  3. Tincture of iodine.
  4. Suspender for the testicles.
  5. Lint.
  6. Collodion.
  7. Plaister.


VESICO-VAGINAL FISTULA.

  1. Duckbill speculum.
  2. Scalpels set in long handles, curved blades.
  3. Long-handled curved scissors.
  4. Long-handled forceps.
  5. Long-handled hooked forceps.
  6. Long-handled sharp hook.
  7. Narrow curved spatula.
  8. Needles to carry silver wire suture.
  9. Silver wire.
  10. Probes.
  11. Short curved needles, to carry fine silk suture.
  12. Needle holder.
  13. Suture tightener.
  14. Lead clamp.
  15. Awl for perforating the clamp.
  16. Clamp adjuster.
  17. Split shot.
  18. Forceps for placing and pinching the shot.
  19. Small sponges set on slips of wood.
  20. Large sponges.
  21. Sims’ catheter.
  22. Ice-cold water.
  23. Syringe and flexible catheter for injecting the bladder,
      to test the perfect closure of the fissure.
  24. Chloroform and inhaler.
  25. Oil.


RETENTION OF URINE.

  1. Flexible catheters (Nos. 8 to ½) (English and French).
  2. Finest gum bougies (No. ¼).
  3. Silver catheters.
  4. Long prostatic catheter.
  5. Oil.
  6. Glass syringe.
  7. Injecting bottle.
  8. Tapes and string.
  9. Strapping plaister.
  10. Scissors.
  11. Trocar for tapping per rectum.
  12. Tincture of opium.
  13. Morphia suppository.
  14. Chloroform and inhaler.


EXTERNAL URETHROTOMY.

  1. Scalpels.
  2. Catheters, silver.
  3. Catheters, flexible.
  4. Four feet of india-rubber tubing to fit catheter.
  5. Probes, straight and grooved, with flat handles.
  6. Syme’s shouldered narrow grooved staff.
  7. Marshall’s long jointed grooved sound, with flexible catheter
      sliding on it.
  8. Curved director.
  9. Lithotomy tapes or anklets.
  10. Tapes.
  11. Sponges.
  12. Tenaculum.
  13. Artery forceps.
  14. Ligatures.
  15. Oil.
  16. Ice.
  17. Chloroform and inhaler.


LITHOTOMY.

  1. Firm table, of convenient height.
  2. Folded blankets.
  3. Mackintosh sheet.
  4. Tray of sand, or saw-dust.
  5. Pair of lithotomy tapes, or anklets.
  6. Lint.
  7. Sound.
  8. Staff.
  9. Catheter to fit syringe, for injecting the bladder.
  10. Lithotomy scalpels.
  11. Forceps.
  12. Scoops.
  13. Searcher.
  14. Bistouri caché.
  15. Syringe, various nozzles.
  16. Gorget.
  17. Tubes, with and without petticoats.
  18. Lithotrite.
  19. Catheter to fit syringe.
  20. Artery forceps.
  21. Tenaculum.
  22. Ligatures.
  23. Half grain morphia suppository.
  24. Chloroform and inhaler.
  25. Oil.
  26. Sponges.
  27. Bandages and tape.
  28. Brandy, ammonia.


LITHOTRITY.

  1. Lithotrites, fenestrated and flat.
  2. Hollow sound, with short beak.
  3. Clover’s apparatus for washing out the bladder.
  4. Oil.
  5. Lithotrite catheters.
  6. Urethral forceps.
  7. Injecting bottle, with nozzle to fit the hollow sound.
  8. Half grain morphia suppository.
  9. Hot linseed poultice.
  10. Firm bolster or pillow.


REMOVING FOREIGN BODIES FROM THE URETHRA AND BLADDER.

  1. Catheters, silver, gum, elastic.
  2. Sounds of different curves.
  3. Bougies olivaires.
  4. Urethral forceps with long blades.
  5. Fine dressing forceps.
  6. Fine polypus forceps.
  7. Coxeter’s urethral forceps.
  8. Urethral lithotrite forceps.
  9. Hunter’s tube forceps.
  10. Loop of wire set in long handle.
  11. Leroy d’Etiolles’ jointed scoop.
  12. Leroy’s tube, and sliding hook.
  13. Charrière’s hair-pin retractor.
  14. Charrière’s bougie retractor.
  15. Three-branched forceps.
  16. Endoscope.
  17. Oil.
  18. Glass syringe.
  19. Scalpel.
  20. Dissecting forceps.
  21. Hook.
  22. Artery forceps.
  23. Ligature.
  24. Sutures.
  25. Tapes.
  26. Sponges.
  27. Chloroform and inhaler.


INSTRUMENTS FOR OPERATIONS ON THE LIMBS.

  LIGATURE OF THE LARGER ARTERIES.

  RESECTIONS, OF THE HEAD OF THE HUMERUS, ELBOW, HIP, AND KNEE.

  REMOVAL OF NECROSED BONE.

  AMPUTATIONS AT THE SHOULDER-JOINT, JOINT, ARM, FOREARM AND WRIST;
  METACARPUS, HIP, THIGH AND LEG; BY SYME’S AND CHOPART’S OPERATIONS;
  METATARSUS.


LIGATURE OF THE LARGE ARTERIES.

  1. Scalpel.
  2. Grooved director.
  3. Dissecting forceps.
  4. Broad grooved director.
  5. Probe.
  6. Blunt hooks.
  7. Metallic retractors.
  8. Aneurism needle.
  9. Ditto, helix curve.
  10. Waxed compressed whipcord.
  11. Artery forceps.
  12. Fine ligatures.
  13. Sutures.
  14. Scissors.
  15. Sponges on sticks.
  16. Larger sponges.
  17. Strapping.
  18. Lint.
  19. Bandage.
  20. Chloroform and inhaler.


RESECTION OF THE SHOULDER.

  1. Scalpels.
  2. Saw (Irish bow-saw).
  3. Retractors.
  4. Lion’s-tooth forceps.
  5. Blunt hooks.
  6. Artery forceps.
  7. Torsion forceps.
  8. Tenacula.
  9. Acupressure needles.
  10. Linen retractors.
  11. Ligatures.
  12. Sutures.
  13. Key to compress the subclavian artery.
  14. Cautery iron.
  15. Wire nippers.
  16. Lint.
  17. Bandages.
  18. Strapping.
  19. Oiled silk.
  20. Sponges.
  21. Mackintosh sheet.
  22. Chloroform and inhaler.


RESECTION OF THE ELBOW.

  1. Straight bistoury.
  2. Retractors.
  3. Blunt hooks.
  4. Bow-saw.
  5. Probes.
  6. Gouges.
  7. Torsion forceps.
  8. Artery forceps.
  9. Lion’s-tooth forceps.
  10. Bone forceps.
  11. Ligatures.
  12. Sutures.
  13. Lint.
  14. Oiled silk.
  15. Bandages.
  16. Strapping.
  17. Sponges.
  18. Mackintosh sheet.
  19. Angular splint to support the arm.
  20. Chloroform and inhaler.


RESECTION OF THE UPPER END OF THE FEMUR.

  1. Strong bistoury.
  2. Probe-pointed bistoury.
  3. Long probes.
  4. Bow-saw.
  5. Retractor.
  6. Blunt hooks.
  7. Narrow linen retractor.
  8. Gouges and chisels.
  9. Bone forceps.
  10. Artery forceps.
  11. Torsion forceps.
  12. Tenaculum.
  13. Ligatures.
  14. Sutures.
  15. Bandages.
  16. Lint.
  17. Sponges.
  18. Straight bracketed long splint and pads.
  19. Chloroform and inhaler.
  20. Mackintosh sheet.


RESECTION OF THE KNEE.

  1. Straight bistoury.
  2. Scalpels.
  3. Metallic retractors.
  4. Bow-saw.
  5. Gouge.
  6. Chisel.
  7. Artery forceps.
  8. Torsion forceps.
  9. Acupressure needle.
  10. Tenaculum.
  11. Ligatures.
  12. Sutures.
  13. Tourniquet.
  14. Sponges.
  15. Lint.
  16. Bandages.
  17. Oiled silk.
  18. McIntyre’s splint and pads.
  19. Chloroform and inhaler.
  20. Mackintosh sheet.


REMOVING NECROSED BONE.

  1. Scalpels.
  2. Straight and curved bistouries, with sharp and probe points.
  3. Long and short probes.
  4. Directors.
  5. Retractors.
  6. Gouges.
  7. Chisels.
  8. Bone forceps (various).
  9. Gouge forceps.
  10. Sequestrum forceps.
  11. Lion’s-tooth forceps.
  12. Osteotrites.
  13. Artery forceps.
  14. Tenaculum.
  15. Torsion forceps.
  16. Acupressure needles.
  17. Ligatures.
  18. Sutures.
  19. Lint.
  20. Bandages.
  21. Oiled silk.
  22. Mackintosh sheet.
  23. Chloroform and inhaler.


AMPUTATION AT THE SHOULDER JOINT.

  1. Tourniquet.
  2. Long amputating knife.
  3. Artery forceps.
  4. Fine ligatures, stout ligatures.
  5. Tenaculum.
  6. Acupressure needles.
  7. Needle nippers.
  8. Key to compress subclavian artery.
  9. Sutures.
  10. Strapping cut into strips.
  11. Bandages.
  12. Lint.
  13. Oiled silk.
  14. Sponges.
  15. Cautery irons.
  16. Ice.
  17. Mackintosh sheet.
  18. Chloroform and inhaler.


AMPUTATION OF THE ARM.

  1. Tourniquet.
  2. Amputating knife.
  3. Saw.
  4. Artery forceps.
  5. Torsion forceps.
  6. Ligatures.
  7. Sutures.
  8. Tenaculum.
  9. Acupressure needles.
  10. Wire nippers.
  11. Strapping.
  12. Lint.
  13. Bandages.
  14. Wadding.
  15. Straight splints.
  16. Sponges.
  17. Mackintosh sheet.
  18. Chloroform and inhaler.

If a circular amputation—

  19. Split linen retractor; and
  20. Round-pointed straight-edged knife.


AMPUTATION OF THE FOREARM AND WRIST.

  1. Tourniquet.
  2. Large bistoury, or small amputating knife.
  3. Torsion forceps, artery forceps, and ligature thread.
  4. Artery forceps.
  5. Saw.
  6. Acupressure needles.
  7. Needle nippers.
  8. Tenaculum.
  9. Fine ligatures.
  10. Sutures.
  11. Lint.
  12. Wool.
  13. Splints.
  14. Bandages.
  15. Oiled silk.
  16. Sponges.
  17. Mackintosh sheet.
  18. Chloroform and inhaler.


AMPUTATION OF METACARPAL BONES AND PHALANGES.

  1. Narrow-bladed bistoury.
  2. Bone forceps.
  3. Torsion forceps.
  4. Artery forceps.
  5. Fine ligatures.
  6. Small suture.
  7. Strapping.
  8. Narrow bandage.
  9. Wadding.
  10. Splint to support the arm and hand.
  11. Bandage.
  12. Lint.
  13. Oiled silk.
  14. Mackintosh sheet.
  15. Sponges.
  16. Tourniquet.
  17. Chloroform and inhaler.


AMPUTATION AT THE HIP JOINT.

  1. Lister’s aorta compressor.
  2. Long hip knife.
  3. Artery forceps.
  4. Stout and fine ligatures.
  5. Torsion forceps.
  6. Tenaculum.
  7. Acupressure needles.
  8. Needle nippers.
  9. Silk and silver sutures.
  10. Lint.
  11. Strapping plaister.
  12. Sponges.
  13. Bandages.
  14. Ice.
  15. A bone-holder, or lion’s-tooth forceps, if the fragment
      of the bone is too short to grasp in the hand.
  16. Chloroform and inhaler.
  17. Mackintosh sheet.

(See also the List for the Operating Room).


AMPUTATION OF THE THIGH AND LEG.

  1. Tourniquet.
  2. Amputating knife.
  3. Scalpel.
  4. Bone forceps.
  5. Saw.
  6. Torsion forceps.
  7. Artery forceps.
  8. Stout and fine ligatures.
  9. Sutures.
  10. Tenaculum.
  11. Strapping.
  12. Hare-lip pins.
  13. Wire nippers.
  14. Lint.
  15. Bandages.
  16. Oiled silk.
  17. Cautery iron.
  18. Ice.
  19. Sponges.
  20. Mackintosh sheet.

In a circular amputation—

  21. A round-pointed knife, and a linen retractor split into two
  tongues for the thigh and three for the leg, the centre one being
  well waxed.


AMPUTATION AT THE ANKLE AND FOOT.

(_Syme’s and Chopart’s Operations._)

  1. Tourniquet.
  2. Strong bistoury.
  3. Strong scalpel (Syme’s).
  4. Saw.
  5. Bone forceps.
  6. Artery forceps.
  7. Torsion forceps.
  8. Tenaculum.
  9. Acupressure needles.
  10. Wire nippers.
  11. Strapping.
  12. Sutures.
  13. Lint.
  14. Bandages.
  15. Oiled silk.
  16. Wool.
  17. Sponges.
  18. Chloroform and inhaler.
  19. Mackintosh sheet.


AMPUTATION OF THE METATARSAL BONES AND TOES.

  1. Tourniquet.
  2. Straight bistoury.
  3. Tenaculum.
  4. Torsion forceps.
  5. Acupressure needles.
  6. Needle nippers.
  7. Artery forceps.
  8. Ligatures.
  9. Sutures.
  10. Lion’s-tooth, or sequestrum forceps.
  11. Strapping.
  12. Lint and wool.
  13. Bandages.
  14. Narrow saw.
  15. Bone forceps.
  16. Mackintosh sheet.
  17. Chloroform and inhaler.




INDEX.


  A.

  Abdominal support, 165.

  —— tourniquet, 149.

  Acromion, fracture of, 56.

  Administering chloroform, 179.

  Air-bath, the hot, 154.

  Amputations, 213.

  —— ankle, 215.

  —— arm, 213.

  —— forearm, 214.

  —— hip, 214.

  —— leg, 215.

  —— metacarpal bones, 214.

  —— metatarsal bones, 215.

  —— penis, 208.

  —— phalanges, 214.

  —— shoulder, 213.

  —— thigh, 215.

  Angular splint, 48.

  —— union, 76.

  Ankle, strapping the, 27.

  Apparatus for dislocation at the hip, 104.

  Arch, palmar, wound of, 17.

  Arm, bandage for, 16.

  Arrest of hæmorrhage, 197.

  Artificial respiration, 183.

  Ascites, bandage for, 10.


  B.

  Bandages, 1.

  —— arm, 16.

  —— belly, 10.

  —— bleeding jugular vein, 7.

  —— breast, 8.

  —— elbow, 16.

  —— fingers, 14.

  —— foot, 21.

  —— groin, 9.

  —— hand, 15.

  —— head, 3.

  —— heel, 21.

  —— hernia, 10.

  —— knee, 22.

  —— leg, 21.

  —— many-tail, 23.

  —— plaster of paris, 85.

  —— scultetus, 23.

  —— shoulder, 16, 55.

  —— spica, 9, 10, 14, 16, 55.

  —— starch, 80.

  —— stump, 22.

  —— thumb, 14.

  —— toe, 21.

  Band-box cradle, 81.

  Bath, the hot air, 154.

  —— the vapour, 155.

  Bed, the floating, 141.

  —— the sick, 196.

  Bedsores, 140.

  —— ring of felt for, 140.

  —— Brown Sequard’s treatment, 140.

  Belloc’s sound, 121.

  Belly, bandage for, 10.

  —— tapping the, 204.

  Bicuspid tooth, drawing a, 124.

  Bladder, ice, 7.

  —— washing out the, 137.

  Blanket pad for axilla, 53.

  Bleeding, cupping, 158.

  —— at elbow, 18.

  —— jugular vein, 7.

  —— leech bites, 160.

  —— palmar arch, 17.

  —— socket of tooth, 126.

  —— staff, 19.

  —— tape, 19.

  Blisters, 170.

  Block for McIntyre’s splint, 65.

  Blood, transfusion of, 144.

  Both bones of forearm, fracture of, 43.

  Bougies, 130.

  —— filiformes, 134.

  —— olive-headed, 130.

  Bread poultice, 171.

  Breast, bandaging the, 8.

  —— removing the, 203.

  —— strapping the, 25.

  Broken rib, 36.

  —— finger, 39.

  Bruce’s cautery, 166.

  Bulbous ended catheter, 130, 135.


  C.

  Cæsarian section, 205.

  Calcaneum, separation of the epiphysis of, 60.

  Calomel fumigation, 153.

  Cambric rollers, 1.

  Canine tooth, drawing a, 123.

  Cantharides, 170.

  Cap for shoulder, 54.

  Capelline bandage, 5.

  Carbolic acid dressing, 172.

  Carriage, the sick, 155.

  Carte’s tourniquet, 149.

  Cash’s bandages, 1.

  Casting in plaster of paris, 114.

  Cataract, 199.

  Catheters, 129.

  —— flexible, 129.

  —— passing, 132.

  —— —— in the female, 136.

  —— silver, 129.

  —— tying in, 138.

  —— vulcanised india-rubber, 130, 136.

  Caustics, 168.

  Cauteries, 166.

  Cautery irons, 166.

  —— Clover’s, 168.

  —— galvanic, 168.

  —— gas, 166.

  Cervix uteri, extirpation of, 207.

  Chalk and gum, 89.

  Chassaignac’s drainage tubes, 161.

  Chloride of zinc, 169.

  Chloroform, 179.

  —— in dislocations, 95.

  —— to the uterus, 187.

  —— dangers of, 180.

  Chromic acid, 169.

  Circumcision, 208.

  Clavicle, dislocation of, 96.

  —— fracture of the, 56.

  Cleft palate, 201.

  —— perinæum, 207.

  Clove hitch, the, 99.

  Clover’s cautery, 168.

  —— inhaler, 181.

  Club foot, 113.

  Cold injection, 118.

  Collar bone, fracture of, 56.

  —— ring pad for, 59.

  —— figure of 8 for, 59.

  —— dislocation of, 96.

  Colles’ fracture, 39.

  Collodion, 189.

  Colotomy, 205.

  Common rollers with plaster of paris, 88.

  Compound fracture, openings in splints for, 87.

  Compress, graduated, 17.

  —— for bleeding jugular vein, 7.

  Conformation of urethra, 132.

  Continuous extension, 78, 80.

  Corrigan’s hammer, 169.

  Counter extension, 95.

  Coxeter’s elastic perineal band, 75.

  Cradles, 90.

  —— Salter’s, 64.

  —— of band box, 90.

  Cupping, bleeding, 158.

  —— dry, 156.

  Cushions, water, 142.


  D.

  Delirious patients, manacles for, 12.

  Diathesis, the hæmorrhagic, 126.

  Difficulties in passing catheters, 133.

  Disjunction of articular surfaces, 47.

  Dislocations, 95.

  —— clavicle, 96.

  —— elbow, 101.

  —— —— distinction from fracture, 47.

  —— fingers, 103.

  —— foot, 110.

  —— hip, 104.

  —— —— reduction by manipulation, 107.

  —— knee, 109.

  —— lower jaw, 95.

  —— patella, 110.

  —— shoulder, 97.

  —— thumb, 103.

  Domett’s flannel roller, 112.

  Double inclines, 77.

  —— slung, 78.

  Drainage tubes, 161.

  Drawing teeth, 122.

  Drops for eye, 117.

  Dry cupping, 156.

  —— heat, 172.

  Drying starch bandages, 84.

  Dupuytren’s splint, 61.


  E.

  Ears, syringing the, 117.

  Eight, figure of, 3.

  Eighteen-tail bandage, 23.

  Elastic extension, 75.

  —— perineal band, 75.

  —— socks, 24.

  —— stirrup, 75.

  Elbow, bandaging the, 16.

  —— dislocation at, 101.

  —— fracture near, 47.

  —— resecting the, 212.

  Elevator, 125.

  Emplastrum lyttæ, 170.

  Epiphysis of Os Calcis, separation of the, 60.

  Epispastique, pâte, 170.

  Epistaxis, 118.

  Equinus, talipes, 113.

  Esmarch’s irrigator, 179.

  Essentials of a truss, 162.

  Ether spray, 186.

  Extension in fractures, 75, 76, 78.

  —— in hip disease, 80.

  —— simple, in dislocations, 99.

  —— in the long splint, 75.

  —— by weight and pully, 79.

  External splint for broken jaw, 32.

  Eye douche, 116.

  —— drops, 117.

  —— operations on the, 198.


  F.

  Feeding by the stomach pump, 144.

  Female, passing a catheter in the, 136.

  Femur, fracture of, 72.

  —— resecting the, 212.

  Fibula, fracture of, 60.

  Figure of 8 turn, 3.

  —— bandage, 59.

  Fingers, bandaging, 14.

  —— dislocation of, 103.

  —— splint for, 39.

  Fistula in ano, 207.

  Flannel rollers, 1.

  —— —— for plaster of paris, 86.

  Flexible catheters, 130.

  Floating bed, 141.

  Fomentations, 172.

  Foot, bandaging the, 21.

  —— dislocation of the, 110.

  Forceps, tooth, 122.

  —— —— bicuspid, 123, 124.

  —— —— incisor, 123.

  —— —— molar, 124.

  Forearm, bandaging the, 15.

  —— dislocation of, 101.

  —— fracture of, 43.

  Four-tail bandage, 6.

  Fractures, 30.

  —— acromion, 56.

  —— at ankle, 61.

  —— clavicle, 56.

  —— Colles’, 39.

  —— elbow, 47.

  —— femur, shaft of, 72.

  —— fibula, 60.

  —— forearm, 43.

  —— humerus, neck of, 53.

  —— —— shaft of, 51.

  —— —— lower end of, 47.

  —— —— great tuberosity of, 56.

  —— jaw, 30.

  —— metacarpal bones, 37.

  —— olecranon, 45.

  —— os calcis, 60.

  —— patella, 67.

  —— pelvis, 37.

  —— phalanges, 39.

  —— radius, 39, 44.

  —— rib, 36.

  —— tibia, 61.

  —— transverse ditto, 66.

  —— ulna, 43.

  French bulbous ended catheters, 130.

  Fumigation, 151.

  —— general, 152.

  —— local, 154.


  G.

  Gag, for stomach-pump, 143.

  Galvanic cautery, 168.

  Gas cautery, 166.

  Gauntlet for fractured radius, 42.

  Gauze, wire, 48.

  General rules, 1.

  Glove for metacarpal bones, 38.

  Glue, 89.

  Graduated compress, 17.

  Groin, spica for, 9.

  Gum and chalk, 89.

  Gums, leeches to, 159.

  Gutta-percha, 30, 38, 42, 49, 54, 70, 77, 94.


  H.

  Hæmorrhage, arrest of, 197.

  —— from the tonsils, 201.

  Hæmorrhagic diathesis, 126.

  Hæmorrhoids, 206.

  Hair suture, 116.

  Hammer, Corrigan’s, 169.

  Hand, bandaging the, 14.

  Handle for extending the thumb, 103.

  Hare-lip, 199.

  Head bandage, 3.

  —— ice bladder for, 7.

  Heat, dry, 172.

  Heel, to bandage the, 21.

  Hernia, 162.

  —— spica, 9.

  —— trusses for, 161.

  Hewitt’s transfusion apparatus, 145.

  Hides’ leather felt, 89.

  Hip-disease, extension in, 79.

  —— dislocation, 104.

  —— splint, 92.

  Hitch, the clove, 99.

  Hooks, Malgaigne’s, 71.

  Horizontal position in fractured clavicle, 57.

  Horse heel, 113.

  Horseshoe tourniquet, 148.

  Hot air bath, 154.

  —— fomentations, 172.

  —— water cushions, 172.

  How to hold a roller, 2.

  Humerus, fractures at lower end of, 47.

  —— great tuberosity, 56.

  —— neck of, 53.

  —— shaft of, 51.

  Hydrocele, tapping a, 208.


  I.

  Ice bladders on head, 7.

  —— cold injections, 118.

  Improvised tourniquet, 151.

  Incisor tooth, to draw, 123.

  Incline, double, 77.

  —— —— slung, 78.

  Injecting bottle, 137.

  —— syringe, 117.

  —— chloroform to the uterus, 187.

  —— the urethra, 128.

  Injection, subcutaneous, 187.

  Interdental splints, 33.

  Intracapsular fracture of neck of femur, 77.

  Iodine blisters, 170.

  Iridectomy, 199.

  Irons, cautery, 166.

  Irreducible hernia, 163.

  Irrigation, 177.

  Irrigator, Esmarch’s, 179.

  Irritants, 168.

  Issues, 161.

  —— pea, 161.


  J.

  Jacket, strait, 11.

  Jaw, fracture of, 30.

  —— resection of, 200.

  Joints, strapping, 27.

  —— to be included in starch and plaster of paris, 81, 87.

  Jugular vein, bandage for, 7.


  K.

  Kite’s tail plug, 128.

  Knee, bandage for, 22.

  —— resecting the, 212.

  Knee-pan, fracture of, 67.

  Knotted bandage, 4.


  L.

  L-shaped splint for arm, 49.

  Lamp for air bath, 154.

  Laryngotomy, 201.

  Lateral splints for the tibia, 66.

  Lavallée’s (Morel) splints, 33.

  Leather felt, Hides’, 89.

  —— splints, 90.

  —— —— for hip, 92.

  Leeches, 159.

  —— to make them bite, 159.

  —— to stop the bites, 160.

  —— in the mouth, 159.

  —— at the cervix uteri, 159.

  Leg, bandage for, 21.

  Ligature of arteries, 211.

  Linseed poultice, 171.

  Lister’s dressing, 172.

  —— tourniquet, 149.

  Liston’s long splint, 72.

  Lithotomy, 210.

  —— position, 140.

  Lithotrity, 210.

  Local anæsthesia, 186.

  Long splint, 72.

  Lower jaw, fracture of, 30.


  M.

  McIntyre’s splint, 63.

  Makeshift tourniquet, 151.

  Malgaigne’s hooks, 71.

  Manacles for delirious patients, 12.

  Manipulation in dislocations, 107.

  Many-tail bandage, 23.

  Marshall Hall’s method, 183.

  Materials for rollers, 1.

  Mayor’s double incline, 78.

  Mercurial fumigation, 152.

  —— ointment, 28.

  Metacarpal bones, fracture of, 37.

  Millboard for splints, 80.

  Mixing plaster, 115.

  Molar forceps, 124.

  —— teeth, 124.

  Morel Lavallée’s splints, 33.

  Muslin rollers for plaster of paris, 85.

  Mustard poultices, 169.


  N.

  Nævus, operating on, 203.

  Nares, plugging the, 119.

  Neck of humerus, fracture of, 53.

  Necrosed bone, removing, 213.

  Nipple shields, 126.

  —— artificial, 126.

  Nitrate of silver, 168.

  —— of mercury, 169.

  Nitric acid, fuming, 169.


  O.

  Olecranon, fracture of, 45.

  —— —— Hamilton’s splint for, 47.

  Operating room, the, 195.

  Operator’s position, 2.

  Ordinary bandages, 1.

  Os uteri, leeches to, 159.

  Outside splint for fractured jaw, 32.

  Ovariotomy, 205.

  —— cautery, 167.


  P.

  Palmar arch, wound of, 17.

  Paraffine, 89.

  Paris, bandages of plaster of, 85.

  —— plaster of, casting in, 114.

  —— —— splints of, 88.

  Passing catheters, 132.

  —— —— difficulties, 133.

  Pasteboard splints, 80.

  Pâte epispastique, 170.

  Patella, dislocation of the, 110.

  —— fracture of the, 67.

  —— —— Samborne’s plan, 70.

  —— back splint for, 69.

  Pelvis, fracture of the, 37.

  Penis, amputation of, 208.

  Perineal band, 73.

  Petit’s tourniquet, 147.

  Phalanges, broken, 39.

  Pistol splint, 40.

  Pleura, tapping the, 204.

  Plugging nares, 119.

  —— vagina, 127.

  Points for vaccine, 190.

  Poisons, stomach pump in, 143.

  Position of bandager, 1.

  —— for lithotomy, 140.

  Potassa fusa, 169.

  Poultice, 170.

  —— bread, 171.

  —— linseed, 171.

  —— mustard, 169.

  —— starch, 172.

  Prolapsus ani, 207.

  Pubes, dislocation on, 108.

  Pulley, extension by weight, 80.

  Pulleys, for dislocation, 104.

  Pulverised fluids, 186.

  Pump, the stomach, 143.


  R.

  Radius, fracture of, 39.

  —— near the head, 44.

  —— dislocation of, 102.

  Removing a starch bandage, 84.

  —— a plaster of paris bandage, 88.

  —— foreign bodies from urethra, 210.

  Respiration, artificial, 183.

  Restoratives, 197.

  Reverse turn, 2.

  Rib, broken, 36.

  —— roller for, 37.

  —— strapping, 36.

  Richardson’s spray producer, 186.

  Ring pad, 59.

  —— tourniquet, 147.

  Rollers, how to hold, 2.

  —— varieties of, 1.

  —— muslin, for plaster of paris, 85.

  Rules, general, 1.

  Ruptured tendo achillis, 59.

  Ruptures, 162.

  —— operation for, 206.


  S.

  Salter’s cradle, 64.

  Sand bags, 90.

  Scarificator, 157.

  Scarpa’s shoes, 111.

  Scott’s bandage, 28.

  Scultetus, bandage of, 23.

  Sedatives, 197.

  Separation of epiphysis of the os calcis, 60.

  —— of lower end of humerus, 47.

  Setons, 160.

  Shaft of humerus, 51.

  Shawl cap, 6.

  Shoes, Scarpa’s, 111.

  Shot-bag weight, 80.

  Shoulder, bandage for, 16, 55.

  —— cap, 54.

  —— dislocation at, 97.

  —— dislocation at, simple extension in, 100.

  —— fracture of, 53-56.

  —— resecting the, 211.

  Sick carriage, 155.

  —— room and bed, 196.

  Signoroni’s tourniquet, 148.

  Silicate of soda, 89.

  Silver catheters, 129, 132.

  —— —— tying in, 138.

  —— nitrate of, 168.

  Silvester’s method, 184.

  Skull, trephining the, 198.

  Sling for fracture, 52, 64.

  Slinging a starch bandage, 85.

  Slung double incline, 78.

  Sock, elastic, 24.

  Socket, a bleeding, 126.

  Sore nipples, 126.

  Sores, bed, 140.

  Sounds, 130.

  Sound, Belloc’s, 121.

  Spica for groin, 9.

  —— for hernia, 10.

  —— shoulder, 16, 55.

  —— for thumb, 14.

  Spiral turn, 2.

  Splay foot, 114.

  Splint, the long, 72.

  —— the hip, 92.

  Spray producer, 186.

  Starch bandage, 80.

  —— —— after long splint, 76.

  —— —— splints for, 82.

  —— —— time of applying, 81.

  —— poultice, 172.

  —— rollers, 82.

  Stirrup extension, 76.

  Stockings, elastic, 24.

  Stocking-webbing rollers, 1.

  Stomach pump, the, 142.

  Strait jacket, 11.

  Strangulated hernia, 206.

  Strapping, 25.

  —— ankle, 27.

  —— the breast, 25.

  —— joints, 27.

  —— —— with mercurial ointment, 28.

  —— plasters, 25.

  —— ribs, 36.

  —— testes, 26.

  —— ulcers, 27.

  Strictures of the urethra, 134.

  Stump, bandaging a, 22.

  —— extending, 23.

  Stumps, extracting, 125.

  Subcutaneous injection, 187.

  Supporting interdental splints, 35.

  Suspending the testes, 12.

  Swete’s carriage, 155.

  Syringing the ears, 117.


  T.

  T-bandage, 11.

  Taking off a starch bandage, 84.

  —— a plaster of paris bandage, 88.

  Talipes, 113.

  —— equinus, 113.

  —— valgus, 114.

  —— varus, 113.

  Tape for bleeding, 18.

  Tapping, bandage for, 10.

  Tendo achillis, ruptured, 59.

  Tents, 160.

  Testes, excising, 208.

  —— strapping, 26.

  —— suspending, 12.

  Testing a truss, 162.

  Thumb, bandage for, 14.

  —— dislocation of, 103.

  Tibia, fractures of, 61-67.

  Toe, bandaging a, 22.

  Tongue, excision of, 200.

  Tonsils, excision of, 201.

  —— bleeding, 201.

  Tooth drawing, 122.

  —— bicuspid, 124.

  —— canine, 123.

  —— incisor, 123.

  —— molar, 124.

  —— forceps, 122.

  Tourniquets, 147.

  —— abdominal, 149.

  —— Carte’s, 149.

  —— horseshoe, 148.

  —— makeshift, 151.

  —— Petit’s, 148.

  —— ring, 147.

  —— Signoroni’s, 148.

  Tracheotomy, 202.

  Transfusion of blood, 144.

  Transporting the sick, 155.

  Transverse fracture of the tibia, 66.

  Trunk, bandaging the, 8.

  Trusses, 161.

  —— femoral, 163.

  —— inguinal, 163.

  —— measuring for, 164.

  —— Salmon & Ody’s, 165.

  —— umbilical, 165.

  Tubes, drainage, 161.

  Turns, different, 2.

  Tying for lithotomy, 140.

  —— in a flexible catheter, 139.

  —— in a silver catheter, 138.


  U.

  Ulcers, strapping, 27.

  Ulna, fracture of, 43.

  Umbilical hernia, 165.

  Union, angular, 76.

  Urethra, conformation of, 132.

  —— injecting the, 128.

  Urethral syringe, 128.

  Urethrotomy, 209.

  Urine, retention of, 209.


  V.

  Vaccination, 190.

  Vagina, plugging the, 127.

  Valgus, 114.

  Vapour bath, the, 155.

  Varieties of turns, 2.

  —— of splints for the elbow, 48.

  Varus, 113.

  Venesection, 18.

  Vesicants, 169.

  Vesicle in vaccination, 191.

  Vesico-vaginal fistula, 209.

  Vienna paste, 169.

  Vitriol, oil of, 169.

  Vulcanised india-rubber catheter, 130, 136.

  Vulcanite splint for jaw, 34.


  W.

  Waistcoat, strait, 11.

  Washing out the bladder, 137.

  Water-bed, 141.

  —— can weight, 80.

  —— cushion, 142.

  Wedge-pad for fractured clavicle, 57.

  Weight for pulley, 80.

  Wire gauze splints, 48.

  Wood’s operation for hernia, 206.

  Wool, cotton, 14.

  Wound of palmar arch, 17.

  —— opening in splint for, 87.


  Z.

  Zinc, chloride of, 169.


THE END.


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