LIBRARY OF CONGRESS. ITS ^H @ijap + Sujujrigljt Ifu- Shelf JtfiLSL UNITED STATES OF AMERICA. MINOR SURGERY BANDAGING INCLUDING THE TREATMENT OF FRACTURES AND DISLOCATIONS, TRACHEOTOMY, INTUBATION OF THE LARYNX, LIGATIONS OF ARTERIES AND AMPUTATIONS. BY HENRY R. WHARTON, M.D., 'i DEMONSTRATOR OF SURGERY AND LECTURER ON SURGICAL DISEASES OF CHILDREN IN THI UNIVERSITY OF PENNSYLVANIA , SURGEON TO THE PRESBYTERIAN HOSPITAL, THE METHODIST EPISCOPAL HOSPITAL, THE CHILDREN'S HOSPITAL, AND THE DREXEL HOSPITAL FOR CHILDREN J CONSULTING SURGEON TO THE RUSH HOSPITAL FOR DISEASES OF THE CHEST, ETC. WITH FOUR HUNDRED AND THREE ILLUSTRATIONS. PHILADELPHIA: LEA BROTHERS & CO. 1891. Entered according to the Act of Congress, in the year 1891, by LEA BEOTHEES & CO., in the office of the Librarian of Congress. All rights reserved. DOKNAN, PKIJSTKK. PREFACE The author has, in this work, endeavored to present, in as concise a manner as possible, a description of the various bandages, surgical dressings, and minor surgical procedures which are employed in the practice of surgery at the present time. The preparation and application of the antiseptic dressings now most commonly used have also received full consideration. The article upon Ban- daging is fully illustrated with cuts, mostly new and taken from photographs, which, it is hoped, will prove of value as furnishing an accurate representation of the most important bandages used in surgical practice ; the same is in a measure true of the article upon the dressing of Fractures and Dislocations, in which many new cuts of the same kind appear. The work also contains short articles upon Trache- otomy, Intubation of the Larynx, Ligations of Arteries, and Amputations, and, although these procedures are scarcely to be included with those of Minor Surgery, it is hoped that their description will increase the value of the work to medical students, for whose use it has IV PREFACE. been prepared. The author's thanks are due to Dr. Walter D. Green for his kind assistance in revising the proof-sheets, and to Mr. James Wood for the skilful photographic work used in illustrating several of the articles. 112 South Eighteenth St., Pbiladelpiua, August, 1891. CONTEXTS PART I. BANDAGING. Varieties of Bandages Bandages of the Head and Neck Bandages of the Upper Extremity Bandages of the Trunk . . ... Bandages of the Lower Extremity Special Bandages .... Fixed Dressings or Hardening Bandages PAGE 13-32 32-44 44-58 58-64 65-76 76-82 82-98 PART II. MINOR SURGERY. Theory of Asepsis and Antisepsis in Wound Treatment 99-101 Methods and Dressings Employed in Wounds to Secure Asepsis 101-109 Preparation of Materials and Dressings Used in Aseptic Surgery 109-120 Preparations for and Details of Aseptic Opera- tions 120-129 Materials Used in Surgical Dressings . . 129-135 Procedures Employed in Minor Surgery . . 135-192 Anaesthetics 192-201 Trusses 201-206 Use of Catheters and Bougies .... 206-216 Sutures and Ligatures ...... 217-235 VI CONTENTS. PAGE Ligatures Employed in the Treatment of Vas- cular Growths 235-240 Treatment of Hemorrhage . ... 241-262 Treatment of Abscesses 263-266 Dressing of Wounds, Burns and Scalds, Bedsores, Sprains 266-275 Tracheotomy, Laryngotomy, and Laryngo-trache- otomy ... 275-286 Intubation of the Larynx 286-289 PART III. FRACTURES . . . 290-302 Treatment of Special Fractures .... 302-361 PART IV. DISLOCATIONS , . . 361-364 Treatment of Special Dislocations . . . 364-392 PART V. LIGATION OF ARTERIES . . 393-395 Ligation of Special Arteries . . . . 395-427 PART VI. AMPUTATIONS . . . 428 Special Amputations . . 428-4S0 Index 483 PAET I. BANDAGING Bandages constitute one of the most widely used and important surgical dressings ; they are employed to hold dressings in contact with the surface of the body, to make pressure, to hold splints in place in the treatment of frac- tures and dislocations, and to restore to their natural posi- tion parts which may have become displaced. Bandages may be prepared of various materials, such as linen, crinoline, flannel, cheese or tobacco cloth, rubber sheeting, or muslin, bleached or unbleached ; the latter ma- terial is the most commonly employed, by reason of the ease with which it is obtained and its cheapness ; flannel, from its elasticity, is sometimes used, but its employment for bandages is now generally limited to its use in dressings for operative work in connection with the eye, and for a primary roller in the application of the plaster- of-Paris dressings. Bandages are either simple, when composed of one piece of material such as the ordinary roller bandage, or compound when prepared of one or more pieces, adapted by size and shape to peculiar objects. Bandages are also described as uniting, dividing, com- pressing, expelling or retaining bandages, according to the purposes they serve by their application. The importance of being perfectly familiar with the gen- eral rules of bandaging and proficient in the application of the roller bandage cannot be over-estimated, and both the student and general practitioner will never have cause to 2 14 BANDAGING. regret the time occupied in learning to apply neatly this form of surgical dressing. A well-applied bandage adds to the comfort of the patient, and the method of its application often secu-res for the phy- sician the confidence both of the patient and of his friends, while, on the other hand, a badly applied bandage is apt to be uncomfortable and insecure, and to meet with their ad- verse criticism. The Roller Bandage. The roller bandage consists of a strip of woven material, prepared from some of the materials previously mentioned, of variable length and width according to the portion of the body to which it is to be applied ; this, for ease of applica- tion, is rolled into a cylindrical form. The material commonly employed for the roller bandage is unbleached muslin, although, for special purposes, linen, Fig 1. Bandage winder. flannel, rubber sheeting, crinoline or cheese-cloth may be used. It is important that the roller bandage should consist of one piece, free from seams and selvage, for if made of a number of pieces sewed together, or if it contains creases or THE ROLLER BANDAGE. 15 selvage it cannot be so neatly applied, and it is not so com- fortable to the patient, as it is apt to leave creases upon the skin. In preparing the ordinary muslin bandage the material is torn in strips varying in length and width according to the part of the body to which it is to be applied, and it is then rolled into a cylinder, either by the hand or by a machine constructed for the purpose. (Fig. 1.) It is important that every student and practitioner should be able to roll a bandage by hand, for in practice the medical Fig. 2. Rolling a bandage by band. attendant may at any moment be called upon to roll a ban- dage, in order to apply a dressing, and as the art of preparing a bandage is acquired by a little practice, it should be famil- iar to. every student and physician. To roll a bandage by hand the strip should be folded at one extremity several times until a small cylinder is formed ; this is then grasped by its extremities by the thumb and index finger of the left hand ; the free extremity of the strip is then grasped between the thumb and index finger of the right hand, and by alter- nate pronation and supination of the right hand the cylinder is revolved and the roller is formed ; the firmness of the 16 BANDAGING. roller will depend upon the amount of tension which is kept upon the free extremity of the strip during the revolution of the cylinder. (Fig. 2.) Fig. 3. Single roller. A bandage rolled in the form of a cylinder is called a single or single-headed roller (Fig. 3); if rolled from each Fig. 4. Double roller. extremity toward the centre so that two cylinders are formed joined by the central portion of the strip, the double or GENERAL RULES FOR BANDAGING. 17 double- headed roller is formed. (Fig. 4.) Double rollers are not much used, and in practice the single roller will be found to be amply sufficient for the application of almost all the bandages employed in surgical dressings. The free end of the roller bandage is called the initial extremity ; the end which is enclosed in the centre of the cylinder is its terminal extremity ; and the portion between the extremities the body ; a roller has also two surfaces, external and internal. Dimensions of Bandages. Bandages vary in length and width according to the pur- poses for which they are employed, and in practice it will be found that a small variety of bandages will be amply suffi- cient for the application of the ordinary surgical dressings. The following list comprises those most frequently used and will show their dimensions : Bandage one inch wide, three yards in length, for ban- dages for the hand, fingers, and toes. Bandage two inches wide, six yards in length, for head bandages and for the extremities in children. Bandage two and a half inches wide, seven yards in length, for bandages of the extremities in adults ; a roller of this size is the one most generally used. Bandage three inches wide, nine yards in length, for ban- dages of the thigh, groin, and trunk. Bandages four inches wide, ten yards in length, for ban- dages of the trunk. General Rules for Bandaging. In applying a roller bandage the operator should place the external surface of the free extremity of the roller upon the part, holding it in position with the fingers of the left hand until fixed by a few turns of the roller, the cylinder being held in the right hand by the thumb and fingers ; for thus as the bandage is unwound it rolls into the operator's 18 BANDAGING. hand, thereby giving him more control of it ; care should also be taken that the turns are applied smoothly to the sur- face, and that the pressure exerted by each turn is uniform. If a bandage be applied to a limb the surgeon should see that the part is in the position it is to occupy as regards flexion and extension when the dressing is completed, for a bandage applied when the limb is flexed will exert too much pressure when the limb is extended, and then may, by the pressure it exerts, become a matter of discomfort or even of danger to the patient, or if applied to an extended limb will become uncomfortable upon flexion. My experience has been that, as a rule, those who have had little experience with the application of the roller ban- dage are apt to apply their bandages too tightly, and this Fig. 5. Bandage scissors. may lead to disastrous consequences, especially in the dress- ing of fractures. Professor Ashhurst, in his clinical teach- ing, advises students to make use of a larger number of turns of a bandage in securing fracture dressings rather than to depend upon a few turns too firmly applied ; advice which certainly conduces to the safety and comfort of the patient. When the bandage has been applied the terminal extremity should be secured by a pin or safety-pin applied transversely to the bandage, and if a pin be used its point should be buried in the folds of the bandage ; if the bandage is a narrow one, the end may be split and the two tails result- ing may be secured around the part by tying. In removing a bandage the folds should be carefully gathered up in a loose mass as the bandage is unwound, the mass being trans- VARIETIES OF BANDAGES. 19 ferred rapidly from one hand to the other, thus facilitating its removal and preventing the part from becoming entangled in its loops. If it is desirable to cut the bandage to remove it, the use of scissors made for this purpose will be found most satisfactory. (Fig. 5.) Varieties of Bandages. The Circular Bandage. This bandage consists of a few circular turns around a part, each turn covering accurately the preceding turn. This variety of bandage may be used to retain a dressing to a limited portion of the head, neck, or limbs, to make compression upon the veins of the arm before performing venesection. (Fig. \\ b.) The Oblique Bandage. In this form of bandage the turns are carried obliquely over the part, leaving uncovered spaces between the suc- Fig. Ci. Oblique bandage. cessive turns. (Fig. 6.) Its principal use is for the appli- cation of temporary dressings. The Spiral Bandage. In this bandage the turns are carried around the part in a spiral direction, each turn overlapping a portion of the 20 BANDAGING. preceding one, usually one-third or one-half. (Fig. 7.) This bandage may be used to cover a part which does not in- crease too rapidly in diameter, for instance the abdomen, chest, or arm. Fig 7. Spiral bandage. -The Spiral Reversed Bandage. This bandage is a spiral bandage, but differs from the ordinary spiral bandage in having its turns folded back or Fig. 3. Method of making reverses. reversed as it ascends a part, the diameter of which gradu- ally increases. By its use it is possible to cover by spiral VARIETIES OF BANDAGES. 21 turns a part conical in shape, so as to make equable pressure upon all parts of the surface. The reverses are made as follows : After fixing the initial extremity of the roller, as the part increases in diameter the bandage is carried off a little obliquely to the axis of the limb for from four to six inches ; the index finger or thumb of the disengaged hand is placed upon the body of the bandage to keep it securely in place upon the limb, the hand holding the roller is car- ried a little toward the limb to slacken the unwound portion of the bandage, and by changing the position of the hand holding the bandage from extreme supination to pronation the reverse is made. (Fig. 8.) Care should be taken not to attempt to make the reverse while the bandage is tense, for by so doing the bandage is twisted into a cord which is un- sightly and uncomfortable to the patient, instead of forming a closely fitting reverse. The reverse should be completed before the bandage is carried around the limb, and when it has been completed the bandage may be slightly tightened so as to conform to the part accurately. The reverses should be in line to have the bandage pre- sent a good appearance, and care should be taken that the reverses should not be made over salient parts of the skeleton, for if they occupy such positions they cause creases in the skin and become uncomfortable to the patient. To make reverses neatly and to have them in line requires skill and practice ; a well applied spiral reversed bandage is a test of a competent bandager. Spica Bandages. When the turns of the roller cross each other in the form of the Greek letter lambda, leaving the previous turn about one-third uncovered, the bandage is known as a spica bandage. (Fig. 9, a.) These spica bandages are especially serviceable as a means of retaining surgical dressings upon particular portions of the surface of the body, such as to the shoulder, groin, or foot. 2* 22 BANDAGING. Fig. 9. Spica bandage. Circular bandai Figure-of-eight Bandage. This bandage receives its name from the turns being ap- plied so as to form a figure-of-eight. This method of appli- cation is made use of in the Barton's bandage, the bandages of the knee and elbow, and many other bandages. Fig. 10. Recurrent bandage. Recurrent Bandage. This bandage derives its name from the fact that the roller after covering a certain part of the surface is reflected and brought back to the point of starting ; it is then reversed COMPOUND BANDAGES. 23 and carried toward the opposite point, and this manipulation is continued until the part is covered by these recurrent turns, which are then secured by a few circular turns. (Fig. 10.) This is the bandage usually employed in the dressing of stumps. Compound Bandages. These bandages are usually formed of several pieces of muslin or other material, and are employed to fulfil some special indication in the application of dressings to particular parts of the body. The most useful of the compound ban- dages are the T-bandages and the many-tailed bandages. T-bandages. The single T-bandage consists of a horizontal band to which is attached, about its middle, another having a vertical direction ; the horizontal piece should be about twice the Fig. 11. Single T-bandage. length of the vertical piece. (Fig. 11.) The single T- bandage may be used to retain dressings to the head, the horizontal piece being passed around the head from the occiput to the forehead, the vertical piece being passed over the head and secured to the horizontal piece; the shape and width of the two pieces being varied according to the indica- 24 BANDAGING tions. In applying dressings to the anal region, or peri- neum, or in securing a catheter in a perineal wound, the single Fig. 12. Single T-ba adage for chest. Fig. 13. Lfr4JI T-bandage of groin. T-bandage will be found most useful. In applying a T- bandage for this purpose the body of the bandage is placed COMPOUND BANDAGES. 25 over the spine, just above the pelvis, and the horizontal portion is tied around the abdomen. The free extremity is split into two tails for about two-thirds of its length, and is carried over the anal region and brought up between the thighs, the terminal strips passing one on each side of the scrotum and being secured to the horizontal strip in front. The single T-bandage may be variously modified according to the indications which are to be met; for instance, in applying a dressing to the breasts the horizontal strip passing around the chest may be made ten or twelve inches in width, the vertical strip, two inches in width, passes from the back over the shoulder and is. secured to the horizontal strip in front. (Fig. 12.) The single T-bandage may be variously modified, according to the ideas of the surgeon, so as to meet the indications presented in special cases. For the groin a piece of muslin six inches wide at its base and thirty inches long is sewed to a horizontal strip of muslin one and a half yards long and two inches in width. It may be ap- plied as in Fig. 13 to hold a dressing to this part Double T-bandage. Fig. 14. Double T-bandage. The double T-bandage differs from the single bandage in having two vertical strips attached to the horizontal strip, 26 BANDAGING. and it may be used for much the same purposes as the single T-bandage. (Fig. 14.) It may be conveniently used for retaining dressings to the chest, breasts or abdomen ; when used for this purpose the horizontal portion should be from eight to twelve inches wide and long enough to pass one and a quarter times about the chest ; two vertical strips, two inches wide and twenty inches long, should be attached to the horizontal strip a short distance apart near its middle. In applying this bandage to the chest, the horizontal strip is placed around the chest so that the vertical strips occupy a position on either side of the spine ; the overlapping end of the horizontal portion is secured by pins or safety-pins, and the vertical strips are next carried one over either shoulder and secured to other portions of the bandage in front of the chest. (Fig. 15.) Fig. 15. Double T-bandage of chest. The double T-bandage may also be used to secure dress- ings to the nose, in which event the strips should be quite narrow, about one inch in width, and should be applied as shown in Fig. 16. Many-tailed Bandages or Slings. These bandages are prepared from pieces of muslin of various lengths and breadths, which are split at each ex- COMPOUND BANDAGES. 27 treinity into two, three, or more tails up to within a few inches of their centres, their width and length being regu- lated by the part of the body to which they are applied. The four-tailed bandage may be found useful as a tem- porary dressing in cases of fracture of the jaw, or to hold Fig. l! Fig. i; Double T-bandage of nose. Four-tailed bandage of chin. dressings to the chin. It may be FlG - * prepared by taking a portion of a roller bandage three inches wide and one yard in length, and split- ting each extremity up to within two inches of the centre; it is then applied as seen in Fig. 17. The four-tailed bandage may also be used to retain dressings to the scalp, and can be prepared by taking a piece of muslin one yard and a quarter long and six or eight inches in width, splitting it at each extremity into two tails within three inches of the cen- tre ; it may then be applied as seen in Fig. 18. The four-tailed bandage may also be used in the rary dressing of fractures of the clavicle — the body Four-tailed bandage of head. tempo- of the 28 BANDAGING. bandage being placed upon the elbow of the injured side, two tails passing around the body, fixing the arm to the side, and two tails passing over the sound shoulder. The many-tailed bandage may also be used for holding dressings in contact with the abdomen or trunk, and is the bandage which many surgeons employ to hold the dressings to a laparotomy wound, and to give support to the abdom- inal walls after this operation. In preparing this bandage, a strip of muslin, one and a half yards in length and eigh- teen to twenty inches in width, is required, and the extremi- ties may be split so as to form an eight-tailed bandage. In applying this bandage to the abdomen the body is placed upon the patient's back and the tails are brought around the abdomen and overlap each other, and when sufficiently firmly drawn to make the desired amount of pressure they are secured by means of safety-pins. Handkerchief Bandages. The use of handkerchiefs or square pieces of muslin for the temporary or permanent dressing of wounds, fractures, Fig. 19. _-J> v i i ii! 1 1 I 1 N ' £— — -" 1 -^ yvz 4 i j: \ j=M! 1 rr_j nr if L._\_.jL --^tV--! 1 !!:', •j —== ; ;|i === lt l ^^ \ Fig. 20. The square. The oblong. or dislocations was advocated many years ago by M. Mayor, a Swiss surgeon, who wrote an extensive work upon this subject, in which he reduced their application to a system. HANDKERCHIEF BANDAGES. 29 He employed a handkerchief or square piece of muslin, and by various modifications in the application of these devel- oped a number of very ingenious bandages. The various forms which the handkerchief or square (Fig. 19) is made to assume are as follows: The oblong, made by folding the square once or twice on itself (Fig. 20). The triangle, made by bringing together the diagonal angles of the square (Fig. 21). The line of folding is known as Fig. 21. The triangle. the base, the angle opposite the base the apex, and the other angles the extremities. The cravat is prepared from the triangle by bringing the apex to its base, and folding it a number of times upon itself until the desired width is obtained. (Fig. 22.) Fig. 22. The cravat. Fig. 23. The cord. The cord is formed from the cravat twisted upon itself (Fig. 23). The names of the various handkerchief ban- 30 BANDAGING. dages are derived from the shape of the handkerchiefs used and the parts to which they are applied ; the names serve as guides in their application. It is to be remembered that the base of the triangle or the body of the cravat is to be placed upon the portion the designation of which forms the final portion of the name of the bandage ; thus, in the fronto- occipital triangle, the shape of the handkerchief is given, and we know that the base of the triangle is to be applied to the forehead and then pass to the occiput. In using the cravats the same rule applies ; thus, in . the bis-axillary Fig. 24. Fig. 25. Bis-axillary cravat. Cruro-pelvic triangle. cravat, the body of the cravat is to be placed in the axilla of the affected side, the extremities crossed over the corre- sponding shoulder and carried over the chest, one before, the other behind, to the axilla of the opposite side, where they are secured. To apply the bis-axillary cravat (Fig. 24), a piece of muslin a yard and a quarter long and eighteen inches in width folded into a cravat is required ; this ban- dage may be used to hold dressing to the axilla. The Cruro-pelvic Triangle. This bandage may be applied with a piece of muslin folded into a triangle a yard and a half long and two feet HANDKERCHIEF BAXDAGES. 31 deep. It is applied by placing the base of the triangle obliquely across the right groin and conducting the superior extremity around the left side, across the loins to the right groin, when it is secured. The inferior end should be car- ried around the upper part of the right thigh between it and the scrotum, to a point near the superior extremity, and fastened with a pin (Fig. 25); this bandage maybe em- ployed to secure dressings to the groin, hip, and upper por- tion of the thigh. Barton's Handkerchief. This dressing may be employed to make extension in cases of fracture of the leg or thigh. It is applied by taking a handkerchief folded into a narrow cravat and placing the body of it on the extremity of the os calcis below the inser- tion of the tendo Achillis, so that two-thirds of the cravat comes around under the outer malleolus, and the other third remains on the inside. The inside portion remaining par- allel with the sole of the foot, the outside piece is carried over the instep and passed around it so as to form a knot, and also passed under the sole of the foot to be turned around the first turn and to form another knot at the meta- tarsal articulation, when both ends are carried off perpen- dicularly from the foot. I have described a few of the many very ingenious ban- dages devised by Mayor to substitute the use of the roller bandage, which will give the student some idea of their design and application. It is well to bear in mind this system of dressing, for the occasion might occur in which the other means of bandaging could not be obtained, and the use of handkerchiefs might answer a useful purpose as temporary dressings. I think their principal use is for temporary dressings, and I do not think they will ever take the place of the roller bandage, which can be applied with much greater nicety and exactness^ and certainly presents a much neater appearance. 32 REGIONAL BANDAGES. KEGIONAL BANDAGING. Bandages for the Head and Neck. Barton's Bandage. Roller Two Inches in Width, Six Yards in Length. Application. — The initial extremity of the roller should be placed on the head just behind the mastoid process and the bandage should then be carried under the occipital pro- tuberance obliquely upward under and in front of the parietal eminence across the vertex of the skull, then down- ward over the zygomatic arch, under the chin, thence up- ward over the opposite zygomatic arch and over the top of Fig. 26. Barton's bandage. the head, crossing the first turn, which was made as nearly as possible in the median line of the skull, carrying the turns of the roller under the parietal eminence to the point of commencement. The bandage is then passed obliquely around under the occipital protuberance and forward under the ear to the front of the chin, thence back to the point MODIFIED BARTON'S BANDAGE. 33 from which the roller started. These figure-of-eight turns over the head and the circular turns from the occiput to the chin should be repeated, each turn exactly overlapping the preceding one until the bandage is exhausted. (Fig. 26.) The extremity should then be secured by a pin ; and pins should be introduced at the points where the turns cross each other to give additional fixation to the bandage. In applying the bandage care should be taken to see that the turns overlap each other exactly and that the turns passing over the vertex cross as near as possible in the median line of the skull. Modified Barton's Bandage. To obtain additional security in the application of the Barton's bandage a turn of the bandage passing from the occiput to the forehead may be made, this turn being inter- posed between the turns of the bandage as ordinarily applied. Modified Barton's bandage. (Fig. 27.) In applying this bandage after the first set of turns has been completed, that is after the bandage has been brought back to the occiput, the bandage is carried forward upon the head just over the ear, around the forehead and backward above the ear on the opposite side to the occiput; 34 REGIONAL BANDAGES. this being done, the ordinary figure-of-eight and circular turns are made, and when these have been completed another occipito-frontal turn may be made as described above, and this may be repeated as often as is desired until the bandage is exhausted, when the extremity is fastened with a pin, and pins are also introduced at all points at which the turns cross. Use. — This bandage is one of the most useful of the bandages of the head, being employed to secure fixation of the jaw in cases of fracture or dislocation, and for the application of dressings to the chin. I have also employed it in place of the head-gear in slinging patients for the application of the plaster- of-Paris bandage in cases of disease of the spine, a stout cord or a piece of bandage about three inches wide and one yard long being passed under the turns crossing over the vertex ; this cord is then secured to the cross-bar of the extension apparatus ; this will be found quite as comfortable to the patient as the ordinary head-gear employed and much less likely to slip out of place and interfere with the breathing of the patient. A firmly applied Barton bandage holds the jaws so closely together that care should betaken in applying it to patients who are under the influence of an anaesthetic, for if vomit- ing occurs the material may not be able to escape from the mouth and suffocation might occur unless the bandage were promptly removed. This accident I once saw occur and the patient's condition was alarming until the bandage was cut, allowing the jaw to be opened and the contents of the mouth to escape. Gibson's Bandage. Boiler Two Inches in Width, Six Yards in Length. Application. — The initial extremity of the roller should be placed upon the vertex of the skull in a line with the anterior portion of the ear ; the bandage is then carried downward in front of the ear to the chin, and passed under the chin, and is carried upward on the same line until it 35 reaches the point of starting. The same turns are repeated until three complete turns have been made ; the bandage is then continued until it reaches a point just above the ear, when it is reversed and is carried backward around the occiput, and is continued around the head and forehead until it reaches its point of origin ; these circular turns are con- tinued until three turns have been made. When the ban- dage reaches the occiput, having completed the third turn, Fig. 28. Gibson's bandage. it is allowed to drop down to the base of the skull, and it is then carried forward below the ear and around the chin, being brought back upon the opposite side of the head and neck to the point of origin ; these turns are repeated until three complete turns have been made, and upon the comple- tion of the third turn the bandage is reversed and carried forward over the occiput and vertex to the forehead, and its extremity is here secured with a pin. Pins should also be applied at the points where the turns of the bandage cross each other. (Fig. 28.) Use. — This bandage may be used to fix the lower jaw in cases of fracture or dislocation of the jaw, but is more apt to change its position, and is therefore not so satisfactory as the Barton's bandage for this purpose. 36 kegional bandages. Oblique Bandage of Angle of the Jaw. Roller Two Inches in Width, Six Yards in Length. Application. — The initial extremity of the roller is placed just in front of and above the left ear, and if the left angle of the lower jaw is to be covered in, the bandage is to be carried from left to right, making two complete turns around the cranium from the occiput to the forehead. If the right angle of the lower jaw is to be covered in, the turns should be made in the opposite direction. Having made two turns from the occiput to the forehead, the bandage is allowed to drop down upon the neck, and is carried forward under the ear and under the chin to the angle Fig. 29. Oblique bandage of angle of the jaw. of the jaw ; it is now carried upward close to the edge of the orbit, and obliquely over the vertex of the skull, then down be- hind the right ear, continuing this oblique turn under the chin to the angle of the left jaw, where it ascends in the same direction as the previous turn. Three or four of these ob- lique turns are made, each turn overlapping the preceding one and passing from the edge of the orbit toward the ear RECURRENT BANDAGE OF THE HEAD. 37 until the space is covered in; the bandage is then carried to a point just above the ear on the opposite side, is reversed, and finished with one or two circular turns from the occiput to the forehead, the extremity being secured by a pin. (Fig. 29.) Use. — This will be found to be one of the most useful of the head bandages ; it may be used with a compress in ti eating fractures of the angle of the lower jaw, for holding dressings to the lower part of the chin and to the vault of the cranium, and is especially useful in retaining dressings to the sides of the face and the parotid region. As before stated, it may be applied to cover either the right or left side of the face, and, by reason of the oblique turns, holds its position most securely, having little tendency to become displaced. Recurrent Bandage of the Head. Roller Two Inches in Width, Eight Yards in Length. Application. — The initial extremity of the roller is placed upon the lower part of the forehead and the bandage is carried twice around the head from the forehead to the occiput to secure it. When the bandage is brought back to the median line of the forehead it is reversed and the re- versed turn is held by the finger of the left hand while the roller is carried over the top of the head along the sagittal suture to a point just below the occipital protuberance; here it is reversed again and the reverse is held by an assistant while the roller is carried back to the forehead in an elliptical course, each turn covering in two-thirds of the preceding turn. These turns are repeated with successive reverses at the forehead and occiput until one side of the head is com- pletely covered in, and when this is accomplished a circular turn is made from the forehead to the occiput to hold the reverses in place. The opposite side of the head is next covered in by elliptical reversed turns made in the same manner, and when this has been accomplished two or three circular turns 3 38 REGIONAL BANDAGES. are carried around the head from the forehead to the occiput to fix the previous turns. Pins should be applied at the forehead and occiput at the points where the reversed turns concentrate. (Fig. 30.) Fig. 30. Recurrent bandage of the head. Use. — This bandage when well applied is one of the neatest of the head bandages, and it will be found useful to retain dressings to the vault of the cranium in the treatment of wounds of the scalp in this region. It will also be found of service in holding dressings to fractures of the cranium and to wounds after the operation of trephining. In restless patients it will sometimes become displaced, and it may be rendered more secure by pinning a strip of bandage to the circular turn in front of the ear and carrying it down under the chin and up to a corresponding point on the opposite side, where it is pinned to the circular turn ; or one or two oblique turns passing from the circular turn over the vertex of the skull downward behind the ear, under the chin and up to the circular turn in front of the ear may be applied. The course of these turns is the same as those employed in the oblique bandage of the angle of the jaw, the extremity being secured by a pin. V-BANDAGE OF THE HEAD. 39 V-BANDAGE OF THE HEAD. Roller Tivo Indies in Width, Four Yards in Length. Application. — The initial extremity of the roller is se- cured by two turns of the bandage around the cranium from the forehead to the occiput, and when the roller reaches the occipital protuberance it is allowed to drop slightly a little below this and is carried forward below the ear around the Fig. 31. V-bandage of the head. front of the chin and lower lip, then backward to the point of starting. These turns passing from the occiput to the forehead and from the occiput to the chin are alternately made until a sufficient number have been applied, and the extremity is secured by a pin over the occiput. (Fig. 31.) This bandage may be modified by carrying the turns from the occiput forward under the ear and around the upper lip and back to the occiput and alternating these turns with the occipito-frontal turns ; if employed in this way a bandage of one and one-half inches in width should be used. Use. — This bandage may be employed to hold dressings to the front of the chin, to the upper and lower lips in cases 40 REGIONAL BANDAGES. of wounds, or to give support to these parts after plastic operations. Head and Neck Bandage. Roller Two Inches in Width, Four Yards in Length. Application. — The initial extremity of the roller is placed upon the forehead and carried backward just above the ear to the occiput and is then brought forward around the opposite side of the head to the point of starting. Two Fig. 32. Head and neck bandage. of these circular turns are made to fix the bandage, and when it is carried back to the occiput it is allowed to drop down slightly upon the neck and is then carried around the neck, the turns around the head alternating with the neck turns until a sufficient number of these have been applied, when the extremity of the bandage is secured by a pin at the point of crossing of the turns at the back of the head. (Fig. 32.) CROSSED BANDAGE OF ONE EYE. 41 Use. — This bandage may be found useful in securing dressings to the anterior or posterior portion of the neck or to the region of the occiput. Care should be taken to apply it in such a manner that too much pressure is not made by the turns around the neck, which would be uncomfortable to the patient, and might seriously interfere with respiration. Crossed Bandage of One Eye. Roller Two Inches in Width, Four Yards in Length. Application. — The initial extremity of the bandage is placed upon the forehead and fixed by two circular turns passing around the head from the occiput to the forehead ; Fig. 33. Crossed bandage of one eye. the roller is then carried back to the occiput and passed around this and brought forward below the ear, and passing over the outer portion of the cheek is carried upward to the junction of the nose with the forehead, and is then conducted over the parietal protuberance downward to the occiput; a circular fronto-occipital turn is next made, and when the ban- dage is brought back to the occiput it is brought forward 42 REGIONAL BANDAGES. again to the cheek and ascends to the forehead, covering in two-thirds of the previous turn, and is again conducted back to the occiput ; these turns are repeated, the oblique turns covering the eye alternating with circular turns around the head until the eye is completely enclosed (Fig. 33), and the bandage is finished by making a circular turn about the head and introducing a pin to secure its extremity. It will be found more comfortable to the patient to include the ear on the same side on which the eye is covered in the turns of the bandage. Use. — This bandage will be found useful in retaining dressings to one eye. It will be more comfortable to the patient if a flannel roller be used to apply this bandage, as well as the bandage which includes both eyes. Crossed Bandage of Both Eyes. Roller Two Inches in Width, Six Yards in Length. Application. — The initial extremity of the roller is placed upon the forehead and secured by two circular turns of the bandage, passing around the head from the forehead to the occiput ; the roller is then carried downward behind the occiput and brought forward below the ear to the upper por- tion of the cheek ; it is then carried upward to the junction of the nose with the forehead and conducted over the parietal protuberance to the occiput ; a circular turn is now made around the head from the occiput to the forehead, and the roller is carried from the occiput over the parietal protuber- ance of the opposite side forward to the junction of the nose with the forehead, then downward over the eye and outer portion of the cheek below the ear and back to the occiput ; a circular turn around the head is next made, and this is fol- lowed by a repetition of the previous turns, ascending over one eye, descending over the other eye, each turn alternat- ing with a circular turn around the head. These turns are repeated until both eyes are covered in, and the bandage is finished by making a circular turn around the head, the ex- OCCIPITO-FACIAL BANDAGE. 43 tremity being secured by a pin. (Fig. 34.) In this bandage both ears may be covered in, or left uncovered. Fig. 34. Crossed bandage of both eyes. Use. — This bandage may be used to apply dressings to both eyes, and both of these bandages covering the eyes are used where it is desired to make pressure ; but, for the sim- ple application of a light dressing or of a bandage for the exclusion of light, the Liebreich's bandage (Fig. 68) will be found more comfortable to the patient. Occipitofacial Bandage. Boiler Two Incites in Width, Four Yards in Length. The initial extremity of the roller is placed upon the vertex of the head, and the bandage is carried downward in front of the ear and under the jaw, and upward upon the opposite side in the same line to the vertex ; two or three of these turns are made, one turn accurately covering in the other, and a reverse is made just above and in front of the ear, and two or three turns are made around the head from the occiput to the forehead, which completes the 44 REGIONAL BANDAGES. bandage. (Fig. 35.) Pins should be inserted at the points where the turns of the bandage cross each other. Fig. 35. Occipito-facial bandage. Use. — This bandage is employed to secure dressings to the vertex, temporal, occipital, or frontal regions. Oblique Bandage of the Head. Roller Two Inches in Width, Four Yards in Length. The initial extremity of the bandage is placed upon the forehead, and is secured by two circular turns passing around the head from the forehead to the occiput. From the occiput the bandage is carried obliquely over the highest part of the lateral aspect of the head, which is to be covered in, and is passed over the forehead and back to the occiput, and is then carried to the forehead by a circular turn, then con- ducted obliquely over the other side of the head and back to the occiput. These turns are repeated, so that each suc- ceeding turn covers in three-fourths of the preceding turn until the sides of the head are covered in by descending turns, and the bandage is completed by a circular turn SPIRAL BANDAGE OF THE FINGER. 45 passing around the head from the forehead to the occiput. (Fig. 36.) This bandage may be applied with descending or ascending turns. Fig. 36. Oblique bandage of the head. Use. — This bandage is employed to make pressure upon or to hold dressings to the lateral aspects of the head. Bandages of the Upper Extremity. Spiral Bandage of the Finger. Roller One Inch in Width, One and a Half Yards in Length. Application. — The initial extremity of the roller is secured by two or three turns around the wrist; the bandage is then carried obliquely across the back of the hand to the base of the finger to be covered in, then to its tip by oblique turns ; a circular turn is then made and the finger is cov- ered by ascending spiral or spiral reversed turns until its base is reached ; the bandage is then carried obliquely across the back of the hand and finished by one or two circular 4* 46 REGIONAL BANDAGES. turns around the wrist; the extremity may be pinned or may be split into two tails, which are tied around the wrist. (Fig. 37.) Fig. 37. Spiral bandage of the finger. Use. — This bandage is employed to retain dressings upon the finger and to secure splints in the treatment of fractures or dislocations of the phalanges. Gauntlet Bandage. Boiler One Inch in Width, Three Yards in Length. Application. — The initial extremity of the roller is fixed at the wrist by one or two circular turns of the bandage ; it is then carried down to the tip of the thumb by an oblique turn of the roller, and this is covered in by spiral or spiral reversed turns to the metacarpo-phalangeal articulations ; the roller is then carried back to the wrist and a circular turn is made around it, and the bandage is now carried GAUNTLET BANDAGE, 47 down to the tip of the next finger by an oblique turn, which is covered-in in the same manner. When all the fingers have been covered in, the bandage is finished by circular turns around the hand and wrist. (Fig. 38.) Fig. 38. Gauntlet bandage. Use. — This bandage may be employed to apply dressings to the fingers and hand in case of wounds or fractures. It was formerly much employed in the treatment of burns of the fingers to prevent the opposed ulcerated surfaces from adhering, but its use for this purpose has been supplanted by wrapping each finger in a separate dressing and applying a dressing over the whole with a few recurrent and spiral turns of a wide roller, the application of this dressing being much less painful to the patient, and being at the same time equally satisfactory. 48 REGIONAL BANDAGES. Demi-gauntlet Bandage. Roller One Inch in Width, Four Yards in Length. Application. — The initial extremity of the bandage should be placed upon the wrist and fixed by two circular turns passing from the ulnar to the radial side ; then carry the roller obliquely across the back of the hand to the base Demi-gauntlet bandage. of the index finger, pass the bandage around this and carry the roller back to the wrist, making a circular turn ; it should then be carried obliquely across the hand to the base of the next finger, and so successively until the base of each of the fingers and of the thumb has been included ; the bandage is then completed by a circular turn around the wrist. (Fig. 39.) The demi-gauntlet bandage may be also applied in such a manner as to cover the palm of the hand and leave the back of the hand uncovered. SPIOA BANDAGE OF THE THUMB. 49 Use. — This bandage may be employed to retain light dressings to the dorsal or palmar surface of the hand. Spica Bandage of the Thumb. Roller One Inch in Width, Three Yards in Length. Application. —The initial extremity of the roller is placed upon the wrist and fixed by two circular turns ; then carry the roller obliquely over the dorsal surface of the thumb to its distal extremity ; next make a circular or spiral turn around the thumb, and carry the bandage upward over the back of the thumb to the wrist, around which a circular turn should be made. The roller is next car- ried around the thumb and wrist, m akin or figure-of-eight turns, each turn overlapping the previous one two-thirds as it ascends the thumb, and each figure-of-eight turn alternating with a circular turn about the wrist. These bpica bandage of the thumb. turns are repeated until the thumb is completely covered in with spica turns, and the bandage is finished by a circular turn around the wrist. (Fig. 40.) Use. — This bandage is employed to apply dressings to the dorsal surface of the thumb, and for the retention of splints in the dressing of fractures or dislocations of the bones of the thumb. 50 regional bandages. Spiral Reversed Bandage of the Upper Extremity. Roller Two and a Half Inches in Width, Seven Yards in Length. Application. — The initial extremity of the roller is placed upon the wrist, and secured by two turns around the wrist ; the bandage is then carried obliquely across the back of the hand to the second joint of the fingers, where a circular turn should be made ; the hand is covered in by two or three ascending spiral or spiral reversed turns. When the thumb has been reached, its base and the wrist are covered in by Fig. 41. Spiral reversed bandage of the upper extremity. two figure-of-eight turns'; the bandage is then carried up the forearm by spiral and spiral reversed turns until the elbow is reached ; this may be covered in with spiral re- versed turns, and the bandage is next carried up the arm with spiral reversed turns to the axilla. (Fig. 41.) If, on reaching the elbow, the arm is bent or is to be flexed in the subsequent dressing, the elbow should be covered in with figure-of-eight turns, and when this has been done the arm above may be covered in with spiral reversed turns. When properly applied, the reverses should be in line, and should not be made over the prominent ridge of the ulna. Use. — This is one of the most generally employed of all FIGURE-OF-EIGHT BANDAGE OF ELBOW. 51 the roller bandages ; it constitutes the primary roller which is applied in the dressing of fractures of the humerus, and is also the bandage employed in holding dressings to the arm and forearm, and in securing splints to these parts in the treatment of fractures and dislocations. Figure-of-eight Bandage of the Elbow. Roller Two Inches in Width, Four Yards in Length. Application.- placed upon the —The initial extremity of the bandage is forearm a short distance below the elbow- joint, and fixed by one or two circular turns, the arm being Fig. 42. Figure-of-eight bandage of the elbow. flexed. The bandage is then carried by an oblique turn across the flexure of the elbow-joint, and passed around the arm a few inches above the elbow ; a circular turn is then made, and the roller is next carried across the flexure of the elbow and passed around the forearm. These turns are re- peated, the turns from the forearm ascending and those from the arm descending, each set of turns crossing in the flexure 52 REGIONAL BANDAGES. of the elbow until it is covered in, and a final turn is passed circularly around the elbow-joint. (Fig. 4*2.) Use. — This bandage is often employed as a part of the spiral reversed bandage of the upper extremity when the arm is to be flexed, and is also used to hold dressings to the region of the elbow-joint. It was formerly much used to hold the compress upon the wound resulting from venesec- tion at the elbow. Spica Bandage of the Shoulder (Ascending). Holler Two and a Half Inches in Width, Seven Yards in Length. Application. — The initial extremity of the roller is placed obliquely upon the outer surface of the arm opposite the axillary fold, and fixed by one or two circular turns. If Fig. 43. Fig. 44. Spica bandage of the shoulder (ascending). Spica bandage of (he shoulder (descending). the right shoulder is to be covered, the bandage is next car- ried across the front of the chest to the axilla of the oppo- site side, then around the back of the chest to the point of starting upon the arm ; then conduct the roller around the arm of this side up over the shoulder, across the front of the chest, through the opposite axilla and back over the pos- terior surface of the chest to the point of starting ; continue SPICA BANDAGE OF THE SHOULDER. 53 to make these ascending turns, each turn overlapping the preceding turn about two-thirds until the shoulder is covered in (Fig. 43), when the extremity of the bandage may be secured by a pin at the point of ending, or the last turn may be carried from the shoulder around the back of the neck and brought forward over the opposite shoulder and pinned to the turns which pass around the axilla It should be remembered that the turns of the roller overlap each other exactly in the opposite axilla, and it will be found more com- fortable to the patient to apply a little cotton wadding in the axilla to prevent the bandage from excoriating the skin of this part. Care should be taken to see that the turns are made in such a manner that the spica turns occupy, as nearly as possible, the median line of the shoulder. When this bandage is applied to the left shoulder, after fixing the ini- tial extremity by circular turns around the arm, the roller should be carried over the back of the chest to the axilla of the opposite side and then brought back to the point of start- ing ; the succeeding turns are then applied in the same manner. Spica Bandage of the Shoulder (Descending). Roller Two and a Half Inches in Width, Seven Yards in Length. Application. — The initial extremity of the roller should be fixed upon the arm as near as possible to the axillary line by one or two circular turns, and if it is applied to the right shoulder the bandage should be passed under the axilla and carried obliquely over the shoulder to the base of the neck, then downward across the front of the chest to the axilla of the opposite side; from the axilla the roller is carried over the back of the chest to the base of the neck so as to cross the first turn at this point ; it is then carried to the axilla and through this, then back to the neck, the turns descending toward the shouldei. These turns, taking the same course are repeated, each turn overlapping two-thirds of the pre- 54 REGIONAL BANDAGES. vious one until the shoulder is covered in and the circular turn around the arm is reached, at which point the extrem- ity is secured by a pin. (Fig. 44.) Use. — The spica bandages of the shoulder are employed to hold dressings to the shoulder, to hold compresses over the acromial end of the clavicle in case of dislocation of that portion of the bone, to retain the shoulder-cap used in the treatment of fractures of the upper portion of the humerus, and to retain dressings to the axilla. Figure-of-eight Bandage of the Neck and Axilla. Fig. 45. Roller Two Inches in Width, Five Yards in Length. Application. — The initial extremity of the roller is fixed upon the side of the neck and secured by one or two loosely applied circular turns ; if applied to the right axilla carry the bandage from left to right over the right shoulder to the posterior part of the axilla under which it passes, to ascend in front over the same shoulder to the back of the neck ; these figure-of-eight turns around the neck and axilla, each turn overlapping two-thirds of the previous turn, are repeated until the desired space is covered, and the bandage is completed by a circular turn around the neck. (Fig. 45.) Use. — This will be found a useful bandage to secure dress- ings to the base of the neck, the upper part of the shoulder, and to the axilla, as it does not restrict the motions of the arm unless drawn too tight. Figure-of-eight bandage of the neck and axilla. VELPEAU'S BANDAGE. 55 Velpeau's Bandage. Two Rollers Two and a Half Incites in Width, Seve7i Yards in Length. Application. — The patient should place the fingers of the hand of the affected side on the opposite shoulder ; the initial end of the roller should be placed on the body of the scapula of the sound side and secured by a turn made by Ftg Velpeau's baudage. earning the bandage over the shoulder of the affected side, near its outer portion, then conducting it downward over the outer and posterior surface of the arm of the same side, behind the point of the elbow, and obliquely across the front of the chest to the axilla of the opposite side, thence to the point of starting. This turn should be repeated, to fix the initial extremity of the bandage. Having completed the second turn, carry the roller transversely around the thorax, passing over the flexed elbow of the affected side, from this point to the axilla, and through this to the back. From this point the roller is carried over the shoulder and down the 56 REGIONAL BANDAGES. outer and posterior surface of the arm behind the elbow and obliquely across the front of the chest through the axilla to the back, and continuing, passes transversely across the back of the chest to the elbow, which it encircles, then passing to the axilla. These alternating turns are repeated until the arm and forearm are bound firmly to the side and chest. The vertical turns over the shoulder, each turn covering in two- thirds of the previous turn and ascending from the point of the shoulder toward the neck and from the posterior surface of the arm toward the elbow, are applied until the point of the elbow is reached. The transverse turns passing around the chest and arm are so applied that they ascend from the point of the elbow toward the shoulder, each turn covering in one-third of the previous one, and the last turn should pass transversely around the shoulder and chest, covering the wrist. (Fig. 46.) The extremity of the bandage should be secured by a pin where it ends, and additional fixation will be secured by introducing a number of pins at the points where the turns of the bandage cross each other. Use. — This bandage is employed to fix the arm in the treatment of certain fractures of the clavicle and scapula, also to secure fixation of the humerus after the reduction of dislocations of the shoulder-joint. Desault's Bandage. Three Hollers Two and a Half Inches in Width, Seven Yards in Length. A wedge-shaped pad to fit in the axilla is also required. These rollers are known as the first, second and third rollers. First Roller of Desault's Bandage. Application. — Before applying the first roller the arm of the patient on the injured side should be elevated and carried off at right angles to the body ; the wedge-shaped 57 pad with its base in the axilla should next be applied to the side of the chest, and the initial extremity of the roller is placed upon the middle of the pad and fixed by tw~o or three circular turns around the chest ; the bandage is then carried obliquely across the front of the chest to the sound Fig. 4; First roller of Desault's bandage. shoulder and passed under the axilla, brought over the shoulder and conducted around the chest to pass over the pad, and it is next carried obliquely down to the lower portion of the chest to a point opposite the lower end of the pad ; it is now made to ascend the chest by spiral turns until the top of the pad is reached, where it is secured. (Fig. 47.) Second Roller of Desault's Bandage. Application. — The arm should be brought down against the side so as to press upon the pad previously applied, and the forearm should be flexed upon the arm and brought across the lower portion of the chest. The initial extremity of the roller is placed in the axilla of the sound side, and the bandage is carried around the chest and over the arm of 58 REGIONAL BANDAGES. the injured side, making a circular turn around the chest to fix it ; then spiral turns are made around the chest from above downward until the elbow is reached, the turns being more Fig. 48. Second roller of Desault's bandage. firmly applied as they descend, and when this point reached the end of the bandage is secured. (Fig. 48.) is Third Boiler of Desault's Bandage. Application. — The initial extremity of the roller is placed in the axilla of the sound side, and the bandage is carried obliquely over the front of the chest to the shoulder of the injured side, passed over this, and conducted down the back of the arm to the elbow, thence obliquely upward over the upper fifth of the forearm to the axilla of the sound side. From this point it is carried backward obliquely over the back of the chest to the shoulder ; crossing the previous shoulder-turn it is conducted down the front of the arm to the elbow, then around this and backward obliquely over the back of the chest to the axilla of the sound side. These turns are repeated until three sets of turns have been applied, and the turns should overlie each other exactly. (Fig. 49.) The course of the turns of the third roller is SPIRAL BANDAGE OF THE CHEST. 59 considered the most difficult to remember, and the student may be assisted in its correct application by remembering that all the turns start at the axilla, pass to the shoulder, and then to the elbow, and from the elbow always return to Fig. 49. Third roller of Desault's bandage. the starting-point — the axilla. The turns of the third roller make two triangles, one on the anterior surface of the chest, the other upon the back. After the application of the three rollers the hand and un- covered portion of the forearm should be supported in a sling suspended from the neck. Use. — This bandage, applied completely, or some one of its various rollers, is employed in the treatment of fractures of the clavicle. Bandages of the Trunk. Spiral Bandage of the Chest. Holler Three Inches in Width, Nine Yards in Length. Application. — The initial extremity of the roller is ap- plied to the anterior portion of the waist, and fixed by one or two circular turns ; the bandage is then carried upward, 60 REGIONAL BANDAGES. encircling the chest by ascending spiral turns, each turn covering in one-half of the previous turn until the axillary line is reached; the roller is next carried around the axilla to the back, and obliquely over this to the base of the neck of the opposite side, and then it may be passed down over the chest and pinned to the spiral turns at several points ; a pin should also be inserted at the point where the last turn of the roller leaves the spiral turn upon the back of the chest. (Fig. 50.) Fig. 50. Spiral bandage of the chest. Use. — This bandage is employed to hold dressings to the chest, and may be used as a temporary dressing in fractures of the ribs or sternum. Care should be taken that the bandage be not so tightly applied as to interfere with respi- ration. Anterior Figure-of-eight Bandage of the Chest. Roller Two and a Half Inches in Width, Seven Yards in Length. Application. — The initial extremity of the roller should be placed in the axilla of one side, and fixed by two or three circular turns around the chest ; the bandage is then POSTERIOR FIGURE-OF-EIGHT BANDAGE. 61 carried through the axilla and passed upward over the shoulder of the same side, and obliquely across the anterior portion of the chest to the axilla of the opposite side, then through this to the shoulder of the same side, and obliquely downward to the opposite axilla. These turns should be repeated, ascending from the shoulder toward the neck, each turn overlapping three-fourths of the preceding one, until five or six turns have been applied, the end of the Fig. 51. Anterior figure-of-eight bandage of the chest. bandage being secured by a pin (Fig. 51), or it may be completed by a circular turn around the chest. Use. — This bandage may be employed to bring the shoulders forward, and to hold dressings to the anterior portion of the chest. Posterior Figure-of-eight Bandage of the Chest. Roller Two and a Half Indies in Width, Seven Yards in Length. Application. — The initial extremity of the roller should be placed upon the outer portion of the left shoulder, and the bandage is carried obliquely backward and downward to the axilla of the opposite side ; it is then passed through this 4 62 REGIONAL BANDAGES. and conducted over the shoulder of the same side and passed obliquely downward to the axilla of the opposite side and carried through this and brought up over the shoulder to fix the initial extremity of the roller. These turns are repeated five or six times, the same precautions being observed in Fig. 52. Posterior figure-of-eight bandage of the chest. covering the turns and in ascending from the shoulder toward the neck (Fig. 52). In applying both of these ban- dages the crosses of the bandage, either anterior or posterior, should be made in the median line of the chest. Use. — This bandage may be employed to hold dressings to the posterior portion of the chest and to draw the shoul- ders backward. Suspensory and Compressor Bandage of the Breast. Roller Two and a Half Inches in Width, Seven Yards in Length. Application. — The initial extremity of the roller should be placed upon the scapula of the affected side, and secured by two oblique turns carried over the opposite shoulder and conducted downward under the mamma to be covered in, and then carried to the axilla of the same side. Next carry SUSPENSORY AND COMPRESSOR BANDAGE. 63 the roller transversely around the chest, covering in the lowest portion of the affected mamma. These turns should be repeated, the oblique turns from the axilla over the shoulder Fig 53. Suspensory and compressor bandage of the breast. alternating with the transverse turns around the chest until the breast is covered in, each series of turns ascending, and covering two-thirds of the preceding turn. (Fig. 53.) Use. — This bandage is employed to support the breast and to make compression at the same time ; it may also be employed to hold dressings to the breast. Suspensory and Compressor Bandage of Both Breasts. Two Rollers Two and a Half Inches in Width, Seven Yards in Length. Application. — The initial extremity of the bandage should be secured by oblique turns of the axilla and shoulder as in the preceding bandage ; the bandage should next be carried transversely around the back to the breast, then under the breast and upward over the opposite shoulder, then obliquely downward around the chest to the other side, 64 REGIONAL BANDAGES, being carried transversely over the lower portion of both breasts to the point of starting upon the back. Repeat these oblique turns from the shoulder to the axilla and from the axilla to the shoulder, and alternate these turns with a Fig. 54. Suspensory and compressor e of both breasts. transverse turn around the chest and over both breasts. Both series of turns should ascend, and each turn should overlap two-thirds of the preceding turn. (Fig. 54.) Use. — This bandage is employed to support and compress both breasts and to retain dressings to the breasts. SINGLE SPICA BANDAGE OF THE GROIN. 65 Bandages of the Lower Extremity. Single Spica Bandage of the Groin (Ascending). Roller Two and a Half Inches in Width, Seven Yards in Length. Application. — Place the initial extremity of the bandage upon the anterior portion of the right thigh just below the groin and secure it by one or two circular turns around the thigh, or place the initial extremity of the roller obliquely upon the upper part of the thigh and carry it behind the Fig. 55. Ascending spica bandage of the groin. thigh and upward around the outer side of the thigh to the abdomen, omitting the circular turns ; then carry the ban- dage obliquely across the lower part of the abdomen to a point just below the crest of the left ilium and conduct it transversely around the back of the pelvis to a correspond- ing point on the opposite side; then bring it obliquely downward to the groin over to the inner portion of the thigh, carrying it around the thigh, crossing the starting- turn in the middle line of the thigh. These turns are 66 EEGIONAL BANDAGES. repeated, each turn ascending and covering in two-thirds of the previous turn, until six or eight complete turns have been made, and the bandage is secured at any point where it ends. (Fig. 55.) Single Spica Bandage of the Groin (Descending). Roller Two and a Half Inches in Width, Seven Yards in Length. Application. — Place the initial extremity of the roller obliquely upon the anterior surface of the right thigh and secure it by one or two circular turns around the thigh, or Fig. 56. Descending spica bandage of the groin- start the bandage with an oblique turn, as previously de- scribed ; then carry the bandage obliquely across the abdo- men to a point just below the crest of the ilium, and conduct it transversely around the back of the pelvis to a correspond- ing point on the opposite side ; then bring it obliquely down over the lower portion of the abdomen, crossing the first turn, to the junction of the thigh with the scrotum, pass it under the thigh and bring it up over the lower part of the abdomen, and let it follow the course of the first turn. These turns DOUBLE SPICA BANDAGE OF THE GROINS. 67 are repeated, each turn descending and overlapping two- thirds of the previous turn until the groin is covered (Fig. 56). When either of these bandages is applied to the left groin, after the initial extremity of the roller is fixed, it is carried first to the crest of the ilium of the same side, then around the back of the pelvis to a corresponding point on the oppo- site side, then obliquely across the lower part of the abdo- men to the outer aspect of the thigh, being conveyed under this and brought up between the thigh and the scrotum, passing obliquely over the groin to follow the course of the original turn. The turns may be made either to ascend or descend as the bandage is applied. Double Spica Bandage of the Groins. - Roller Three Inches in Width, Nine Yards in Length. Application. — The initial extremity of the roller is placed upon the abdomen just above the iliac crests and Fig. 57. Double spica bandage of the groins. secured by one or two circular turns ; the bandage is then carried from a point just below the crest of the right ilium 68 REGIONAL BANDAGES. obliquely across the lower portion of the abdomen to the outer portion of the thigh, and is carried around this and brought up between the scrotum and the thigh, and is passed obliquely over the groin, crossing the previous turn in the median line, and is conducted to a point just below the crest of the ilium on the same side. The bandage is then con- tinued around the pelvis to the same point on the opposite side, and from this point is made to pass obliquely over the groin to the inner side of the thigh, passing around this and coming up on its outer side, crossing the previous turn at the middle line of the groin, to be carried obliquely across the groin and lower part of the abdomen to the crest of the ilium on the opposite side. These turns are repeated, each turn covering in two-thirds of the previous turn, until both groins have been covered (Fig. 57). The turns may be so applied as to ascend or descend, forming the ascending or descending double spica bandage of the groin. When properly applied, this bandage presents three sets of cross- ing turns, one in each groin and one in the median line of the abdomen. Use. — The spica bandages of the groin, either single or double, are employed to hold dressings to wounds in the inguinal region — for instance, those resulting from herni- otomy, or from operation upon the glands of the groin. They are also employed to make pressure upon this region, and will often prove of use in the securing of compresses applied for the temporary retention of hernise. Figure-of-eight Bandage of the Knee. Roller Two and a Half Inches in Width, Five Yards in Length. Application. — The initial extremity of the roller is placed upon the thigh three inches above the patella and secured by two or three circular turns; then conduct the bandage over the outer condyle of the femur across the pop- liteal space to the inner border of the tibia and around the FIGURE-OF-EIGHT BANDAGE OF KNEE. 69 anterior surface below the tubercle and head of the fibula and make one circular turn ; the roller should then be car- ried obliquely across the popliteal space to the inner condyle of the femur, crossing the previous turn ; then carry it around the front of the thigh to the outer condyle ; repeat these Fig 58. Figure-of-eight bandage of the knee. turns, ascending toward the knee from the leg and descend- ing from the thigh toward the knee, and finish the bandage by a circular turn over the patella (Fig. 58). Use. — This bandage is employed to hold dressings to the knee-joint either anteriorly or posteriorly. These figure-of- eight turns are often employed in covering the knee in applying the spiral reversed bandage of the lower ex- tremity when it is desired that the patient be allowed to bend the knee. Finecl Wounds. — These wounds are caused by the absorption, by means of a cut or abrasion in the skin, of fluids from a dead body in making dissections or post- mortem examinations or in operating upon living subjects, and often result in serious consequences. Such wounds, as soon as possible after their reception, should be care- fully washed out with a solution of bichloride of mercury, 1 : 2000, or a 30-grain solution of chloride of zinc, and then dressed with an antiseptic dressing. If. however. this precaution is not taken or the wound has escaped notice, and in a few hours becomes inflamed and painful, and evidences of lymphatic involvement show themselves, the wound should be opened and its surface should be thoroughly washed out with a 30-grain solution of chloride of zinc, and finally with a 1 : 2000 bichloride solution, and it should then be dressed with an antiseptic gauze dressing. Under this method of dressing the poisoned wound is often converted into a healthy one. even after the lymphatic in- volvement is well marked, and it usually heals promptly without further constitutional disturbance. Gunshot Wounds. — These wounds are produced by small shot, balls, or fragments of shells, and are of the nature of contused and lacerated wounds, and the vulnerating body as well as portions of the clothing are often imbedded in the tissues. In dressing these wounds any foreign bodies, if they can be located, should be removed, and in the search for and removal of balls from the extremities the application of the Esmarch bandage and strap will be found most useful. The wound should next be thoroughly washed out with a 1 : 2<)<>Q 270 MINOR SURGERY. bichloride solution, and an antiseptic dressing applied as in the case of other contused and lacerated wounds. Powder burns resulting from the explosion of powder, in addition to the burning and laceration of the tissues, are accompanied by the introduction of grains of unburnt powder into the skin, which, if not removed, leave permanent points of pigmentation. These wounds should first be washed with an antiseptic solution, and upon the face, to avoid unsightly pigmentation of the skin, care should be taken to pick out the small masses of powder with a needle or the sharp point of a tenotomy knife. The surface should then be dressed with lint spread with an ointment of boric acid or an ointment of aristol, consisting of half a drachm or a drachm of aristol to an ounce of vaseline, this dressing being covered by a few layers of bichloride or borated cotton, held in place by a roller bandage. Contusions or bruises differ from contused wounds in the fact that the skin is not broken, though in spite of this fact there may exist very extensive laceration of the subcutaneous tissues, accompanied by more or less extravasation of blood from the injured vessels. When not severe enough to re- quire operative treatment, they should be dressed by apply- ing over them several layers of lint saturated with lead-water and laudanum, and over this dressing is placed a layer of waxed paper or rubber tissue, and the dressing is secured by a roller bandage. A solution which I find most satisfactory in the dressing of contusions is as follows : Aramonii chloridi . . ' . . . . . grs. xx. T "- T\. 1 aa f3j. Alcohons j UJ Aquas -. . q. s. ad fgj. Several layers of lint saturated with this solution are laid over the contused tissues, and are covered with waxed paper, oiled silk, or rubber tissue. Extensive collections of blood following contusions often remain in the tissues for some time, but usually are ab- sorbed. If this result does not follow, or an abscess forms, BURNS AND SCALDS. 271 the blood or pus should be removed by aspiration or by incision with full antiseptic precautions. Burns and Scalds. The dressings employed in the treatment of burns and scalds are similar, as the injury to the tissues is practically the same in both classes of injuries. Superficial burns or scalds, in which the effect of the heat has only extended to the superficial layer of the skin, may be treated by the ap- plication of lint saturated with a solution of carbonate of sodium, a drachm to an ounce of water ; this dressing rap- idly relieves the pain, and is a satisfactory application in this variety of burns and scalds. In cases in which the effects of heat have extended to the deeper tissues, the affected surface may be dressed with carron oil, which is prepared by rubbing together lime-water and linseed oil until a thick creamy paste results ; lint is saturated with this mixture and laid over the surface of the burn or scald. The dressing is a comfortable one to the patient, but soon becomes offensive, and for this reason requires frequent re- newals. The disadvantage met with in the antiseptic method of dressing burns and scalds is the fact that the raw surface presented offers the most favorable conditions for the absorp- tion of the antiseptic substances employed in the dressings, and for this reason the use of bichloride of mercury, carbolic acid, and iodoform is not to be recommended in burns or scalds involving a large extent of surface, on account of the toxic symptoms which may result from their employment. A recent burn or scald, by reason of the heat employed in its production, is practically an aseptic wound, and it may be dressed by covering it with boric acid ointment, and placing over this a number of layers of borated or salicylated cotton, and holding the dressings in position by a roller bandage. Aristol, as a substitute for iodoform, may be employed in the dressing of burns or scalds, being either dusted over the 272 MINOR SURGERY. surface or used in the form of an ointment, and over this application should be placed a few layers of borated or salicylated cotton. When blebs are present upon the surface of the burn or scald, they should be opened to allow the serum to escape. If suppuration occurs or the tissues become necrosed by reason of the severity of the injury, the surface of the burn may be washed with a 1 : 60 carbolic solution or 1 : 4000 bichloride solution and the same dressing should then be applied. The ulcers resulting from the separation of the dead tis- sues should be touched with a solution of nitrate of silver, four grains to the ounce of water, and dressed with lint spread with ointment of boric acid or aristol. In the dress- ing of extensive burns or scalds of the neck, face, and region of the joints, the possibility of serious deformity from con- traction of the tissues in healing should not be lost sight of, and position, splints and bandages, should be employed to prevent, as far as possible, this complication. Bedsores. These sores usually occur over the sacrum or hips in patients who are confined to bed for a considerable time, as the result of a long-continued pressure, or in those cases where the vital powers are depressed by adynamic diseases, and are also a frequent and troublesome complication in spinal injuries. Their formation may be prevented in many cases by the use of air-cushions or of a water mattress, and by keeping the parts exposed to pressure scrupulously clean and frequently bathing them with stimulating lotions, such as alcohol, olive oil and alcohol equal parts, or soap lini- ment. The parts should also be protected from pressure by the application of adhesive plaster, or, still better, soap plaster spread upon chamois. When the bedsore has actu- ally formed, and in many cases its formation is very rapid and the slough will be found to involve a large surface of the skin over the sacrum, and to extend down to the bone, SPRAINS. 273 we have present a very serious complication, and one which requires most careful treatment. The dressing of a bedsore before the separation of the slough consists in relieving the part from pressure by the use of an air-cushion placed under the buttocks, and the application of a fermenting poultice until the slough has separated. When the slough has become detached the ulcer remaining should be well washed with a carbolic or bichlo- ride solution and the granulations should be touched with a 5-grain solution of nitrate of silver; and resin cerate, iodo- form, aristol, or boric acid ointment, spread upon lint, should be applied to the surface of the ulcer, and a piece of soap plaster a little larger than the ulcer should be placed over this dressing and held in place by broad strips of adhesive plaster. This dressing should be renewed every day or every other day, and means should be adopted to protect the parts from further pressure, and the constitutional con- dition of the patient should be improved by the adminis- tration of a nutritious diet, tonics, and stimulants. The application of the galvanic current has been employed with good results to promote the healing of the ulcer in obstinate cases. Sprains. Sprains of joints from twists or other external violence resulting in the stretching or laceration of the ligaments are injuries which require careful dressing. Sprains may be first treated by the application of cold- or hot-water dressings for a few hours, or by the application of lead-water and laudanum, the joint being kept at rest by the use of a splint or by confining the patient in the recum- bent posture in the case of sprains of the joints of the lower extremities. After a few days' use of the lead-water and laudanum dressing the swelling usually subsides and the joint may be fixed by the application of a moulded soap-plaster splint or felt splint held in place by a firmly applied roller band- age, which should be worn for a week or ten days; in ordi- 274 MINOR SURGERY. nary cases after this time the splint may be removed and the patient should be encouraged to use the joint. In cases of severe sprain, on the other hand, the pain and swelling persist for some time, and here the fixation of the joint by a soap plaster, or better by a plaster- of-Paris bandage, will be found useful for a few weeks. If upon the removal of this dressing the parts are still painful and swollen, the swollen tissues should be painted with tincture of iodine; or the method of applying tincture of iodine recommended by Mr. Jordan, that is, the application of the iodine in a broad band around and not over the swollen tissues, may be em- ployed. The joint should next be surrounded by a piece of lint spread with an ointment composed of equal parts of ointment of mercury and ointment of belladonna, and a moulded soap-plaster splint being fitted to the joint, it is held in place by a firmly applied bandage. This will be found a most satisfactory dressing in the treatment of sprains after they have passed their acute stage. The dress- ing is removed at intervals of three or four days, the joint is sponged off with alcohol, and a similar dressing is reap- plied; and this method of dressing may have to be continued for some weeks, but the results obtained by its continuous use are often most satisfactory. An ointment of icthyol one part to lanolin three parts may also be used in the same manner as the ointment of belladonna and mercury with good results in the treatment of these injuries. The employment of pressure in the . treatment of sprains, by means of strapping, is also sometimes advantageous. In the chronic stage of a sprain, after all dressings have been removed, the methodical use of massage is often most beneficial ; and after the parts have been thoroughly manipulated a flannel bandage should be applied which, by its elasticity, gives a certain amount of support to the parts. Sprain-fracture. — Under this name Mr. Callender has described an injury which consists in the separation of a ligament or tendon from its point of insertion, with the detachment of a thin shell of bone; this injury is apt to occur about the ankle-, knee-, elbow-, and wrist-joints, and TRACHEOTOMY. 275 the treatment is the same as that of an ordinary fracture in the same locality. This injury is probably much more common than is generally supposed in connection with sprains of the joints, and is, I think, in many cases the cause of the tardy restoration of the function of sprained joints, this injury being overlooked and the injury simply being treated as a sprain, and the patient being encouraged to use the part before the union of the bone has been accomplished. Strains of muscles arid fascia varying in severity from simple stretching of the fibres to absolute rupture are treated by putting the parts at rest and by the application of pressure by means of adhesive straps or of a bandage : in strains of the muscles and fascia of the back the use of broad strips of adhesive plaster, applied as in cases of fracture of the ribs, will be found most satisfactory, and in the treatment of the later stages of the injury the employ- ment of massage will often be followed by good results. Tracheotomy. This operation consists in dividing the tissues over the trachea in the median line of the neck, and after the trachea has been exposed it is opened by dividing two or three of the tracheal rings. The operation of tracheotomy may be required to relieve the dyspnoea dependent upon membranous or diphtheritic laryngitis, growths in the larynx or trachea, growths ex- ternal to these organs causing pressure upon them, oedema of the mucous membrane of the larynx or trachea from inflammation from burns or scalds, or from the inhalation of irritating gases or the swallowing of corrosive liquids. The operation may also be required for the removal of foreign bodies from the larynx, trachea, or from the bronchi. as well as for the relief of the dyspnoea due to their presence, and it is also required in cases of fracture or laceration of the larynx or trachea, and occasionally in cases of spasm of the glottis, and in cases of glossitis to overcome the 276 MINOR SURGERY. mechanical obstruction which prevents the entrance of air into the air-passages. The ease with which the operation is performed varies much in different cases; it is, as a rule, a much simpler operation in adults than in children. In the latter subjects the shortness of the neck, the relatively greater size of the thyroid gland and the possible presence of the thymus body, the great vascularity of the parts, and the abundance of adipose tissue, render the trachea difficult to expose and open. Under certain circumstances the operation may be per- formed with very few instruments ; but if the surgeon has the choice he will find it convenient to have at hand two small scalpels, one short grooved director, a tenaculum, two aneurism needles which may be used as retractors, one pair of artery forceps, haemostatic forceps, two pairs of dissect- ing forceps, a pair of scissors, a sharp-pointed tenotome, a pair of tracheal forceps, a tracheal dilator, tracheotomy tubes, tapes, ligatures, sponges, a flexible catheter, and feathers. The director should be short; the ordinary grooved director is too long to use with satisfaction in oper- ating upon the short necks of children ; so that I have had made a shorter and somewhat broader one, which has a bevelled extremity which allows it to be passed with ease between the different layers of the tissue. (Fig. 199.) Fig. 199. Author's tracheotomy director. Hcemo static forceps are also of great use in controlling hemorrhage during the operation in case of the division of vessels which bleed freely, when the operator from the urgency of the case does not think it justifiable to ligature them at the time of their division. They may also be em- ployed under similar circumstances to clamp the isthmus of TRACHEOTOMY. 277 the thyroid gland on either side of the trachea when it becomes necessary to divide it to expose the trachea. A sharp-pointed tenotome is the instrument I prefer to employ in opening the trachea as its sharp point enables it to be easily thrust into the trachea, and its short cutting surface and the narrowness of the blade obscure as little as possible the line of incision and thus enable the operator to see exactly where he is cutting. Tracheal dilators of various kinds are employed, but the most satisfactory tracheal dilator which I have employed is that of Golding-Bird (Fig. 200), which is a self-retaining instrument; the blades are slipped through the tracheal incision and are then expanded by turning the screw to which they are attached. Trousseau's tracheal dilator, the blades of which are in- troduced through the incision in the trachea and are ex- panded by bringing together the handles, is also a satisfactory instrument (Fig. 201), but is not as useful as the tracheal Fig 200. Fig. 201. Golding-Bird's tracheal dilator. Trousseau's tracheal dilator. dilator previously mentioned, as it has to be retained in position by the hand. Tracheal dilators may be improvised from bent hairpins or pieces of wire, which will often serve a useful purpose where ordinary dilators cannot be obtained. It is also well to have at hand a number of pliable feathers to be used in cleaning the trachea or larynx of mucus or membrane after it has been opened, and by their use this object can be accomplished with little risk of injury to the mucous membrane. Tracheal forceps, which are constructed with a double 13 278 MINOR SURGERY. spring and curved blades are also useful in removing mem- brane or foreign bodies from the larynx above the wound or from the trachea below the tracheal incision. (Fig. 202.) Fig. 202. Tracheal forceps. Tracheotomy -tubes of various shapes are made of silver, aluminium, hard and soft rubber, but the tube which I think is the most satisfactory for general use is a silver quarter- circle tube with a movable collar (Fig. 203), and provided with a fenestrated guide. (Fig. 204.) A good tracheotomy-tube is Fig. 203. Fig. 204. Silver tracheotomy-tube. silver tracheotomy-tube with fenestrated guide. one which inflicts the least possible injury upon the mucous membrane of the trachea, and to insure this object the part of the tube within the trachea should lie exactly in its axis and its free extremity should be capable of as little move- OPERATION OF TRACHEOTOMY. 279 ment as possible. The tracheotomy-tube is held in position after being introduced by means of tapes attached to the shield of the tube and tied around the neck. Position of Patient for Tracheotomy. The best position in which to place the patient for this operation is that which brings the neck into the greatest prominence, and this can best be obtained by laying the patient upon his back upon a firm table and placing under the shoulders a round cushion ; or an empty wine-bottle, or a roller-pin wrapped in towels will answer the same pur- pose. If an anaesthetic is not used the arms should be held by an assistant, which is better than securing them by a binder fastened around the chest, which restricts respiratory movements. Use of an Anaesthetic in Tracheotomy. As a rule, I think it is better not to administer an anaes- thetic in performing this operation, as little pain is experi- enced, in cases in which the dyspnoea is well marked, after the incision in the skin has been made, and I have seen the dyspnoea which was well marked before the use of the anaes- thetic suddenly become so alarming that the trachea had to be opened before it was thoroughly exposed, which is a pro- cedure always attended with risk. So strong is my con- viction that the risks of the operation are much increased by the employment of an anaesthetic that in later years I have abandoned its use. Operation of Tracheotomy. The trachea may be opened above the isthmus of the thy- roid gland or below it, and these operations constitute respectively the high and low operations. The high operation is generally selected, because at this point the trachea is more superficial and is more easily exposed, whereas in the low operation the trachea is more difficult to expose by reason of its relatively greater depth, 280 MINOR SURGERY. the large size and number of the veins, and its proximity to the large arterial trunks. The patient being placed in position, the operator stands at the head of the patient ; this position I prefer, as it is easier from this point to keep the incisions exactly in the median line of the neck. The operator next makes himself familiar with the landmarks of the neck ; locating the position of the cricoid cartilage, he makes an incision through the skin in the median line of the neck from one and a half to two inches in length, the position of the cricoid cartilage being the middle point. There is no disadvantage in making a longer incision if a freer exposure of the parts is required. Having divided the skin, the operator will often see a large vein lying in the superficial fascia — the superficial anterior jugular ; this should be displaced, and the fascia divided upon the director. The surgeon should keep his incisions strictly in the median line of the neck, for this is the line of safety ; and he should be careful, as the wound increases in depth, not to make the incisions too short, so that it becomes funnel- shaped. When the deep fascia is exposed it should be picked up and divided upon the director, and any large veins in the line of the wound should be carefully displaced, or, if this is impossible, they should be ligatured on each side and then divided between the ligatures. The operator now looks for the intermuscular space between the sterno-hyoid and the ster no-thyroid muscles, which can generally be found without difficulty, and the muscles are now separated in this line with the handle of the knife or with the director, and the isthmus of the thyroid gland will be exposed. The muscles should now be held aside by retractors placed on either side. A caution here as to the use of retractors may not be out of place : the operator should place them himself and allow the assistants to hold them. I once almost lost a case in which I had the trachea exposed, and while I turned aside to pick up a knife with which to open it, my assistant, in replacing a retractor which had slipped, included the movable trachea in the grasp of the OPERATION OF TRACHEOTOMY. 281 retractor, pulling it to one side and completely shutting off respiration ; when I attempted to find the trachea to open it I could only feel the anterior surface of the vertebrae at the bottom of the wound, and it was only when I appreciated what had occurred, and lifted the retractor, allowing the trachea to spring back into its normal position, that I was able to open it. Mr. Durham and Mr. Marsh mention somewhat similar cases in which the trachea and vessels were held aside with retractors by assistants until the surgeon had exposed the cervical vertebrae. The operator should carefully explore the wound with the finger, to locate exactly the position of the trachea, and to ascertain, if possible, the presence of any anomalous arteries. The isthmus of the thyroid gland is exposed, which generally occupies a position over the first three tracheal rings ; this is usually surrounded by a plexus of veins which should be displaced with the director, or, if this is impos- sible, they should be ligatured on each side and divided between the ligatures. The thyroid isthmus is next dis- placed upward or downward, according as the surgeon desires to open the trachea below or above this body. This is often done without difficulty, especially its upward dis- placement; but when there is difficulty in displacing it downward, a procedure recommended by Bose may be em- ployed, which consists in making a transverse incision across the cricoid cartilage to divide the layer of fascia by which the isthmus is bound down ; a director is then passed into this incision, and the isthmus is gently depressed without diffi- culty. Having displaced the isthmus of the thyroid gland upward or downward, the trachea, yellowish-white in appearance, covered by the tracheal fascia, should be exposed ; this fascia should next be thoroughly broken up with the director or handle of the knife so as to bare the trachea, and in doing this the operator can feel it crepitate under the finger from the suction of air drawn in with inspiration. Having arrived at this stage of the operation the operator should examine the wound to see that it is free from hemorrhage and he should also replace the retractors so as to expose as 282 MINOR SURGERY large a portion as possible of the trachea, for, be the case ever so urgent, he now feels assured that he can open the trachea in a moment if the breathing should cease. The trachea is now fixed with a tenaculum introduced into it a little to one side of the median line ; an incision is made into it with a narrow knife from below upward, from one- half to three-fourths of an inch in length (Fig. 205), care Fig. 205. Opening the trachea. (Liston.) being taken to see that this incision is in the median line, for if the trachea be opened by a lateral incision the wound does not heal so promptly and the tracheotomy-tube does not fit well, and its lower extremity may cause injury to the mucous membrane of the trachea. If the wound be a deep one, after fixing the trachea with the tenaculum the opera- tor may lift it slightly from its bed, thereby bringing it more prominently into view and making it more superficial in the wound, thus facilitating its opening. As soon as the incision is made into the trachea there is a gush of air from the wound in the trachea mixed with blood or membrane ; this should be wiped away with a sponge and a tracheal dilator should next be introduced and the trachea should be cleared of membrane, if it is present in the region of the wound, with a feather or with forceps. The tracheotomy-tube is OPERATION OF TRACHEOTOMY. 283 next introduced and is secured in position by tapes tied around the neck. If respiration has ceased artificial respiration should be resorted to or the use of a tube attached to a bellows, or Fell's apparatus, and these efforts should be continued for at least fifteen minutes, for I have seen resuscitation take place in patients who were apparently dead by a persistent employment of artificial respiration. The care of the tube is a matter of some importance after its introduction ; the inner tube should be removed at short intervals, washed and replaced, and if the operation has been done for an inflammatory condition of the larynx or trachea a moistened feather should occasionally be passed through the tube into the trachea to withdraw any mucous or membrane which is present. In cases of croup after tracheotomy the use of a spray of steam or of a spray com- posed of Carbonate of soda 3j to o'J ss - Glycerin f.^ij- "Water ^S v j* applied by means of a steam atomizer, the spray being directed over the opening of the tube, will be found most satisfactory in softening the discharges and thus facilitating their expulsion through the tube. The tracheotomy-tube is usually allowed to remain in the trachea from five to ten days : its permanent removal is in- dicated as soon as the patient is able to breathe through the larynx with the wound in the trachea closed ; its use may be required for a longer time, but as soon as the indication for its presence has disappeared the sooner it is removed the better, for its presence sometimes sets up a troublesome tracheitis. x\fter its removal the wound rapidly diminishes in size, the healing taking place by granulation and con- traction. Difficulty is occasionally met with in the perma- nent removal of tracheotomy-tubes; for the causes and treat- ment of this complication the reader is referred to special works upon tracheotomy. Where the operation of tracheotomy is done for the re- 284 MINOR SURGERY. moval of foreign bodies from the air-passages, the steps of the operation are the same, but after the removal of the foreign body the treatment of the wound is somewhat dif- ferent. If the foreign body has remained in the trachea only for a short time the wound in the soft parts may be closed by means of sutures or may be allowed to remain open, being covered by a piece of moistened gauze, and the use of the steam spray is here also beneficial for a few days. If, however, the body has remained in the larynx, trachea, or one of the bronchi for some time and has set up a certain amount of inflammatory trouble, it is better to introduce a tracheotomy-tube and allow it to remain for a few days. If it is found impossible to locate or remove the foreign body at the time of operation, a tracheotomy-tube should be in- troduced and allowed to remain until the foreign body is expelled through the tube or removed subsequently by means of forceps. Laryngectomy. In this operation an opening is made into the air-passages through the crico-thyroid membrane. It is a simple opera- tion, and one which is practically free from risk, and can therefore be performed much more rapidly and safely in urgent cases than tracheotomy. In this operation the same objection exists to the use of an anaesthetic as in tracheotomy, and therefore it should be dispensed with. The patient being placed in the recumbent posture, with the shoulders slightly elevated and the head thrown back to make the neck as prominent as possible, the surgeon feels for the prominence of the thyroid cartilage, and steadying the larynx between the finger and thumb of the left hand, he makes an incision in the median line over the centre of the thyroid cartilage and extending downward for an inch or an inch and a half. The skin and superficial fascia being divided, the fascia between the sterno-liyoid muscles and the areolar tissue is exposed and divided, and the crico-thyroid membrane is exposed. The knife is then passed transversely through the membrane into the larynx, LARYNGOTOMY. 285 care being taken that both that membrane and the mucous membrane which covers its inner surface are divided at the same time. As soon as the knife enters the cavity of the larynx blood and mucus will be forcibly expelled. The wound should be carefully enlarged and a tube intro- duced, which differs from the ordinary tracheotomy-tube in being slightly flattened ; this is secured in position by tapes tied around the neck as in the case of the ordinary tracheal tube. The only bleeding which is likely to occur is from the crico-thyroid arteries or veins, and if these cannot be avoided, and are divided in the operation, they should be temporarily secured by haemostatic forceps or ligatured, and if the case is not extremely urgent, all bleeding should be arrested before the crico-thyroid membrane is incised. The after-treatment of cases of laryngotomy is similar to that of cases of tracheotomy ; the same attention is required in the care of the tube and in the general management of the patient. Laryngo-tracheotomy. This operation consists in making an incision into the air-passages by dividing one or two of the upper rings of the trachea, the crico-tracheal membrane, the cricoid cartilage, and the crico-thyroid membrane. This operation is employed in cases where, from the age of the patient, the crico-thyroid space is too small to admit of a sufficient opening, or in those in which, for any reason, the surgeon does not deem it advisable to attempt to open the trachea lower down. The incision in the skin and superficial fascia of the neck is made in the same manner as in the operation of laryngotomy, but is carried a little further downward. It may be necessary to displace the isthmus of the thyroid gland downward to expose the upper portion of the trachea, and when the trachea is exposed the incision should be made through this and the cricoid cartilage from below upward. This operation is more often performed in the high opera- tion of tracheotomy than is generally supposed. A trache- otomy-tube is introduced through the wound and secured by 13* 286 MINOR SURGERY. tapes tied around the neck, and the care of the tube should be similar to that in cases of tracheotomy. Intubation of the Larynx. This procedure, at the present time, is widely employed as a substitute for tracheotomy in the treatment of the dyspnoea due to inflammatory affections of the larynx or trachea, or stenosis of the larynx ; it consists in the intro- duction of a metallic tube into the larynx, which is allowed to remain in place for a few days. The operation has been recently reintroduced to the profession by Dr. O'Dwyer, of New York, who has devised a set of ingenious instruments for the purpose of laryngeal intubation. Fig. 206. Mouth-gag. The instruments required are a mouth-gag (Fig. 206), with which the jaws are separated and held open ; an in- strument for the introduction of the tube, which is fastened Fig. 207. Intubation-tube and introductor. to the obturator which fills the cavity of the tube (Fig. 207), and an instrument for extracting the tube after it has been placed in the larynx. (Fig. 208.) The tubes are of metal INTUBATION OF THE LARYNX 287 and have a collar which rests upon the false cords and bulge slightly toward their middle and again taper toward their lower extremity ; at the collar of the tube there is a perfora- tion through which a strand of silk is passed which is made into a loop ; this is used to allow the operator to remove the Fig. 208. Intubation-tube extractor. Fig. 209. 3-4- tube if on its introduction it is found to have passed into the oesophagus instead of the larynx, and also is used to remove the tube if it becomes occluded with mem- brane while in the larynx. The intubation set now in common use is provided with six tubes ranging in size from such as are suited for a child of one year or less up to the age of twelve or fourteen years. (Fig. 209.) In performing the operation of intuba- tion of the larynx the child is placed upon the lap of the nurse or assistant wrapped in a blanket and the arms are secured by the nurse holding the elbows so as not to interfere with the respiratory movements. The patient's head is next secured by an assistant, and the position of the head, neck and body, should be that as if it hung from the top of the head, and this position should be firmly maintained during the in- sertion of the tube. The mouth-gag is next inserted upon the left side and the blades dilated so as to open the jaws widely, and as the gag is self-retaining this position is easily maintained. The jaws being thus held open, the operator, Scale of intuba- tion-tubes. 288 MINOR SURGERY. sitting on a chair facing the patient, next introduces the index finger of the left hand into the mouth and passes it over the tongue until he feels the epiglottis ; the introducing instrument to which the tube is attached is held in the right hand and this is now introduced into the mouth, first seeing that the silken loop is free, and it is swept over the tongue and passed down until it touches the epiglottis ; this is hooked up by the index finger of the left hand and the tube is passed into the larynx ; the index finger of the left hand is then transferred to the edge of the tube and by drawing upon the trigger of the instrument with the index finger of the right hand the obturator is detached, and the instrument is withdrawn, and before removing the finger it is well to place it upon the head of the tube and to sink it well into the larynx. As soon as the obturator is removed there is usually a violent expiratory effort which is accompanied by a gush of mucus, muco-purulent matter or membrane from the tube, and after this escapes the breathing is usually satis- factorily established. If the operator has passed the tube into the oesophagus and has detached it from the introducing instrument, and no improvement in the respiration takes place, it should be withdrawn by the silk loop and attached to the obturator and another attempt should be made to in- troduce it into the larynx. The mistake which inexperienced operators make in in- troducing the tube is in not hugging the posterior surface of tongue closely, so that they pass the tube over the epiglottis into the oesophagus. The silken lopp may be brought out at one side of the mouth and fastened around the ear or fastened to the side of the face by strips of adhesive plaster for a few hours, so that by drawing upon it the nurse or attendant is able to withdraw the tube instantly if it should become obstructed with membrane ; or, if it is coughed up, by this means it may be withdrawn from the oesophagus if it has not been expelled from the mouth. Some operators keep the loop attached to the tube during the time it is retained in the larynx, others prefer to remove it after several hours and remove the tube by means of the extracting instrument when INTUBATION OF THE LARYNX. 289 required. The tube is removed at the end of the second or third day and if the child is able to breathe comfortably for an hour or two it is not reintroduced ; if. however, the dys- pnoea returns it is reintroduced and allowed to remain one or two days longer ; several attempts may have to be made before the tube is permanently removed, but it is usually dispensed with from the third to the eighth day. The most serious complication which is apt to occur during the introduction of the intubation-tube is the de- tachment and pushing of a mass of membrane in front of the tube into the trachea ; if this is too large to be expelled through the tube the breathing is suddenly arrested, and the tube should be removed, and if the mass of membrane does not escape upon the expiratory efforts of the patient the trachea should be rapidly opened as the only means of re- establishing the respiratory function. So much do I dread this accident, which has occurred in a few cases, that I never introduce an intubation-tube without having at hand the necessary instruments to do a tracheotomy if it should be suddenly required, and if possible obtain the consent of the parents or friends to perform tracheotomy if it should be indicated. One of the greatest troubles after intubation of the larynx is the satisfactory feeding of the patient ; liquids as a rule are not swallowed well, a portion of them escaping into the tube, causing coughing and difficulty in breathing. The diet I usually order is of semi-solids, such as corn-starch, soft-boiled eggs, and mush ; and if these are not well swal- lowed it may be necessary to resort to nutritious enemata or the use of a stomach-tube to introduce food. Some patients swallow liquids and semi-solids quite w T ell if the head is dropped a little lower than the body during the act of deglutition. PART III. FRACTURES In the following article the author has endeavored to confine himself simply to a description of the varieties of fracture and to their dressing and treatment, and he has tried as far as possible to avoid the multiplication of dress- ings, being satisfied to describe a few of the methods of dressing most frequently employed. He has also avoided the description of complicated splints and dressings, by the use of which in certain fractures most excellent results are obtained, but has preferred to recommend the employment of simple splints and dressings, which can be obtained by physicians practising in districts remote from large cities, where the services of an instrument-maker cannot be ob- tained to construct special apparatus for the treatment of these injuries. Varieties of Fractures. A complete fracture is one in which the line of separation completely traverses the bone, involving the entire thickness of the bone. An incomplete fracture is one in which there is only«a partial separation of the bone-fibres (Fig. 210), under which name are included partial or " green- stick" fracture, in which some of the bone-fibres have given way, while the remaining fibres have been bent by the force and have not been broken. (Fig. 211.) Fissured, punctured, indented, VARIETIES OF FRACTURE 291 and perforating fractures are also included in the class of incomplete fractures. (Fig. 212.) A simple or closed fracture is a fracture in which there are but two fragments, and the seat of injury in the bone does Fig. 210. Fig. 211. Fig. 212. Incomplete fractun of femur. Partial or green-stick fracture of radius. Fissured fracture of humerus. (Gurlt.) not communicate with the external air by a wound in the soft parts. Compound or open fractures are fractures in which the seat of injury in the bones communicates with the external air by a wound in the soft parts. Comminuted fractures are those in which there are more than two fragments, the lines of fracture intercommunicating with each other. (Fig. 213.) 292 FRACTURES. A multiple fracture is one in which a bone is the seat of two or more distinct fractures at different points, the lines of fracture not necessarily communicating with each other. Complicated fractures are such as are accompanied by some serious injury of the parts in the region of the frac- ture — as, for instance, the laceration of important blood- vessels or nerves, contusion or laceration of the muscles, or dislocation of a neighboring joint. Fig. 213. Fig. 215. Comminuted frac- ture of patella. Fig. 214. Impacted fracture. Transverse frac- ture of femur. (GuRLT.) Impacted fractures are those in which one fragment is driven into and fixed in the other, the impaction taking place at the time of fracture, or being caused by force sub- sequently applied. (Fig. 214.) DIRECTION OF FRACTURE. 293 Direction of Fracture. A transverse fracture is one in which the general line of division of the bone is at right angles with the long axis of the bone. (Fig. 215.) Transverse fractures of the long bones are rarely met with, the line of fracture usually being more or less oblique. Fig. 216. Fig. 217 Oblique fracture of humerus. (Stimson.) Longitudinal fracture of tibia. (Stimson.) An oblique fracture is one in which the line of separation is oblique to the long axis of the bone. This is one of the most common directions of the line of fracture. (Fig. 210.) A longitudinal fracture is one in which the line of sepa- ration runs in the general direction of the long axis of the 294 FRACTURES. bone. (Fig. 217.) This form of fracture is rare, but is sometimes met with in the long bones as the result of gun- shot injury. Epipthy seal fracture or separation occurs before complete ossification has taken place between epiphysis and diaphysis, and is rarely seen after the twentieth year of life ; the direc- tion of the epiphyseal separation is transverse. (Fig. 218.) Epiphyseal fracture of head of humerus. (Moore.) The deformity or displacement in fractures is either angu- lar, transverse, longitudinal, or rotary. Repair of Fractures. The process of repair in cases of fracture is concisely stated by Ashhurst as follows : " The traumatic irritation propagated from the broken bone causes swelling of the periosteum, active proliferation, and formation of a sheath of new bone around the seat of fracture ; this is the ensheathing or ring callus of surgical writers. At the EXAMINATION OF CASES OF FRACTURE. 295 same time, the medulla feels the effect of the irritation, becomes hardened, and partially ossified ; this constitutes the interior or pin callus. Lastly, the osseous tissue itself undergoes cell-proliferation, and union of the fragments takes place — mutatis mutandis — precisely by the same pro- cess that we have already studied in considering wounds of the soft tissues. The new material which is thus developed between the fragments themselves, constitutes what Dupuy- tren called the intermediate, permanent, or definitive callus, in contradistinction to the ensheathing and interior forms of callus, which are temporary or provisional." Examination of Cases of Fracture. In examining a*case of fracture to locate the nature and seat of fracture, the clothing should be removed from the part with as little disturbance as possible, and it is better, in most cases, to cut or rip the clothing, rather than to attempt to remove it in the ordinary manner. The surgeon should first inspect the injured part, and, where possible, com- pare it with its fellow, as in the case of injuries of the extremi- ties ; much valuable information is also derived from the patient or his friends as to the manner in which the injury was produced. The part should next be carefully examined by the surgeon ; if it be one of the extremities which is injured, it should be gently lifted, firm extension being made at the same time, the surgeon by his touch and by gentle movements seeking to locate the seat of fracture ; and he may, by this manipulation, at the same time develop crepitus. All manipulations should be made with care, and with the greatest gentleness, not only to save the patient from pain, but also to prevent the soft parts in the region of the fracture from being injured by the rough or sharp fragments of the bone. Rough handling of fractures may increase the mus- cular spasm by the irritation caused by the sharp fragments of the bones, and may also result in the injury of important vessels and nerves, and indeed a simple fracture may be converted into a compound one by forcible and injudicious manipulations. 296 FRACTURES. The sooner the examination is made after the fracture has occurred the better, for at this time there is less swelling in the region of the injury, and the surgeon can locate the bony prominences with much more ease, and can often discover the exact seat of the fracture with the least amount of manipulation of the parts. When a case of suspected frac- ture is not subjected to examination for several days after the reception of the injury, the parts in the region of the supposed fracture are often so much swollen that it is impos- sible to accurately locate its seat, and in such a case it is often necessary to wait until the swelling has subsided before the position of the fracture can be satisfactorily fixed, the case being treated in the meantime as one of fracture. Ancestheties may be employed to relieve the patient from pain and to obliterate muscular spasm in the examination of fractures, and their employment is often of the greatest service in the diagnosis of obscure or complicated fractures, especially those in the neighborhood of joints ; but the sur- geon should remember that all manipulations should be made with the same gentleness as when the examination is con- ducted without anaesthesia, for there is the same risk of injury to the surrounding structures by the fragments ; this pre- caution is often neglected when an anaesthetic has been given, the surgeon often being inclined to handle the parts more roughly than he otherwise would ; such practice can- not be too severely condemned. Provisional Dressings in Cases of Fracture. It generally happens that fractures occur at localities more or less distant from the point where the treatment of the fracture is to be conducted, and the transportation of the pa- tient and the temporary dressing of the fracture are, therefore, matters of the first importance. In fractures of the upper extremities, if the fracture be simple, the clothing need not be removed, and the arm should be bound to the side by some article of clothing, or supported in a sling made from handkerchiefs or the clothing, and the patient can usually PROVISIONAL DRESSINGS. 297 Fig. 219. walk or ride for a short distance without much injury to the parts in the region of the fracture or inconvenience to him- self. When the bones of the lower extremities or the trunk are the parts involved, the transportation of the patient is a matter of more difficulty. When the bones of the trunk are in- volved, the part should be sur- rounded by a binder firmly pinned or tied, made from the clothing or from towels, or sheets or other strong materials which are at hand. When the bones of the lower extremity are involved, if the fracture be a simple one, the clothing need not be removed, and the motion of the fragments should be pre- vented by applying to the sides of the limb, extending above and below the seat of fracture, strips of wood, shingles, pasteboard, bundles of straw, strips of bark taken from trees, or bundles of twigs, these being held in place by handkerchiefs or strips torn from the clothing. Umbrellas or canes, or broomsticks (Fig. 219), applied in the same man- ner, may be employed, the object of any of these dressings being to secure temporary fixation of the fragments of bone during the transportation of the patient. If the fragments are not fixed in some way, but are allowed to move about during the transportation of the patient, much damage may result to the soft parts surround- ing the fractured bones, and simple fractures may become compound ones by the bones being forced through the skin, the discomfort of the patient at the same time being much increased. Provisional dressing for fracture of the leg. (Esmarch.) 298 FRACTURES. Having applied any dressing to bring about fixation of the fragments, the patient should next be placed upon a broad board or settee ; if a mattress cannot be obtained, the fractured limb should be laid upon a mass of clothing, or upon some straw, and he should be placed in a wagon or carried to the point where the subsequent treatment of the fracture is to be conducted. Reduction or Setting of Fractures. This should be effected as soon as possible after the occur- rence of the injury and as soon as the surgeon is prepared to' apply the dressings to keep the parts in their proper posi- tion ; reduction at an early period is less painful to the patient and is accomplished with more ease to the surgeon than at a later period when marked swelling and inflamma- tion are present at the seat of fracture. It consists in bringing the fragments by manipulation as nearly as possible in their normal position, and it is accomplished by extension and manipulation with the hands, care being taken to use as little force as possible to attain the object. Very little force is often required if the surgeon places the part in such a position as to relax the muscles which produce the displace- ment ; when this is accomplished the fragments can usually be pressed into, position by the fingers without the applica- tion of any considerable force. When the reduction of a fracture has been accomplished the fragments are retained in position by the application of various splints or dressings which serve to prevent their displacement. Materials and Appliances Used in the Dressing of Fractures. Fracture Bed. Many ingenious forms of beds have been devised for the use of patients suffering from fractures of the bones of the trunk and lower extremities, but a simple bedstead provided MATERIALS AND APPLIANCES USED. 299 with a firm hair mattress having a perforation near its centre, into which is fitted a firm pad, and provided with a pan ^ which slides in a framework beneath a corresponding open- ing in the bedstead, will prove a useful appliance. The mattress is covered by a sheet perforated to correspond to the opening in the mattress, and when the pad is removed the evacuations of the patient are passed into the pan. In fractures of the trunk or lower extremities it will be found more convenient in handling the patient to use a single bed not over thirty-two or thirty-six inches in width, and it is not essential that the mattress be perforated, as a bed-pan can usually be slipped under the patient ; the mattress should be a firm one stuffed with hair. The use of an ordinary tin pie-plate covered with a piece of old muslin to receive the fecal evacuations may be substituted for the bed- pan and will be found in many cases more satisfactory, especially in the case of children suffering from fracture of the lower extremity. Splints. After the reduction or setting of the fragments in cases of fracture they are usually retained in position until union occurs by the use of splints held in position by means of bandages or strips of muslin. Splints may be made of wood, or of tin, lead, copper or wire which possess the requisite amount of firmness and permit of their being moulded to the part, which latter may be found useful in certain cases. Wooden splints. — The simplest and best splints are made from wood — white pine, willow or poplar being the best material to employ for their construction, being sufficiently strong to give fixation to the parts and at the same time being light. Splints made from smooth white pine, willow or poplar boards from one-eighth to one-half an inch in thickness may be employed in the form of straight or angu- lar splints, and their preparation is a matter of little diffi- culty. Wooden splints before being applied to the part should be well padded with cotton, wool, oakum, or hair, and where 300 FRACTURES. lateral wooden splints are employed in the treatment of v fractures of the lower extremity it is usual to place bran- bags or junk-bags between the limb and the splint. The carved wooden splints which are sold by the instrument- makers are not to be recommended, as a rule, for unless the surgeon has a large number to select from it is rare that a splint can be obtained to accurately fit any individual case. Binder's board or pasteboard is an excellent material from which to construct splints ; it is first soaked in boiling water and when sufficiently soft is padded with cotton or a layer of lint and moulded to the part, and secured in position by a bandage : as it becomes dry it hardens and retains the shape into which it was moulded. Undressed leather is also an excellent material from which to construct splints ; it is applied by first soaking it in boiling water, and after padding it with cotton or lint it is moulded to the part and retained in position by a bandage. Felt made from wool saturated with gum shellac, pressed into sheets, is also a good material from which to construct splints. This material is prepared for application to the surface by heating it before a fire until it becomes pliable, or by dipping it into boiling water. Gutta-percha splints made from sheets of this material, in thickness from ^ to J- of an inch, may often be employed with advantage ; it is prepared for use by immersing it in hot water, when it becomes soft and can be moulded to the surface. Care should be taken that it is not allowed to become too soft by too long immersion to permit of its being conveniently handled. Paper splints made from layers of manilla paper stiffened with starch constitute a very fair substitute for some of the varieties of splints previously mentioned. Plaster- of -Paris, starch, chalk and gum, silicate of potassium or sodium may be employed for the construction of splints, either movable or immovable, in the treatment of fractures ; their method of preparation and application is MATERIALS AND APPLIANCES USED. 301 described (p. 84 et seq.); the plaster-of-Paris dressing is the one which is most generally used at the present time. Fracture-box. — This is a form of splint used in the treatment of fractures of the lower extremity, and consists of a piece of board eighteen to twenty inches in length, with a foot-board firmly secured NSfi, ! gemrig, . -. . *\ 1 . t V 1_ . i at its lower extremity ; the sides _ . , ... . . . . i-i n Fracture-box with movable are secured by hinges which allow sides them to be raised or lowered (Fig. 220). A fracture-box of greater length is required for the treatment of fractures about the knee-joint. Bran, Sand, or JtcnJc Bags. These are constructed by taking a piece of unbleached muslin five feet in length and fourteen and a half inches in width, doubling it and securing the free margins except at the mouth by stitches so as to form a bag ; the bag is then in- verted so that the edges of the seams are brought in the inner surface of the bag. The bags are next filled with dry sand, bran, or hair, or with straw, and the mouth of the bag is closed by stitches or by being tied with a string. Bran bags with splints or sand bags are frequently employed in the treatment of fractures of the femur. Bandages made of muslin are used to retain splints in the treatment of fractures, and are also sometimes applied directly to the injured part before the application of splints to control muscular spasm and limit the amount of swell- ing ; when a bandage is so used it is known as a primary roller. The use of the primary roller is sometimes of the greatest service in the dressing of fractures ; but its use in inexperienced hands has often been followed by such unfor- tunate results in the early treatment of fracture, or in cases which are not under constant observation, that I think it is a safe rule of practice to discard entirely the use of the primary roller. 14 302 FRACTURES. Compresses made from a number of folds of lint, of cotton or oakum, are often employed to retain fragments in position or to make localized pressure upon certain points in the treatment of fractures. The compresses are held in position by strips of adhesive plaster, by a few turns of a roller bandage, or by the splints. Compresses are some- times employed to protect bony prominences of the skeleton from the pressure of the splints ; but this purpose is often better effected by the use of small pieces of soap plaster spread on chamois fitted over the prominent points. Fig. 221. Rack for supporting bed-clothes in fracture of the lower extremity. A rack or cradle, made of wire or wooden hoops, is often employed to support the weight of the bed-clothes in the treatment of fracture of the lower extremity (Fig. 221). Dressing of Special Fractures. Fracture of the Nasal Bones. Fractures of the nasal bones are often accompanied with fractures involving the septum, the nasal process of the maxillary bone, and the nasal spine of the frontal bone. The treatment consists in replacing the fragments, if dis- placement exists, by manipulation with the fingers over the seat of fracture and by pressure made from within the nos- trils by a probe or a steel director. When the displace- ment is once corrected it is not apt to recur, and in the majority of cases no dressing is required. Before resorting to any manipulation within the nasal cavities the mucous membrane should be thoroughly cocainized to render the FRACTURE OF THE NASAL BONES. 303 operation painless to the patient. "When there is depression of the fragments or displacement of the septum, after cor- recting the deformity by raising the depressed fragment or bending the septum into place by a director, the parts may be held in position by packing the nasal cavity firmly with a strip of antiseptic gauze. In lateral displacements of the nasal bones from fracture, after reducing the displacement, a small compress held over the fragment by strips of adhesive plaster will be the only dressing required. Mason transfixes the nose, after reduction of the frag- ments, with a stout needle, and steadies the pieces with a Fig. 222. Mason's dressing for fractures of nasal bones. strip of plaster crossing the bridge of the nose and fastened to the ends of the needle. The needle is kept in position for eight or ten days (Fig. 222). Roberts, in cases in which there is a displacement of the cartilaginous portion of the 304 FRACTURES. nose, after reducing the deformity, holds the parts in position by transfixing them with steel pins. Profuse hemorrhage sometimes occurs after fracture of the nasal bones and may require plugging of the nares to control it. Fractures of the nasal bones are usually firmly united in from ten to twelve days, and dressings may be dispensed with after this time. Fractures of the Malar Bone and Zygoma. These fractures are usually the result of direct force ; the displacement is upward or backward, and when the zygo- matic arch is broken the fragments from pressure upon the masseter muscle or on the tendon of the temporal muscle may interfere with the movement of the lower jaw in mastica- tion. This displacement is corrected by cutting down upon the fragment and elevating it or by passing a tenaculum into the fragment and raising it. Outward displacements may be corrected by pressure and the application of a compress. The dressing of these frac- tures after the correction of the deformity, consists in the application of a compress of lint over the seat of fracture, held in position by strips of adhesive plaster or a bandage. There is little tendency to recurrence of the deformity after it has been corrected, and union at the seat of fracture is usually firm at the end of three weeks. Fractures of the Upper Maxilla. These fractures may involve the body, the nasal processes or the alveolar processes. The displacement should be cor- rected and if any teeth have been displaced they should be replaced ; if there is comminution of the alveolus the teeth in the separate fragments may be fastened together by fine wire to fix the fragments and hold them in place ; and the teeth of the lower jaw should be brought up in contact with those of the upper jaw, and the jaws should be secured together by the application of a Barton's or a Gibson's FRACTURES OF THE LOWER MAXILLA. 305 bandage (Fig. 223). Inter-dental splints, made of cork with grooves to fit the teeth, or of gutta-percha, are also em- ployed in the dressing of these fractures. The patient should not be allowed to move the jaw in mastication, and Fig. 223. Dressing for fracture of the upper jaw. should be nourished by liquid and semi-solid food which can be taken without removing any teeth to give space for its introduction. The bandage should be removed every second or third day, and after the face and neck have been sponged off with alcohol it should be reapplied. These fractures are usually firmly united at the end of four or five weeks, and dressings may be dispensed with at this time. Fractures of the Lower Maxilla. The lower jaw may be broken at or near the symphysis, the most usual seat of fracture being near the mental fora- men ; it is often broken at two places at once and the frac- tures are in many cases rendered compound by laceration of the mucous membrane, or the injury may consist in a separa- tion of a portion of the alveolar process of the bone. The 306 FRACTURES. dressing of a fracture of the lower jaw, after reducing the displacement and replacing any loosened or detached teeth, Fig. 224. Dressing for fracture of the lower jaw. Fig. 225. Four-tailed bandage applied for fracture of the lower jaw. consists in applying a pad of lint under the chin and bring- ing the jaw up against the upper jaw and holding the com- FRACTURES OF THE LOWER MAXILLA. 307 press in place and securing the jaws firmly in contact by applying a Barton (Fig. 224), modified Barton or Gibson's bandage. The bandage should be removed and reapplied at the end of the second or third day, and at like intervals during the course of treatment. The patient should be fed upon a liquid or semi-solid diet, not being allowed to chew any solid food until the union at the seat of fracture has become firm. A very satisfactory temporary dressing for fracture of the lower jaw consists in the application of a four-tailed sling. (Fig. 225.) Some surgeons prefer to use an external splint moulded from pasteboard or gutta-percha fitted to the chin in the Fig. 226. Fig. 227. Shape of splint before being'fitted to chin. dressing of this fracture, this being padded with cotton and held in place by a Barton or Gibson bandage. (Fig. 227.) Where there is much difficulty in keeping the fragments in position the wiring together of the teeth may be employed, or the frag- ments may be perforated with a drill and held in place by a strong silver- wire suture ; inter-dental splints of metal or gutta-percha are also some- times used for this purpose. During the course of the treatment in frac- ture of the jaws the mouth often becomes very offensive from the fer- mentation of the saliva and discharges, and it is well to use frequently a mouth-wash of chlorate of potash, tincture of myrrh, glycerin and water. Splint moulded to fit chin. 308 FRACTURES. The dressings for fracture of the lower jaw are usually- applied for four or six weeks, the union usually being quite firm at the end of this time. Fracture of the Hyoid Bone. In fracture of the hyoid bone, if displacement exists, its reduction is facilitated by pressure made with the finger in the pharynx. The treatment consists in enforced quiet and the use of opium if cough is a prominent symptom, and the inflam- matory symptoms may require the employment of active local treatment. A dressing may sometimes be employed with advantage, consisting of a splint of pasteboard or leather moulded to the anterior portion of the neck. Fractures of the Larynx or Trachea. In fractures of the larynx or trachea where there is little displacement and dyspnoea is not marked, the parts should be supported by the application of compresses of lint held in place by strips of adhesive plaster. If, on the other hand, the respiration is embarrassed or there is free expec- toration of blood, tracheotomy should be performed, and if the injury be seated in the larynx the displacement of the fragment may be overcome by manipulation with the finger or a director through the tracheal wound, or the larynx may be packed with a strip of antiseptic gauze to control hemor- rhage or hold the fragments in position, the patient in the meantime breathing through a tracheotomy tube secured in the tracheal wound ; the packing should be removed in a few days, the tracheotomy-tube being permanently removed as soon as the patient can breathe comfortably through the larynx with the tracheal wound closed. In fractures of the. trachea the opening into the trachea should be below or at the seat of injury. FRACTURES OF THE RIBS. 309 Fractures of the Trunk Fractures of the Ribs. Fractures of the ribs are more frequent than fractures of any other bones of the trunk ; the ribs most commonly broken are those from the fourth to the tenth ; the most common seat of fracture is near the junction of the costal car- tilages or at the angle. The dressing of fractures of the ribs is best accomplished by enveloping the side of the chest on which the rib Fig. 228. . or ribs are broken with broad straps of adhesive plaster. The adhesive straps should be two and a half inches in width and long enough to extend from the spine to the middle of the sternum. The straps are warmed and the first strap is firmly applied a short distance below the seat of fracture, extending from the spine to the mid-sternal line; a .,, . . . , ^ > Adhesive plaster dressing number ol ascending straps are for fracture of the ribs. applied in this way, each strap over- lapping the preceding one by about one-third of its width, until half the chest is covered in. (Fig. 228.) This dress- ing usually gives the patient much comfort, and the straps need not be renewed until they become slightly loosened, usually at the end of a week or ten days ; they should then be renewed in the same manner. The dressings for fractures of the ribs are usually dispensed with at the end of three or four weeks, as repair of the fracture is generally well advanced by this time. A satisfactory temporary dressing for fractures of the ribs consists in surrounding the chest by a broad binder of stout linen or muslin ; indeed, some surgeons prefer to employ this dressing during the course of treatment, but as a rule I think it is not as good a dressing as the adhesive 14* 310 FRACTUKES. plaster dressing, as the former confines the movements of both sides of the chest. Fractures of the Costal Cartilages. These fractures often take place at the junction of the cartilages with the ribs or in the body of the cartilages, and the union of the fracture usually takes place by the pro- duction of a mass of bone at the seat of fracture. The dressing for fractures of the costal cartilages consists in the application of strips of adhesive plaster applied in the same manner as for fracture of the ribs, and the dressing should be retained for about the same time. Fractures of the Sternum. Fractures of the sternum are rare injuries, but diastasis of the bones of the sternum is a more common accident. The dressing for either variety of injury is the same, and Fig. 229.- Adhesive piaster dressing for fracture of the sternum. consists in the application of a compress over the seat of fracture held in place by a broad bandage, or, better, by strips of adhesive plaster (Fig. 229), applied so as to cover and fix the anterior portion of the chest, covering the entire length of the sternum. This dressing should be retained FRACTURES OF THE SACRUM AND COCCYX. 311 for at least four weeks, being renewed if it becomes loose at the end of a week or ten days. Fractures of the Pelvis. These fractures are often serious injuries from implication of the pelvic viscera. The reduction of the displacement should first be accomplished as far as possible by external manipu- lation, together with internal manipulation by the fingers introduced into the rectum, or into vagina in the female. The patient should be placed upon a firm bed on his back, with the knees slightly flexed over a pillow, and the parts should be kept at rest by surrounding the pelvis with broad straps of adhesive plaster or a stout muslin binder, or by a firmly applied padded pelvic belt. The hip-joints should be kept at rest by the application of pasteboard splints or by sand-bags. The dressings should be retained for a period of at least six weeks. When these fractures are complicated by injury of the pelvic viscera various operative procedures may be required, which will compel the surgeon to modify the method of dressing. Fractures of the Sacrum and Coccyx. The dressing of these fractures, after effecting reduction of the fragments as far as possible by pressure within the rectum, and, when the sacrum is involved, the application of broad adhesive straps, or of a padded belt, should be em- ployed, and the patient should be kept at rest in bed. When the coccyx only is fractured, after reduction of the displacement, the patient should be confined to bed and the bowels should be kept at rest by the use of opium by sup- pository. The patient should be kept at rest for three or four weeks, and, in case of fracture of the sacrum, the dressings should be retained for this time. 312 FRACTURES. Fractures of the Vertebra. Fractures of the vertebrae are always most serious injuries, not only from the injury of the bones themselves, but also from the damage to the spinal cord, membranes, and nerves, which often accompanies them. In transporting, or turning in bed, a patient suffering from fracture of the vertebrae, great care should be exercised, for rough or sudden motions might cause a displacement of the fragments which might, by injury of, or pressure upon, the spinal cord, rapidly prove fatal. In the treatment of fractures of the spine, if the deformity is marked, efforts should be made to reduce it by extension and counter-extension, and the result may be successful, especially if the fracture be associated with a dislocation of the vertebrae. In some cases the use of permanent exten- sion by means of weights attached to the legs, shoulders, and chest by adhesive plaster and bandages has been suc- cessful in reducing the deformity. The patient should be placed upon his back upon a bed with a hair mattress, or better, if it can be obtained, a water-bed, which consists of a rubber mattress filled with water, which distributes the weight of the patient's body evenly over the surface. Whatever form of bed be used, the greatest care should be exercised to keep the patient abso- lutely clean, and the parts of the body or limbs which are exposed to pressure should be frequently bathed with alcohol or soap liniment, and to distribute the pressure, small pads should be placed under the parts and changed at intervals. These precautions are necessary to prevent, if possible, the formation of extensive bedsores, which are a frequent and troublesome complication of these injuries. The bowels should be carefully watched, and, if constipa- tion is present, it should be relieved by the use of enemata ; and, as it is not desirable to lift the patient to slip a bed-pan under him, the discharges can be received in a flat tin plate pushed under the thighs and buttocks, or on pads of oakum or old muslin. FRACTURES OF THE SKULL. 313 The care of the bladder is also a matter of the greatest importance ; the retention which at first exists should be relieved by the use of a flexible catheter introduced with great gentleness, and when incontinence supervenes the catheter should also be used at intervals ; the employment of a soft instrument, if used with care, is not apt to produce any injury to the urethra or bladder. The employment of a plaster-of-Paris jacket has been followed, in some cases, by good results, and it may be applied early in the case, or it may be used after the patient has been kept in the recumbent posture for some weeks ; by its use it is often possible to get the patient out of bed and allow him to sit in a chair. In fractures involving the cervical vertebrae, care should be exercised in lifting or moving the head, and it is often of advantage in these cases to apply short sand-bags to the sides of the neck and head, to give additional fixation to the parts while the patient is in the recumbent posture, or, if he is allowed to get out of bed, to apply a moulded leather or pasteboard splint to the neck, shoulders, and back of the head for the same purpose. Trephining of the spine in cases of fracture of the verte- brae, to remedy the displacement and relieve the cord from pressure, has been recommended and employed in some cases, and although the operation under strict antiseptic methods is not attended with much risk, the results obtained up to the present time scarcely seem to warrant its per- formance. The course of treatment in cases of fractures of the ver- tebrae, if the patient does not succumb to the injury in a few days or weeks, often extends over many months, and recovery is often more or less incomplete as regards the function of the parts below the seat of fracture. Fractures of the Skull. The treatment of fractures of the skull, whether simple or compound, depends largely upon the nature of the injury and the condition of the cranial contents. In simple frac- 314 FRACTURES. tures unaccompanied with cerebral symptoms no special dressing is required, but in compound fractures where loose fragments are present, these should be removed; and if there is no depression of the fragments, and if no cerebral symptoms are present, the wound should be drained and closed and dressed antiseptically, the dressings being held in place by a recurrent bandage of the head. The patient should be put to bed and the use of an ice-cap to the head is often of service. The diet should be restricted and calomel and opium and bromide of potassium should be administered ; it is well to keep the patient for a few weeks in a quiet and darkened room. Where cerebral symptoms are present, either in simple or compound fractures, and trephining is resorted to, the dressing of the wound is similar, and the same general treatment should be adopted. In all cases of fracture of the skull, whether subjected to operative treatment or not, it is well to keep the patient at rest in bed for three or four weeks, and he should be cau- tioned to avoid excesses and should not resume active work for some months. Fractures of the Upper Extremity. Fractures of the Clavicle. Fractures of the clavicle may be complete or incomplete, and in the latter variety of injury, the deformity is not usually very marked. The indications for treatment in complete fractures of the clavicle are to relax the sterno- cleido-mastoid muscle, to prevent the weight of the arm on the injured side from dragging down the outer fragment of the clavicle, and by fixing the scapula, to carry the attached external fragment outward and forward. A large number of dressings have been devised and used to accomplish these objects. The treatment of fractures of the clavicle by position is accomplished by placing the patient in bed on his back upon a firm mattress with a low pillow under his head, and the arm on the side of injury should be fastened FRACTURES OF THE CLAVICLE. 315 to the side of the chest by a few circular turns of a ban- dage passing around the arm and chest ; the deformity is usually very satisfactorily reduced upon the patient assum- ing this position, and after three weeks' rest in this position the union is generally sufficiently firm to allow the patient to get out of bed and be about with the arm bound to the side or carried in a sling or with a Yelpeau bandage applied, without any recurrence of the deformity. A satisfactory temporary dressing for fractures of the clavicle consists in the application of a four-tailed bandage ; the bandage is made from a piece of muslin two yards in Four-tailed bandage for fracture of clavicle. length and fourteen inches in width ; a hole is cut in its centre about four inches from its margin, to receive the point of the elbow ; the bandage is then split into four tails in the line of the hole and to within six inches of it ; the body of the bandage should be applied so that the point of the elbow rests in the hole, and a folded towel being placed in the axilla, the lower tails should be carried, one anteriorly, the other posteriorly, diagonally across the chest and back to the neck on the side opposite the seat of fracture and secured ; the remaining tails are next carried around the 316 FRACTURES. lower part of the chest and secured so as to fix the arm to the side of the body. (Fig. 230.) In some cases the deformity is corrected by the applica- tion of a posterior figure-of-eight bandage, the forearm on the side of injury being carried in a sling. (Fig. 231.) Fig. 231. Posterior figure-of-eight dressing for fracture of the clavicle. (Hamilton.) Sayres dressing for fracture of the clavicle consists of two strips of adhesive plaster three and a half inches wide and two yards in length. The first strip is looped around the arm just below the axillary margin, and is pinned or sewed with the loop sufficiently open not to constrict the arm. The arm is then drawn downward and backward until the clavicular portion of the pectoralis major muscle is put sufficiently upon the stretch to overcome the action of the sterno-cleido-mastoid muscle, and in this way draws the sternal fragment of the clavicle down to its place. The strip of plaster is then carried completely around the body and pinned or stitched to itself on the back. (Fig. 232.) The second strip is next applied, commencing upon the front of the shoulder of the sound side ; thence it is carried over the top of the shoulder diagonally across the back, FRACTURES OF THE CLAVICLE 317 under the elbow, diagonally across the front of the chest to the point of starting, where it is secured by pinning or sewing. A slit is made in this strip to receive the point of the elbow. Before the elbow is secured by the plaster, it should be pressed well forward and inward. (Fig. 233.) Velpeaus dressing may also be used in the treatment of fractures of the clavicle. (Fig. 234.) A compress may also Fig. 232. Fig. 233. Sayre's dressing for fracture of the clavicle. First strip applied. Sayre's dressing for fracture of the clavicle. Second strip applied. be secured by the vertical turns of this bandage over the seat of fracture if needed. The application of the bandage is described (p. 55). In any form of dressing in which the arm is held against the side of the chest, it is well to apply a folded towel or piece of lint between the arm and chest to prevent the sur- faces from becoming excoriated. A modified form of the Velpeau dressing for fracture of the 318 FRACTURES. Fto. 234. Velpeau's dressing for fracture of the clavicle. clavicle is applied as follows : A soft towel or piece of lint is placed against the side of the body and over the front of the chest, and held in position by a strip of adhesive plaster ; the arm is next placed in the Yelpeau position, a good-sized pad of lint is next applied over the scapula, and this is held in place by a broad strip of adhesive plaster two and a half inches in width and one and a half yards in length ; this strip is continued downward and forward so as to pass over the point of the elbow, and is carried diagonally across the chest to the shoulder of the opposite side and is secured, a slit being cut in it to receive the point of the elbow ; a compress of lint is next placed over the seat of fracture and held in place by a strip of adhesive plaster ; an additional strip of plaster is next carried from the spine around the arm and chest and secured on the opposite side of the chest ; circular turns of a roller bandage are then passed around the chest, including the arm, from below upward until the arm is securely fixed to the body, and the dressing is fin- ished by making one or two turns of the third roller of Desault. (Fig. 235.) • In the treatment of fractures of the clavicle in children the Velpeau or modified Velpeau dressing will be found to be the most satisfactory dressing to employ, and as these patients are particularly apt to disarrange their dressings it is well to render the dressing additionally secure by applying a few broad strips of adhesive plaster over the turns of the roller bandage, the strips following the turns of the bandage. The removal of dressings and their reapplication will depend upon the comfort of the patient and the manner in which they keep their position. As a rule in fractures of FRACTURES OF THE CLAVICLE 319 the clavicle the dressings are removed at the end of the second or third day, the parts are inspected, and the skin is sponged off with dilute alcohol or whiskey ; the dressings are then reapplied, and if they are comfortable and the Fig. 235. Modified Velpeau dressing for fracture of the clavicle. parts are in good position, the dressings are made at less frequent intervals until union is completed at the seat of fracture. Union in cases of fracture of the clavicle is generally quite firm at the end of four or five weeks, and at this time the dressings may be removed, and the patient should carry the arm of the affected side in a sling for several weeks, and should not undertake any work requiring forcible move- ments of the arm until eight or ten weeks have elapsed from the receipt of the injury. The time required for union in fractures of the clavicle in children is somewhat shorter ; the dressings may be removed at the end of three weeks. 320 FRACTURES. Fractures of the Scapula. Fractures of the scapula may involve the body, neck, acromion or coracoid process of the bone. Fractures of this bone are quite rare. Fracture of the Body of the Scapula. In dressing this fracture, if deformity is present, it is re- duced by manipulation, and compresses of lint are placed above and below the seat of fracture and held in place by adhesive strips ; the arm is next fixed to the side of the body by spiral turns of a roller bandage passing around the arm and chest, and the forearm is supported in a sling. Fracture of the Week, Acromion or Coracoid Process of the Scapula. These fractures may be dressed by placing a pad of lint or a folded towel in the axilla and binding the arm to the Fig. 23( Velpeau dressing for fracture of the scapula. body by spiral turns of a roller bandage passing around the arm and chest and supporting the forearm in a sling. FRACTURES OF THE HUMERUS. 321 Or these fractures of the scapula may be dressed by first placing a pad of lint or a folded towel in the axilla and then securing the arm in the Velpeau position by the appli- cation of a Yelpeau's bandage. (Fig. 236.) In fractures of the acromion or coracoid processes the union is usually fibrous. In the treatment of fractures of the scapula the dressing: should be retained for about four weeks. Fractures of the Humeru: Fig. 23; Fractures of the humerus may involve the upper ex- tremity, the shaft or the lower extremity of the bone. Fractures of the Upper Extremity of the Humerus include fractures of the head and anatomical neck of the bone, fractures through the tuberosities, fractures through the sur- gical neck of the humerus, and epiphyseal fracture or disjunc- tion of the upper epiphysis of the humerus. The most satisfactory dressing for all fractures of the humerus above the upper third of the bone is applied as follows : A primary roller should be evenly applied from the tip of the fingers to the seat of the fracture, the arm being flexed at the elbow before the bandage is carried above this point, to prevent the danger- ous constriction which might result if the bandage were applied with the arm in the straight position, and it were after- wards flexed at the elbow. A folded towel or a thin pad of lint should next be placed in the axilla and over the outer surface of the chest, to furnish a firm basis of sup- port for the humerus and also^to prevent excoriation from the contact of the skin surfaces. A splint of pasteboard, felt or leather (Fig. 237) is next moulded to the shoulder and arm; this should be long enough to extend some distance below the seat of fracture and wide enough to cover in about one-half of the circum- Moulded splint for shoulder and arm. 322 FRACTURES. ference of the arm, and is padded with cotton and fitted to the shoulder and arm. The splint and arm are next secured to the side of the body by spiral turns of a roller bandage including the arm and chest in its turns and applied from the elbow to the top of the shoulder. The forearm is car- ried in a narrow sling suspended from the neck (Fig. 238). This dressing should be removed at the"end of twenty-four Fig. 238. Dressing for fracture of the upper extremity of the humerus. or forty-eight hours, and after the parts have been inspected and sponged over with alcohol, the dressings should be reap- plied in the same manner, and if the -patient is comfortable they need not be disturbed again for three or four days, subsequent dressings being made at the same intervals. Union in fractures of the upper extremity of the humerus, except in intra-capsular fracture, in which bony union is the exception, is usually quite firm at the end of five or six weeks, and the dressings can be dispensed with at this time. Fractures of the Shaft of the Humerus. The dressing consists in the application of a primary roller from the tips of the fingers to the seat of fracture; a short FRACTURES OF THE HUMERUS. 323 well-padded wooden splint extending from the axilla to a point a little above the internal condyle is next placed on the inner surface of the arm and against the chest ; a moulded pasteboard or felt splint, fitted to the shoulder and outer side of the arm and extending a short distance below the seat of fracture, is padded with cotton and applied to the shoulder and arm. The splints are held in position and the arm is secured to the body by spiral turns of a roller bandage carried around the chest and arm, and the forearm is carried in a sling suspended from the neck. The dressing is much the same as that for fracture of the upper part of the humerus, with the addition of the short internal splint. Fractures of the shaft of the humerus may also be dressed by first applying a primary roller and then placing the fore- arm and arm upon a well-padded internal angular splint. (Fig. 239.) Care should be taken to see that the end of Fig. 239. Internal angular splints. the splint extends only to the axilla and does not press upon the brachial vein. A pasteboard or felt moulded splint is next applied to the shoulder and outer side of the arm. The splints are held in position by turns of a roller bandage beginning at the fingers and carried up to the shoulder. (Fig. 240.) The arm is supported by a sling applied at the wrist, and sometimes for additional security the arm is se- cured to the side of the body by spiral turns of a bandage carried around the arm and chest. The after-treatment of 324 FRACTUEES. these fractures as regards the removal and renewal of the dressings is the same as in cases of fracture of the upper portion of the humerus. Fig. 240. Dressing for fracture of the shaft of the humerus with internal angular splint. In fractures of the shaft of the humerus the dressings should be retained for five or six weeks. Fractures of the Lower Extremity of the Humerus. These include fractures at the base of the condyles, splitting fractures between the condyles or those of the internal or external condyle, and epiphyseal fracture or disjunction of the lower epiphysis of the humerus. In dressing fractures of the lower extremity of the humerus, if a primary roller is employed it should be carried up only to the elbow; the displacement is reduced by extension and manipulation, and before applying any splint it is well in many cases to apply over the region of the fracture several folds of lint saturated with lead-water FRACTURES OF THE HUMERUS. 325 and laudanum, and to cover this dressing with waxed paper or rubber tissue to diminish as far as possible the swelling, which is very marked after these injuries. An anterior angular splint (Fig. 241) well padded with cotton or oakum Fig. 241. Anterior angular splint. is next applied and held in position by the turns of a roller bandage applied from the fingers to the upper portion of the splint. (Fig. 242.) These fractures may also be dressed with a well-padded internal angular splint, this splint being Fig. 242. Dressing for fracture of the lower extremity of the humerus with anterior angular splint. substituted by an anterior angular splint at the end of ten days or two weeks. These fractures may also be dressed by placing the arm in a posterior angular trough (Fig. 243) made of pasteboard 15 326 FEACTURES. or leather. Some surgeons prefer to dress fractures of the condyles of the humerus with the arm in the extended posi- tion upon a straight anterior splint, or with short, narrow pasteboard splints applied around the joint, as favoring more accurate coaptation of the fragments. If this position is employed a straight wooden splint is applied to the anterior surface of the arm and forearm, or moulded splints of pasteboard may be used, and after the union is moderately firm, at the end of two weeks, the elbow should be flexed and kept in this position during the remaining time of the treatment. When fractures of the lower extremity of the humerus involve the elbow-joint a certain amount of impairment of joint-motion is apt to occur either from ankylosis or from displacement- of the fragments which in many cases it is impossible to completely reduce, so that flexion and exten- sion of the joint is restricted. Bearing these facts in mind, it is well to make passive motion in these cases as early as the second or third week. It is well to explain to the patient or his friends that impairment of joint-motion may result in these fractures in spite of the greatest skill and care in the treatment. In a case of fracture in the region of the condyles of the humerus the dressings should be removed in twenty-four hours and it should be re-dressed in the same manner, and if the swelling does not increase and the dressing is comfortable to the patient it should after- ward be dressed at less frequent intervals; the union is generally quite firm at the end of four weeks and the splint may be removed at this time. Fractures of the condyles of the humerus are very common in children and epiphyseal disjunctions of the lower epiphyses are also met with ; the dressing of these injuries in this class of patients is similar to that described for fractures of the condyles of the humerus. FRACTURES OF THE OLECRANON 32^ Fractures of the Olecranon Process of the Ulna. Fractures of the olecranon may consist in simply a sepa- ration of the cortical layer of bone over the summit of the process to which the triceps is principally attached, or the line of fracture may pass through the sigmoid fossa. Fractures of the olecranon are dressed with the arm slightly flexed at the elbow, or with it completely extended: Fig. 244. Adhesive strap applied to draw fragment downward. the former position is possibly a little less irksome to the patient. The separation of the fragment by the action of Fig. 245. Fracture of olecranon dressed in the extended position. the triceps muscle is usually not very marked ; but, if the displacement is marked, it may in a measure be overcome by the use of a compress above the fragment, over which figure- of-eight strips of adhesive plaster are fastened to draw it 328 FRACTURES. down into position (Fig. 244). A primary roller should then be carefully applied to the forearm and arm with figure- of-eight turns at the elbow to reinforce the action of the strips of plaster, and a well-padded straight wooden splint extending from the upper third of the arm to the ends of the fingers is next securely fastened to the arm by the turns of a roller bandage (Fig. 245). This fracture may also be dressed by first applying a pri- mary roller up to the elbow, and then placing the arm upon a well-padded anterior obtuse-angled splint, or a straight splint with a good-sized pad of lint or oakum fastened at a point corresponding to the position of the flexure of the elbow. When either of these splints is placed upon the arm a position of moderate flexion is obtained. A compress of lint is next placed above the fragment, if there is displace- ment, and one or two narrow strips of adhesive plaster are fastened to this and passed obliquely downward and attached to the splint on either side. The splint is then securely fastened to the arm by the turns of a roller bandage applied from the fingers to the upper end of the splint. The dressings in a case of fracture of the olecranon should be removed at the end of twenty-four or thirty -six hours, or sooner if there is evidence of swelling of the tissues in the region of the fracture, and they should be reapplied in the same manner. If the dressing is comfortable to the patient, and there is no evidence of swelling, the subsequent dressings should be made at less frequent intervals ; the dressings are usually retained in this fracture for five or six weeks. Passive motion should not be made until this time, as flexion of the elbow tends to separate the fragments, unless union has taken place. The repair of a fracture of the olecranon is, in most cases, by fibrous union, but in a few instances bony union has been found to have taken place. Fractures of the Coronoid Process of the Ulna. Fractures of the coronoid process are rarely met with, and their dressing is accomplished by placing the arm in a flexed FRACTURES OF BOTH BONES OF FOREARM. 329 position and applying a well-padded internal right-angled splint, or a posterior right-angled splint, and securing it to the arm by the turns of a roller bandage. A moulded paste- board or leather gutter may be substituted for the angular splints. The dressings should be changed at intervals, and after their removal at the end of three or four weeks, passive motion should be practised. Fractures of the Head and Neck of the Radius. These fractures are also quite rare, and, when met with, should be dressed, after reducing the fragments by manipu- lation, by flexing the elbow and keeping it in this position by the application of a well-padded anterior right-angled splint, the splint being firmly secured in position by the turns of a roller bandage applied from the tips of the fingers to the upper end of the splint. The splint should be changed at intervals, and should not be permanently re- moved for four weeks, at which time passive motion, consist- ing in flexion and extension at the elbow and pronation and supination of the forearm, should be made. (Fig. 242.) An internal angular splint applied to the inner surface of the forearm and arm may also be used in the treatment of these fractures. (Fig. 240.) Fractures of Both Bones of the Forearm. These fractures are often met with as the result of direct or indirect violence, and after reducing the displacement, which is always marked when both bones are broken, and is not so marked when one bone only is broken, by making extension from the hand and by manipulation; the forearm is placed in the supine position or in a position between pro- nation and supination. The supine position is, as a rule, to he preferred in any fracture of the radius, as the upper fragment is supinated by the action of the biceps and supinator brevis muscles, and, therefore, unless the lower 330 FRACTURES. fragment be placed in the supine position union with rotary deformity will almost inevitably ensue. Two straight wooden splints, well padded, a little wider than the forearm, are employed. The anterior splint should be long enough to extend from the elbow to the tips of the fingers, and the posterior splint should extend from the elbow to the wrist. A primary roller should never be ap- Fig. 246. Dressing for fracture of both bones of the forearm. plied to the forearm in dressing these fractures, as its applica- tion diminishes the interosseous space and its use has been followed by gangrene of the hand and forearm. In apply- ing the anterior splint to the palmar surface of the forearm and hand care should be taken to see that the upper end of the splint does not press upon the brachial artery and vein at the elbow when the forearm is flexed ; the posterior splint is next applied from the elbow to the wrist and the splints are held in position by the turns of a bandage car- ried from the fingers to the elbow. (Fig. 246.) In fracture either of the shaft of the radius or of the ulna alone, the deformity is usually not so marked as when both bones are broken at the same time, the unbroken bone acting as a splint ; the dressing for these fractures is the same as for fracture of both bones of the forearm. The dressing should be removed in twenty-four or thirty- six hours, and after inspecting the parts and sponging them FRACTURES OF LOWER END OF RADIUS. 331 with dilute alcohol the splints should be replaced in the same manner and secured, and the dressings should be removed and renewed at intervals of two or three days for two weeks at least, and after this time the dressings should be made at less- frequent intervals. The time required for union in these fractures is usually five or six weeks, and the splints should be retained for this time. Fractures of the forearm should be seen by the surgeon frequently for the first two weeks of the treatment, for it is in these fractures that the most unfortunate results have occurred from neglect of this precaution. In children incomplete or green-stick fractures of the bones of the forearm are very common : their dressing, after reducing the deformity, which consists in bending the bones back into place, which often converts the incomplete frac- ture into a complete one, is accomplished in the same man- ner as described above. In these patients there is a great tendency to displace the splints or rather to draw the fore- arm out of the splints, and to prevent this I often employ an anterior angular splint, in place of the straight an- terior splint, the upper portion of which, being fastened to the arm, prevents the child from dragging the arm out of the dressings. Fractures of the Lower End of the Radius. The most common fracture of the radius is one situated from one-half of an inch to one and one-half inches above the lower articular surface of the bone, the line of fracture being more or less transverse, although it may in some cases be slightly oblique ; the characteristic deformity in this fracture is represented in Fig. 247. The most important point in the treatment of this frac- ture is to effect complete reduction before the application of any splint; this is done by making extension from the hand, and at the same time, by extending and flexing the wrist and by manipulation, the deformity can usually be com- pletely reduced. The arm should then be brought into the 332 FRACTURES. position of supination, and a firm compress of lint is next placed over the lower end of the upper fragment on the Fig. 247. Fracture of the radius near its lower extremity. Fig. 248. Position of compresses in Colles's fracture. Fig. 249. Bond's splint palmar surface of the forearm ; a second compress is then placed over the upper end of the lower fragment (Fig. 248), and a well-padded Bond splint (Fig. 249) is applied to the FRACTURES OF LOWER END OF RADIUS. 333 palmar surface of the arm and held in place by the turns of a roller bandage. (Fig. 250). Fig. 250. Dressing for fracture of the lower end of the radius. Many surgeons treat this fracture with the hand in a position between pronation and supination, the thumb point- ing upward. A substitute for Bond's splint may be pre- pared by fastening a roller bandage obliquely upon a straight wooden splint as suggested by Dr. Hays. (Fig. 251.) Fig. 251. Substitute for Bond's splint. Two straight splints with compresses are also employed in the treatment of this fracture, and a vast number of splints have been devised ; among these may be mentioned those of Gordon, Coover, and the metal splint of the late Dr. R. J. Levis. The most important point in the treat- ment of this fracture is the complete reduction of the de- formity at the first dressing, and if this has been satisfac- 15* 334 FRACTURES. torily done almost any splint may be used with a good result, and indeed some surgeons use no splint, applying only a compress over the palmar fragment, held in place by a strip of plaster, the arm being carried in a sling. The after-treatment of these fractures consists in removing the splint and compresses after twenty-four or thirty-six hours and in sponging the surface of the skin with dilute alcohol, and the compresses and splint should then be reap- plied in the same manner ; the fracture should be dressed every second or third day for the first two weeks, and after this time it should be dressed at less frequent intervals. Union is usually quite firm at the end of four weeks, and the splint should be dispensed with at this time. A certain amount of stiifness of the wrist and fingers is apt to follow this fracture, which is usually soon overcome by passive motion and physiological use of the parts. In children epiphyseal separations or fractures of the lower epiphysis of the radius are often met with, and their treatment is similar to that described above ; a Bond splint with compresses or two straight splints with compresses being the most satisfactory dressing to employ in this in- jury, the dressings being retained for three weeks. Fractures of the Carpal Bones. These fractures are usually compound or open fractures, and are so frequently associated with extensive laceration of the arm and hand that operative measures have to be re- sorted to ; but if such is not the case they are dressed, when compound, with an antiseptic dressing, and the hand and forearm are supported upon a well-padded palmar splint held in place by a roller bandage; more or less impairment in the motion of the wrist is apt to follow these fractures. In simple fractures of the carpal bones the use of an evapo- rating lotion for a few days, in connection with the splint just mentioned, will be found useful. The dressings should be retained for three or four weeks, and after their removal passive motion should be employed to overcome as far as possible the joint-stiffness resulting. FRACTURES OF THE PHALANGES. 335 Fractures of the Metacarpal Bones. These fractures are often met with as the result of direct or indirect force applied to the metacarpal bones. The treatment of fractures of the metacarpal bones consists in first reducing the deformity, which is usually an angular one, the projection of the angle being toward the back of the hand ; this is reduced by pressure with the fingers, and the hand and forearm should then be placed upon a palmar splint (Fig. 252) with a pad of oakum or cotton under the Fig. 252. Agnew's splint for fracture of the metacarpal bone a compress of lint is next placed over the seat of fracture, and the hand and forearm are bound to the splint by the turns of a roller bandage. (Fig. 253.) At the end Fig. 253. Dressing for fracture of the metacarpal bones. of three weeks union at the seat of fracture is usually quite firm, and the splint should be dispensed with at this time. Fractures of the Phalanges. The treatment of fractures of the phalanges consists in reducing the displacement by extension and manipulation, 336 FRACTURES. and in placing the finger in a moulded gutta-percha or paste- board splint (Fig. 254), and securing the splint in position Fig. 254. Gutta-percha splint for fracture of phalanx. (Hamilton.) by the turns of a roller bandage. When the proximal phalanx is fractured a narrow, padded, wooden splint extend- ing from the end of the finger to the wrist should be applied upon the palmar surface of finger and hand, and a short dorsal splint should also be used ; if there is a tendency to Fig. 255. Dressing for fracture of phalanx with anterior and posterior splints. lateral displacement short lateral splints should also be employed, and the splints should be held in place by strips of plaster or by a roller bandage. (Fig, 255.) Union in fractures of the phalanges is usually quite firm FRACTURES OF THE FEMUR. 337 at the end of three weeks, and the splints can be dispensed with at that time. Fractures of the Lower Extremity. Fractures of the Femur. Fractures of the upper extremity of the femur are those involving the neck, great trochanter, and upper end of the shaft of the bone. In dressing fractures of the upper extremity of the femur the patient should be placed in bed upon a firm mattress, and an extension apparatus made from adhesive plaster should be applied to the leg, extending as far as the knee- joint. The extension apparatus is constructed by taking a piece of adhesive plaster two and a half inches in width and long enough to extend from the outer side of the knee Fig. 256. Adhesive plaster extension apparatus applied to limb. (Ashhcrst.) to four inches below the sole of the foot, and from this point back to the inner side of the knee ; in the centre of this strip is placed a block of wood, two and a half inches wide and four inches in length, with a perforation in its centre; the block and the inner surface of the strip on each side are next faced with a similar strip of adhesive plaster to a 338 FRACTURES. point about an inch above each malleolus ; a few straps are next wound around the wooden block to fix the previously applied straps; the strip of plaster is next warmed and applied to the sides of the leg and held in position by three strips of adhesive plaster carried around the leg at intervals (Fig. 256), and the plaster is made additionally secure by the application of a roller bandage applied to the foot and leg and carried up to the knee. Through the perforation in the block or stirrup is fastened a cord which passes over a pulley attached to the bed, and to this cord is attached the extending weight. The extension apparatus being applied, lateral support is given to the leg and thigh by sand-bags applied on either side; the outer sand-bag should extend from the foot to the axilla, and the inner one from the foot to the groin. A weight of five or ten pounds is attached to the extending cord, and the lower feet of the bed should be raised on blocks a few inches high to prevent the patient from slipping down in bed ; a pad of oakum or cotton should also be placed under the tendo Achillis to relieve the heel from pressure. This dressing is kept in place for from four to six weeks, and if union has occurred the patient is kept in bed for a few weeks longer and is then allowed to be about using crutches. In the majority of cases of frac- ture of the neck of the femur fibrous union only takes place, and after employing the dressing before described for six weeks the patient is allowed to get up and go about on crutches. It often happens that the subjects in whom these fractures occur are old and feeble, and if it is found that restraint in bed with the dressings here described is not well borne, under such circumstances they should be discarded and the patient should be allowed to sit up in bed with the limb resting on a pillow, or in a chair, the treatment of the local condition having to be disregarded, attention being given to the patient's constitutional condition. The application of a plaster- of Paris bandage to the leg, thigh and pelvis is also sometimes made use of in the treat- ment of fractures of the upper extremity of the femur ; extension should be made from the foot while the bandage is being applied. (Fig. 257.) In fractures of the neck of FRACTURES OF THE FEMUR. 339 the femur and of the upper part of the shaft of the bone the anterior wire splint of Prof. N. R. Smith is sometimes Fig. 257. Plaster-of- Paris bandage applied to thigh. (Hamilton.) used with advantage ; the limb being swung from the splint the patient is able to move in bed without causing him pain Fig. 258. ^X J 7 Smith's anterior splint for fracture of the femur. or disturbing the fragments. (Fig. 258.) In fractures in the upper portion of the femur where there is marked tilting for- 340 FRACTURES. ward of the upper fragment Prof. Agnew employs extension made from the thigh and places the limb upon a double in- Fig. 259. Dressing of fracture of the femur with extension upon an inclined plane. (Agnew.) clined plane and maintains this position during the treatment of the case. (Fig. 259.) With the same object in view, in place of the double inclined plane a double inclined frac- Fig. 260. Double inclined fracture-box. ture-box may be employed, extension being made from the thigh by means of adhesive plaster strips applied above the knee, to which a weight is attached. (Fig. 260.) Fractures of the Shaft of the Femur. In the treatment of fractures of the shaft of the femur the dressings are applied to diminish as far as possible the shortening and to prevent angular or rotary displacement FRACTURES OF THE FEMUR. 341 of the fragments. In dressing these fractures the patient should be placed upon a fracture-bed or an ordinary bed with a firm hair mattress ; an extension apparatus of adhesive plaster is applied and extension is made by a weight attached to this as previously described. Lateral support is given to the limb by the application of two wooden splints — the outer or long one extending from the axilla to the foot, the inner or short one extending from the groin to the foot. The splints at their upper extremity should be about six inches in width and at their lower extremity about three and a half inches. The splints are wrapped in a splint cloth which extends from the foot to the groin, and after this has been placed under the limb the splints are fixed in their proper positions, the short one to the inner side, the long one to the outer side of the limb. Between the limb and the splints are interposed bran-bags ; the outer bag should be long enough to extend from the axilla to the foot, the inner one from the groin to the foot. The splints and bran-bags are held in Fig. 261. Dressing for fracture of the shaft of the femur with splints and bran-bags. (Ashhukst.) place by five or six strips of bandage passing under the limb and body and around the splints and bran-bags at intervals. The heel is saved from pressure by placing a wad of oakum or cotton under the tendo Achillis and after the splints have been brought into place the strips of ban- 342 FRACTURES, dage are firmly tied to secure them and a weight of ten or twelve pounds is attached to the extending cord. The foot of the bed is raised to prevent the patient from slipping downward and to allow the weight of the body to act as a counter-extending force. After the application of the dress- ings the thigh should be slightly abducted. During the after-treatment of these fractures the surgeon should see that the splints and bran-bags are kept firmly in place and that the foot does not roll outward : this is accomplished by untying the strips and readjusting the bags and then bring- ing up the splints and securing them in position by fastening the strips. The extension apparatus usually does not require renewal during the course of treatment. The extension and splints are kept in place for four or six weeks and at this time union at the seat of fracture is usually quite firm, so that they may be removed, and the fracture is then sup- ported by moulded pasteboard splints or by the application of a plaster-of-Paris splint for several weeks longer, and at the end of eight weeks it is safe to allow the patient to be up and around on crutches. Many surgeons, in fracture of the shaft of the femur, prefer to use a long external sand-bag and a shorter internal one in place of the corresponing long and short splints and bran-bags, and, if care is observed to see that the sand-bags are kept accurately in contact with the limb and body, ex- cellent results may be obtained by this form of dressing. After considerable experience with both methods of furnish- ing lateral support in the dressing of fractures of the shaft of the femur, I am well satisfied that angular deformity is less likely to result where the splints and bran-bags are employed. The plaster-of-Paris dressing, including the foot, leg, thigh, and pelvis, is employed by some surgeons in the early treatment of fracture of the shaft of the femur, the limb being kept well extended until the plaster has thoroughly set. The double inclined plane and the anterior angular wire splint are also sometimes employed in the dressing of fractures of the shaft of the femur. FRACTURES OF THE FEMUR 343 Fractures of the Shaft of the Femur in Childre n. Fig. 262. The treatment of these fractures in young children by extension by a weight and pulley and lateral splints is often unsatisfactory on account of the difficulty in keeping the patient quiet upon his back, and from the soiling of the dressings by the feces and the urine. In children two years of age and over I have never found much trouble in employ- ing extension and. lateral support by splints and bran-bags or sand-bags, and in these cases I make additional fixation at the seat of fracture, and guard against displacement of the fragments by the child sitting up in bed when not watched, by carefully moulding external and internal pasteboard or felt splints to the thigh, and holding them in place by the turns of a bandage. I have employed this form of dressing even in children under two years of age with the most satisfactory results. In cases of fracture of the femur in children from a few months to a year or eighteen months of age, in whom it is difficult to obtain quietude, or who have to be moved to give them nourishment if they are taking the breast, the dressing which I have found most satisfactory consists in first applying a roller bandage from the foot to the groin, and then moulding to the outer half of the foot, leg, thigh, and also to half of the pelvis, a pasteboard or felt splint which is well padded with cotton, and held in position by the turns of a bandage carried from the foot to the pelvis and finished with circular turns about the pelvis. The splint should be so moulded as to in- clude a little more than one-half of the circumference of the thigh and leg. If this splint becomes soiled it is easily replaced by a fresh one, and its removal and renewal is much easier than that of the plaster-of-Paris Fracture of the fe- mur treated by ver- tical extension. 344 FRACTURES. splint which is recommended by some surgeons in these cases. In young children fractures of the femur are often incom- plete or green-stick fractures ; and, even when complete, the shortening is usually not marked, as the line of fracture is apt to be transverse, the periosteum often not being completely ruptured, which tends to hold the fragments in position. In green-stick fractures the deformity should be reduced by manipulation, even if it is necessary to convert the incom- plete fracture into a complete one to accomplish this object. Mr. Bryant recommends that fractures of the femur in young children be treated in the vertical position ; the in- jured limb, together with the sound one, is flexed at a right angle to the pelvis and fixed with a light splint, and attached to a cradle or bar above the bed. (Fig. 262. ) If the plaster-of- Paris dressing is used, the limb should be first enveloped from the foot to the pelvis with a flannel bandage, and extension should be made while the plaster- of-Paris bandage is being applied and should be kept up until the bandage has become fixed. The plaster bandage should extend from the toes to the pelvis, and it is well to fix the hip-joint by carrying several turns of the bandage about the pelvis. To prevent the splint from absorbing the discharges and becoming offensive, the upper portion of it may be coated with shellac. The time required for union in fractures of the femur in children is about three weeks, and the dressings may be removed at this time, but the child should not be allowed to use the limb for several weeks after this period. Fractures of the Lower End of the Femur. The fractures met with in this portion of the femur are supra-condyloid fractures, or those in which one condyle is separated, or comminuted fractures in which both condyles are separated ; epiphyseal disjunctions of the lower end of the femur, met with in young subjects, may also be classed with fractures at this portion of the bone. The dressing of supra-condyloid fractures, if there is short- FRACTURES OF THE PATELLA. 345 ening, should be similar to that employed in fractures of the shaft of the femur, consisting in the application of an exten- sion apparatus, and bran-bags and splints or sand-bags to give lateral support ; if, however, there is no marked shortening the dressing employed should be the same as that applied in fractures involving one or both condyles or epiphyseal separations. The dressing employed in fracture of one or both con- dyles or in epiphyseal disjunction of the lower end of the femur consists in placing the limb in a long fracture-box extending from the foot to the upper third of the thigh, the box being well padded with a soft pillow, or a well-padded posterior splint, or a moulded pasteboard or felt gutter may be employed ; if either of these dressings is employed, the splint or gutter should be long enough to extend from the lower part of the leg to the middle of the thigh. If there is much eifusion into the joint or soft parts, lead- water and laudanum should be applied over the region of injury for some days, until the swelling has subsided. At the end of two weeks it is well to place the limb in a plaster- of- Paris dressing, extending from the foot to the middle of the thigh. This dressing should be retained for four weeks, and at the end of this time the dressing should be removed, and if the union is sufficiently firm to allow the patient to go about on crutches, a fresh plaster-of-Paris splint should be applied extending from the middle of the leg to the middle of the thigh, or lateral splints of pasteboard may be substituted for the plaster dressing. A certain amount of permanent impairment of the joint motion is apt to follow fractures involving one condyle or both condyles of the femur. Fractures of the Patella. The dressing of fractures of the patella consists, first, in the application of a roller bandage from the toes to the upper part of the leg ; a well-padded posterior wooden splint long enough to extend from the middle of the leg to the 346 FRACTURES. middle of the thigh, or an Agnew splint, which is provided Avith pegs for the attachment of strips of adhesive plaster (Fig. 263) is next placed under the limb. A small compress of lint is next placed above the upper fragment, and a Fig. 263. Agnew's splint for fracture of the patella. similar compress is placed below the lower fragment ; a strip of adhesive plaster one and a half inches in width and twenty-four inches in length has its middle portion applied over the compress, and its ends are then brought obliquely downward and fastened to the splint, or to the pegs if Fig. 264. iiiiiiiiii Agnew's splint applied. Agnew's splint be used; this may be reinforced by a second or third strip. The object of these strips is to bring the upper fragment down in contact with the lower fragment. A strip of plaster with the ends passing in the opposite direction is next placed over the lower compress, and the ends are fastened to the splint or pegs ; this strip serves FRACTURES OF THE PATELLA. 347 only to steady the lower fragment, as it cannot be drawn upward to meet the upper fragment by reason of the inex- tensibility of its ligamentous attachment. (Fig. 264.) If the Agnew splint is employed the strips of plaster may be tightened by turning the pegs to which they are fastened without removing the splint. The splint is next firmly fixed in contact with the limb by the turns of a roller bandage extending from the lower to the upper end of the splint. The limb should next be placed upon an inclined plane or in a long fracture-box with its foot elevated to relax the quadriceps femoris muscle. This dressing should be removed and reapplied in a few days, as the dressings become loose as the swelling about the seat of injury subsides, and after this disappears the dressings re- quire renewal at less frequent intervals and usually at the end of three weeks the splint may be removed and a plaster- of-Paris bandage may be applied extending from the middle of the leg to the middle of the thigh. At the end of six weeks the patient may be allowed to walk upon the limb, the knee-joint being fixed with a plaster-of-Paris or pasteboard splint - It is well, after the removal of the splints, for the patient to wear for some months a laced muslin knee-supporter, which gives some support to the knee-joint. The union in fractures of the patella is usually fibrous, although in rare cases bony union has occurred. A great variety of splints have been devised and used in the treatment of fractures of the patella, the main object of which is tu fix the knee-joint and bring the fragments as nearly as possible in apposition. Malgaigne's hooks or Levis's modification of the same are employed by some sur- geons to secure close apposition of the fragments. The method of treatment in fractures of the patella, which con- sists in exposing the fragments by an incision and drilling and suturing them with catgut or silver wire sutures, is also employed at the present time, the strictest antiseptic precau- tions being taken to prevent infection of the wound. In cases of rupture of the fibrous union after fracture of the patella, which is not an uncommon accident, the treat- 348 FRACTURES. ment of the case should be the same as that for a recent fracture of the patella. Fracture of the Bones of the Leg. In fractures of both bones of the leg the displacement is usually very marked ; when one bone only is broken, the sound bone, acting as a splint, prevents much deformity, except in case of fracture at the lower end of the fibula, when the foot inclines to the injured side. The dressing for fractures of both bones of the leg or for fracture of the tibia or fibula alone, except in cases where the lower portion of the fibula is the seat of injury, is best accomplished by the use of a fracture-box. (Fig. 265.) Fig. 265. Fracture- box with movable sides The displacement being overcome as far as possible by ex- tension and manipulation, the leg is placed in a fracture- box, which is prepared for the reception of the limb by having the sides let down and having a soft pillow laid in it ; the foot is next secured to the footboard by a loop of ban- dage passed around the foot, the ends being tied after passing through the slots in the footboard ; a pad of oakum or cotton is placed under the tendo Achillis to relieve the heel from pressure, and a similar pad is placed between the sole of the foot and the footboard. (Fig. 266.) The sides of the box are then brought up and secured by two or three strips of bandage tied around the box. In using a fracture-box in the treatment of fractures of the bones of the leg the surgeon should see that the foot is kept well down to the footboard and is at a right angle with the leg, that there is no eversion of the knee and that the pillow is FRACTURE OF THE BONES OF THE LEG. 349 full enough to make equable pressure upon the leg when the sides of the box are secured, and that the heel is not sub- jected to undue pressure — the use of a pad of oakum or Fir.. 266. Application of the fracture -box. cotton under the tendo Achillis being employed to prevent this complication. Where there is a tendency to tilting up- ward of the lower end of the upper fragment the lower fragment can be brought in line with this by raising the foot by a mass of oakum or cotton placed under the tendo Achillis and heel and so overcoming the deformity. Ftg. 267. Plaster bandage applied to fracture of the leg. The subsequent dressings of the cases are conducted by letting down the sides of the box and correcting any dis- placement, if present, by adjusting the limb and pads in their proper position, and again bringing up the sides of the 16 350 FRACTURES. box and securing them. At the end of two or three weeks the fracture-box may be removed and a plaster- of-Paris dressing may be applied to the limb, which will allow the patient more freedom of movement in bed, or permit of his sitting up without disturbing the fragments (Fig. 267). Union in fractures of the bones of the leg is usually quite firm in six weeks, but the patient should not be allowed to put his weight upon the limb in walking for at least eight weeks. If the patient is restless, and finds his position with the fracture-box resting upon the bed irksome, the fracture-box may be swung from a frame fastened over the bed (Fig. 268). Fig. 268. Fracture-box suspended. (Agnew.) FRACTURE OF THE BONES OF THE LEG. 35 L The application of a plaster-of- Paris dressing as a primary dressing — the ordinary plaster-of-Paris bandage or the Bavarian dressings being applied — in fractures of the bones Fig. 269. ;'3^ Moulded binder's board splints for fractures of the leg. of the leg, is adopted by some surgeons, and, if employed, the case should be under constant supervision for a few days, so that the dressing can be removed if a dangerous amount of swelling takes place. Moulded splints of felt or paste- board are also sometimes applied in the treatment of these cases. (Fig. 269.) In patients suffering with delirium tremens, or in maniacal patients, the use of a fracture-box in the treatment of fractures of the bones of the leg is often not satisfactory on account of the difficulty in restraining the movements of the patient, 352 FRACTURES. and the consequent displacement of the fragments. In such cases it is well to apply a few strips of binder's board, well padded with cotton, to the limb, extending above and below the seat of the fracture, holding them in place by a few turns of a roller, and then to wrap the limb and foot in a soft pillow and hold this in place by the turns of a roller ban- dage applied with moderate firmness. This dressing allows the patient to move the limb without serious disturbance of the fragments, and, after the patient recovers from his attack, the leg may be placed in the fracture-box. In fractures of the bones of the leg in young children the same difficulty is often experienced in keeping them quiet, and for this reason a fracture-box cannot be used with satis- faction. In dressing these cases, two lateral splints of paste- board, moulded to the foot and leg and well padded with cotton, may often be employed with the best results. The splints should not be wide enough to meet on the anterior or pos- terior surface of the leg or foot. The splints, after being carefully adjusted, are held in place by the turns of a roller bandage ; and, after these splints have been applied for two weeks, and all swelling has subsided at the seat of fracture, a plaster-of-Paris bandage may be substituted for them, which should be worn for three weeks ; at the expiration of this time union is usually firm enough to dispense with all dressings. Fractures of the Fibula. In fractures of the fibula, with the exception of that frac- ture occurring at the lower end of the bone, the deformity is not marked, and they are usually dressed with a fracture-box applied as in the dressing of fractures of both bones of the leg, and at the end of two weeks a plaster-of-Paris dressing should be applied, and the patient may be allowed to get out of bed and move about on crutches. The union in a fracture of the fibula is usually quite firm at the end of five weeks, and all dressings may be dispensed with at that time. FRACTURES OF THE FIBULA. 353 Fracture of the Lower JSnd of the Fibula. This fracture usually occurs in the lower fifth of the bone and is often associated with a laceration of the internal lateral ligament of the ankle-joint or a sprain fracture of the internal malleolus and is usually accompanied by marked eversion of the foot. This fracture is commonly known as Pott's fracture. In this fracture after reducing the displacement by exten- sion and manipulation, the limb should be placed in a frac- ture-box provided with a soft pillow, the foot should be secured to the footboard and a pad of oakum or cotton should be placed under the tendo Achillis ; before bringing up the sides of the box and securing them two firm com- presses of lint or oakum should be placed in contact with the leg, one just above the inner malleolus, the other just below the outer malleolus. The sides of the box are next brought up and secured, and by the pressure of these com- presses the foot is brought into an inverted position and the deformity is corrected. The after-dressing of this fracture consists in letting down the sides of the box, and in inspecting the parts to see that the foot is kept in the proper position, and care should be taken to see that undue pressure is not made upon the skin by the compresses, which might result in ulceration ; this may be avoided by sponging the skin with alcohol and changing the positions of the compresses slightly at each dressing. At the expiration of ten days the fracture-box and compresses may be removed and the limb may be put up in a plaster-of- Paris dressing including the foot and leg up to the knee. The patient may then be allowed to go about on crutches and at the end of five weeks all dressings may be dispensed with. A certain amount of stiffness and even permanent impairment in the motion of the ankle- joint often results from these fractures. This fracture is also dressed by means of Dupuytreris splint, which consists of a straight wooden splint long enough to extend from the condyles of the femur to end of the toes ; this splint is provided with padding the thickest part of which, several 354 FRACTURES inches in thickness, should rest upon the skin just above the inner malleolus when the splint is applied to the inner side of the leg. The splint is applied to the inner surface of the leg with the thickest part of the pad resting upon the skin just above the inner malleolus, and is secured in position by the turns of a roller applied over the foot and at the upper part of the leg. After using this dressing for a few days if the displacement is satisfactorily corrected the splint may be removed and the leg may be placed in a fracture-box or in a plaster- of-Paris dressing. (Fig. 270.) Fig. 270. Dupuytren's splint applied. This splint, when applied with sufficient firmness to correct the displacement, is not, as a rule, a comfortable dressing to the patient, so that in practice the use of the fracture-box and compresses w r ill be found a more comfort- able dressing and one equally satisfactory in correcting the deformity. Fracture of the Bones of the Foot. Fractures of the Tarsal Bones. The calcaneum and astragalus are the tarsal bones most frequently fractured. The dressing of fractures of the cal- caneum after reducing the displacement, w T hich is not usually marked unless the posterior portion of the bone is involved, by manipulation, consists in placing the leg and foot in a fracture box, and care should be taken to see that the foot is kept at a right angle to the leg. When the fracture involves the posterior portion of the bone and there is displacement FRACTURES OF THE TARSAL BONES. 355 by the action of the muscles inserted into the fragment, the leg should be flexed upon the thigh and the foot should be extended ; this position may be maintained by applying a well- padded curved splint to the anterior portion of the leg and foot and securing it in position by a bandage, or the same result may be obtained by applying a band or padded collar around the thigh, which is made fast by a cord or strap to the heel of a slipper applied to the foot. (Fig. 271.) Apparatus for fracture of posterior portion of the calcaneum. (Hamilton.) Fractures of the astragalus, after reducing any deformity which is present by extension and manipulation, are dressed by placing the foot and leg in a fracture-box, care being taken to see that the foot is kept at a right angle to the leg. This precaution is important, as ankylosis not infrequently occurs after this fracture, and if the foot is in the proper position it is much more useful to the patient. As soon as the swelling, which is usually very marked after fracture of the calcaneum or astragalus, subsides, the foot and leg should be put up in a plaster-of-Paris bandage. The amount of tension and the inability to reduce the dis- placement in cases of fracture of the astragalus may be in- dications for excision of the fractured bone. The time re- quired for union in fractures of the tarsal bones is from five to six weeks. 356 FRACTURES. Fractures of the Metatarsal Bones. These fractures are dressed by placing the foot upon a well- padded plantar splint, and using compresses to hold the fragments in place if there is much displacement, the splint and compresses being held in position by a bandage ; or they may be treated by placing the foot and leg in a fracture-box, the foot-board of the box acting as a plantar splint ; the plaster-of-Paris dressing may also be used in these cases. The time required for union in fractures of the metatarsal bones is from three to four weeks. Fractures of the Phalanges of the Toes. These fractures are often compound and attended with so much laceration of the soft parts that immediate ampu- tation is required ; when, however, the fractures are simple, or in compound fractures where amputation is not required, the dressing consists in applying a plantar splint of wood or binder's board, extending beyond the toes and securing it in position by the turns of a roller bandage. When a single toe only is broken a moulded splint of gutta-percha or binder's board may be applied and a portion of the splint should extend some distance upon the sole of the foot to fix the proximal joint and also to give it a firm point of fixation ; the moulded splint should be held in position by a narrow roller bandage or by strips of adhesive plaster. The time required for union in fractures of the phalanges of the toes is about three weeks. Dressing of Compound or Open Fractures. In the dressing of compound or open fractures the same dressings and splints which are generally used in the treat- ment of simple or closed fractures may be employed ; the wound in the soft parts requires a special dressing and this should be so arranged as to secure free drainage and promote its prompt healing. In some cases of compound DRESSING OF COMPOUND FRACTURES. 357 fracture the treatment of the injures of the soft parts de- mands attention first, and in such cases the injury to the bones is for a time disregarded, care being taken to see that the fragments are kept quiet so as to prevent further damage to the soft parts until the wound is in such a con- dition that the proper manipulation to reduce the displace- ment and fix the fragments by splints and suitable dressings can be undertaken without interfering with the repair of the wound. In the dressing of compound or open fractures the skin surrounding the wound should be first carefully cleansed and the wound should next be thoroughly irrigated with a 1 : 2000 bichloride solution or a 1 : 40 carbolic solution and any foreign bodies or loose fragments of bone should be re- moved, and if there is hemorrhage it should be controlled by securing the bleeding vessels with ligatures. The reduc- tion of the displacement should next be accomplished by making extension and by manipulation (Fig. 272); if the Fig. 272. Method of reducing a compound fracture. (Hamilton.) fragments project from the wound, before this can be satis- factorily accomplished it may be necessary to enlarge the wound, and to resect one or both ends of the fractured bones, and in some cases it may be necessary to drill the ends of the fragments and introduce a strong wire or catgut suture to hold them in their proper positions. After reduction of 16* 358 FRACTURES. the displacement the wound should again be thoroughly irrigated with the antiseptic solution, and after making pro- vision for drainage by the introduction of a drainage-tube or tubes, counter-openings being made to secure free drain- age if necessary, the dressings should be applied. The wound, if a small one, need not be closed with sutures ; but, if extensive, a few catgut, silk, or silkworm- gut sutures may be applied to bring the edges of the wound into apposition, care being taken to avoid making undue tension ; if the soft parts have been much lacerated or con- tused, it is better to introduce no sutures. A final irrigation of the wound through the drainage-tube is next made, and the wound is covered by a piece of protective, and the ordi- nary gauze dressing should be applied and covered by a number of layers of bichloride cotton, the whole dressing being held in position by a gauze bandage applied with moderate firmness. The reduction of the fragments and the dressing of the wound having been accomplished as has been described, the splints and dressings appropriate for a similar fracture, if it were a simple or closed one, are next applied. If the sur- geon has been able to render the wound aseptic, and has applied an antiseptic dressing, the compound fracture is often soon converted into a simple one, by the prompt healing of the wound, and the patient may exhibit no more constitu- tional disturbance than he would have with a similar simple or closed fracture. The re-dressing of a compound fracture dressed in this way need not be made for a week or ten days, unless there is a rise in the patient's temperature or the dressings become soaked with discharges from the wound, or they become uncomfortable to the patient by reason of swelling of the soft parts in the region of the wound. When the re-dressing of the fracture becomes necessary, the dress- ings are removed, and the drainage-tubes may be removed if no longer needed ; the wound being re-dressed with an anti- septic dressing, the splints are reapplied, and, after the wound is healed, the subsequent dressing of the fracture should be the same as that of a simple fracture. The time required DRESSING OF COMPOUND FRACTURES. 359 for union in a compound fracture is usually much longer than in a corresponding simple fracture. Many ingenious splints have been devised for the dressing of special compound fractures, but these were principally used before the introduction of the antiseptic method of wound-treatment, and as the treatment of these cases has been much simplified by its use, they possess no special advantage over the ordinary splints and dressings used in simple fractures. The plaster-of- Paris dressing may be used as a primary dressing in compound fractures; the displacement being reduced and the wound being dressed with an antiseptic Fig. 273. Fenestrated plaster dressing for compound fracture of the leg. (Stimson.) gauze dressing, a plaster-of-Paris bandage is applied to the part so as to firmly fix the fragments ; the joints on either side of the fracture should be fixed by the bandage, and the parts should be held in position until the plaster has set firmly. After the plaster has become firm, a fenestrum should be made over the position of the wound, so that it can be inspected or dressed through this when necessary. The ends of a piece of stout wire, bent into a semicircle, may be incorporated in the turns of the plaster bandage above and below the position of the fenestrum, to give it additional strength after the removal of a portion of the bandage to make the fenestrum. (Fig. 273). 360 FRACTUKES. If the plaster-of-Paris dressing is applied as a primary dressing in compound fractures the case should be carefully watched for a few days, and if much swelling occurs at the seat of fracture its removal and renewal is indicated ; pro- fuse discharge of serum may also soak the dressings and bandage so that its renewal is necessitated. Some surgeons, therefore, prefer to defer the application of the plaster-of- Paris dressing in compound fractures for a few weeks until the swelling has diminished and the wound is nearly or quite healed ; the wound being covered with an antiseptic dressing the plaster bandage is applied and a fenestrum is made over the position of the wound if required. Binder s- board or felt splints may also be employed in the dressing of compound fractures, being moulded to the parts after an antiseptic dressing has been applied to the wound, and held in position by the turns of a roller bandage. The principal advantage in the use of these splints is the ease with which they can be removed and reapplied if fre- quent dressings of the fracture are necessary for any reason. They may be used during the course of treatment, or, after a few weeks when the swelling has diminished at the seat of fracture and the wound is well advanced toward repair, they may be discarded and a plaster-of-Paris dressing substituted. In compound fractures of the bones of the leg, after reducing the displacement and applying an antiseptic dressing to the wound, I usually apply moulded binder's board splints to either side of the leg, including the foot, and place the leg in a fracture-box for additional security, and after a few weeks I discard the binder's-board splints and apply a plaster-of-Paris dressing. The bran dressing for compound fractures was formerly a popular dressing in this city, especially for compound fractures of the leg and thigh. It was applied by placing a piece of muslin or rubber cloth over the bottom and sides of a fracture-box and upon this was placed a layer of bran ; the fractured leg was next placed in the box upon the layer of bran, the foot was then fastened to the footboard and the sides of the box were brought up and secured ; bran was next poured into the box and firmly packed around and DRESSING OF COMPOUND FRACTURES. 361 over the limb. The bran absorbed the discharges which escaped from the wound and at the subsequent dressings the soiled bran was renewed without disturbing the limb and fresh bran was packed about the limb. Sawdust which has been saturated with a solution of bichloride of mercury and dried may be used in the same manner as bran in the dressing of compound fractures and the former, which has been rendered antiseptic, has decided advantages over the bran dressing. Continuous irrigation of compound fractures by a warm antiseptic solution either of bichloride of mercury 1 : 4000 or of carbolic acid 1 : 60 in cases in which so much contu- sion or laceration of the soft parts exists that the applica- tion of the ordinary dressings would be attended with the risk of gangrene, will be found a most satisfactory method of treatment. This dressing is applied by supporting the injured extremity upon a splint laid on a pillow covered by a rubber cloth, and a can or jar with a nozzle containing the solution is placed over the part and the irrigation is ac- complished by allowing the fluid to run continuously over the wound ; this irrigation may be kept up for days or weeks and when the vitality of the parts is assured, an antiseptic dressing with the ordinary splints or a plaster-of-Paris ban- dage may be applied. PART IV. DISLOCATIONS A dislocation is the displacement of the articular sur- faces of bones which enter into the formation of a joint. Dislocations may be complete, partial, simple, compound, and complicated, and they are also known as recent and old dislocations, the latter terms being used not entirely with reference to the length of time the displacement of the articular surfaces of the bones has existed. A complete dislocation is one in which no portions of the articular surfaces of the bones remain in contact with each other. A partial dislocation is one in which portions of the articular surfaces of the bones still remain in contact with each other. A simple dislocation is one in which there exists dis- placement in the relation of the articular surfaces of the bones with little injury to the soft parts adjacent to the joint, and the displaced ends of the bones do not communicate with the air by a wound in the soft parts. A compound dislocation is one in which there exists dis- placement of the articular surfaces of the bones which com- municates with the air through a wound in the soft parts. A complicated dislocation is one in which in addition to the displacement of the articular surfaces of the bones, there exists a fracture, or a laceration of important bloodvessels, nerves, or muscles in proximity to the dislocation. A recent dislocation is one in which the displacement of TREATMENT OF DISLOCATIONS. 363 the articulating surfaces of the bones has existed for such a period, that time has not been afforded for inflammatory changes to have taken place in the articular surfaces of the bones or in the adjacent tissues, which would seriously inter- fere with their reduction. An old dislocation is one in which the displacement of the articulating surfaces of the bones has existed for some time, and in this variety of dislocation the displaced bones often form firm adhesions to the surrounding tissues. Treatment of Dislocations. The first indication in the treatment of dislocations is to return the displaced articular surfaces of the bones to their normal position and to retain them in this position by the use of suitable dressings The return of the articular sur- faces of the bones to their normal position or the reduction of the dislocation, is accomplished by manipulation, extension, and counter-extension. The reduction of dislocations should be attempted as soon as possible after they have occurred. The principal obstacles to the reduction. of dislocations are muscular resistance and the anatomical peculiarities of the joints. The former is best overcome by the use of an anaes- thetic given to the point where complete muscular relaxation is produced. The resistance offered by the changed rela- tions of the articular surfaces and the ligaments is to be overcome by the surgeon making such manipulations, founded upon his knowledge of the anatomy of the parts, as will make the ligaments, muscles, and bones assist in the reduction of the dislocation. In recent dislocations by the use of extension and manipu- lation, especially if an anaesthetic be employed, the reduction is usually accomplished without the use of much force, but in old dislocations, where absolute muscular shortening has taken place, the use of extending bands is often required, and in securing these bands to the limb the clove-hitch knot is useful. (Fig. 274.) The treatment of dislocations after reduction consists in 364 DISLOCATIONS. placing the joint at complete rest by the application of suitable splints and bandages, and in treating any inflam- matory complications if they arise, by the application of Fig. 274. Clove-hitch knot applied. (Erichsen.) evaporating lotions, and in a week or two after the injured ligaments have been repaired, passive motion should be resorted to for restoring the function of the joint. Special Dislocations. Dislocations or the Vertebrae. Dislocations of the lumbar and dorsal vertebra?, as simple dislocations, are extremely rare accidents ; they are occasion- ally met with, but are more often associated with fractures of the vertebrae in these regions ; their occurrence in the cervical vertebrae is more common. The treatment of dis- locations of the vertebrae, whether complicated with fracture or not, consists in attempting reduction by making extension and counter-extension with manipulation, and by this means in many cases the luxations can be reduced. If, however, the efforts at reduction are unsuccessful, permanent extension should be applied by means of a weight-extension apparatus from both legs, and from the shoulders and head. The after- treatment consists in keeping the patient at rest upon his back in bed upon a firm mattress, and if the cervical ver- DISLOCATION OF THE JAW. S6r> tebne have been involved the head and neck should be sup- ported by short sand-bags, and in case of the vertebras below this point, the application of a plaster-of- Paris jacket may be used to give support and fixation to the parts. The general management of the case as regards complications is similar to that in cases of fracture of the vertebrae. Dislocations of the coccyx are reduced by manipulation with the finger in the rectum and external manipulation at the same time. The only after-treatment required is rest in bed for a few days, and the administration of opium to keep the bowels quiet. Dislocation of the Jaw. This dislocation may consist in the displacement of one or both condyles of the jaw from the glenoid fossae, consti- Fig. 275. Bilateral dislocation of the jaw. (Ashhubst.) tuting the unilateral or bilateral dislocation of the jaw ; the latter is the more common form of dislocation of the jaw 3.66 DISLOCATIONS met with, and the deformity resulting is shown in Fig. 275. The reduction of a dislocation of the lower jaw is accom- plished as follows : The surgeon placing his thumbs, well protected by strips of bandage or a towel, on the molar teeth or behind them presses the angles of the jaw downward while he elevates the chin with his fingers, and by this manipula- Fig. 276. Method of reducing dislocation of the lower jaw. (Hamilton.) tion the condyles of the jaw usually slip back into place with a snap. After reduction of the dislocation the jaw should be fixed for a week or ten days by the application of a Barton's bandage or a four-tailed sling. Dislocation of the Hyoid Bone. A few cases of dislocations of the hyoid bone have been recorded ; the treatment consists in throwing back the head as far as possible, to place the muscles of the neck upon the stretch, depressing the lower jaw and pressing the luxated bone into position. Dislocations of the Ribs. The ribs may be dislocated at their vertebral articulations, or at the junction with their costal cartilages. The treatment of these dislocations consists in reducing the displacements by manipulation and pressure and then in fixing the chest to DISLOCATIONS OV THE PELVIS. 367 secure immobility of the ribs by strapping the affected side with strips of adhesive plaster, the same dressing being applied as in case of fracture of the ribs, the dressings being retained for three or four weeks. Dislocation of the Sternum. Dislocation or diastasis of the sternum may occur at the junction of the manubrium and gladiolus or at the junction of the ensiform cartilage and gladiolus. The reduction is effected by extension of the chest by bending the dorsal spine over a firm cushion placed under the back and by pressure upon the projecting bone; when the displaced bone has been reduced, a compress should be placed over the seat of injury and held in place by broad strips of adhesive plaster or by a bandage to keep the parts at rest. The dressing should be retained for three or four weeks. In the few examples of dislocations of the ensiform car- tilage which have been reported, the displacement of the cartilage has in some cases given rise to persistent vomiting, which was relieved by reduction of the displacement ; it is, however, almost impossible to keep the fragment in place after reduction, and the vomiting gradually disappears after a time in these cases where it was impossible to keep the cartilage in its normal position. Dislocations of the Pelvis. Dislocations or diastasis of the bones of the pelvis may occur at the pubic or sacro-iliac symphyses. These are generally serious injuries, as they are apt to be complicated by lesions of the pelvic viscera. The reduction of these dislocations is effected by pressure and manipulation, and after reduction the parts should be supported by a compress held in place by a stout binder or by broad strips of adhesive plaster, the patient being kept quiet in bed, and the pelvis being supported by means of 368 DISLOCATIONS sand-bags. The dressings should be retained for from four to six weeks. Dislocations of the Clavicle. Dislocations of the clavicle may occur either at the sternal or acromial end, and the latter injury some writers describe as a dislocation of the scapula, following the gen- eral rule that the distal bone is the one dislocated. Dislocations of the sternal end of the clavicle may occur in a forward, backward, or upward direction, and the dis- placement is generally well marked. (Fig. 277.) The re- duction of this dislocation is effected by placing the knee against the spine and drawing the shoulders outward and backward and pressing the displaced end of the clavicle Fig. 277. Fig. 278. Dislocation of sternal end of clavicle forward. (Bryant.) Dislocation of clavicle at acromial end. (Bryant.) into place. The reduction is generally easy, but it is often difficult to keep the end of the bone in its proper position. To accomplish this, a compress should be placed over the end of the bone, and this should be secured in place by broad strips of adhesive plaster ; the shoulders should be brought well backward and secured by a posterior figure-of- eight bandage of the chest, and the arm of the injured side DISLOCATIONS OF THE SCAPULA. 369 should be fastened to the side of the chest by spiral turns of a bandage. In some cases, in addition to the compress over the end of the bone, securing the arm of the injured side in the Velpeau position will be found all that is necessary to retain the bone in position. Dislocation of the acromial end of the clavicle may be upward, downward, or backward. (Fig. 278.) The reduc- tion is effected by manipulation of the arm and scapula and by pressure over the displaced end of the clavicle ; the dis- placement is usually reduced without much trouble, but it is often a matter of difficulty to keep the end of the bone in its proper place. The dressing consists in placing a compress over the acromial end of the clavicle and holding it in place by broad strips of adhesive plaster; the arm should at the same time be fixed in the Velpeau position. These dress- ings after reduction of dislocations of the clavicle should be kept in place for at least three weeks. Although in many cases a certain amount of deformity persists, the disability resulting from the injury is not often marked. Dislocations of the Scapula. Dislocation of the acromion processes of the scapula from the outer end of the clavicle, which has been described under dislocation of the acromial end of the clavicle, is classed by some writers as a scapular dislocation. Dislocation or projection of the inferior angle of the scapula, due to its escape from under the latissimus dorsi muscle or relaxation of this muscle and of the serratus magnus, is sometimes described as a dislocation of the in- ferior angle of the scapula. The reduction of this deformity consists in the employment of manipulation and pressure to overcome the displacement, and the use of a compress held in place by broad strips of adhesive plaster to secure the bone in its proper position. 370 DISLOCATIONS. Dislocations op the Shoulder. The head of the humerus may be dislocated downward, forward, or backward. Subglenoid or downward dislocation of the head of the humerus is that variety of dislocation in which the head of the bone rests in the axilla. (Fig. 279.) Fig. 279. Subglenoid dislocation of the shoulder. (Stimson.) Subcoracoid or forward dislocation of the head, of the humerus is that variety of dislocation in which the head of the humerus rests beneath the coracoid process of the scapula. (Fig. 280.) Subclavicular dislocation of the head of the humerus may be considered an aggravated form of the latter variety of DISLOCATIONS OF THE SHOULDER. 371 dislocation : the head of the humerus in this variety of dis- location rests beneath the clavicle. Fig. 280. Subcoracoid dislocation of the shoulder. (Stimsox.) Subspinous or backward dislocation of tlie head of the hu- meru8 is that variety of dislocation in which the head of the humerus rests beneath the spine of the scapula. (Fig. 281.) The reduction of dislocations of the humerus is effected by manipulation, by extension and counter-extension, and by a combination of these methods. Manipulation in the reduction of subglenoid dislocation of the humerus is practised by first flexing the forearm upon the arm to relax the long head of the biceps muscle; the elbow is next seized and abducted so as to bring it to the side of the patient's head, thus relaxing the deltoid and supra-spinous muscles ; the surgeon or an assistant next 372 DISLOCATIONS, places his hand upon the head of the humerus in the axilla, and, as the arm is drawn outward to a right angle with the Fig. 281. Subspinous dislocation of the head of the humerus. (Erichsek.) body by the other hand, he pushes the head of the bone into the glenoid cavity. In the reduction of subglenoid and subclavicular disloca- tions the manipulation is the same except that the arm is to be rotated outward before being carried downward. In the reduction of subspinous dislocations after the arm has been abducted it should be rotated inward and direct pressure should be made upon the head of the bone as the arm is adducted. Reduction may also be effected by exten- sion and counter-extension as in Cooper's method, where extension is made from the arm downward and counter- extension is made by the heel in the axilla. (Fig. 282.) Reduction may also be accomplished by extension made upward, as in Mothe's method, the scapula being fixed by the foot or hand placed over the acromion process. (Fig. 283.) After reduction of dislocations of the head of the humerus the arm should be bound to the side of the body by the DISLOCATIONS OF THE SHOULDER. Fig. 282. 373 Reduction of shoulder by heel in the axilla. (Erichsen.) Fig. 283. WJ i k't.-. 1 - .:> _^__- — Reduction of shoulder by extension upward. turns of a spiral bandage of the chest, or should be held against the side by the application of a Velpeau bandage (Fig. 46, p. 55); this dressing should be removed at in- 17 374 DISLOCATIONS. tervals of a few days, and after ten days or two weeks all dressings should be dispensed with, passive motion should be employed and the patient should be allowed to move the arm. • Dislocations of the Elbow. Dislocation of the Bones of the Forearm. Dislocations of the bones of the forearm at the elbow may either be backward, forward, or lateral. The backward dis- location is the most common form. (Fig. 284.) Fig. 284. Dislocation of both bones of the forearm backward. (Liston.) The reduction of backward dislocations is effected by making traction upon the forearm and at the same time making pressure upon the lower end of the humerus as the forearm is flexed upon the arm. Or the reduction may be accomplished by bending the arm slowly and forcibly over the knee placed upon the inner surface of the elbow so as to press upon the radius and ulna, separating them from the humerus and freeing the coronoid process from its abnormal position. (Fig. 285.) Lateral dislocations of the bones of the forearm at the elbow are reduced by making extension from the forearm, and at the same time making direct pressure on the dis- placed bones and counter-pressure on the lower end of the humerus. DISLOCATIONS OF THE ELBOW. 375 Forward dislocations of the bones of the forearm at the elbow are reduced by making forced flexion at the elbow, together with extension or counter-extension, or by making Fig. 2S5. Reduction with the knee in the bend of the elbow. (Hamilton.) Fig. 286. Dressing after reduction of dislocations of the elbow. 376 DISLOCATIONS. forced extension of the "forearm at the elbow, pressing the humerus backward and suddenly flexing the forearm. The dressing, after the reduction of dislocations at the elbow, consists in the application of a well-padded anterior Fig. 287. Dislocation of head of the radius forward. (Liston.) right- or slightly obtuse- angled splint, to keep the forearm in a flexed position — the dressing being practically the same as that for fractures of the lower end of the humerus, with an anterior angular splint (Fig. 286). This dressing should be retained for two or three weeks, being removed at inter- vals of several days ; after the removal of the splint, passive DISLOCATIONS AT THE WRIST. 377 motion should be practised, to prevent stiffness of the elbow- joint. Dislocation of the Head of the Radius. The head of the radius may be displaced forward, outward, or backward, the forward dislocation being the most frequent. (Fig. 287.) The reduction of these dislocations is effected by making extension from the forearm and counter-extension from the lower end of the humerus, and at the same time the head of the bone is pressed into its proper position. The dressing after reduction of the displacement consists in the application of a compress over the head of the bone, and the arm and forearm should be placed upon a well-padded ante- rior angular splint, which is secured by a roller bandage. The dressing is similar to that employed in fractures of the lower end of the humerus, in which an anterior angular splint is employed (Fig. 242, page 325). Difficulty is sometimes experienced in keeping the head of the bone in position after reduction, so that the use of the compress in addition to the use of the splint is often required. The arm should be kept upon the splint for three weeks, being redressed at intervals. Dislocation of the Upper End of the Ulna. The upper end of the ulna may be displaced backward, the olecranon projecting behind the condyles of the humerus, while the head of the radius occupies its normal position. The reduction of this displacement is effected in the same manner as that of both bones of the forearm backward, and the dressing after reduction is similar to that employed when both bones have been displaced. Dislocations at the Wrist. The lower end of the ulna may be dislocated from the radius forward, backward, or inward. The reduction of these displacements is effected by fixing the radius and push- ing the ulna back into place. The dressing after reduction 378 DISLOCATIONS. consists in placing the wrist-joint at rest by the application of well-padded anterior and posterior straight splints. The splints should be retained for three or four weeks, dressings being made at intervals of two or three days. Dislocations of the carpus upon the bones of the forearm may be forward (Fig. 288), or backward (Fig. 289). The Fig. 288. Fig. 289. Dislocation of the carpus forward. (Hamilton.) Dislocation of the carpus backward. (Hamilton.) reduction in either variety of displacement is effected by extension from the hand and by pressure. After reduction of the displacement, which does not tend to recur, the hand and forearm should be placed upon a well-padded straight splint applied to the palmar surface of the hand and fore- arm. The splint should be retained for ten days or two weeks. Dislocations of the Bones of the Carpus. The displacement of the individual bones of the carpus occasionally takes place, the os magnum, the semilunars and pisiform being the bones most usually displaced, although other bones of the carpus are sometimes dislocated. Reduc- DISLOCATIONS OF THE FINGERS. 379 tion is effected by means of extension and pressure, and the part should afterward be dressed with a palmar splint and compresses. Dislocations of the Metacarpal Boxes. The metacarpal bones may be dislocated upon the carpus ; the bones most commonly displaced are those of the thumb, and of the index and middle fingers ; the latter are usually displaced backward, while the metacarpal bone of the thumb may go either backward or forward. Reduction is effected by extension and pressure. The dressing after reduction consists in the application of a palmar splint to the hand and forearm and a compress over the displaced bone. The dressings should be retained for two weeks. Dislocations of the Fingers. Dislocations of the phalanges of the hand usually take place at the metacarpophalangeal junction, but sometimes occur at the intra-phalangeal joints. The reduction is usually easily effected by extension (Fig. 290), or by push- Fig. 290. Backward dislocation of phalanx Reduction by extension. (Hamilton* ) ing the phalanx back until it stands perpendicularly upon the metacarpal bone, when by strong pressure upon its base, from behind forward, it is readily carried by flexion into its natural position. 380 DISLOCATIONS. Where difficulty is experienced in making extension in the reduction of these dislocations, the ingenious apparatus of the late Dr. Levis (Fig. 291), or the " Indian puzzle " apparatus (Fig. 292) may be employed with success. Fig. 291. Levis's apparatus for dislocation of the phalanges applied. Fig. 292. Extension by Indian puzzle. (Bryant.) In dislocations of the proximal phalanx of the thumb backward (Fig. 293), great difficulty in reduction is often Fig. 293. Dislocation of proximal phalanx of thumb backward. (Farabeuf.) experienced from the head of the metacarpal bone slipping between the two heads of the short flexor muscle, or be- DISLOCATIONS OF THE HIT 381 tween the lateral ligaments. The interposition of the exter- nal sesamoid bone is considered by some surgeons to be the cause of difficulty in the reduction of this displacement. In this dislocation reduction is effected by firmly press- ing the metacarpal bone of the thumb strongly toward the palm of the hand to relax the two portions of the short flexor muscle. The thumb is next extended upon the wrist until its tip points to the elbow. An assistant now places his finger behind the proximal phalanx to prevent its slip- ping backward and by bringing the thumb down to the flexed position the bone slips into place. It sometimes happens that all efforts at reduction fail, and in such cases Fig. 294. Fig. 295. Backward and upward dislocation of femur. (Cooper.) Backward dislocation of femur. (Cooper.) 382 DISLOCATIONS it may be necessary to divide one head of the short flexor muscle subcutaneously or through an open wound, before the displacement can be relieved. The dressing of dislocations of the phalanges after reduc- tion consists in the application of splints of wood, or moulded splints of binder's board or gutta-percha to fix the joint, which should be retained for ten days or two weeks. Dislocations of the Hip. The head of the femur is most frequently dislocated back- ward, downward or upward, although it may assume other positions in exceptional cases. Posterior or backward dislocations of the head of the femur are either backward and upward, and are described as iliac or dorsal, the bone resting upon the dorsum of the ilium (Fig. 294). Or the dislocation may be backward, the head of the bone resting upon the ichiatic notch ; these are known as ischiatic dislocations or dislocations of the femur dorsal below the tendon (of the obturator internus), according to Bigelow (Fig. 295). The reduction of the posterior dislocations of the femur can gen- erally be effected by manipulation. The patient being anaesthetized and placed upon his back, the surgeon grasps the leg at the ankle and knee, flexes the leg upon the thigh, and the thigh upon the pelvis ; he then abducts the limb and rotates it outward, bringing it in a broad sweep across the abdomen, and by bringing it down to its natural position the head of the bone will slip into the acetabulum (Fig. 296). Downward Dislocation of the Head of the Femur, or Downward arid Forward Dislocation. — In this variety of Reduction of backward dis- location of femur.(BiGELOW.) DISLOCATIONS OF THE HIP. 383 dislocation the head of the bone rests upon the thyroid foramen ; this form of displacement is sometimes spoken of as a thyroid dislocation. (Fig. 297.) The reduction of downward and forward dislocations of the head of the femur is effected by flexing the leg and thigh and bringing the limb into a position of abduction ; it is then adducted and rotated inward in a broad sweep across the abdomen and brought down to its natural position, and the head of the bone slips into the acetabulum. (Fig. 298.) Fig. 297. Fig. 298. Downward and forward dislocation of femur. (Cooper.) Reduction of downward and for ward dislocation of he femur (Bigelow.) In making these manipulations the head of the bone sometimes slips back upon the dorsum of the ilium, con- verting the downward dislocation into a posterior one if 384 DISLOCATIONS Upivard Dislocation, Upward, of the Head this accident occurs the displacement should be remedied by making the manipulation appropriate for the reduction of the latter dislocation. or the Dislocation Forward and of the Femur. — In this variety of dislocation the head of the bone rests upon the pubis ; this form of displacement is also spoken of as a pubic dislocation. (Fig. 299.) The reduction of forward and upward dislocations of the head of the femur is effected by much the same manipulation as is employed in the reduction of downward and forward dislocations, except that in the pubic dislocation the flexed limb should be carried across the sound thigh at a higher point. The thigh being flexed the head of the bone is drawn down from the pubis; it is then semi-abducted and rotated inward to disengage the bone completely. While ro- tating inward and drawing on the thigh the knee should be carried inward and downward to its place by the side of its fellow, and the head of the bone will usually slip into the acetabulum. As before stated various anoma- lous displacements of the head of the femur occasionally occur ; the head of the bone may pass directly upward, or downward between the sciatic notch and thyroid foramen, or downward and back- ward on the body of the ischium, or downward and back- ward into the lesser sciatic notch, or downward, inward, and forward into the perineum. These anomalous displacements Forward and upward dis location of the femur (CuOPER.) DISLOCATIONS OF THE PATELLA. 385 usually occur where there has been extensive laceration of the capsular and Y-ligaments. The dressing of cases, after reduction of dislocations of the head of the femur, consists in keeping the patient at rest in bed upon his back, and the limb should be kept at rest by sand-bags applied to either side of the limb, or the knees should be tied together. The patient should be kept at rest for two or three weeks, and at the end of this time may be allowed to get out of bed and go about on crutches. Fig. 300. Dislocations of the Patella. The patella may be dislocated outward, inward, or upward, or it may be rotated upon its own axis. The outward dis- location is the displacement most usually seen. (Fig. 300.) Upward dislocation of the patella can only result from laceration of the ligamentum patellae, and the treatment in such cases is similar to that for fracture of the patella. The reduction of dislocations of the patella is effected by ex- tending the leg upon the thigh, and flexing the thigh upon the pelvis to relax the quadriceps femoris muscle, when the patella can usually be forced back into place ; in some cases alternate flexion and extension of the leg will accomplish the same result. The dressing after reduction of the displacement consists in the application of a posterior straight splint or a moulded binder's-board or felt splint to keep the joint at rest: the splint should be worn for a week or ten days. Outward dislocation of the patella. (Duplay.) 386 dislocations. Dislocations of the Knee. The head of the tibia may be dislocated forward, back- ward, or laterally ; the latter dislocations are always incom- plete, forward dislocation being the variety of displacement most commonly met with. (Fig. 301.) JSxfl condyle of femur Forward dislocation of the knee. (Bryant.) The reduction of dislocations of the knee is effected by extension and counter-extension with forced flexion of the knee with pressure, aided by rocking movements. The treatment of cases of dislocation of the knee after reduction consists in fixing the knee-joint by the application of a straight posterior splint or a moulded splint of binder's board. As there is usually marked swelling following these injuries from violence to the joint-structures, the application of evaporating lotions for a few days will be found useful. As soon as the swelling has subsided the joint should be put up in a plaster- of-Par is dressing and this should be retained for four weeks. Dislocation of the Semilunar Cartilages. The displacement here consists in the slipping forward or backward and wedging of the semilunar cartilages between the femoral condyles and the tibia. Reduction of the displaced cartilages can usually be effected by hyper-flexion of the knee followed by sudden full extension, or by alternately flexing and extending the DISLOCATIONS OF THE ANKLE. 387 joint. Excision of the displaced cartilages is sometimes required in cases in which they cannot be reduced by man- ipulation. The dressing of these cases after reduction of the dis- placed cartilages consists in the application of a posterior straight splint or a plaster-of-Paris dressing to fix the knee- joint ; the splint should be worn for three or four weeks, and if there is a tendency to redisplacement the patient should wear a knee-cap of leather or muslin to partially fix the joint, with compresses so arranged as to make pressure upon the edge of the joint. Dislocation of the Fibula. Dislocations of the fibula may occur at either of its ex- tremities, and the direction of the displacement may be forward, backward, or upward, dislocation of the head or upper extremity of the fibula being the most common, although all are rare forms of displacement. The reduction of dislocations of the head of the fibula is effected by flexing the leg upon the thigh and making direct pressure and extension. Dislocations of the lower extremity of the fibula are reduced by manipulation and pressure. The dressing of cases after reduction of dislocations of the fibula consists in the application of a compress and moulded binder's board splint, and the dressing should be retained for three or four weeks. Dislocations of the Ankle. Dislocation of the foot upon the bones of the leg results from the separation of the articular surface of the astragalus from that of the tibia and fibula, and the displacement may be forward^ hackivard (Fig. 302), or lateral (Fig. 303), the latter variety being often associated with fracture of the malleoli. The reduction of dislocations of the ankle is effected by traction, combined with flexion and rotation of the ankle- 388 DISLOCATIONS. joint, the leg being first flexed upon the thigh to relax the tendo Achillis, and in some cases the subcutaneous division of this tendon is required before the reduction can be satis- factorily accomplished. Fig. 302. Fig. 303. Dislocation of foot backward. (Bryant.) Dislocation of foot inward. (Bryant.) The dressing of dislocations of the ankle after reduction consists in the application of a fracture-box, or of pasteboard splints to fix the ankle, care being taken to see that the foot is fixed at a right angle to the leg, and in the application of evaporating lotions for a few days ; after the swelling has subsided, a plaster-of-Paris dressing should be applied and retained for three or four weeks. Dislocations of the Tarsal Bones. The astragalus may be dislocated from the bones of the leg and from the other tarsal bones, being thrust forward, backward, outward (Fig. 304), or inward. The reduction of dislocations of the astragalus outward is effected by first flex- DISLOCATIONS OF THE TARSAL BONES. 389 Fio. 304. ing the leg upon the thigh and making extension from the foot and rotating it at the same time, direct pressure being made upon the displaced bone ; in some cases subcutaneous sec- tion of the tendo Achillis has assisted materially in the reduc- tion of the displaced bone. Backivard dislocation of the astragalus is usually irreduci- ble, the patient, however, in many cases recovers with a useful foot. In cases of irre- ducible dislocations of the as- tragalus, excision of the as- tragalus may ultimately be re- quired. After the reduction of dis- locations of the astragalus, the foot and leg should be put at rest in a fracture-box, or by means of moulded splints of pasteboard or felt ; evaporat- ing lotions should also be em- ployed to the region of the in- jury for a few days, and when the swelling has subsided, a plaster-of-Paris dressing should be applied and retained for three or four weeks. Dislocations of the calcaneum and scaphoid upon the astragalus, or of the calcaneum upon the astragalus and cuboid, or upon the astragalus alone ; of the scaphoid and cuboid upon the calcis and astragalus ; or of the cuboid, scaphoid, or cuneiform bones, are occasionally met with. Their reduction is effected by traction and direct pressure, and, after this has been accomplished, the parts should be put at rest by the application of a splint and compresses. Dislocation of astragalus out- ward. (Hamilton.) 390 DISLOCATIONS. Dislocations of the Metatarsal Bones and Pha- langes op the Toes. These dislocations usually result from crushing forces which destroy the vitality of the soft parts so completely that amputation is required. Their reduction in cases of simple or uncomplicated dislocations is effected by traction, manipulation, and pressure. After reduction of the dis- placement, the parts should be kept in position by the appli- cation of splints and compresses. Old Dislocations'. The reduction of old dislocations is attended with more difficulty and danger than that of recent dislocations, due to the permanent contraction and structural changes which Fig. 305. Reduction of old dislocation of the femur by pulleys. (Cooper.) occur in the muscles, and to the abnormal adhesions which form between the displaced bone and the parts with which it is in contact. The reduction of old dislocations can usually be accomplished by the manipulations appropriate for recent dislocations of the same variety, but occasionally the use of more forcible extension is required, which is made by bands OLD DISLOCATIONS. 391 and pulleys (Fig. 305), or by vertical extension (Fig. 306). The first step in the reduction of old dislocations consists in thoroughly breaking up the adhesions which have been formed between the displaced bone and the surrounding tis- sues ; this has, in some cases, resulted in the laceration of Fig. 306. Reduction of old dislocation of hip by vertical extension. (Bigelow.) muscles, nerves, and bloodvessels, and in the fracture of the displaced bones or neighboring bones, so that the manipula- tions should be made with the least force that will accom- plish the object desired. After the reduction of old dislocations, difficulty is sometimes experienced in main- taining the bone in its proper place, due to the changes which have occurred in the articular surfaces. 392 dislocations. Compound Dislocations. These are always grave injuries, and amputation or excision is often required. When, however, operative measures are not required, the reduction is effected in the same manner as in simple dislocations of corresponding parts, the greatest care being taken to render the wound aseptic, and to keep it in this condition by the application of a full antiseptic dressing. Complicated Dislocations. In dislocations complicated by fracture near the seat of displacement, the displaced bone should, if possible, be first reduced, and this in many cases is a matter of much diffi- culty as the fracture prevents the surgeon from using lever- age otherwise present, in the reduction, and he has often to depend entirely upon pressure and manipulation to restore the displacement. After reduction of the dislocation the fracture should be reduced and dressed. Dislocation complicated by rupture of the main artery of the limb may require, after reduction of the displacement, exposure and ligation of the vessel or amputation of the limb. Rupture of an important nerve trunk complicating a dislocation may call for subsequent exposure and suturing of the divided nerve. Spontaneous Pathological and Congenital Dislocations. In the treatment of these varieties of dislocations after the reduction of the displacement by manipulation and pres- sure much difficulty is often experienced in maintaining the reduction. To effect the latter object the use of splints and bandages is employed and also the use of many ingenious forms of apparatus adapted to particular dislocations. Tenotomy or myotomy are often required to prevent recurrence of the deformity, and continuous extension is also of much value in the treatment of these displacements. PART V. LIGATION OF ARTERIES In the application of a ligature to an artery in its con- tinuity the surgeon should make his incision in the line which corresponds to the general course of the vessel and he should be thoroughly familiar with the anatomy and with the surgical landmarks of the part. A portion of the vessel, when possible, should be selected for the application of the ligature half an inch or an inch from any large col- lateral branch. The position of the incision being selected the surgeon steadies the skin with two fingers and makes an incision of the required length through it with a scalpel ; the superficial fascia is next picked up on a director, any large superficial veins which come into view being displaced, and divided to an equal length with the incision in the skin ; the deep fascia being exposed it should be nicked and divided upon a director ; the inter-muscular space or the edge of the muscle or muscles which are the guide to the vessel should next be sought for, small vessels coming from the main vessel through these spaces will often serve as valuable guides to the position of the vessel. The surgeon next separates the tissues with the director, handle of the knife, or the finger until the sheath of the vessel is exposed ; this is recognized by its communicated pulsation and by the absence of the smooth shining surface and pinkish-white color which the surface of the artery presents. The sheath of the artery should be picked up with forceps and nicked with the point of the knife applied flatwise ; the incision into the sheath should be very limited, only large enough to allow the 391 LIGATION OF ARTERIES. aneurism needle to pass through it around the vessel ; ex- tensive dissections or separations of the sheath from the vessel should be avoided as the nutrition of the artery at the point of ligature may thus be impaired and sloughing and secondary hemorrhage may result. A distinct sheath is found only about the main arterial trunks, which is replaced in the smaller arteries by a layer of loose cellular tissue. The wall of the artery being exposed an aneurism needle is Fig. 307. Fig. 308. Opening sheath. Passing ligature around the vessel. Tying artery. (Bryant.) Aneurism needle. passed around the vessel, threaded with a catgut ligature, and withdrawn ; the needle may be threaded before being passed, in which case the ligature is grasped with forceps and drawn through while the needle is withdrawn. The best material for ligatures is carefully prepared chromicized catgut. The needle should be passed away from important structures such as accompanying veins and nerves. Before the ligature is tied the surgeon should satisfy him- self that the ligature when tied will control the circulation LIGATION OF INNOMINATE ARTERY. 395 in the vessel below its point of application, by placing the tip of his finger upon the vessel and drawing upon the ends of the ligature so as to occlude the vessel at the point of application. Being satisfied as to this point the ligature is tied with a reef-knot, or a surgeon 's-knot and reef-knot com- bined. Some authorities recommend the application of two liga- tures a short distance apart in the ligation of vessels in their continuity, and a division of the vessel between them, so that both ends can retract into the cellular sheath. The ends of the ligature are cut short in the wound, which is irrigated and drained if necessary, and is closed by the application of a few sutures, and an antiseptic dressing is applied. Ligation of Special Arteries Ligation of the Innominate Artery. The innominate artery lies immediately behind the sterno- clavicular articulation, and is in relation in front with the innominate veins and pneumogastric nerve, on the inner side with the trachea, on the outer side and behind with the pleura. Incision. — A Y-shaped incision, each branch of which is two and a half or three inches in length, one of which lies over the anterior edge of the sterno-cleido-mastoid muscle, and the other parallel to and a little above the clavicle. (Fig. 309, ^4.) The incisions are carried down to the super- ficial fascia and a flap is dissected up. If the anterior jugular vein is met with it should be displaced. The sternal and clavicular attachments of the sterno-cleido-mastoid are next divided upon a director half an inch above the bone. The sterno- thyroid and sterno-hyoid muscles and the middle cervical fascia are next exposed, covered by the thyroid veins. The outer fibres of the sterno-hyoid and sterno-thyroid muscles are next divided, the thyroid vein being held aside, when upon tearing through the fascia with a director the common carotid artery is exposed and traced down to the 396 LIGATION OF ARTERIES. innominate artery; the innominate veins are pressed against the sternum with the finger and the artery is separated from its sheath about half an inch below its bifurcation, and the Fig. 309. Line of incision for — A, innominate artery ; B, right subclavian artery ; C, left subclavian artery ; D, vertebral or inferior thyroid artery ; E, axil- lary artery below clavicle. (Stimson.) aneurism needle is passed around the vessel from the outer side so as to avoid the vein, pneumogastric nerve, and pleura. Ligation of the Subclavian Artery. This artery, may be tied at three points ; in its first por- tion, between the trachea and scaleni muscles ; in its second portion, behind the scaleni muscles, and in its third portion external to the scaleni muscles. The left subclavian artery in its first portion is larger and more vertical in its direction than the right subclavian and is situated more posteriorly ; from the difficulty in exposing LIGATION OF SUBCLAVIAN ARTERY. 397 this portion, and from the possibility of injuring the thoracic duct, the ligation of this artery in its first portion has been seldom attempted. Incision for the first portion of the subclavian artery is the same as that for the innominate (Fig. 309, A), and the ligature is passed from the outer side, the pneumogastric and phrenic nerves being pressed inward toward the carotid artery. The right or left subclavian arteries are also seldom tied in their second portions, that is behind the scaleni muscles, but are frequently tied in their third portions, that is ex- ternal to the scaleni muscles. Fig. 310. Ligation of subclavian and lingual arteries. (Bryant.) 18 398 LIGATION OF ARTERIES Incision for the second portion of the subclavian artery begins an inch external to the sterno-clavicular articulation half an inch above and parallel to the clavicle, and is three or four inches in length. (Fig. 309, B or 0.) The steps of the operation are the same as for ligation of the third portion, and when the scalenus anticus muscle has been exposed it is divided upon a director ; the phrenic nerve which lies upon its anterior aspect is to be avoided. Incision for the third portion of the subclavian artery is the same as for the second portion. (Fig. 309, B or C.) The skin and platysma being divided, the jugular vein is exposed and drawn to one side or divided between the liga- tures ; the superficial fascia is next divided upon a director ; the posterior belly of the omo-hyoid muscle is next found and drawn upward and outward ; the outer border of the scalenus anticus is next felt for and followed down to the tubercle of the first rib — the artery lies against this, between it and the lowest bundle of the brachial plexus. The artery is next denuded with the director and the needle is passed from below, care being taken not to include the lowest bundle of the brachial plexus in the ligature. (Fig. 310.) Ligation of the Vertebral Artery. Incision for the ligation of the vertebral artery is three or three and a half inches in length, parallel with the ante- rior edge of the sterno-cleido-mastoid muscle, ending an inch above the clavicle. (Fig. 309, B.) The anterior edge of the sterno-cleido-mastoid being exposed the middle cervical fascia is divided and the carotid artery and jugular vein are exposed and drawn inward. The gap between the longus colli muscle and the scalenus anticus muscles is next felt for about an inch below the carotid tubercle ; the fascia covering it is next torn through and the muscles are sepa- rated and the vertebral vein comes into view ; this is held aside and the vertebral artery is exposed, and the ligature is then passed around it. LIGATION OF COMMON CAROTID ARTERY 399 Ligation of the Inferior Thyroid Artery. Incision for the inferior thyroid artery is the same as that for the vertebral artery. (Fig. 309, D.) The anterior edge of the sterno-cleido-inastoid muscle being exposed it is drawn outward, the middle cervical fascia is next divided and the carotid artery and internal jugular vein are drawn outward with a retractor. The head being flexed slightly, the surgeon feels for the carotid tubercle, and then separates the cellular tissue with a director and the artery should be found below the carotid tubercle. The needle should be passed between the artery and vein. Ligation of the Common Carotid Artery. The point of election for the ligation of the common carotid artery is just above the omo-hyoid muscle, about Fig. 311. Line of incision for common carotid artery at point of election. (Stimsox.) three-quarters of an inch below the bifurcation of the vessel, which takes place at a point on a line with the upper border of the thyroid cartilage. 400 LIGATION OF ARTERIES. Incision for the common carotid artery, is three inches in length along the anterior border of the sterno-cleido- mastoid muscle, the centre of which corresponds with the crico-thyroid space. (Fig. 311.) Divide the skin, platysma and cellular tissue and aponeu- rosis, avoiding the superficial veins, and expose the ante- rior edge of the sterno-cleido-mastoid ; seek for the inter- ^ -.Descendens N *n,oni> nerve ••"---"Omo-7i N \ muscic . j;..Carctid \artery \- ::: ^>'-<-"'-Int*iuffular AnL'? border cf Sterrm Mastoid Muscle Ligation of common carotid artery. Ligation of facial artery. (Bryant.) space between this muscle and the sterno-hyoid and sterno- thyroid muscles, draw the latter muscles inward and the artery will be exposed with the jugular vein external to it; the descendens noni nerve lying upon its sheath, which should be displaced outward. The sheath is next picked up and opened and the artery is separated from it with a director ; EXTERNAL CAROTID ARTERY, 401 the artery lies internally, the internal jugular vein externally and somewhat more superficial, and the pneumogastric nerve lies between the two and is more deeply placed. (Fig. 312.) Relation of the left common carotid artery above the omo-hvoid muscle. Esmarch.) The sympathetic nerve is posterior to the vessel external to the sheath. . The needle is passed from without inward, care being taken to avoid injury of the vein and nerve. (Fig. 313.) Ligation of the External Carotid Artery. Incision for the ligation of the external carotid artery is over the inner edge of the sterno-cleido-mastoid muscle from the angle of the jaw to a point corresponding to the middle of the thyroid cartilage. (Fig. 314. B) The skin, platysma and cellular tissue being divided, the external jugular vein is drawn aside when encountered : the deep fascia being 402 LIGATION OF ARTERIES opened, the facial and lingual veins will be exposed, which should be drawn to one side; the artery is next exposed covered by the hypoglossal nerve and the stylo-hyoid and digastric muscles. The vessel should next be isolated from the internal carotid artery and internal jugular vein, both of which lie along its outer side. The needle should be passed from without inward. Ligation of the Internal Carotid Artery. Incision the same as for the external carotid artery (Fig. 314, J5); the vessel is external to the external carotid artery, Fig. 314. Line of incision for — A. Lingual artery. B. External and internal carotid artery. C. Occipital artery. D. Temporal artery. E. Facial artery. (Stimson.) and in passing the needle the point should be directed from the internal j ugular vein, that is from without inward. LIGATION OF LINGUAL ARTERY 403 Ligation of the Superior Thyroid Artery. Incision about three inches in length along the anterior border of the sterno-cleido-mastoid muscle, starting a little lower down than that for the external carotid artery. The skin, superficial fascia, platysma, and deep fascia being di- vided, the cellular tissue in the sulcus between the upper portion of the larynx and the great vessels of the neck is broken up with the director and the vessel is exposed. The needle should be passed around the vessel from above down- ward. Ligation of the Lingual Artery. Incision a curved one two inches long, its concavity di- rected upward from the anterior edge of the sterno-cleido- mastoid muscle, half an inch above the great horn of the Fig. 315. Relations of the lingual artery. (Esmarch.) hyoid bone, to a point one inch short of the median line of the neck. (Fig. 314, A.) Divide the skin and platysma, displacing the superficial veins, and open the deep fascia, when the submaxillary gland will be exposed ; this is dis- placed upward with the handle of the knife and the tendon 404 LIGATION OF ARTERIES. of the digastric muscle attached to the hyoid bone, and the hypoglossal nerve will be exposed ; next divide the fibres of the hyoglossus muscle midway between the hypoglossal nerve and the hyoid bone, and the lingual artery will be ex- posed. (Fig. 315.) The needle should be passed around the vessel from above downward in order to avoid the nerve. Ligation of the Facial Artery. The facial artery passes over the inferior maxilla just in front of the anterior edge of the masseter muscle and is accompanied by the facial vein, which lies nearer to the muscle. Incision either a horizontal one along the lower border of the maxilla or a vertical one an inch in length. (Fig. 314, E.) The skin, subcutaneous tissue, and fascia being divided, the artery is exposed and the needle should be passed around the vessel away from the vein. Ligation of the Occipital Artery. Incision two inches in length, starting from a point half an inch below and in front of the apex of the mastoid pro- cess carried obliquely backward parallel to the border of this process. (Fig. 314, C) Divide the skin and fascia and expose the insertion of the sterno-cleido-mastoid muscle, which is also divided, and the aponeurosis of the splenius is exposed ; this is also opened and the digastric groove is felt for, and when the belly of the digastric muscle is exposed the artery is brought into view by separating the cellular tissue in the anterior angle of the wound with a director. (Fig. 316.) Ligation of the Temporal Artery. Incision a transverse one, one inch in length, starting from the tragus of the ear forward over the zygomatic arch LIGATION OF AXILLARY ARTERY. 405 (Fig. 313, D). or a vertical one of the same length a little in front of the tragus of the ear. Divide the skin and expose the subcutaneous cellular tissue, which in this region is verv dense and fibrous. This Fig. 316. Fig. 317. Ligation of the occipital artery. (Skey.) Ligation of the temporal artery. (Skey.) tissue should be broken up with a director and the artery should be found in it about a quarter of an inch in front of the ear. (Fig. 317.) The temporal vein accompanies the artery and lies nearer to the ear, and in some cases the auriculotemporal nerve is in close relation to the artery. The needle should be passed from behind forward. Ligation of the Axillary Artery. The axillary artery extends from the middle of the clavicle to the insertion of the teres major into the humerus ; the axillary vein lies upon the inner side and in front of the artery. The axillary artery is tied either in its upper por- tion, just below the clavicle, or at its lower portion in the axilla. Ligation of the Axillary Artery Below the Clavicle. Incision four inches in length from the summit of the coracoid process inward a short distance below the clavicle 18* 406 LIGATION OF ARTERIES. (Fig. 309, E), or an incision three inches in length com- mencing at a point one-half an inch from the sterno-clavicu- lar articulation and carried obliquely downward toward the axilla. The skin and subcutaneous tissue having been divided the deep fascia is exposed and opened, or the axillary artery may be reached by following the intermuscular space be- tween the sternal and clavicular fibres of the pectoralis major which leads upward toward the clavicle and to the pectoralis minor; or the fibres of the pectoralis major being exposed are cut through and the costo coracoid fascia is next torn through with a director, care being taken to avoid in- jury of the cephalic vein at the outer portion of the wound ; the pectoralis minor is now seen, and after separating the cellular tissue with a director the axillary vein is seen cross- ing from the upper edge of the muscle to the clavicle ; the Fig. 318. A. Incision for axillary artery in axilla. B. Incision for brachial artery. (Stimson.) vein almost completely covers the artery, which is exposed by drawing the vein inward. The needle is passed around the artery from within outward. Ligation of the Axillary Artery in the Axilla. Incision two and a half inches long, started at the upper part of the axilla and carried down the arm at the edge of LIGATION OF BRACHIAL ARTERY. 407 the coraco-brachialis muscle. (Fig. 318, A.) The skin only is divided in the first incision and the deep fascia is picked up and divided upon a director, and the fibres of the inner border of the coraco brachialis muscle are exposed and held aside by a retractor, and the operator will see the median nerve, the musculo- cutaneous nerve, and the axillary artery. To the inner side of the artery are the axillary vein, ulnar Fig. 319. Relations of right axillary artery in axilla. (Esmarch.) and internal cutaneous nerves. The needle should be passed around the artery from the vein toward the coraco-brachialis muscle. Ligation of the Brachial Artery. Incision at the middle of the arm three inches long on a line corresponding to the inner edge of the biceps muscle. (Fig. 318, B.) The skin and cellular tissue being divided', care being taken not to injure the basilic vein, which should be drawn posteriorly, the deep fascia is next cut through and the fibres of the biceps muscle are exposed (Fig. 320) ; 408 LIGATION OF ARTERLES. this should be drawn forward and the sheath of the vessels enclosing the artery, veins, and median nerve is exposed ; Fig. 320. Relations of right brachial artery at middle of arm. (Esmarch.) this is opened, the median nerve is pressed aside and the artery is separated from its veins and the needle is passed from the side of the nerve around the vessel. Fig. 321. Tendinous J/wneurof is divided ^^^§§^|^§^?$Ss|^^ : Ligation of the brachial artery at bend of elbow. (Bryant.) In ligating the brachial artery the occasional high division of the vessel must be borne in mind. LIGATION OF RADIAL ARTERY. 409 Ligation of Brachial Artery at Bend of Elbow. Incision two inches in length, along the inner border ot the tendon of the biceps muscle. Divide the skin, superficial fascia, and the bicipital aponeurosis, under which the artery will be exposed, resting upon the brachialis anticus muscle. (Fig. 321.) The median nerve is to the inner side and some distance from the artery. The needle should be passed around the vessel, after isolating the veins, from within outward. Ligation of the Radial Artery. The radial artery extends in a straight line from a point half an inch below the centre of the fold of the elbow to the inner side of the styloid process of the radius. The radial artery may be tied at its upper, middle, or lower third, or at the root of the thumb. Ligation of the Radial Artery in the Upper Third of the Forearm. Incision for the radial artery at its upper third is two and a half inches in length on a line drawn from the middle of the bend of the elbow to the ulnar side of the styloid process of the radius ; the incision should begin one and a half inches below the bend of the elbow. (Fig. 322, A.) Divide the skin and superficial fascia, avoiding the superficial veins. When the deep fascia is exposed find the edge of the supi- nator longus muscle and divide the aponeurosis along its ulnar side and expose the fibres of the pronator radii teres muscle. The vessel lies in the interspace between these muscles surrounded by adipose tissue, and upon being ex- posed the veins should be isolated and the needle passed from without inward. The nerve lies so far external to the artery that it is not often exposed in the operation. (Fig. 323.) Ligation of the Radial Artery in the Middle Third of the Forearm. IncUion two inches in length, following the same line as that for the upper third of the artery. After dividing the 410 LIGATION OF ARTERIES skin, superficial and deep fascia, the artery is found in the interspace between the flexor carpi radialis on the inner side Fig. 322. Relations of right radial artery in the upper third of the forearm. (Esmarch.) Fig. 324. Line of incision for — A. Radial artery in upper third. B. Radial artery in lower third. C. Ulnar artery in upper third. D. Ulnar artery in lower third. (Stimson.) Relations of right radial artery above the wrist. (Esmarch.) and the supinator longus on the outer side; the radial nerve at this part of the arm is in close relation with the vessel to the radial side, and the needle should be passed around the artery from without inward. LIGATION OF ULNAR ARTERY. 411 Ligation of the Radial Artery in the Lower Third of the Forearm. Incision two inches in length following the same line (Fig. 822, B), ending one inch above the wrist. The skin, superficial fascia, and deep fascia being divided, the artery will be found between the tendon of the flexor carpi radialis on the inner side and the tendon of the supinator longus on the outer side. (Fig. 324.) The veins being separated the needle may be passed in either direction. Ligation of the Radial Artery at the Root of the Thumb. The radial artery may also be tied at the root of the thumb. Incision one inch in length between the tendons of the extensor ossis metacarpi pollicis and extensor primi inter- nodii pollicis on the outer side, and the tendon of the ex- tensor secundi internodii pollicis on the inner side. The skin and superficial fascia being divided and the radial vein being displaced, the deep fascia is opened and the artery is exposed at the bottom of the wound; the needle may be passed in either direction. Ligation of the Ulnar Artery. The ulnar artery is tied at the junction of the upper and middle third of the forearm and at the lower third. Ligation of the Ulnar Artery at the Junction of the Upper and Middle Thirds of the Forearm. Incision three inches in length, starting four inches below the internal condyle of the humerus, on a line passing from the internal condyle of the humerus to the outer border of the pisiform bone. (Fig. 322, C.) Divide the skin and superficial fascia, and when the deep fascia has been exposed the interspace between the flexor carpi ulnaris and the flexor sublimis digitorum appears, enter this interspace and raise 412 LIGATION OF ARTERIES. the flexor sublimis digitorum and work transversely across the arm, and the artery will be found resting upon the deep flexor, with the ulnar nerve to the ulnar side. The needle should be passed from the nerve around the artery. (Fig. 325.) Fig. 325. Relations of the right ulnar artery at upper third of forearm. (Esmarch.) Fig. 326. Ligatioii of the Ulnar Artery in the Lower Third of the Forearm. Incision two inches in length a little to the radial side of the tendon of the flexor carpi ulnaris, which is attached to the pisiform bone, ending an inch above the wrist. (Fig. 322, B.) Divide the skin and superficial fascia and open the deep fascia, and the artery will be exposed, with accompanying veins, between the tendons of the flexor carpi ulnaris and flexor sublimis digitorum, the ulnar nerve being to the ulnar side of the vessel. The needle should Relations of right ulnar artery be passed from within outward above the wrist. (Esmarch.) to avoid the nerve. (Fig. 326.) LIGATION OF COMMON ILIAC ARTERY. 413 Ligation of the Interosseous Artery. Incision similar to that employed in the ligation of the ulnar artery in its upper third. Ligation of the Abdominal Aorta. Incision in the linea alba from a point three inches above the umbilicus to a point three inches below it. The super- ficial structures being divided the peritoneum is opened upon a director, and the intestines are pressed aside and the aorta is exposed covered by peritoneum, with the fila- ments of the sympathetic nerve resting upon it, and the vena cava to the right side. Tear through the peritoneum and pass the needle from left to right around the vessel. After tving the ligature the ends should be cut short, and the external wound should be closed as in the ordinary laparotomy wound. The vessel may also be exposed by an incision along the anterior border of the quadratus lumborum muscle, from the last rib to the crest of the ilium. The skin, lumbar muscles, and fascia transversalis being divided, the wound is held open with blunt hooks, so that the retro-peritoneal space is exposed and the aorta brought into view. The vessel being separated from the vena cava and nerves, the needle is passed around it and the ligature applied. Ligation of the Common Iliac Artery. The aorta divides into the two common iliac arteries on the left side of the fourth lumbar vertebra, and these arteries are usually about two inches in length, and bifurcate oppo- site the sacro-iliac synchondrosis to form the internal and external iliac arteries ; the length of the common iliac artery, however, may vary considerably, being three or four inches in length in some cases. Incision for ligation of the common iliac artery is four to six inches in length, beginning one-half inch above the middle 414 LIGATION OF ARTERIES of Poupart's ligament, and is carried outward curving up- ward after passing the anterior superior spine of the ilium. (Fig. ,327, A.) Divide the skin, superficial fascia and aponeurosis of the external oblique muscle, and then divide the fibres of the in- ternal oblique and transversalis muscles upon a director, and expose the transversalis fascia. This is opened at the lower Fig. 327. Line of incision for — A, common iliac artery. B, external iliac artery. C, femoral artery in Scarpa's triangle. (Stimson.) part of the wound, and the finger is introduced and the peritoneum is pressed back ; the opening in the transversalis fascia is next enlarged, and the peritoneum is carefully drawn inward and upward with the fingers toward the inner edge of the wound. The operator next feels for the external iliac artery, and passes the finger along this until the common iliac artery is reached. The loose cellular tissue in which it is imbedded is next separated, and the needle is passed from within outward, to avoid the common iliac vein (Fig. 328), LIGATION OF INTERNAL ILIAC ARTERY. 415 which on the left side lies on the inner side of the artery, and on the right side it lies behind the artery. The ureter generally remains attached to the peritoneum ; if not, it is seen crossing the bifurcation of the common iliac with the Fig. 328. Ligation of the common iliac artery. (Liston.) genito-crural nerve, and care should be taken to avoid injury of these structures if present. The common iliac artery may also be exposed and tied by an incision made over the artery through the peritoneal cavity ; the vessel being tied, the ends of the ligature are cut short, and the external wound is closed in the same manner as that resulting from the exposure of the abdominal aorta by incision through the peritoneum. Ligation of the Internal Iliac Artery. Incision in the same line as for the common iliac artery, but it need not be quite so long. (Fig. 327, A.) The peri- 416 LIGATION OF ARTERIES. toneum being exposed, it is pushed upward and inward, and the internal iliac artery is exposed. The vessel is carefully isolated from the vein, which lies behind and on the inner side, and the needle is passed from within outward. Ligation of the External Iliac Artery. Incision three or four inches in length, half an inch above the middle of Poupart's ligament, made at first par- allel to it and then curved upward. (Fig. 327, B.) The tissues of the abdominal wall being divided and the peri- Relations of the right external iliac artery. (Esmarch.) toneum exposed, it is pushed upward and inward in the same manner as for exposure of the common iliac artery. The artery lies at the inner border of the psoas muscle, the vein on its inner side, and the anterior crural nerve covered by the iliac fascia on the outer side ; the genito-crural nerve passes obliquely across the artery. (Fig. 329.) The needle should be passed from within outward. SCIATIC AND INTERNAL PUDIC ARTERIES. 417 Ligation of the Gluteal Artery. Incision three or four inches in length, from the posterior superior spinous process of the ilium to a point midway between the tuber ischii and the great trochanter. (Fig. 330, A.) After division of the skin and fascia, the fibres Fig. 330. Line for — A, gluteal artery. B, sciatic and internal pudic artery. (Stimson.) of the gluteus maximus muscle are separated and held apart, and the deep fascia is divided, and the artery is sought for above the pyriformis muscle at the upper border of the great sacro-sciatic notch. It is accompanied by large veins, injury to which should be avoided in exposing the artery and pass- ing the needle. Ligation of the Sciatic and Internal Pudic Arteries. Incision three or four inches in length, a little lower than that employed for exposure of the gluteal artery. (Fig. 330, 418 LIGATION OF ARTERIES. B.) Divide the skin, superficial fascia and fibres of the gluteus maximus muscle and deep fascia, and search for the vessels as they leave the great sciatic notch at the lower edge of the pyriformis muscle. The internal pudic artery enters the pelvis through the lesser sciatic notch, lying on the inner side of the sciatic artery during its passage over the spine of the ischium. The vessels are isolated and the needle is passed so as to avoid injury of the veins. Ligation of the Femoral Artery. The femoral artery may be ligated just below Poupart's ligament, at the apex of Scarpa's triangle, at the middle of the thigh, or in Hunter's canal. Ligation of the Femoral Artery below Poupart's Ligament. Incision beginning midway between the anterior supe- rior spinous process of the ilium and the symphysis pubis, Fig. 331. Relations of the right femoral artery below Poupart's ligament. (Esmaech.) LIGATION OF FEMORAL ARTERY. 419 one-fourth of an inch above Poupart's ligament, and ex- tending ten inches downward. Divide the skin and super- ficial fascia and the deep fascia and expose the sheath of the vessels ; open this one-half an inch below Poupart's ligament and isolate the femoral artery from the femoral vein which lies to the inner side ; the anterior crural nerve lies to the outer side. Pass the needle from within outward. Ligation of the Femoral Artery at the Apex of Scarpa s Triangle. Incision three inches long, the centre of which should be a little above the point where the sartorius muscle crosses a line drawn from the middle of Poupart's ligament to the inner condyle of the femur. (Fig. 332.) Divide the skin, Fig. 332. — - Lines of incision for the femoral artery. (Stimson.) superficial fascia and deep fascia, avoiding the internal saphenous vein, and expose the edge of the sartorius muscle, which may be recognized by the direction of its fibres. This muscle is drawn outward and the sheath of the vessels is exposed and opened ; the vein lies on the inner side and somewhat behind the artery and the long saphenous nerve is on the outer side. (Fig. 333.) Pass the needle from within outward. 420 LIGATION" OF AKTERIES, Ligation of the Femoral Artery in the Middle of the Thigh. Incision in the line above mentioned, its centre being a little above the middle of the thigh. Divide the skin, super- Fig. 333. Fig. 334. Eelations of right femoral artery at the apex of Scarpa's triangle. (Esmarch.) Eelations of the right femoral artery in the middle of the thigh. (Esmarch.) ficial and deep fascia and expose the sartorius muscle which is drawn outward after the leg has been flexed; the sheath of the vessels is exposed and opened ; the long saphenous nerve lies upon the artery and the femoral vein lies behind the artery; the saphenous vein lies more superficially and internal to the vessel. Pass the needle from within out- ward. (Fig. 334.) Ligation of the Femoral Artery in Hunter s Canal. Incision three inches in length along the tendon of the adductor magnus, the centre of which is at the junction of the lower and middle thirds of the thigh. (Fig. 332.) Divide the skin, superficial fascia and deep fascia, care being LIGATION" OF POPLITEAL ARTERY 421 taken not to injure the internal saphenous vein, which should be displaced and expose the sartorius muscle, which should be displaced downward and expose the aponeurosis which forms the anterior wall of the vascular canal ; this should be opened upon a director, and the artery is uncovered and should be separated from the vein, which lies upon the outer side. The needle is passed from without inward. Ligation of the Popliteal Artery. Indsion three or four inches in length, along the exter- nal border of the semi-membranosus muscle. Divide the Fig. 33! Relations of the right popliteal artery. (Esmabch. skin and superficial fascia, taking care not to injure the saphenous vein, and open the deep fascia. The edges of the 19 422 LIGATION OF ARTERIES wound being held apart the adipose tissue is broken up with a director, and the internal popliteal nerve will be first Fig. 336. • ./ Ligation of popliteal artery. (Smith.) exposed, and next the vein — both external to the artery. (Fig. 335.) The artery is isolated and the needle is passed from without inward. (Fig. 336.) Ligation of the Anterior Tibial Artery. The anterior tibial artery may be tied in the upper, middle, and lower thirds of the leg ; the general direction of the artery corresponds with a line drawn from the middle of the space between the head of the fibula and the tubercle of the tibia to the middle of the anterior intermalleolar space. Ligation of the Anterior Tibial Artery in the Upper Third of the Leg. Incision two and a half to three inches in length, one and one-fourth inches external to the spine of the tibia. Divide the skin and superficial fascia, and when the deep fascia is exposed open it on a line corresponding to the intermuscular space between the tibialis anticus and the LIGATION OF ANTERIOR TIBIAL ARTERY. 423 extensor longus digitorum muscles. Separate the muscles and work down in this interspace, and the artery will be found with a vein on either side of it, and the anterior tibial nerve externally. (Fig. 337.) The needle should be passed from without inward, veins. Fig 337. after isolating the Ligation of the Anterior Tibial Artery at its Middle Third. Incision three inches in length in the same line as that for the upper portion of the vessel. After dividing the skin, superficial and deep fascia, the interspace between the tibialis anticus and the ex- tensor longus digitorum muscles is opened and a third muscle comes in view, the extensor proprius pollicis The artery lies between the ex- tensor proprius pollicis and the tibialis anticus muscles, and the anterior tibial nerve is to the outer side. The veins should be isolated and the needle should be passed from with- out inward. Ligation of the anterior tibial artery at its upper third. (Stimson.) Ligation of the Anterior Tibial Artery in its Lower Third. Incision two inches in length, beginning three inches above the ankle-joint on the line of the artery. Divide the skin, superficial and deep fascia, and seek for the tendon of the extensor proprius pollicis muscle, the second tendon from the tibia. The artery is found in the interspace be- tween this tendon and the tendon of the extensor longus digitorum muscle, the nerve being to the outer side. The veins are isolated from the artery, and the needle is passed from without inward. 424 LIGATION OF ARTERIES. Ligation of the Dorsalis Pedis Artery. Incision one inch in length on a line drawn from the middle of the anterior inter-malleolar space to a point midway between the extremities of the first two metatarsal bones or along the outer border of the tendon of the extensor proprius pollicis. Divide the skin, superficial and deep fascia, and Fig. 338. muscle Extensor Tj/rvis cliff Horn mi-- — r If^ ,| Te/ir7on of --WTs/esiso/ :d//ro/irius I /lollicis i Ligation of the dorsalis pedis artery. (Bryant.) the artery will be found lying next to the inner tendon of the short extensor muscle of the toes. (Fig. 338.) The nerve is to the outer side. After separating the veins the needle is passed from without inward. Ligation of the Posterior Tibial Artery. The course of the posterior tibial artery is indicated by a line drawn from the middle of the popliteal space to a point LIGATION OF POSTERIOR TIBIAL ARTERY. 425 midway between the tendo Achillis and the internal mal- leolus of the tibia. The posterior tibial artery may be ligated in its upper, middle, and lower thirds. Ligation of the Posterior Tibial Artery at its Upper Third. Incision three inches and a half in length, one-half inch from the inner edge of the tibia, beginning two inches from the upper edge of the tibia. (Fig. 339.) Divide the skin and superficial fascia, avoiding large superficial veins; next open the deep fascia and detach the origin of the soleus muscle from the tibia, and on raising it, its under surface will pre- sent a white shining sheath of tendinous material, beneath which will be seen a layer of fascia covering the tibialis pos- ticus muscle. If search is made toward the middle of the leg, the artery will be found covered by the inter- muscular fascia, the nerve being to the outer side. The needle is passed from without inward after the veins have been separated from the artery (Fig. 340). Lines of incision for the posterior tibial artery. (Stimsox.) Ligation of the Posterior Tibial Artery at its Middle Third. Incision two and a half inches in length, parallel with the inner edge of the tibia and half an inch from its border. 426 LIGATION OF ARTERIES. Divide the skin, superficial and deep fascia, and the inner edge of the soleus will be exposed ; press this outward and Fig. 340. Relations of the right posterior tibial artery in its upper third. (Esmaech.) the artery with its veins will be exposed, also the posterior tibial nerve to the outer side. Pass the needle from without inward after separating the veins. Ligation of the Posterior Tibial Artery Behind the Inner Malleolus. Incision a curved one two inches in length, midway be- tween the tendo Achillis and the internal malleolus. (Fig. 339.) Divide the skin and superficial fascia and lift the deep fascia upon a director and open it freely and the artery will be exposed with the tendons of the tibialis posticus and flexor longus digitorum muscles on the inuer side and the posterior tibial nerve and the tendon of the flexor longus LIGATION OF POSTERIOR TIBIAL ARTERY. 427 Fio 341. Ligation of the posterior tibial artery behind inner malleolus. (Bryant.) pollicis muscle on the outer side. (Fig. 341.) After sepa- rating the veins from the artery the needle should be passed from without inward. PAET VI AMPUTATIONS The term amputation is now generally applied to the re- moval of a limb, and this may be removed through the bones, when the operation is spoken of as an amputation in the continuity of the limb ; or it may be removed through its joints, and is then known as an amputation in the con- tiguity or a disarticulation. Methods of Amputating. Amputations may be performed by the circular, flap, oval, and elliptical methods; the modified circular operation, and Teales method by rectangular flaps, are also employed. Amputation by circular method. (Druitt.) METHODS OF AMPUTATING. 429 Fig. 343. Circular Method. In performing an amputation by this method the incision of the skin is made at a distance below the point where the bone is to be divided. An assistant grasps the limb and draws the skin evenly and firmly toward the root of the part and the surgeon passes the heel of the knife well into the tissues and makes a circular sweep around the limb and com- pletes the division of the skin and cellular tissue with one mo- tion of the knife. (Fig. 342.) In some cases a cutaneous sleeve consisting of the skin and cellular tissue is dissected up and turned back, and sometimes it may be necessary to make a slit on one side of the flap to allow it to be turned up. The second incision in an am- putation by the circular method consists, after retraction of the skin, in making a circular cut through all of the tissues down to the bone. (Fig. 343.) The third step in an amputation by the circular method consists, after retracting the skin and muscles and holding them back by a retractor, in the division of the bone with a saw. Flap Method, This method of amputating is susceptible of many varia- tions. There may be one or two flaps of equal or unequal length ; the flaps may be cut antero-posteriorly, laterally, or obliquely. (Fig. 344.) They may be made by transfixing the limb and cutting outward, or they may be cut from without inward, or they may be made to include the whole thickness of the tissues down to the bone, or merely the skin and superficial fascia, the deeper structures being divided by a circular incision. The flaps may have a curved outline 19* Division of muscles in circular amputation. (Smith.) 430 AMPUTATIONS or may be rectangular in shape. In amputating by the anteroposterior flap operation the surgeon grasps the limb Fig. 344. Double-flap amputation; antero-posterior and lateral flaps. (S. Smith.) and enters the point of a long knife into the tissues at the side nearest himself, and pushing it across and around the Fig. 345. Amputation by antero-posterior flaps. (Bryant.) bone or bones brings its point out through the skin at a point diametrically opposite its point of entrance. He then shapes the flap by cutting downward with a rapid sawing METHODS OF AMPUTATING. 431 motion and then cuts obliquely forward until all the tissues are divided. The flap being turned up, he reenters his knife at the same point and passes it on the other side of the bone or bones and cuts the second flap in the same manner. (Fig. 345.) A retractor is next applied and the bone is divided with a saw. The Oval Method. The oval amputation is really a circular one in w T hich the cuff of skin has been slit at one side and the angles rounded off. This is the form of amputation frequently performed at the metacarpophalangeal and metatarso- phalangeal joints, and is one of the methods of amputation at the shoulder- joint. Elliptical Method. This is a form of the oval method of amputation which is employed in amputations at the knee- and elbow-joints, the incision forming an ellipse coming below the joint on the front or outside of the limb, the resulting flap being folded upon itself. Fig. 346. Modified circular amputation. (Skey.) 432 AMPUTATIONS. Modified Circular Method. In this method of amputation two oval skin flaps, antero- posterior or lateral, are turned up, and the muscles are next divided by a circular sweep of the knife down to the bone (Fig. 346). Teales Method by Rectangular Flaps. In this method of amputation, two flaps are made of un- equal length ; the incisions are so planned that the shorter flap contains the main vessel or vessels. The flaps are cut of equal width and the length of the long flap should be one-half of the circumference of the limb at the point where the bone is to be divided ; the length of the short flap should be one-eighth of the circumference of the limb. The flaps are cut from without inward, and embrace all of the tissues of the limb down to the bone. After the flaps have been dissected up, the bone is divided with a saw, and the long flap is folded over and sutured to the short flap (Fig. 347). Fig. 347. Teale's method of amputation. (Bryant.) The disadvantage of this method of amputation is that in muscular limbs it requires the bone to be divided at a higher point than would otherwise be necessary. INSTRUMENTS FOR AMPUTATIONS. 433 Periosteal Flaps. In any of the methods of amputation previously described the periosteum may be dissected up in two flaps attached to the muscles, or pushed up as a sleeve by means of a direc- tor or periosteotome before the bone is sawed. This pro- cedure is most easily accomplished in young subjects. When these flaps are made and they are brought together, the periosteum covers the cut surface of the bone, to which it soon forms adhesions. Instruments Required for Amputations. The instruments required for amputations are knives of various shapes and sizes, saws, dissecting forceps, bone for- ceps, artery forceps, tenacula, haemostatic forceps, scissors, periosteotome, tourniquets, Esmarch's bandage and strap, retractors, ligatures, sutures, and suture needles. Amputating Knives. The knives required for amputations vary according to the method of amputation and the part to be amputated. Fig. 348. Scalpel. Fig. 349. Straight bistoury. In certain amputations a scalpel (Fig. 348) or straight bis- toury may be used (Fig. 349), while in other cases the em- ployment of amputating knives of various sizes will be found more satisfactory. For amputations of the thigh a knife with a blade of eight or nine inches is generally em- -±34 AMPUTATIONS. ployed, and for smaller limbs a knife with a blade of six or seven inches in length ; double-edged catlins are employed in Fig. 350. ■ LCYLENTZ &SONS Amputating knife and catlin. amputations of the leg and forearm to divide the inter- osseous tissues before applying the saw. The amputating knives now employed are constructed with solid metal handles so that they can be rendered thoroughly aseptic by immersion in boiling water before being used. Amputating Saivs. Several kinds of amputating saws are in general use ; one with a blade ten inches long by two and a half inches wide, Fig 351. Amputating saw. Fig. 352. Small amputating saw, with a heavy back to give it additional firmness, is a very good variety of saw (Fig. 351). For amputations about the foot or hand a narrow saw with a movable back will be INSTRUMENTS FOR AMPUTATIONS. 435 found very convenient. (Fig. 352.) A bow saw with a metallic handle and a reversible blade is a very useful variety of saw, as it can be used either in amputations or in Fig. 353. C\ vs>t.--;jt<=^-~vji Amputating saw with reversible blade. excisions, and, being constructed entirely of metal, it can be easily rendered aseptic. (Fig. 353.) Bone Forceps, or Cutting Pliers. These instruments are used in smoothing off any rough edges of bone left after the use of the saw, or for the division of the small bones in amputations of the fingers and toes. Fig. 354. Bone forceps, or cutting pliers. The forceps should be from ten to twelve inches in length, with blades from one to one and a half inches in length. (Fig. 354.) Per {osteotome. The periosteotome, or raspatory, is employed for dissecting up a flap of periosteum, which, after sawing the bone, is drawn down over the sawed end of the bone. (Fig. 355.) 436 AMPUTATIONS. Fig. 355. Periosteotome. Artery Forceps and Tenacula. These instiuments are used for taking up the vessels, and one of the best forms of artery forceps is that known as the double-spring artery forceps. (Fig. 188, p. 252.) Tenacula Fig. 356. Eetractor applied. (Esmarch.) are also employed for the same purpose. Hcemostatic for- ceps will also be found most useful in cases of amputation, for the rapid control of hemorrhage from small vessels after the tourniquet has been removed, the vessels being secured by ligatures before the haemostatic forceps are removed. INSTRUMENTS FOR AMPUTATIONS. 437 Retractors. These consist of pieces of muslin six or eight inches in width, one end of which is split into two or three tails ; the former variety of retractor is employed where one bone is divided, as in amputations of the arm and thigh, and the latter in cases where two bones are divided, as in amputa- tions of the forearm and leg. (Fig. 356.) Ligatures. The best material to employ for the ligature of vessels is juniper or chromicized catgut, the preparation of which has been described. Sutures. The materials employed for sutures in cases of amputation may be silkworm -gut, catgut, silk, or silver wire ; deep or buried sutures of catgut in bringing together the edges of the Fig. 357. Fig. 35S. Deep or buried sutures of muscles. | EsMARCH.) Sutures of skin. (Esmarch.) periosteal flaps, muscles, and fascia, are often employed with advantage in amputations (Fig. 357), the skin flaps being brought together with interrupted or continuous sutures of silk, catgut, silkworm-gut, or silver wire. (Fig. 358.) 438 AMPUTATIONS. Tourniquets. For the control of hemorrhage during the amputation the Esmarch apparatus (Fig. 186), or Petit's tourniquet (Fig. 179) is employed ; or the employment of both at the same time will often be found most satisfactory. The Esmarch bandage and tube being applied, after the removal of the bandage the tourniquet of Petit is loosely applied at a higher point, and after the main vessels have been secured the elastic strap is removed and the tourniquet is screwed down and controls the bleeding until the smaller vessels have been secured by ligatures. Details of an Amputation. The following are the steps of an amputation of the lower part of the thigh : The skin is first thoroughly cleansed by rubbing it with turpentine and soap and water and is then washed with an antiseptic solution either of carbolic acid 1 : 40 or bichloride of mercury 1 : 2000. Provision is next made to prevent the loss of blood during the operation by the application of Esmarch's bandage and tube; the bandage being removed a tourniquet is placed over the femoral artery in Scarpa's triangle and loosely secured. The limb is again washed with bichloride solution. The instruments having been previously placed in an antiseptic solution, a rubber cloth covered with towels wrung out in a bichloride solution is placed under the limb. The variety of amputation having been decided upon, the flaps are cut and the muscles are divided down to the bone ; the periosteum being dissected up, a two- tailed retractor is applied and the tissues are held back by an assistant while the surgeon divides the bone with the saw. When the bone has been divided the retractor is removed and the surface of the wound is irrigated with a 1 : 2000 bichloride solution. The femoral artery and vein are next found and secured with ligatures, and any branches which can be found are also secured. The elastic str .p is removed after screwing down the tourniquet, and by letting up the DETAILS OF AMPUTATION. 439 pressure on this, smaller vessels which bleed are picked up with artery forceps or hemostatic forceps and secured. After all bleeding has been controlled the tourniquet is re- moved and the wound is again thoroughly irrigated with a 1 : 2000 bichloride solution. If there is much oozing from smaller vessels this solution should be as hot as the hands of the operator can comfortably stand, which will act promptly in controlling this variety of bleeding. The periosteal flaps, if they have been made, are brought together by two or three catgut sutures, and a drainage-tube is next introduced or two short tubes are introduced at either extremity of the wound Fig. 359. Stump showing application of sutures and drainage-tubes. (Smith.) and secured by sutures or safety-pins ; the muscles should next be brought together by a few deep or buried sutures of catgut, and the skin flaps should then be brought into appo- sition by a number of interrupted sutures. The inner sur- face of the stump is next irrigated by a stream of bichloride solution introduced through the drainage-tube, and the sur- face of the stump is washed with the same solution ; a piece of protective is next placed over the line of the wound and over this is placed a moist carbolized, bichloride, or 440 AMPUTATIONS. iodoform gauze dressing, and over this a number of layers of dry gauze ; this is next covered by rubber tissue and a num- ber of layers of bichloride cotton, or if the dry method of dressing is preferred the rubber tissue is omitted and a number of layers of bichloride cotton are laid over the gauze dressing, and the whole dressing is held in place by a recurrent bandage of the stump. Re-dressing of Amputations. The first dressing of an amputation, if strict antiseptic precautions have been observed at the time of operation, need not, as a rule, be made for a week or ten days, except in cases where the oozing is so profuse as to soak the dress- ings, or where consecutive hemorrhage has occurred, or the patient's condition shows that the wound is not running an aseptic course. The re-dressing of a stump can be accom- plished without pain to the patient if the surgeon and his assistants are careful in their manipulations. The dressings to be applied, the solutions for irrigation, and the instruments required should be prepared and at hand before the stump is exposed. The surgeon and his assistants should wash their hands carefully, and then dip them in a 1 : 2000 bichloride solution. The bandage retain- ing the dressings to the stump should be divided with ban- dage scissors without lifting the stump from the pillow upon which it rests. After the bandage has been divided and turned aside, the gauze dressing is next unfolded and turned down ; an assistant now slips his hands under the stump and gently raises it from the dressings, and at the same time a rubber cloth covered with towels which have been wrung out in a 1 : 2000 bichloride solution is slipped under the stump and the soiled dressings are removed. The protective cover- ing the incision is next removed and the surface of the stump is irrigated with a 1 : 2000 bichloride solution ; the drainage-tubes are next examined and the cavity of the stump is irrigated with the bichloride solution through the tubes by means of a syringe or an irrigating apparatus. AMPUTATIONS OF THE FINGERS. 441 If the wound is aseptic and there seems to be no further indication for the use of the drainage-tubes they may be re- moved and the track of the tube should be washed out with the antiseptic solution by the syringe or irrigator. The sutures are next examined and if the wound is firmly healed alternate sutures may be removed ; if catgut or silkworm-gut sutures have been used they need not be disturbed at this dressing, and their removal may be postponed until a subsequent dressing. The wound should next be covered w T ith a piece of pro- tective, and a gauze dressing should be applied consisting of a number of layers of bichloride cotton, and the dressings should be held in place by a recurrent bandage of the stump. In holding the stump the assistant should hold it firmly to prevent muscular spasm, and after the dressings have been secured it should be placed upon a clean pillow prepared for its reception. The same procedures are adopted at subsequent dressings, and if the wound has run an aseptic course, two or three dressings, at most, will be required. Special Amputations. Amputations of the Hand. Amputations of the Fingers. The fingers may be amputated in the continuity of the phalanges or in their contiguity, and, as a rule, as it is im- portant to save as much as possible of the finger, the former method is generally to be employed instead of disarticula- tion at a higher point. The incisions should be so planned that the cicatrix does not occupy the plantar surface ; the larger flap should, therefore, be taken from the palmar aspect of the finger. In amputating the phalanges of the fingers in their continuity the circular method (Fig. 363, B) or a short dorsal flap and a long palmar flap may be em- ployed. In disarticulating a phalanx it is best to enter the joint with a narrow knife from the dorsal side, and after 442 AMPUTATIONS. having carried it through the joint, to cut a long palmar flap, keeping close to the bone. (Fig. 360.) In locating Amputation of finger: long palmar flap. (Ertchsen.) the position of the phalangeal joints it is well to remember that the prominence of the knuckle, when the finger is flexed is formed entirely of the head of the proximal, and Fig. 361. Phalanges flexed. Guides to articulations of the finger. (Smith.) not of the base of the distal phalanx (Fig. 361), and also that the folds on the palmar surface of the finger do not correspond exactly to the joints. (Fig. 362.) AMPUTATIONS OF THE FINGERS. 443 Amputation of the Finger' through Metacarpo-phalangeal Articulation. In this variety of amputation an incision is made from a point of the dorsal surface of the metacarpal bone a quarter of an inch above the articulation, which is carried through the interdigital web and back upon the palmar sur- Fig. 363. A. Disarticulation of phalanx, palmar flap. B. Amputation in contin- uity, circular. C. Metacarpo-phalangeal disarticulation. D. Amputation of metacarpal bone in continuity. E. Disarticulation of little finger. F. Disarticulation of fifth metacarpal bone. G. Amputation at the wrist, circular. H. Amputation at the wrist. (Stimson.) face to a point a quarter of an inch above the flexor fold (Fig. 363, C). A similar incision beginning and ending at the same points is made upon the opposite side of the finger. The flaps are dissected back, and the lateral ligaments, ten- dons, and remainder of the capsule are divided. The 444 AMPUTATIONS finger may also be amputated at the metacarpophalangeal joint by making an incision on one side and dissecting the flap back to the joint, then dividing the lateral ligament, opening the joint and carrying the knife across this, divid- ing the tendons and lateral ligament on the other side and cutting a flap from within outward. Removal of the head of the metacarpal bone if desired may be accomplished by the use of cutting pliers (Fig. 364), Fig. 364. Eemoval of head of metacarpal bone. (Skky.) but, as a rule, this procedure is not to be recommended, for, although the deformity is diminished, the strength of the hand is also diminished. In amputating the little and index fingers a full lateral flap may be cut on the free side and an incision is next car- ried across the palmar surface to the angle of the web and thence back to the joint, which is opened and the disarticu- lation is effected. (Fig. 363, E.) In amputations of the finger at the phalangeal joints or at the metacarpophalangeal joints two vessels usually re- AMPUTATIONS OF THE HAND. 445 quire ligaturing, and after these are secured a catgut drain or a small drainage-tube is introduced and the flaps are brought together by a few interrupted sutures. Amputations of the Metacarpal Bones. In amputating the metacarpal bones it is advisable to leave the carpal ends of the bones to avoid opening the wrist-joint, except in the case of the first and fifth meta- carpal bones, which do not communicate with the others and with the synovial sacs. The incisions for the removal of the metacarpal bones are the same as for the removal of a finger at the meta- carpo-phalangeal joint, the incision being prolonged back- ward as far as necessary over the dorsal surface of the bone. (Fig. 363, D.) After the metacarpal bone has been bared for a sufficient distance, it is cut through with bone-pliers or disarticulated, and the distal end is raised from its bed and carefully separated from the soft parts, care being taken to avoid injury of the structures of the palm of the hand. In amputating the fifth metacarpal bone the incision should be made along the inner border of the hand and carried down to the bone between the skin and the ab- ductor minimi digitii muscle. (Fig. 365.) The lower end of the incision passes over the knuckle to the web of the finger and backward under the palmar surface to join the first incision. Amputation of the entire thumb with its metacarpal bone is effected by making an oval flap from the palmar surface ; in case of the left thumb the joint may be opened by an oblique incision on the dorsal surface of the hand, beginning a little in front of the joint and being carried down to the web between the thumb and fore- finger ; the palmar flap is then made by 20 Incision for re- moval of the fifth metacarpal bone. ('Smith. ) 446 AMPUTATIONS. thrusting the knife upward to its point of entrance and cut- ting downward and outward. In amputating the right thumb with its metacarpal bone it is better to make the palmar flap first by transfixion, the dorsal flap being made subsequently. Amputation of the hand at the carpo- metacarpal joint is occasionally performed, or between the rows of carpal bones, but is not as a rule to be recommended, as the carpal bones are apt subsequently to become diseased and require removal, so that it is better to amputate at the radio-carpal joint. Amputations at the Wrist. Circular Method. The skin of the forearm near the wrist being retracted by an assistant, a circular incision of the skin and cellular Fig. 366. Amputation at the wrist. (Erichsen.) tissue is made half an inch below the point of the styloid process of the radius. (Fig. 363, G-.) The skin and cellu- lar tissue are next dissected back as far as the joint, which is opened and the disarticulation is completed. AMPUTATIONS OF THE FOREARM. 447 Antero-posterior Flap Method. This method is also employed in amputations at the wrist- joint ; an incision carried downward is made on the back of the hand from one styloid process to the other; the hand being flexed the tendons are divided and the joint opened, and the palmar flap, which should extend as far as the base of the metacarpal bones, is cut from within outward. (Fig. 366.) Amputation at the wrist is sometimes done by cutting a single flap from the palm, the joint being opened by a transverse incision on the back of the hand from one styloid process to the other. Lateral Flap Method. This method (Fig. 363, H) is also sometimes employed in amputation at the wrist, and may be employed with ad- vantage in cases of laceration of the hand, in which the injury to the tissues prevents the formation of the flaps used in the other methods of amputation. Amputations of the Forearm. The forearm may be amputated by the circular or flap methods, or by making rectangular flaps (Teale's method). Circular Method. At the lower portion of the forearm the circular method of amputation is to be preferred. A circular incision of the skin and cellular tissue is made and a cuff is dissected up, the muscles and interosseous membrane being cut through ; a three-tailed retractor is next applied and the bones are divided with a saw. Mixed Method. Amputation of the forearm by the mixed method, which consists in first dissecting up two antero-posterior oval flaps of skin and cellular tissue and then dividing the muscles by a circular incision, is also a satisfactory operation. (Fig. 367.) 448 AMPUTATIONS. In amputations at the upper portion of the forearm, antero-posterior, or lateral flaps, cut from without inward or by transfixion, or rectangular flaps may be made with advantage. Fig. 367. Amputation of the forearm by mixed method. (Bryant.) The principal vessels requiring the application of liga- tures in amputations of the forearm are the radial, ulnar, and interosseous arteries. Amputations at the Elbow. The methods of amputation employed at the elbow are the anterior flap, lateral flap, and circular. Anterior Flap Method. A flap three inches in length with its base parallel to and half an inch below the condyles of the humerus, is cut either by transfixion or from without inward. The joint is next opened and the lateral ligaments divided and the olecranon is exposed and the attachment of the triceps is separated and a posterior flap is cut from without inward, or from within outward a little below the line of the condyles. (Fig. 368,4.) Lateral Flap Method. In amputation at the elbow-joint lateral flaps may be em- ployed, cut either from without inward or by transfixion. (Fig. 368, B) An external flap three inches in length is made on the outer side of the arm, starting from a point a finger's breadth below the bend of the elbow, by transfixion AMPUTATIONS AT THE ELBOW 449 or by cutting from without inward; a shorter internal flap is next cut in the same manner, and the joint is opened and the disarticulation effected. (Fig. 369.) Fig. 368. Fio. 3fi9. Amputation at the elbow- joint. A. Anterior flap method. B. External flap method. C. Circular method. (Stimson.) Lateral flap method of amputation at the elbow-joint. (Smith.) Fig. 370. Circular amputation at the elbow. (Smith.) Circular Method. An incision dividing the skin and cellular tissue is made around the limb three inches below the line of the condyles of the humerus (Fig. 368, (7), the skin is dissected up and a circular incision made through the muscles, the joint is opened and the disarticulation effected. (Fig. 370.) 450 AMPUTATIONS, Amputations of the Arm. The arm may be removed at any point below the attach- ment of the muscles at the axilla, by either the circular, flap, oval, or modified circular methods. Circular Method. This operation is usually employed in removing the arm in its lower third : a circular incision of the skin and muscles Fig. 371. Circular amputation of the arm. is first made, and when the cuff has been dissected up, a circular division of the muscles is made, and after applying the retractor the bone is sawed through. (Fig. 371.) Flap Method. From the central position of the bone in the arm the flap method in amputating the arm is preferred by many operators. The arm being grasped by the hand the point of a medium-sized amputating knife is thrust through the arm so as to pass over the humerus and make its exit at a corresponding point in the skin on the opposite side ; a flap of sufficient length is cut from within outward. The knife is next passed behind the bone and a posterior flap is cut in AMPUTATIONS OF THE ARM. 451 the same manner (Fig. 372) ; the bone is next cleared of muscular tissue and the flaps are retracted and it is divided with a saw. Fig. 372. Amputation of the arm by flap operation. (Bktant.) Lateral flaps may be made in this amputation in the place of the antero-posterior flaps, and they are cut from within outward in the same manner. Oval, or Modified Oval Method. This method of amputating the arm is also employed with advantage. An oval flap of skin and cellular tissue is made and dissected up, and the muscular tissue is divided by a circular incision. Or two oval flaps of skin and cellular tissue are cut and dissected up, and the muscles are next divided by a circular sweep of the knife. In all amputations of the arm it is well to remember the possibility of a high division of the brachial artery, and to see that the abnormal vessel is properly secured, if present. In high amputations of the arm there is sometimes not room enough to apply Esmarch's strap or a tourniquet to the arm itself to control the hemorrhage during the opera- tion, and in such cases the strap may be passed from the axilla around the outer end of the clavicle, as is done to control the bleeding during amputation at the shoulder-joint. (Fig. 373). 452 AMPUTATIONS Fig. 373. Esmarch's strap applied in high amputation of the arm. (Smith.) Amputations at the Shoulder-joint. Several methods of operation are employed in amputating at the shoulder-joint, such as the oval method, or Larrey's method, flap method, Lisfranc's or Dupuytren's method, and Fig. 374. Amputation at the shoulder-joint. A. Oval, or Larrey's method. B. Double-flap, or Lisfranc's method. (Stimson.) AMPUTATIONS AT THE SHOULDER-JOINT. 453 Spence's method. (Fig. 374.) The control of the bleeding from the axillary artery during the operation is a matter of the first importance, and it may be arrested by pressure made upon the subclavian artery, as it crosses the first rib, with the thumb, or the padded handle of a large key, or by the fingers of an assistant grasping the axillary flap and com- pressing the vessel after the head of the bone has been dis- articulated, or by the use of an elastic strap applied around the axilla and shoulder. (Fig. 373.) Oval, or Larrey's Method. In this method of amputation the point of the knife is entered just below the acromion process, and a deep incision Amputation at the shoulder-joint by Larrey's method. three inches in length is made down to the head of the bone in the axis of the arm ; from the middle of this incision two 20* 454 AMPUTATIONS. others are made obliquely downward to the points where the anterior and posterior folds of the axilla end in the tissues of the arm : the latter incision should be only deep enough to divide the skin and superficial fascia. The flaps are then dissected up until the head of the bone is well exposed, and, after opening the capsule and dividing the muscles inserted into the neck and tuberosities of the humerus, which division may be facilitated by rotating the head of the bone outward and inward, the disarticulation is effected by adducting the elbow ; the knife is next passed downward behind the bone and made to cut outward in the line of the cutaneous incis- ions — an assistant controlling the artery before it is divided, by grasping the axillary tissues behind the knife with his fingers. Flap, or Dupuytreri 's Method. In this method of amputation at the shoulder -joint the flaps may be cut either by transfixion, or from without in- Fig. 37 Amputation at the shoulder-joint, Dupuytren's method. (Bryant.) ward ; the large flap embraces the greater part of the deltoid muscle, and the smaller or short flap is cut from the inside of the arm after the head of the bone has been dis- articulated. When cut by transfixion, the point of the knife AMPUTATIONS AT THE S HOU LDE R- JOINT , 455 should be entered an inch in front of the acromion process and pushed across the outer aspect of the head of the humerus, and should be brought out at the posterior fold of the axilla ; the knife is made to cut downward until a large deltoid flap is formed. This flap is turned up, and the head of the bone is disarticulated ; the knife being placed behind it, a short flap is cut out, keeping close to the bone so that the vessel is divided with the last cut of the knife. (Fig. 376.) An assistant should control the vessel by grasping the axillary tissues with his fingers behind the knife. Double Flap, or Lisfrancs Method. In this method of amputation at the shoulder-joint the point of the knife is entered at the outer side of the cora- coid process, and is carried across the outer aspect of the head of the humerus and brought out a little below the posterior border of the acromion process, and a long flap is cut downward. This flap is turned up and the attachments of the head of the FlG - 377 - bone are divided and it is disarticu- lated. The knife is again entered behind the bone, and a long posterior flap is cut from within outward. (Fig. 374, B) Spenee's Method. In this method of amputation at the shoulder-joint an incision is made down to the head of the humerus immediately in front of the coracoid process, and is continued downward through the clavicular fibres of the deltoid and pectoralis major muscles until the attachment of the latter to the humerus is reached. (Fig. 377.) The incision is now carried backward to the posterior fold of the axilla. A second incision, including only the skin and cellular tissue, is next made from the anterior portion of the first incision Amputation at the shoulder-joint. Spenee's method. (Stimson.) 456 AMPUTATIONS. across the inside of the arm to meet the incision on the outer part. The outer flap thus formed is turned up and the head of the bone is disarticulated, and the operation is com- pleted by dividing the remaining tissues on the axillary aspect. Many other methods of removing the arm at the shoulder- joint have been devised and employed, including the circular method. Amputation above the Shoulder- joint. This form of amputation consists in the removal of the arm with a part or the whole of the scapula and sometimes a portion of the clavicle. As this form of amputation is required in cases in which the laceration of the parts has passed beyond the shoulder- joint, or in cases of growths involving the tissues beyond the joint, no definite rule can be laid down for the incisions ; the only rule being as far as possible to make the incisions in such a manner that the least possible amount of skin is sacrificed, so that a sufficient covering for the wound can be obtained. Amputations of the Foot. Amputations of the Toes. The phalanges of the toes may be removed in the same manner as those of the fingers. It is better to amputate at the metatarso-phalangeal articulations than to attempt to remove them at the joints in front of this articulation, ex- cept in the case of the great toe, as the preservation of a portion of a toe is rather a discomfort than an advantage, except in the instance mentioned. All incisions should be made so that the resulting cicatrix does not occupy the plantar surface, and it is well to remember that the web of the toes is considerably below the position of the metatarso- phalangeal joint. (Fig. 378.) The toes are usually removed by an incision on the dorsal AMPUTATIONS OF THE TOES, 457 surface a little above the joint, which is carried down the bone for about an inch and then diverges into the web, and Fig. 378. Fig. 379. Relations of web and metarso- phalangeal joint of toes. (Stimsox.) Incisions for amputation of toes and metatarsal bones. (Stimsox.) is carried under the toe and back on the other side to the point of divergence. (Fig. 378.) Amputation of Two Adjoining Toes. The dorsal incision should be made in the inter-metatarsal space just above the level of the joint (Fig. 379, B) and carried down to the beginnino; of the web ; then over the toe to the beginning of the adjoining web, and under the 458 AMPUTATIONS. plantar surface of both toes in the line of the digito-plantar fold, through the web and back to the point of divergence. Amputation of the Great Toe. This may be accomplished by means of the racket-shaped incision employed in amputation of the other toes or by means of a lateral flap. In the latter case the knife is made to enter the joint by cutting through the commissure, and the operation is completed by carrying the knife through the joint and along the outer or inner side of the bone, forming a flap of the required size. (Fig. 380.) In this amputation a short dorsal flap and long plantar flap may be employed, or a long internal flap may be used. Amputation of All the Toes. To amputate all the toes, make a dorsal incision from the head of the fifth to the head of the first metatarsal Fig. 380. Fig. 381. Amputation of the great toe. (Smith.) Incision for amputation of all the toes. (Smith.) bone ; the incision should be a curved one passing just in front of the joints. (Fig. 381.) Dissect up the flap and open the joints, dividing the lateral ligaments, and pass the AMPUTATION OF METATARSAL BONES. 459 knife behind the phalanges and cut a flap from the plantar surface. Amputation of the Metatarsal Bones. It is better in these amputations to leave the tarsal head of the metatarsal bone in place and divide the bone, or in other words to do an amputation in continuity to prevent opening up the tarsal articulations. Amputation of the Metatarsal Bone of the Great Toe. The incision begins upon the dorsal surface of the meta- tarsal bone, a little below the point at which the bone is to be divided, and is carried down below the metatarso-phalan- Fig. 382. Amputation of the great toe and first metatarsal bone. (Smith.) geal joint, then diverges and passes under the toe and comes back again to the point of divergence. (Fig. 379, 0.) The bone is exposed and cut through with cutting forceps and is then lifted up and dissected loose from the tissues. (Fig. 382.) 460 AMPUTATIONS. Amputation of the Fifth Metatarsal Bone. The incision for the removal of the fifth metatarsal bone is made over the bone a little below the metatarso-tarsal articulation, and is carried down and curved around the toe (Fig. 379, D), and after the bone is exposed by dissecting back the flaps, it is divided, or the joint is opened and it is dissected out. Amputation Through the Metatarsal Bones. In performing this amputation an incision is made across the dorsum of the foot and a short dorsal flap is dissected up ; the metatarsal bones are next divided with a saw and a long plantar flap is cut from within outward by entering the knife behind the ends of the bones. Tarso-metatarsal Amputations. In all amputations of the foot involving the tarsus the surgeon should be thoroughly familiar with the anatomy of the foot and the surgical landmarks of the diiferent articu- lations. I shall refer to those laid down by Mr. Bryant, which are as follows : " On the inner side of the foot not far from the inner malleolus the tubercle of the scaphoid (Fig. 383, A), is to be felt as a marked prominence ; about one-half an inch in front of this will be found the articulation with the cunei- form bone (i?), and one inch in front of this the joint which the surgeon will have to open in Lisfranc's or Hey's opera- tion (0); just above the tubercle of the scaphoid will be found the articulation with the astragalus, the line of Cho- part's amputation (D). On the outer side of the foot, one inch below the external malleolus, a sharply defined projec- tion will always be felt, which is the peroneal tubercle (E), one-half an inch in front of this will be found the joint which separates the os calcis from the cuboid (J 7 ), this joint forming the outer circle to Chopart's amputation. Half an inch in front again or one inch from the tubercle, the AMPUTATIONS OF THE FOOT 461 prominence of the fifth metatarsal bone is always to be felt (H), the line above this prominence indicating the articula- Fig. 3S3. Surgical guides to the foot as expressed by anatomy. (Bbyant.) Fig. 384. Incision for — A. Lisfranc' amputation. B. Chopart' amputation. (Stimson.) tion with the cuboid bone, which forms the outer boundary of the incision for Hey's or Lisfranc's amputations. Tar so- metatarsal Amputation [Lisfranc 's). The incision for this amputation is a curved one carried across the dorsum of the foot from the base of the fifth to the base of the first metatarsal bone. (Fig. 384, A.) The incision should involve the skin only, its centre lying half 462 AMPUTATIONS. an inch or more below the centre of the line of the articu- lations, and it should begin and end at the sides of the foot at their junction with the sole. A plantar flap should be marked out by a curved incision crossing the sole of the foot near the origin of the toes, starting and ending at the same points as the dorsal incision. The dorsal flap is next dissected back to the line of the articulations ; the tendons, muscular fibres, and fascia being divided, the joints between the tarsal and metatarsal bones are opened with a stout, narrow-bladed knife. (Fig. 385.) Fig. 385. Amputation at tarso-metatarsal joint (Lisfranc's). (Skey.) Difficulty is sometimes experienced in opening the joint be- tween the head of second metatarsal bone and the second cuneiform bone, which occupies a position higher on the foot than the other articulations. The disarticulation may also be facilitated by forcibly depressing the anterior por- tion of the foot. After the joints have all been opened, the knife is passed behind the ends of the metatarsal bones and a plantar flap is cut from within outward, following the line of the incision previously marked out. The plantar flap may be cut from without inward if preferred. AMPUTATIONS OF THE FOOT. 463 Tarso-metatarsal Amputation (Hey's). The line of incision and the steps of this operation are similar to those in Lisfranc's amputation, with the excep- tion that Hey sawed off the projecting portion of the internal cuneiform bone after disarticulating the metatarsal bones. This modification, although it improves the appear- ance of the stump, possesses no advantages over the previous procedure. Medio-tarsah or Chopart's Amputation. In this amputation the disarticulation is through the joints formed by the astragalus and calcaneum behind and the scaphoid and cuboid in front. An incision is made from Fig. 386. Line of incision for — A. Chopart's amputation. B. Syrne's amputation. C. Section of bone in Syme's amputation. D. Subastragaloid amputation. (3TIM30N-.) the tubercle of the scaphoid across the dorsum of the foot an inch in front of the head of the astragalus to the lower and outer border of the cuboid. (Fig. 386, A.) The plan- tar flap is next marked out by an incision beginning and ending at the same points as the first incision and crossing 464 AMPUTATIONS. the sole of the foot four or five finger-breadths nearer the toes. The dorsal flap is next dissected up, and after the tendons and fascia have been divided the joint is opened Chopart's amputation. (Bryant.) and a plantar flap is cut from within outward following the line of the previously marked out plantar incision. (Fig. 387.) Subastragaloid Amputation. In this amputation all the bones of the foot are removed except the astragalus. An incision is made beginning an inch below the tip of the external malleolus which is car- ried forward to the base of the fifth metatarsal bone ; it is then carried over the dorsum of the foot to the calcaneo- cuboid articulation. (Fig. 386, D.) The joints between the scaphoid and astragalus and between the astragalus and calcis are opened, and the latter bone is carefully dis- sected out ; the ligaments are divided and the astragalus only is allowed to remain in place. Amputations at the Ankle-joint. Syrnes Amputation at the Ankle-joint. In this amputation, the foot being at a right angle to the leg, an incision is made from the centre of one malleolus AMPUTATIONS AT THE ANKLE-JOINT. 465 directly across the sole of the foot to the centre of the oppo- site malleolus. (Fig. 386, B ) The tissues of the heel are next carefully dissected from the bone by keeping the knife close to the osseous surface until the tuberosity of the os calcis is fairly turned. The two extremities of the first incision are then joined by a transverse one across the in- step, and, the joint being opened, the lateral ligaments are divided to complete the disarticulation. (Fig. 388.) The Fig. 388. Syme's amputation at the ankle-joint. (Pkey.) knife is next used to clear the malleoli, and they are next removed by the saw in the line indicated. (Fig. 386, C.) Pirogoff's Amputation at the Ankle-joint. In this amputation the posterior portion of the os calcis is retained. The incision is carried from the tip of the inner malleolus, over the instep, half an inch in front of the anterior edge of the tibia, to a point half an inch in 466 AMPUTATIONS. front of the tip of the outer malleolus ; a second incision, crossing the sole of the foot and carried down to the bone, Fig. 389. Pirogoff's amputation. A, cutaneous incision. B, line of section of bones. (Stimson.) is next made. (Fig. 389, J..) The plantar flap is dissected back for a quarter of an inch, the joint is opened by dividing Fig. 390. Application of saw to calcis in Pirogoff's amputation. (Erichsen.) AMPUTATIONS AT THE ANKLE-JOINT. 467 the lateral ligaments, and the astragalus is disarticulated, and the malleoli are exposed. A narrow saw is next applied to the upper and posterior part of the calcaneum behind the astragalus, and it is divided obliquely downward in the line of the plantar incision. (Fig. 39(3.) The malleoli and a thin slice of the tibia are next removed with the saw as in Syme's amputation. (Fig. 386, C.) Some surgeons do not remove the malleoli, but press the sawed sur- face of the os calcis between them FiG - 39L when it is possible to do so. The position of the os calcis in relation to the tibia after union has occurred, is shown in Fig. 391. Rouxs Amputation at the Ankle-joint. wmm Union between calca- neum and tibia in Piro- goff's amputation. (Hew- sox.) In this method of amputation an incision is made at the outer edge of the tendo Achillis, a little above its insertion, which is carried forward under the outer malleolus, and across the instep half an inch in front of the anterior edge of the tibia, and back to a point just in front of the inner malleolus ; the incision is car- ried from this point downward and partly across the sole of the foot, and then back to the point of origin of the original incision. (Fig. 392.) The flaps are dissected up for a short distance, the ankle-joint is then opened, and the disarticulation is effected, and the internal flap is carefully dissected from the bones. Other methods of amputation of the foot are sometimes emloyed ; such, for instance, as that advocated by Hancock, who has combined Pirogoff's amputation with the subastrag- aloid method, bringing the sawed surface of the os calcis in contact with a transverse section of the astragalus. Hancock has advocated the propriety of amputating in the foot without regard to the position of the tarsal joints, cutting 468 AMPUTATIONS. the flaps of sufficient length and dividing the bones with a saw. Tripier has also modified the subastragaloid amputation by leaving the upper part of the calcaneum, which he saws through on a level with the sustenaculum tali, and at right angles to the axis of the leg ; the external incisions are made as in Chopart's amputation. Fig. 392. Incisions in Eoux's amputation. In the method advocated by Mikulicz the astragalus and calcaneum are removed, the ends of the tibia and fibula are sawed off, and the sawed surface of the scaphoid and cuboid are approximated to these, the stump resulting resembling the foot of pes equinus. Amputations of the Leg. The leg may be amputated at its lower, middle, or upper third, the rule being to save as much of the limb as possible, but as regards the application of prothetic apparatus, I think the stumps resulting from amputations in the middle and upper thirds will be found more satisfactory. It is well also in sawing the bones to divide the fibula at a slightly higher point than the tibia. AMPUTATIONS OF THE LEG. 469 Amputation at the Lower Third of the Leg. At this position the leg may be amputated by the circular, modified circular, or elliptical method. Circular Method. A circular incision is made through the skin and con- nective tissue just above the malleoli and the cuff is dissected up for a sufficient distance, and a circular incision of the tendons and muscles is next made and the tissues being retracted the bones are divided with a saw. Modified Circular Method. In this method of amputation of the leg a circular in- cision of the skin and connective tissue and two short lateral incisions are made and the flaps are dissected up to the end of the incisions, and a circular division of the muscles is next made. (Fig. 393, A.) Or oval skin flaps are made and dissected up, and the tissues are next divided down to the bone by a circular incision and the bones are divided with a saw. (Fig. 395.) Elliptical Method. In this method of amputation the incision is in the form of an ellipse, its lower end crosses the heel below the inser- tion of the tendo Achillis and the upper end of the incision is about an inch above the anterior articular edge of the tibia. (Fig. 394, B.) Long Anterior Flap Method. An anterior flap equal in length to the diameter of the leg at its base is marked out by a curved incision through the skin beginning at the posterior edge of the tibia on the inner side, a little below the point at which the bones are to be divided, and is carried over the leg to a point directly 21 470 AMPUTATIONS. opposite over the fibula. (Fig. 394, A.) The anterior muscles are divided transversely half an inch above the Fig. 393. Fig. 394. Amputation of the leg. A. Modified, circular method. B. Eectangular flap. C. Antero- posterior flaps. (Stimson.) Amputation of the leg. A. Long anterior flap. B. Supra- malleolar long posterior flap. C. At upper third. (Stimson.) AMPUTATIONS OF THE LEG. 471 lower end of the flap and are dissected from the bones to the base of the flap. Fig. 395. Oval skin flaps with circular division of the muscles. The posterior flap is then made by entering the knife behind the bones at the point of the original incision and cutting directly outward. Long Anterior Rectangular Flap Method. (Teale.) In this method of amputation of the leg an incision equal in length to half of the circumference of the leg is made from the point at which the bones are to be divided on one side of the leg and is carried across the limb and back upon the opposite side to a point opposite the point of starting. The flap thus marked out is dissected up to its base and a posterior flap one-fourth the length is next cut by a transverse incision down to the bones and is dissected back to the line of the origin of the first incision. (Fig. 393, B.) The long flap is next doubled back and its edges secured to the posterior flap, or the long flap may be cut from the posterior surface of the leg and the short flap from the anterior surface. Antero-posterior Flap Method. A long anterior flap including half of the circumference of the limb may be cut from without inward, composed of skin, connective tissue, and muscles, and a short posterior flap cut from within outward may also be employed. This method is often employed in amputations in the upper por- tion of the leg. (Fig. 393, C.) 472 AMPUTATIONS. Lateral Flap Method. In the lower and middle thirds of the leg the method of amputation by means of lateral skin flaps may be employed with advantage. In this method an incision is made over the spine of the tibia and an oval flap, embracing one-half of the circumference of the leg, composed of the skin and connective tissue, is dissected up ; starting from the same point a similar flap is cut upon the opposite side of the leg and dissected up ; the muscles at the upper extremity of the flaps are next divided by a circular incision and the bones are divided with a saw. External Flap Method.' (Sedillot.) In this method of amputation of the leg the point of the knife is entered a finger's breadth external to the spine of the tibia and carried outward, grazing the fibula and is brought out as far as possible to the inner side ; a flap three or four inches in length is then cut from within outward ; the ex- tremities of the incision are next united by an incision across the inner side of the limb involving the skin only ; any remaining muscular tissue is next divided and the bones are sawed, and the long external flap is brought over the ends of the bones and fastened to the edges of the incision on the inner side of the limb. Prof. Ashhurst modifies this operation by cutting the long external flap from without inward, and makes also a short internal flap in the same manner. By either method the resulting stump is a good one, with the ends of the bone covered by the tissues of the external flap. Amputations at the Knee-joint. Amputations at the knee-joint may be done either by the circular or elliptical incision or by means of flaps, and may consist in simple disarticulations or sections through the condyles of the femur. AMPUTATIONS AT THE KNEE-JOINT. 473 Elliptical or Oval Method. In this operation an incision crossing the spine of the tibia five finger-breadths below the lower extremity of the patella is carried around the back of the leg three finger- breadths higher than in front ; the tissues on the front of the leg are dissected up until the tendon of the patella is exposed ; the leg is then flexed and the ligament of the patella is divided ; the capsular ligament and the lateral and crucial ligaments are next divided, care being taken not to injure the popliteal vessels with the point of the knife. The tibia is next drawn forward and the knife is passed behind its posterior border, and the remaining soft parts are divided from within outward. Anterior Flap Method. In this method of amputation a long cutaneous flap is formed ; the incision beginning half an inch below the articulation is carried five inches below the patella; cross- ing the anterior surface of the leg it is carried back to the condyle of the femur on the opposite side. This flap is dissected up and the ligament of the patella is divided, and the disarticulation is effected. A short posterior flap, uniting the anterior incision one inch below its extremities, is next cut by transfixion or from without inward. (Fig. 396, A.) Amputation through the Condyles of the Femur. In this amputation, which is known as Garden's amputa- tion, an anterior flap, whose lower extremity is three finger- breadths below the patella, is cut and the disarticulation is effected, and the posterior soft parts are divided. The patella is removed and the condyles next sawed through just above the edge of the articular cartilage. (Fig. 396, B.) Lateral Flap Method. In this operation an incision is made just below the patella, which is carried down the spine of the tibia for 474 AMPUTATIONS. Fig. 396. Fig. 397. Amputations at the knee-joint and lower third of thigh. A. Long anterior flap. B. Ampu- tation through condyles. (7 Modified flap at lower third of thigh. (Stimson.) Amputation at knee-joint by la f eral flaps. (SmithO three inches, and is then carried backward to the middle of the leg to a point opposite the be- ginning of the incision ; a simi- lar flap is cut on the opposite side of the leg, and the flaps are dissected up to the line of the articulation, and when this point is reached the joint is opened and the disarticulation is effected. The patella is not removed. (Fig. 397.) Gritti 's Amputation at the Knee- joint. In this operation a long rec- tangular anterior flap is first cut and dissected up, and after the disarticulation has been effected the skin covering the posterior surface of the knee is cut from within outward. The condyles of the femur are next removed by a saw above the edge of the articular cartilage, and the articular surface of the patella is removed by the saw or cutting forceps. The patella is next brought down so that its sawed surface AMPUTATIONS OF THE THIGH. 475 is in contact with the sawed surface of the condyles, and the flaps are brought together. (Fig. 398, A.) Amputations of the Thigh. Modified Flap Method. Two semilunar flaps of skin and connective tissue, the upper extremity of which are several inches above the con- dyles of the femur, are cut and dissected up, and the muscles are next divided by a circular incision, and the bone is cut through with the saw. (Fig. 396, C.) Long Anterior Flap Method. In this operation an incision is made on the anterior aspect of the thigh, marking out a flap whose length is equal to one-third, and whose width at its base is equal to two-thirds, of the circumference of the limb. The anterior muscles are next divided obliquely upward and backward, so that the flap shall not be too thick, and the posterior muscles are cut transversely and the bone is divided with a saw. (Fig. 398, B.) Amputation in the lower third of the thigh may also be effected by employing a long anterior and short posterior flap. The anterior flap is cut, its lower extremity extending down to the lower edge of the patella, and after dissecting up the skin and cellular tissues to the upper extremity of the patella, the muscles are cut obliquely up to the point at which the bone is to be divided. A short posterior flap is next cut, and the soft parts being retracted, the bone is sawed through. (Fig. 398, C.) Amputation of the Thigh by Transfixion. In amputations of the thigh the flaps may also be cut by transfixion, either lateral or antero-posterior flaps being em- ployed. (Fig. 399.) 476 AMPUTATIONS. Fig. A. Gritti's amputation at the knee. A'. Lines of division of the bones. B. Amputation of the thigh, long anterior flap. B' . Division of the bone. C. Amputation at the lower third of the thigh. C , Division of the bone D. Disarticulation at the hip-joint. Amputation of the Thigh through the Trochanters. When, for any reason, it is inadvisable to amputate at the hip-joint, an amputation may be made through the trochan- ters, a long anterior and short posterior flap being employed with a circular division of the muscles. AUPUTATIONS AT THE HIP-JOINT. 477 Fig. 399. Amputation of thigh by flaps cut by transfixion. Amputations at the Hip-joint. In amputations at the hip-joint it is important that pro- vision be made for the control of hemorrhage during the Fig. 400. Abdominal tourniquet. 21* 478 AMPUTATIONS. operation, and this is accomplished by the use of an abdomi- nal tourniquet (Fig. 400), or by the use of Davy's lever making compression upon the common iliac artery from the rectum, or by compression of the femoral artery by the fingers of an assistant, or by the preliminary ligation of the femoral artery just below Poupart's ligament. Esmarch's Fig. 401. Esmarch's elastic strap applied to control hemorrhage during amputation at the hip-joint. elastic strap may also be employed for the control of bleed- ing during amputation at the hip-joint, the strap being ap- plied in such a manner that it occupies the position of the turns of a spica bandage of the groin. (Fig. 401.) The most satisfactory method of controlling the bleeding during amputation at the hip-joint, or at the trochanters, is that recommended by Wyeth, which consists in the use of two stout steel pins twelve inches in length, and a piece of rubber tubing one-half of an inch in diameter and five or six yards in length. The point of one pin is inserted into the tissues one and a half inches below the anterior spine of the ilium, and is passed through the tissues external to the neck of the femur, and its point is made to project from the skin AMPUTATIONS AT THE HIP-JOINT. 479 just back of the great trochanter ; the second pin is passed through the skin an inch below the level of the groin in- ternal to the saphenous opening, and is carried through the adductor muscles and its point made to emerge half an inch in front of the tuberosity of the ischium ; the rubber tubing is next wound around the thigh above the pins and securely tied. The methods of amputation at the hip-joint are the oval, ant ero-posterior flap, and lateral flap, and modified circular methods. Oval Method. This is performed by entering the point of a strong knife into the tissues below the anterior superior spinous process of the ilium and making two oblique incisions, one forward and downward and the other backward, both incisions meet- ing on a transverse line on the inner side of the thigh. The muscles are next divided on a little higher line, and when the joint is exposed disarticulation is effected from the out- side and any remaining tissue is divided. Anfero posterior Flap Method. In this method the point of a long amputating knife is thrust into the tissues about two finger-breadths below the anterior superior spinous process of the ilium, and is pushed through the tissues grazing the hip-joint and is Drought out on the opposite of the thigh close to the junc- tion of the scrotum. The knife is next carried downward close to the bone and an anterior flap of sufficient length is cut from within outward. This flap is held up by an assist- ant and the head of the bone is disarticulated, and the knife being passed behind the bone, a posterior flap of equal length is cut from within outward. (Fig. 402.) Guthrie 8 method of amputation at the hip-joint consists in cutting the flaps from without inward, a smaller knife being used for this purpose and the posterior flap being cut first. 4:80 AMPUTATIONS. Fig. 402. Amputation at the hip-joint by antero-posterior flaps. (Holmes.) Modified Circular Method. In this operation short antero-posterior flaps of skin and connective tissue are cut and dissected up, and the muscles Fig. 403. Amputation at the hip-joint by external and internal flaps. (Bryant.) AMPUTATIONS AT THE HIP-JOINT. £81 are divided by a circular incision on the level of the joint, and the disarticulation of the head of the femur is next effected. Lateral Flap Method. In this operation two flaps are cut from the inner and outer side of the thigh by transfixion, or by cutting from without inward and exposing the joint, which is opened and the disarticulation of the head of the femur is effected as in the previous methods. (Fig. 403.) INDEX. ABDOMINAL aorta, ligation of, 413 bandage, 28 Abscess, acute. 263 cbronic. 264 cold. 261 deep-seated, opening of, 263 dressing of, 263 opening of, 263 sinuses from, 265 Absorbent cotton, 131 A. C. E. ana?sthetic mixture, 202 Acromion process of scapula, fracture of, 320 Actual cautery, 155 Acupressure, 251 first method of, 254 second method of, 251 third method of, 255 fourth method of. 255 fifth method of. 255 sixth method of, 256 seventh method of, 256 Acupuncture. 152 needles, 152 Acute abscess, 263 Adhesive plaster. 131 Agnew's splint for fracture of patella, 346 American bandage of foot. 72 Amputating knives, 133. 131 saws, 131 Amputation or amputations, 425 at ankle-joint. 161 Pirogoff s, 165 Roux's. 407 Byrne's, 164 of arm. 450 circular. 420 details of, 438 at elbow, 44-5 elliptical, 431 of fingers, 441 metacarpophalangeal, 443 Amputations, flap, 429 of foot. 460 Hancock's. 467 Hey's, 463 Lisfranc's, 161 Mikulicz's, 46S Tripier's, 467 of forearm, J 47 of hand, 441 carpo-meta carpal, 446 at hip-joint, 477 et seq. Guthrie's. 479 instruments for, 433 at knee-joint, 472 Carden's, 473 Gritti's, 474 of leg, 468 et seq. Sedillot's, 472 medio-tarsal, 463 of metacarpal bones, 445 of metatarsal bones, 459 methods of, 428 modified circular. 431 oval, 431 periosteal flaps in, 433 by rectangular flaps, 432 re-dressing of, 440 above shoulder-joint, 456 at shoulder-joint, 452 et seq. Dupuytren's, 454 Larrey's, 453 Lisfranc's, 455 Spenee's, 455 subastragaloid, 464 sutures in, 437 tarso-metatarsal. 460 Hey's, 403 Lisfranc's, 461 Teale's method. 432 of thigh, 475 et seq. of toes, 456 at wrist, 446 Anaesthesia from cocaine, 193 from cold, 192 484 INDEX. Anaesthesia, local, 192 from nitrous oxide gas, 194 from rapid respiration, 193 from rhigolene, 192 Anesthetic mixture, A. C. E., 202 Anaesthetics, 192 in tracheotomy, 279 Aneurism needle, 394 Ankle-joint, amputations at, 464 Pirogoffs, 465 Eoux's, 467 Syme's, 464 dislocations of, 387 Anterior tibial artery, ligation of, 422 Antisepsis, 99 Antiseptic bandages, 118 dressings, improvised, 118 gauze, 115 poultice, 142 Aorta, abdominal ligation of, 413 compressor, Lister's, 245 Aqua ammonia, 149, 151 Aristol, 108 Arm, amputations of, 450 Arterial hemorrhage, 241 control of, permanent, 249 temporary, 241 transfusion, 167 Arteriotomy, 164 Artery or arteries — anterior tibial, ligation of, 422 axillary, ligation of, 405 brachial, ligation of, 407 common carotid, ligation of, 399 iliac, ligation of, 413 dorsalis pedis, ligation of, 424 external carotid, ligation of, 401 iliac, ligation of, 416 facial, ligation of, 404 femoral, ligation of, 418 et seq. forceps for, 436 gluteal, ligation of, 417 inferior thyroid, ligation of, 399 innominate, ligation of, 395 internal carotid, ligation of, 402 iliac, ligation of, 415 pudic, ligation of, 417 interosseous, ligation of, 413 ligation of, 393 et seq. lingual, ligation of, 403 occipital, ligation of, 404 popliteal, ligation of, 421 posterior tibial, ligation of, 424 radial, ligation of, 409 sciatic, ligation of, 417 Artery, subclavian, ligation of, 396 superior thyroid, ligation of, 403 temporal, ligation of, 404 ulnar, ligation of, 411 vertebral, ligation of, 398 wounded, ligation of, 258 Artificial respiration, 170 direct method of, 171 Howard's method of, 171 Marshall Hall's method of, 175 Sylvester's method of, 174 Asepsis, 99 Aseptic operation, details of, 122 preparation for, J 20 surgery, materials used in, pre- paration of, 109 Aspiration, 177 Aspirator, 177 Astragalus, dislocation of, 388 fracture of, 355 Auto-transfusion, 168 Axillary artery, ligation of, 405 BACILLUS pyocyaneus, 100 pyogenes foetidus, 100 Bandage or bandages — abdominal, 28 antiseptic, 118 Barton's, 32 modified, 33 of chest, anterior figure-of-eight, 60 posterior figure-of-eight, 60 circular, 19, 22 compound, 23 crossed, of eye, 41 of both eyes, 42 demi -gauntlet, 48 Desault's, 56 dimensions of, 17 Esmarch's, 247 figure-of-eight, 22 of elbow, 51 of knee, 68 of both knees, 69 of leg, 75 of neck and axilla, 54 of foot, American, 72 covering heel, 72 not covering heel, 73 French, 73 spica, 71 four-tailed, of chin, 27 of head, 27 INDEX 485 Bandage, gauntlet, 46 Gibson's, 34 glue and oxide of zinc, 96 gum and chalk, 95 handkerchief, 28 cord, 29 cravat, 29 oblong, 28 square, 28 triangle, 29 for hands and feet, 78 of head, 32 and neck, 40 oblique, 44 Liebreich's, 78 of lower extremity, 65 many-tailed, 26 et seq. of neck, 32 oblique, 19 of angle of jaw, 36 occipito-facial, 43 paraffin, 96 plaster-of- Paris, 83 application of, 84 preparation of, 84 removal of, 93 trapping of, 92 Pott's, 80 recurrent, 22 of head, 37 of stump, 77 roller, 14 rubber, 81 scissors, 18 of Scultetus, 79 silicate of potassium, 95 of sodium, 95 special, 76 spica, 21 of foot, 71 of groin, ascending, 65 descending, 66 of shoulder, ascending, 52 descending, 53 of thumb, 49 spiral, 19, 20 of chest, 59 of finger, 45 reversed, 20 of lower extremity, 74 of penis, 76 of upper extremity, 50 starched, 94 suspensorv and compressor, of " breast, 62 of both breasts, 63 Bandage of trunk, 59 of upper extremity, 45 Velpeau's, 55 winder, 14 Bandaging, 1 3 rules for, general, 1 7 et seq. Barton's bandage, 32 modified, 33 handkerchief, 31 Bavarian dressing, 90 Bedsores, 272 Bellocq's canula, 201 Beta-naphthol, 105 Bichloride cotton, 119 of mercury, 103 gauze, 115 Binder's-board splints, 98, 300 in compound fractures, 360 Bis-axillary cravat, 30 Bladder, hemorrhage from, 262 washing out of, 215 Blood, transfusion of, 164 direct, 165 indirect, 166 Bloodletting, 157 Bond's splint, 332 Bone forceps, 435 Boric acid, 107 Boro-salicylic lotion, 107 Bougies, 209 bulbous, 209 filiform, 209 oesophageal, 180 rectal, 191 Bouisson's suture, 230 Brachial artery, ligation of, 407 Bran bags, 301 dressing in compound fractures, 360 Bread poultice, 141 Breast, strapping of, 137 suspensory and compressor bandage of, 62 double, 63 Bruises, 270 Bulbous bougies, 209 Buried suture, 223 Burns, 271 Button suture, 226 CA.LCANEUM, fracture of, 354 Cantharidal collodion, 150 Cantharis, 150 Capillary hemorrhage, 241 486 INDEX, Capillary hemorrhage, treatment of, 257 Capsicum, 149 Carbolic acid, 104 Carbolized gauze, 117 Carbuncle, strapping of, 140 Carden's amputation at knee-joint, 473 Carpal bones, fracture of, 334 Carpo-metacarpal amputation of hand, 446 Carpus, dislocation of, 378 Carotid artery, common, ligation of, 399 external, ligation of, 401 internal, ligation of, 402 Cartilages, costal, fractures of, 310 semi-lunar, dislocations of, 386 Catgut, chromic acid, 111 for drainage, 113 juniper, 111 ligatures, 111 sutures, 111 Catheter, elbowed, 208 female, 212 introduction of, 212 flexible, 207 introduction of, 209 metallic, 206 prostatic, 207 soft rubber, 208 tying in, 213 Cauterization in arterial hemorrhage, 251 Cautery, actual, 155 Charcoal poultice, 142 Chest, figure-of-eight bandage of, anterior, 60 posterior, 60 spiral bandage of, 59 strapping of, 137 T-bandage of, double, 26 single, 24, 25 Children, fractures of the femur in, 343 leg in, 352 Chin, four-tailed bandage of, 27 Chloride of zinc, 106 Chloroform, 148, 151,200 administration of, 200 apparatus, Clover's, 201 Chopart's amputation of foot, 463 Chromic acid catgut, 111 Chronic abscess, 264 Circular amputation, 429 bandage. 19, 22 Clavicle, dislocations of, 368 of acromial end of, 369 of sternal end of, 368 fracture of, 314 et seq. in children, 318 modified, Velpeau's dressing for, 319 Sayre's dressing for, 316 Velpeau's dressing for, 317 Cleanliness, surgical, 102, 120 Clinical thermometer, 189 Closed fracture, 291 Clove-hitch, 364 Clover's chloroform apparatus, 201 Cocaine, anaesthesia from, 193 Coccyx, dislocations of, 365 fracture of, 311 Cold abscess, 264 anaesthesia from, 192 in arterial hemorrhage, 249 compresses, 146 Cold-water dressings, 146 Colles's fracture, 332 Collodion, cantharidal, 150 Condyles of femur, fractures of, 344 Congenital dislocations, 392 Consecutive hemorrhage, 241 Constitutional treatment of hemor- rhage, 241 Continued suture, 223 Contused wounds, 268 Contusions, 270 Comminuted fracture, 291 Common carotid artery, ligation of, 399 iliac artery, ligation of, 413 Complete dislocation, 362 fracture, 290 Complicated dislocation, 362, 392 fracture, 292 Compound bandages, 23 dislocation, 362, 392 - fracture, 291 Binder's board splints in,360 bran dressing in, 360 dressing of, 356 felt splints in, 360 plaster-of-Paris dressing in, 359 sawdust dressing in 361 Compresses, 132, 302 cold, 146 in hemorrhage, 242 hot, 143 Coracoid process of scapula, fracture of, 320 INDEX. 487 Coronoid process, fracture of. 328 Corrosive sublimate gauze, 115 Costal cartilages, fractures of, 310 Cotton, 130 absorbent, 131 bicbloride, 119 Counter-irritation, 147 Creolin, 107 Crossed bandage of eye, 41 of both eyes, 42 Cruro-pelvic triangle, 30 Cupping, 15S dry, 159 -glass, 159 wet, 160 Cutting pliers, 435 Czerny suture, 231 DEEP incisions, 15S Demi-gauntlet bandage, 48 Desault's bandage, 56 first roller, 56 second roller, 57 third roller, 58 Diastasis of sternum, 367 Diffused suppuration, 265 Digital compression in hemorrhage, 241 Dilators, tracheal, 277 Director, tracheotomy, 276 Dislocation or dislocations, 362 of acromion process of scapula, 369 of ankle, 387 of astragalus, 388 of carpal bones, 378 of carpus, 378 of clavicle, 368 of coccyx, 365 complete, 362 complicated, 362, 392 compound, 362, 392 congenital, 392 dressing of. 362 of elbow, 374 of femur, 382 anomalous, 334 downward and forward, 382 forward and upward, 384 pubic, 384 thyroid, 383 of fibula, 387 of fingers, 379 of head of radius, 377 of hip, 382 of hyoid bone, 366 Dislocation of the inferior angle of scapula, 369 of jaw, 365 of knee, 386 of metacarpal bones, 379 of metatarsal bones, 390 old, 363, 390 vertical extension in, 391 partial, 362 of patella, 385 pathological, 392 of pelvis, 367 of phalanges of toes, 390 of proximal phalanx of thumb, 380 recent, 362 of ribs, 366 of scapula, 369 of semilunar cartilages, 386 of shoulder, 370 reduction of, 371 simple, 362 spontaneous, 392 of sternum, 367 of tarsal bones, 388, 389 of toes, 390 treatment of, 363 of upper end of ulna, 377 of vertebrae, 364 of wrist, 377 Dorsal dislocation of femur, 382 Dorsalis pedis artery, ligation of, 424 Double cyanide of mercury and zinc. 109 gauze, 116 ligature, 236 roller bandage, 16 spring artery forceps, 252 Drainage, catgut for, 113 horsehair for, 113 -tubes, 112 glass, 113 rubber, 112 Dressing or dressings — antiseptic, 101 improvised, 118 moist method in, 125 reapplication of, 125 Bavarian, 90 cold water, 146 of compound fractures, 356 of dislocations. See under each dislocation. dry sterilized, 120 of' fractures. Pee under each fracture. 488 INDEX. Dressing, fixed, 82 gauze, 115 preparation of, 115 hardening, 82 moss, 117 plaster-of- Paris, interrupted, 86 sawdust, 117 of septic wounds, 128 of wounds, 266 Dry cupping, 159 dressings in wounds, 101 sterilized dressings, 120 Dupuytren's amputation at shoulder- joint, 454 splint, 353 ELASTIC ligatures, 240 Elbow, amputations of, 448 dislocations of, 374 figure-of-eight bandage of, 51 Elbowed catheter, 208 Electrolysis, 186 Elliptical amputation, 431 Endoscope, 214 Enema, glycerin, 191 Enemata, 191 nutritious, 191 Epiphyseal fracture, 294 separation, 294 Epistaxis, 259 Erichsen's ligature, 239 Esmarch's bandage, 247 elastic strap, 246 Ether, 195 administration of, 195 first insensibility from, 197 inhaler, 196 Exploring needle, 184 trocar, 184 Extension, vertical, in old disloca- tions, 391 External carotid artery,ligation of,40 1 iliac artery, ligation of, 416 Eye, Liebreich's bandage for, 78 crossed bandage of, 41 Eyes, crossed bandage of both, 42 FACIAL artery, ligation of, 404 Fascia, strains of, 275 Faradization, 187 Felt splints, 98, 300 in compound fractures, 360 Female catheter, 212 Femoral artery, ligation of, 418 et seq. hernia, truss for, 205 Femur, dislocations of, 382 Femur, dislocations, anomalous, 384 backward, 382 reduction of, 382 downward and forward, 382 reduction of, 383 dorsal, 382 reduction of, 382 below tendon, 382 forward and upward, 384 reduction of, 384 iliac, 382 ischiatic, 382 posterior, 382 pubic, 384 reduction of, 384 thyroid, 383 reduction of, 383 fracture of, 337 in children, 343 condyles of, 344 dressing of, 337 green-stick, 344 lower end of, 344 shaft of, 340 upper extremity of, 337 Fermenting poultice, 142 Fibula, dislocations of, 387 fracture of, 352 of lower end of, 353 Figure-of-eight bandage, 22 of chest, anterior, 60 posterior, 61 of elbow, 51 of knee, 68 of both knees, 69 of leg, 75 of neck and axilla, 54 Filiform bougie, 209 Fingers, amputation of, 441 et seq. dislocations of, 379 spiral bandage of, 45 Fissured fracture, 291 Fixed dressings, 82 Flap amputation, 429 Flaps, periosteal in amputation, 433 Flaxseed poultice, 141 Flexible catheters, 207 Fomentations, hot, 142 Foot, American bandage of, 72 amputations of, 460 Chopart's, 463 Hancock's, 467 Hey's, 463 Lisfranc's, 461 Mikulicz', 468. Tripier's, 467 INDEX. 489 Foot, bandage of, not covering heel, 73 covering heel. 72 -bath, mustard, 149 fractures of bones of, 354 spica bandage of, 71 Forced respiration, 176 Forceps, arten r , 436 double spring, 252 bone, 435 hemostatic, 247, 276, 436 torsion. 251 tracheal, 278 Forearm, amputation of. 447 fracture of bones of, 329 green-stick fracture of, 331 Foreign bodies, tracheotomy for, 2S4 Fracture or fractures, 290 of acromion process of scapula, 320 anaesthetics in, 296 of astragalus, 355 -bed, 298 -box, 301 double inclined, 340 of body of scapula, 320 of bones of foot, 354 of leg in children, 352 of calcaneum, 354 of carpal bones, 334 of clavicle, 314 et seq. closed, 291 of the coccyx, 311 comminuted, 291 complete, 290 complicated, 292 compound, 291 binder's-board splints in, 360 bran dressing in, 360 continuous irrigation in, 361 dressing of, 356 felt splints in, 360 plaster-of-Faris dressing in, 359 sawdust dressing in, 361 of coracoid process of scapula, 320 of coronoid process of ulna, 328 of costal cartilages, 310 direction of, 293 dressing of, 290 et seq. provisional, 296 epiphyseal, 294 examination of, 295 of femur, 337 Fracture of femur in children, 343 of libula, 352 fissured, 291 of forearm, 329 green-stick, 290 of humerus, 321 of lower extremity, 324 of shaft, 322 of upper extremity, 321 of hyoid bone, 308 impacted, 292 incomplete, 290 indented, 290 of jaw, 304, 305 of larynx, 308 of leg, 348 longitudinal, 293 of malar bone, 304 of maxilla, lower, 305 upper, 304 of metacarpal bones, 335 of metatarsal bones, 356 multiple, 292 of nasal bones, 302 of neck of radius, 329 of scapula, 320 oblique, 293 of olecranon, 327 open, 291 dressing of, 356 partial, 290 of patella, 345 of pelvis, 311 of phalanges of fingers, 335 of toes, 356 Pott's, 353 punctured, 290 of radius, 329, 331 of head, 329 of lower end, 331 reduction of, 298 repair of, 294 of ribs, 309 of sacrum, 311 of scapula, 320 setting of, 298 of shaft of femur, 340 simple, 291 of skull, 313 of sternum, 310 of trachea, 308 transverse, 293 of trunk, 309 of ulna, 327 of upper extremity, 314 varieties of, 290 490 INDEX. Fracture of vertebrae, 312 of zygoma, 304 French bandage of foot, 73 f\ ALVANO-CAUTERY, 186 \JT Gastrostomy, sutures for, 233 Gastrotomy, sutures for, 235 Gauntlet bandage, 46 Gauze, bichloride of mercury, 115 carbolized, 117 corrosive sublimate, 115 double cyanide of mercury and zinc, 116 dressings, 115 preparation of, 115 iodoform, 116 Gely's suture, 229 Gibson's bandage, 34 Glass drainage-tube, 113 Glover's suture, 223 Glue and oxide of zinc bandage, 96 Gluteal artery, ligation of, 417 Golding-Bird's tracheal dilator, 277 Granny knot, 22 1 Green -stick fracture, 290 of bones of forearm, 331 Gritti's amputation at knee-joint, 474 Groin, spica bandage of, ascending, 65 descending, 66 double, 67 T-bandage of, 24, 25 Gum and chalk bandage, 95 Gunshot wounds, 269 Guthrie's amputation at hip-joint, 479 Gutta-pecha splints, 300 HEMOSTATIC forceps, 247, 276, 436 Hancock's amputation of foot, 467 Hand, amputation of, 441 carpo-metacarpal, 446 Hands, cleansing of, 120 removal of plaster-of- Paris from, 93 Handkerchief bandages, 28 Barton's, 31 Hardening dressings, 82 Hare-lip suture, 224 Hatter's felt splints, 98 Head, bandages of, 32 four-tailed, 27 oblique, 44 recurrent, 37 Head and neck bandage, 40 V-bandage of, 37 Hemorrhage, arterial, 241 cauterization in, 251 cold in, 249 control of, permanent, 249 temporary, 241 hot water in, 249 ligation in, 252 position in, 249 pressure in, 250 torsion in, 251 styptics in, 250 from bladder, 262 capillary, 241 treatment of, 257 compresses in, 242 consecutive, 241 deep suture in. 253 digital compression in, 241 Esmarch's elastic strap in, 246 intermediary, 241 parenchymatous, treatment of, 257 primary, 241 from rectum, 262 secondary, 241 treatment of, 257 Spanish windlass in, 244 treatment of, 241 constitutional, 241 local, 241 from urethra, 261 venous, 241 treatment of, 256 Hernia, femoral, truss for 205 inguinal, truss for,204 irreducible, truss for. 206 umbilical, truss for, 205 Hey's amputation of foot, 463 Hip-joint, amputations at, 477 et seq. Guthrie's, 479 Hip, dislocations of, 382. See Femur. Hoey's clamp, 245 Hood's truss, 204 Horsehair for drainage, 113 Hot compresses, 143 fomentations, 142 water, 147 in arterial hemorrhage, 249 Howard's method of artificial respi- ration, 171 Humerus, dislocation of, subclavicu- lar, 370 subcoracoid, 370 subglenoid, 370 INDEX 491 Humerus, dislocation of, subspinous, 371 fracture of, 321 of lower extremitv of. 324 of shaft of, 322 of upper extremitv of, 321 Hydrogen peroxide, 106 Hypodermic syringe, 183 injections, 182 Hvoid bone, dislocation of, 366 fracture of, 308 ICE-BAG, 147 Iliac artery, common, ligation of, 413 external, ligation of, 416 internal, ligation of, 415 dislocation of femur, 382 Impacted fracture, 292 Incised wounds, 266 Incisions, deep, 158 Incomplete fracture, 290 India-rubber suture. 224 Indented fracture, 290 Inferior thvroid artery, ligation of. 399 Inguinal hernia, truss for, 204 Injections, hypodermic, 1 82 intra-venous. of milk, 169 of saline solution, 168 rectal. 191 urethral. 216 Innominate artery, ligation of, 395 Instruments for amputation, 433 sterilizing of, 121 Internal carotid artery, ligation of, 402 iliac artery, ligation of, 415 pudic artery, ligation of, 417 Intermediary hemorrhage, 241 Interosseous artery, ligation, of, 413 Interrupted suture, 222 Intestinal anastomosis, sutures for, 232 Intra-venous injection of milk, 169 of saline solution, 168 Intubation of larvnx, 286 -tube. 286 extractor, 287 Iodoform, 105 gauze, 116 Irreducible hernia, truss for, 206 Irrigating apparatus, 123 Irrigation, 143 continuous, 144 in compound fractures, 361 Irrigation, mediate. 145 Ischiatic dislocation of femur, 382 Isinglass plaster, 135 Issue pea, 153 Issues, 152 JACKET, plaster-of Paris, applica- tion of, 86 Jaw, bandage of angle of, oblique, 36 dislocations of, 365 lower, fracture of, 305 splint for, 307 upper, fracture of, 304 Jobert's suture, 231 Joints, strapping of, 139 Jugular vein, external, bleeding from, 163 Juniper catgut, 111 Junk bags, 301 Jury-mast, application of. 89 Jute, 131 KXEE, figure-of-eight bandage of, 68 of both, 69 -joint, amputations at, 472 Carden's, 473 Gritti's, 474 dislocations of, 386 Knives, amputating, 433, 434 Knot, granny, 221 reef or flat, 219 Staffordshire, 221 surgeon's, 220 Kreolin, 107 LACERATED wounds, 267 Larrey's amputation at the shoulder-joint, 453 Laryngotomy, 284 Laryngo-tracheotomy, 285 Larvnx, fractures of, 308 'intubation of, 286 Leather splints, 97, 300 Leech, mechanical, 162 Leeching, 160 Lembert's suture, 228 Leg, amputation of, 468 et seq. Sedillofs, 472 figure-of-eight bandage of, 75 fracture of, 348 in children, 352 Liebreich's bandage, 78 Ligation of abdominal aorta, 413 of anterior tibial artery, 422 in arterial hemorrhage, 252 492 INDEX. Ligation of arteries, 393 et seq. of axillary artery, 405 of brachial artery, 407 of common carotid artery, 399 iliac artery, 413 of dorsalis pedis artery, 424 of external carotid artery, 401 iliac artery, 416 of facial artery, 404 of femoral artery, 418 of gluteal artery, 417 of inferior thyroid artery, 399 of innominate artery, 395 of interosseous artery, 413 of internal carotid artery, 402 iliac artery, 415 pudic artery, 417 of lingual artery, 403 of occipital artery, 404 of popliteal artery, 421 of posterior tibial artery, 424 of radial artery, 409 of sciatic artery, 417 of subclavian artery, 396 of superior thyroid artery, 403 of temporal artery, 404 of ulnar artery, 411 of vertebral artery, 398 of wounded arteries, 258 Ligature or ligatures, 437 catgut, 111 double, 236 elastic, 240 Erichsen's, 239 quadruple, 237 securing of, 219 single, 235 subcutaneous, 237 for vascular growths, 235 Lingual artery, ligation of, 403 Lint, 129 Lisfranc's amputation of foot, 461 at shoulder-joint, 455 Lister's aorta compressor, 245 Local anaesthesia, 192 Longitudinal fracture, 293 Lower extremity, bandages of, 65 spiral reversed, 74 Luxations. See Dislocations. MACKINTOSH, 114 Malar bone, fracture of, 304 Marshall Hall's method of artificial respiration, 175 Massage, 188 Maxilla, lower, fracture of, 305 upper, fracture of, 304 Mechanical leech, 162 Medio-tarsal amputation, Chopart's, 463 Mercier's catheter, 208 Mercury bichloride, 103 Metacarpal bones, amputation of, 445 dislocations of, 379 fracture of, 335 Metallic catheters, 206 Metatarsal bones, amputation of, 459 dislocation of, 390 fractures of, 356 Mikulicz, amputation of foot, 468 Milk, intra-venous injection of, 169 Minor surgery, 99 Moist dressings in wounds, 102 Moss dressing, 117 Motion, passive, 188 Moulded plaster-of- Paris splints, 91 Mouth -gag, 286 -to-mouth inflation, 170 Moxa, 153 Multiple fracture, 292 Muscles, strains of, 275 Muslin, oiled, 131 Mustard, 148 foot-bath, 149 papers, 149 plaster, 148 YTASAL bones, fracture of, 302 _Ll Neck, bandages of, 32 Needle or needles, acupuncture, 152 aneurism, 394 exploring, 184 -holder, 219 mounted, 218 seton, 154 surgical, 218 Nitrate of silver, 151 Nitrous oxide gas, 194 Nose, T-bandage of, double, 26 Nutritious enemata, 191 OAKUM, 130 poultice, 142 Oblique bandage, 19 Oblique bandage of angle of jaw, 36 of head, 44 fracture, 293 Occipital artery, ligation of, 404 Oceipito-facial bandage, 43 Oesophageal bougie, 180 Oiled muslin, 131 silk, 131 Old dislocation, 363, 390 Olecranon, fractures of, 327 INDEX. 493 Open fracture. 291 dressing of. 356 Operation, aseptic, details of, 122 preparation for. 120 of patient for, 121 Oval amputation, 431 PAPER, paraffin, 132 parchment, 114, 132 splints. 300 waxed. 132 Paquelin's tkermo-cautery, 156 Paraffin bandage, 96 paper, 132 Parchment paper, 114, 132 Parenchymatous hemorrhage, treat- ment of. 257 Partial dislocation, 362 fracture, 290 Passive motion, 188 Pasteboard splints. 9S Patella, dislocations of, 385 fracture of. 345 Pathological dislocations, 392 Pelvis, dislocation of, 367 fractures of, 311 Penis, spiral reversed bandage of. 76 Periosteal fl?ps in amputation, 433 Peri osteotome, 435 Permanganate of potassium, 108 Peroxide of hydrogen, 106 Petit's tourniquet, 243 Phalansres of fingers, dislocation of, 379 fractures of. 335 of toes, dislocations of, 390 fractures of, 356 PirogofFs amputation at ankle-joint, 465 Plaster or plasters. 134 adhesive, 134 isinglass. 135 mustard, 148 resin, 134 rubber adhesive, 134 soap, 135 spice, 149 Plaster-of- Paris bandage, 83 application of, 84 preparation of, 84 removal of. 93 saw for, 93 shears for, 94 trapping of, 92 dressing in compound frac- tures, 359 Plaster-of-Paris bandage in fracture of femur, 339 interrupted, 86 jacket, application of, 86 suspensory apparatus for, 87 removal of. from hands, 93 splints, 300 moulded, 91 Plate suture, 226 Poisoned wounds, 269 Popliteal artery, ligation of, 421 Porous felt splints, 98 Porte-moxa, 153 Position in arterial hemorrhage, 249 Posterior tibial arterv, ligation of, 424 Potassium permanganate, 108 Pott's bandage, 80 fracture, 353 Poultice or poultices, 140 antiseptic, 142 bread, 141 charcoal, 142 fermenting. 142 flaxseed, 141 oakum, 142 Powder-burns, 270 Pressure in arterial hemorrhage, 250 Primarv hemorrhage. 241 roller, 301 Prostatic catheters, 207 Protective. 113 Provisional dressings of fracture. 296 Pubic dislocation of femur. 384 Pudic arterv, internal, ligation of, 417 Puncturation, 158 Punctured fracture, 290 wounds, 268 Pyoktanin, 108 QUADRUPLE ligature, 237 Quilled suture, 225 Quilt suture, 224 RACK for fractures. 302 Radial arterv. ligation of. 409 Radius, dislocation of head of. 377 fracture of, 329 head of, 329 lower end of, 331 neck of, 329 Rapid respiration, anaesthesia from, 193 22 494 INDEX. Kaw-hide splints, 97 Eecent dislocations, 362 Eectal bougies, 191 injections, 191 tube, 190 Bectum, hemorrhage from, 262 Recurrent bandage, 22 of head, 37 of stump, 77 Eeduction of dislocations, 363 of fractures, 298 Eeef knot, 219 Eesin plaster, 134 Eespiration, artificial, 170 direct method of, 171 Howard's method, 171 Marshall Hall's method of, 175 Sylvester's method of, 174 forced, 176 Eetractors, 133, 437 three-tailed, 133 two-tailed, 133 Ehigolene, anaesthesia from, 192 Eibs, dislocations of, 366 fractures of, 309 Eoller bandage, 14 double, 16 preparation of, 15 single, 16 primary, 301 Eoux's amputation at ankle-joint, 467 Rubber adhesive plaster, 134 bandage, 81 drainage-tube, 112 tissue, 114, 132 Eubefacients, 147 SACEUM, fractures of, 311 Saline solution, intra-venous injection of, 168 Sand bags, 301 Saphena vein, internal, bleeding from, 164 Saw, amputating, 434 for plaster-of-Paris bandage, 93 Sawdust dressing, 117 in compound fractures, 361 Sayre's dressing for fracture of clavicle, 316 Scalds, 271 Scapula, dislocations of, 369 acromial process of, 369 inferior angle of, 369 fracture of, 320 Scapula, fracture of body of, 320 neck of, 320 Scarification, 157 Scarificator, 160 Sciatic artery, ligation of, 417 Scissors, bandage, 18 skin-grafting, 185 Scultetus, bandage of, 79 Secondary hemorrhage, 241 treatment of, 257 sutures, 217 Sedillot's amputation of leg, 472 Semilunar cartilages, dislocation of, 386 Septic wounds, dressing of, 128 Seton, 153 needle, 154 Setting of fractures, 298 Shears for plaster-of-Paris bandage, 94 Shotted suture, 227 Shoulder, dislocations of, 370 reduction of, 371 -joint, amputation above, 456 amputation at, 452 et seq. Dupuytren's, 454 Larrey's, 453 Lisfranc's, 455 Spence's, 455 spica bandage of ascending, 52 descending, 53 Signorini's tourniquet, 245 Silicate of potassium bandage, 95 of sodium bandage, 95 Silk, 110 oiled, 131 Silkworm-gut, 111 Simple dislocation, 362 fracture, 291 Sinapism, 148 Single ligature, 235 roller bandage, 16 Sinuses from abscesses, 265 Skin-grafting, 185 Skull, fractures of, 313 Slings, 26 Soap plaster, 135 Soft rubber catheter, 208 Sounds, 209 Spanish windlass, 244 Spence's amputation at the shoulder- joint, 455 Spica bandage, 21 of foot, 71 of groin, ascending, 65 descending, 66 INDEX. 495 Spica bandage of groin, double, 67 of shoulder, ascending, 52 descending, 53 of thumb, 49 Spice plaster, 149 Spiral bandage, 19, 20 of chest, 59 of finger, 45 reversed bandage, 20 of lower extremity, 74 of penis, 76 of upper extremity", 50 Splints, 299 angular, anterior, 325 internal, 323 binder's board, 98, 300 in compound fractures, 360 Bond's, 332 Dupuytren's, 353 felt, 300 in compound fractures, 360 gutta-percha, 300 hatter's felt, 98 leather, 97, 300 moulded binder's-board, 351 paper, 300 pasteboard, 98 plaster of- Paris, 300 moulded, 91 porous felt, 98 raw-hide, 97 wooden, 299 Sponges, 109 Spontaneous dislocations, 392 Sprain-fracture, 274 Sprains, 273 Staffordshire knot, 221 Staphylococcus pyogenes albus, 100 aureus, 100 Starched bandage, 94 Sterilization, chemical, in dressing of wounds, 101 Sterilized dressings, dry, 120 Sterilizing of instruments, 121 oven, 119 Sternum, diastasis of, 367 dislocations of, 367 fractures of, 310 Stomach-pump, 180 -tube, 178 Strains of fascia, 275 of muscles, 275 Strangury, 151 Strapping, 135 of breast, 137 Strapping of carbuncle, 140 of chest, 137 of joints, 139 of testicle, 136 of ulcers, 138 Streptococcus pyogenes, 100 Stump, recurrent bandage of, 77 Styptics in arterial hemorrhage, 250 Subastragaloid amputation, 464 Subclavian artery, ligation of, 396 Subclavicular dislocation of humerus, 370 Subcoracoid dislocation of humerus, 370 Subcutaneous ligature, 237 Subglenoid dislocation of humerus, 370 Subspinous dislocation of humerus, 371 Sulphocarbolate of zinc, 106 Superior thyroid artery, ligation of, 403 Suppuration, diffused, 265 Surface thermometer, 189 Surgeon's knot, 220 and reef knot combined, 220 Surgery, aseptic, materials used in, preparation of, 199 minor, 99 Surgical cleanliness, 102, 120 needles, 218 Suspensory apparatus for plaster-of- Paris jacket, 87 and compressor bandage of breast, 62 of both breasts, 63 Sutures or suture, 217, 437 of approximation, 217 Bouisson's, 230 buried, 223 button, 226 catgut, 111 of coaptation, 217 continued, 223 Czerny, 231 deep, in hemorrhage, 253 for gastrostomy, 233 for gastrotomy, 235 Gely's, 229 glover's, 223 hare-lip, 224 India-rubber, 224 for intestinal anastomosis, 232 interrupted, 222 Jobert's, 231 Lembert's, 228 496 INDEX. Sutures, plate, 226 quilled, 225 quilt, 224 of relaxation, 217 removal of, 228 secondary, 217 securing of, 219 shotted, 227 tongue-and-groove, 227 twisted, 224 Sylvester's method of artificial respi- ration, If 4 Syme's amputation at ankle-joint, 464 Syringe, hypodermic, 183 T -BANDAGE, 23 of chest, double, 26 single, 24, 25 double, 25 of groin, 24,25 of nose, double, 26 single, 23 Tarsal bones, dislocation of, 388, 389 Tarso-metatarsal amputations, 460 Teale's amputation, 432 Temporal artery, ligation of, 404 Tenaculum, 252, 436 Tent, 133 Testicle, strapping of, 1 36 Thermo-cautery, Paquelin's, 156 Thermometer, clinical, 189 surface, 189 Thigh, amputation of, 475 et seq. Three-tailed retractors, 133 Thumb, dislocation of proximal pha- lanx of, 380 spica bandage of, 49 Thyroid artery, inferior, ligation of, 399 superior, ligation of, 403 dislocation of femur, 383 Tibial artery, anterior, ligation of, 422 posterior, ligation of, 424 Tissue, rubber, 114, 152 Toes, amputation of, 456 dislocations of, 390 fractures of, 356 Tongue-and-groove suture, 227 Torsion in arterial hemorrhage, 251 forceps, 251 Tourniquets, 243, 438 abdominal, 477 Petit's, 243 Signorini's, 245 Trachea, fracture of, 308 Tracheal dilators, 277 Golding-Bird's, 277 Trousseau's 277 forceps, 278 Tracheotomy, 275 ansesthetics in, 279 director, 276 for foreign bodies, 284 position of patient in, 279 operation of, 279 tubes, 278 Transfusion, arterial, 167 of blood, 164 direct, 165 indirect, 165 Trapping of plaster-of- Paris bandage, 92 Transverse fracture, 293 Tripier's amputation of foot, 467 Trocar, exploring, 184 Trousseau's tracheal dilator, 277 Trunk, bandages of, 59 fractures of, 309 Truss or trusses, 202 application of, 203 et seq. for femoral hernia, 205 Hood's, 204 for inguinal hernia, 204 for irreducible hernia, 206 for umbilical hernia, 205 Tube, rectal, 190 tracheal, 278 Turpentine, 148 stupe, 148 Twisted suture, 224 Two-tailed retractors, 133 ULCERS, strapping of, 138 Ulna, dislocation of lower end of, 377 upper end of, 377 fracture of, 327 coronoid process of, 328 olecranon process of, 327 Ulnar artery, ligation of, 411 Umbilical hernia, truss for, 205 Upper extremity, bandage of, 45 fractures of, 314 spiral reversed bandage of, 50 Urethra, hemorrhage from, 261 Urethral injections, 216 Urethroscope, 215 V -BANDAGE of head, 39 Vaccination, 181 Vascular growths, ligatures for, 235 INDEX. 497 Vein, jugular, bleeding from, 163 saphena, bleeding from, 164 Velpeau's bandage, 55 dressing for fracture of clavicle, 317 Venesection, 162 Venous hemorrhage, 241 treatment of, 256 Vertebra?, dislocations of, 364 fractures of, 312 Vertebral artery, ligation of, 398 Vesicants, 150 TI7A8HING out the bladder, 215 }} Water-bed, 312 Waxed paper, 132 Wet cupping, 160 Wooden splints, 299 Wounds, aseptic, dressing of, 101 Wounds, chemical sterilization in, 101 contused, 268 dressing of, 266 dry dressing in, 101 gunshot, 269 incised, 266 lacerated, 267 moist diessings in, 102 modified, 102 poisoned, 269 punctured, 268 septic, dressing of, 128 Wrist, amputation at, 446 dislocations of, 377 ZINC, chloride of, 106 sulpho-carbolate of, 106 Zygoma, fracture of, 304 ®atalop* of §ooltss PUBLISHED BY LEA BROTHERS AND COMPANY. The books in the annexed list will be sent by mail, post-paid, to any Post Office in the United States, on receipt of the printed prices. No risks of the mail, however, are assumed, either on money or books. Gen- tlemen will, therefore, in most cases, find it more convenient to deal with the nearest bookseller. LEA BROTHERS & CO., Nos. 706 and 708 Sansom Street, Philadelphia. fkriobicals. 1S9L THE MEDICAL NEWS, A WEEKLY JOURNAL. OF MEDICAL, SCIENCE, Editbd by HOBART AMORY HARE, M.D. Published every Saturday, containing 24-28 large double- columned quarto pages of reading matter in each number. F O T7R DOLLARS ($4) per annum, in advance* THE AMEKICAN JOURNAL OF THE MEDICAL SCIENCES. Edited by EDWARD P.DAVIS, A.M., M.D. Published every Month. 112 large octavo pages, fully illustrated in each number. Price REDUCED TO c OUR DOLLARS PER ANNUM. COMBINATIONS AT REDUCED RATES. The American Journal of the Medical Sci-1 _ .. . ences.S4.00 T °# 7 e ?0 er ] The Medical News, $4.00 .... J $7S0 The Medical News Visiting List for 1891 (see below and ' Together on page 16;, $1.25 . . ^ . . . r $8.50 With either or both above periodicals, 75 cents. The Year-Book op Treatment for 1891 (see page 16), $1.50 With either or both above periodicals, 75 cents. ' THE MEDICAL NEWS VISITING LIST. This List, which is by far the most handsome and convenient now attainable, has been thoroughly revised for 1891. A full description will be found on page 16. It is issued in four styles. Price, each, $1 25. For Special Combination Rates with periodicals and the Year-Book of Treatment see above. Thumb letter Index for quick use 25 cents extra. (4.1.1) 2 LEA BROTHERS & CO.'S PUBLICATIONS. ALLEN (HARRISON). A SYSTEM OF HUMAN ANATOMY. WITH AN INTRODUCTORY SECTION ON HISTOLOGY, by E. O.Shakespeare, M.D. Comprising 813 double-columned quarto pages, with 380 engravings on stone on 109 plates, and 241 woodcuts in the text. In six sections, each in a portfolio. Sec- tion I. (Histology), Section II. ( Bones and Joints), Section III. (Muscles and Fasciae), Section IV. (Arteries, Veins and Lympha- tics), Section V. (Nervous System), Section VI. (Organs of Sense, of Digestion and Genito-Urinary Organs, Embryology, Develop- ment, Teratology, Post Mortem Examinations, General and Clini- cal Indexes). Price per section, $3 50. Also, bound in one volume, cloth, $23. Sold by subscription only . AMERICAN SYSTEM OF DENTISTRY. In treatises by various authors. Edited by Wilbur F. Litch, M.D., D.D.S. In three very handsome super-royal octavo volumes, containing 3180 pages, with 2863 illustrations and 9 full-page plates. Now ready. Per volume, cloth, $6 ; leather, $7 ; half Morocco, $8. For sale by subscription only. Apply to the publishers. AMERICAN SYSTEMS OF GYNECOLOGY AND OBSTETRICS. In treatises by the most eminent American specialists. Gynecology edited by Matthew D. Mann, AM., M.D., and Obstetrics edited by Barton C. Hirst, M.D. In four large octavo volumes comprising 3612 pages, with 1092 engravings, and 8 colored plates. Per volume, cloth, $5 ; leather, $6 ; half Russia, $7. For sale by subscription only. Prospectus free on application to publishers. ASHHTJRST (JOHN, Jr.) THE PRINCIPLES AND PRACTICE OF SURGERY. FOR THE USE OF STUDENTS AND PRACTI- TIONERS. New (fifth) and revised edition. In one large and handsome octavo volume of 1144 pages, with 642 woodcuts. Cloth, $6 j leather, $7. ASHWELL (SAMUEL) . A PRACTICAL TREATISE ON THE DIS- EASES OF WOMEN. Third edition. 520 pages. Cloth, $3 50. A SYSTEM OF PRACTICAL MEDICINE BY AMERICAN AUTHORS. Edited by William Pepper, M.D., LL.D. In five large octavo volumes, containing 5573 pages and 198 illustrations. Price per volume, cloth, $5 00; leather, $6 00; half Russia, $7 00. Sold by subscription only. Address the publishers. ATTFIELD (JOHN). CHEMISTRY ; GENERAL, MEDICAL AND PHARMACEUTICAL. Twelfth edition, specially revised by the Author for America. In one handsome 12mo. volume of 782 pages, with 88 illustrations. Cloth, $2 75 ; leather, $3 25. ALL (CHARLES B.) DISEASES OF THE RECTUM AND ANUS. In one 12mo. vol. of 417 pages, with 54 illus. and 4 colored plates. Cloth, $2 25. See Series of Clinical Manuals, p. 13. BARKER (FORDYCE). OBSTETRICAL AND CLINICAL ESSAYS. In one handsome 12mo. volume of about 300 pages. Preparing. BARLOW (GEORGE H.) A MANUAL OF THE PRACTICE OF MEDICINE. In one 8vo. volume of 603 pages. Cloth, $2 50. BARNES (ROBERT). A PRACTICAL TREATISE ON THE DIS- EASES OF WOMEN. Third American from 3d English edition. In one 8vo. vol. of about 800 pages, with about 200 illus. Preparing. BARNES (ROBERT and FANCOURT). A SYSTEM OF OBSTET- RIC MEDICINE AND SURGERY, THEORETICAL AND CLIN- ICAL. The Section on Embryology by Prof. Milnes Marshall In one large octavo volume of 872 pages, with 231 illustrations Cloth, $5; leather, $6. B LEA BROTHERS & CO.'S PUBLICATIONS. 3 BARTHOLOW (ROBERTS). MEDICAL ELECTRICITY A PRAC- TICAL TREATISE ON THE APPLICATIONS OF ELECTRICITY TO MEDICINE AND SURGERY. Third edition. In one 8vo. vol. of 308 pages, with 110 illustrations. Cloth, $2 50. "DASHAM (W. R.) RENAL DISEASES ; A CLINICAL GUIDE TO -U THEIR DIAGNOSIS AND TREATMENT. In one 12m., volume of 304 pages, with illustrations. Cloth, $2 00. BELLAMY (EDWARD). A MANUAL OF SURGICAL ANATOMY. In one 12mo.vol. of 300 piges, with 50 illustrations. Cloth, $2 25. "DELL (F. JEFFREY). COMPARATIVE PHYSIOLOGY AND ANAT- OMY. In one 12mo. volume of 561 pages, wi'h 229 woodcuts. Cloth, $2. See Students'' Series of Manuals, p. 14. BERRY (GEORGE A.) DISEASES OF THE EYE; A PRACTICAL TREATISE FOR STUDENTS OF OPHTHALMOLOGY. Very handsome octavo, 685 pages, with 144 original illustrations in the text, of which 62 are exquisitely colored. Cloth, $7 50. BILLINGS (JOHN S.) THE NATIONAL MEDICAL DICTIONARY. Including in one alphabet English, French, German, Italian, and Latin Technical Terms used in Medicine and the Collateral Sciences. In two very handsome imperial octavo volumes, containing 1574 pao-es and two colored plates. Per volume, cloth, $6 ; leather, $7; haff Morocco, $8 50. For sale by subscription only. Specimen, pages on application to publishers. BLOXAM (C L.) CHEMISTRY, INORGANIC AND ORGANIC. With Experiments. New American from the fifth London edition... In one handsome octavo volume of 727 pages, with 292 illustra- tions. Cloth, $2; leather, $3. BRISTOWE (J. S.) A TREATISE ON THE SCIENCE AND PRAC- TICE OF MEDICINE New (seventh) edition. Large octavo, volume, 1325 pages, 114 illustrations. Cioth, $6.50 ; leather, $7.50. Just ready. BROADBENT (W. H). THE PULSE. In one 12mo. volume of 317" pages, with 59 engravings. Cloth, $1 75. Just ready. See Series oj Clinical Manuals, p. 13. BROWNE (LENNOX). A PRACTICAL GUIDE TO DISEASES OF THE THROAT AND NO-E, including Associated Affections of the Ear. Third edition, revised and enlarged In one imperial octavo volume of 714 pages, with 235 engravings and 120 illustra- tions in color. Cloth, $6 50. KOCH'S REMEDY IN RELATION ESPECIALLY TO THROAT CONSUMPTION. In one octavo volume of 121 pages, with 45 illus- trations, 4 of which are colored, and 17 charts, Cloth, $1 50. Just ready. BRUCE (J. MITCHELL). MATERIA MEDIC A AND THERA- PEUTICS. Fourth edition. In one 12mo. volume of 591 pages-. Cloth, $1 50. See Students' Series of Manuals, p. 14. BRUNTON (T. LAUDER). A MANUAL OF PHARMACOLOGY, THERAPEUTICS AND MATERIA MEDICA; including the Pharmacy, the Physiological Action and the Therapeutical Uses of Drugs. New (third and revised) edition, in one octavo volume of 1305 pages, with 230 illustrations. Cloth, $5 50 ; leather, $6 50. BRYANT (THOMAS). THE PRACTICE OF SURGERY. Fourth American from the fourth English edition. In one imperial octavo volume of 1040 pages, with 727 illustrations. Cloth, $6 50; leather, $7 50. BUMSTEAD (F.J.) and TAYLOR (R W.) THE PATHOLOGY AND TREATMENT OF VENEREAL DISEASES. New edition. See Taylor on Venereal Diseases. BURNETT (CHARLES H.) THE EAR: IT^ ANATOMY, PHYSI- OLOGY AND DISEASES. A Practical Treatise for the Use of Students and Practitioners. Second edition. In one 8vo. vol of 580 pp., with 107 illus. Cloth, 4 ; leather, $5. 4 LEA BROTHERS & CO.'S PUBLICATIONS. ■DUTLIN, (HENEY T.) DISEASES OF THE TONGUE. In one pocket-size 12mo. vol. of 466 pp., with 8 col. plates and 3 woodcuts. Limp cloth, $3 50. See Series of Clinical Manuals, p. 13. p^RPENTER (WM.B) PRIZE ESSAY ON THE USE OF ALCO- VE HOLIC LIQUORS IN HEALTH AND DISEASE. New Edition, with a Preface hy D. F. Condie, M.D. One 12mo. volume of 178 pages. Cloth, 60 cents. PRINCIPLES OF HUMAN PHYSIOLOGY. A new American, from the eighth English edition. In one large 8vo. volume. pARTEa (R. BRUDENELL) AND FROST (W. ADAMS) OPHTHAL- MIC SURGERY. In one pocket-size 12mo. volume of 559 pages, with 91 engravings and one plate. Cloth, $2 25. See Series of Clinical Manuals, p. 13. CHAMBERS (T. K.) A MANUAL OF DIET IN HEALTH AND DISEASE. In one handsome 8vo. vol. of 302 pages. Cloth, $2 75. pHAPMAN (HENRY C ) A TREATISE ON HUMAN PHYSIOLOGY. In one octavo volume of 925 pages, with 605 illustrations. Cloth, $5 50 ; leather, $6 50. pHARLES (T. CRANSTOUN). THE ELEMENTS OF PHYSIO- ^ LOGICAL AND PATHOLOGICAL CHEMISTRY. In one hand- some octavo volume of 451 pages, with 38 woodcuts and one colored plate. Cloth, 3 50. pHURCHILL (FLEETWOOD). E«SSAYS ON THE PUERPERAL ^ FEVER. In one octavo volume of 464 pages. Cloth, $2 50. pLARKE (W. B.) AND LOCKWOOD (C. B.) THE DISSECTOR'S MANUAL. In one 12mo. volume of 396 pages, with 49 illustrations. Cloth, $1 50. See Students' Series of Manuals, p. 14. CLASSEN'S QUANTITATIVE ANALYSIS. Translated hy Edgar F. Smith, Ph.D. In one 12mo. vol of 324 pp., with 36 illus. Cloth, $2 00. pLELAND (JOHN). A DIRECTORY FOR THE DISSECTION OF ^ THE HUMAN BODY. In one 12mo. vol. of 178 pp. Cloth, $125. pLOUSTON (THOMAS S.) CLINICAL LECTURES O.Nf MENTAL ** DISEASES. With an Abstract of Laws of U. S. on Custody of the Insane, by C. F. Folsom, M.D. In one handsome octavo vol. of 541 fjages, illustrated with woodcuts and 8 lithographic plates. Cloth, #4 #0. Dr. Folsom's Abstract is also furnished separately in one •oetavo volume of 108 pages. Cloth, $1 50. riLOWES (FR \NK) . AN ELEMENTARY TREATISE ON PRACTI- T CAL CHEMISTRY AND QUALITATIVE INORGANIC ANALY- SIS. New American from the fourth English edition. In one hand- some i2m©, volume of 387 pages, with 55 illustrations. Cloth, $2 50. ^pOATS (JOSEPH) A TREATISE ON PATHOLOGY. In one vol. of ^ 829 pp., with 339 engravings. Cloth, $5 50 ; leather, $6 50 pOHEN (J. SOLIS). DISEASES OF THE THROAT AND NASAL PASSAGES. Third editioa, thoroughly revised. In one handsome octavo volume. Preparing. riOLEMAN (ALFRED). A MANUAL OF DENTAL SURGERY AND ** PATHOLOGY. With Notes and Additions to adapt it to American Practice. By Thos. C. Stellwagen, M. A., M.D., D.D.S. In one hand- some 8vo. vol. of 412 pp , with 331 illus. Cloth, $3 25. LEA BROTHERS & CO.'S PUBLICATIONS. 5 QONDIE (D.FRANCIS). A PRACTICAL TREATISE ON THE DIS- EASES OF CHILDREN. Sixth edition, revised and enlarged. In one large 8vo. vol. of 719 pages. Cloth, $5 25; leather, $6 25. riOOPER(B.B.)LECTURESONTHE PRINCIPLES ANDPRACTICE ^ OF SURGERY. In one large 8vo. vol. of 767 pages. Cloth, $2 00, QORNIL (V.) SYPHILIS : ITS MORBID ANATOMY, DIAGNOSIS ^ AND TREATMENT. Translated, with notes and additions, by J. Henry C Simes, M.D , and J. William White, M D. In one Svo. volume of 461 pages, with 84 illustrations. Cloth, $3 75. pULLERIER (A.) AN ATLAS OF VENEREAL DISEASES. Trans- lated and edited by Freeman J. Bumstead, M.D., LL.D. A large quarto volume of 328 pages, with 26 plates containing about 150 figures, beautifully colored, many of them life-size. Cloth, $17. TjALTON (JOHN C.) DOCTRINES OF THE CIRCULATION OF THE BLOOD. In one handsome 12mo. vol. of 293 pp. Cloth, $2. A TREATISE ON HUMAN PHYSIOLOGY. Seventh edition, thoroughly revised, and greatly improved. In one very handsome 8vo. vol. of 722 pages, with 252 illustrations. Cloth, $5 ; lea- ther, $6. ■nANA (JAMES D.) THE STRUCTURE AND CLASSIFICATION OF ^ ZOOPHYTES. Withillust.onwood. In oneimp. 4to. vol. CI. ,$4. TjAVENPORT (F. H.) DISEASES OF WOMEN. A Manual of Non- Surgical Gynaecology. For the use of Students and General Prac- titioners. In one handsome 12mo. volume of 306 pages with 105 illustrations. Cloth, $1 50. TjAVIS (F.H.) LECTURES ON CLINICAL MEDICINE. Second edition In one 12mo. volume of 287 pages. Cloth, $175. DELABECHE'S GEOLOGICAL OBSERVER. In one large 8vo.voL of 700 pages, with 300 illustrations. Cloth, $4. TYRAPER (JOHN C.) MEDICAL PHYSICS. A Text book for Stu- dents and Practitioners of Medicine. In one handsome octavo vol- ume of 734 pages, wi'h 376 illustrations. Cloth, $4; TYRUITT (ROBERT). THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new American from the 12th London edition, edited by Stanley Boyd, F.R C.S. In one large octavo volume of 965 pages, with 373 illustrations. Cloth, $4 ; leather, $5. "HTINCAN (J. MATTHEWS). CLINICAL LECTURES ON THE DIS- EASES OF WOMES. Delivered in St. Bartholomew's Hospital. In one octavo volume of 175 pages. Cloth, $1 50. DTJNGLISON (ROBLEY). MEDICAL LEXICON; A Dictionary of Medical Science. Containing a concise explanation of the various subjects and terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medi- cal Jurisprudence and Dentistry; noticesof Climate and of Mineral Waters ; Formulae forOfficinal ; Empirical and Dietetic Preparations; with the accentuation and Etymology of the Terms, and the French and other Synonymes. Edited by R. J. Dunglison, M.D. In one very large royal 8vo. vol. of 1139 pages. Cloth, $6 50 ; leather, $7 50; half Russia, $8. EDES' TEXT-BOOK OF THERAPEUTICS AND MATERIA MEDICA, In one 8vo. volume of 544 pages. Cloth, $3 50; leather, $4 50. 6 LEA BROTHERS & CO.'S PUBLICATIONS. T7DIS (ARTHUR W.) DISEASES OF WOMEN. A Manual for Stu- dents and Practitioners. In one handsome 8vo. vol. of 576 pp., with 148 illustrations. Cloth, $3 ; leather, $4. "PLUS (GEORGE VINEB). DEMONSTRATIONS IN ANATOMY. Being a Guide to the Knowledge of the Human Body by Dissection. From the eighth and revised English edition. In one octavo vol. of 716 pages, with 249 illustrations. Cloth, $4 25 ; leather, $5 25. THMMET (THOMAS ADDIS). THE PRINCIPLES AND PRACTICE "" OF GYNECOLOGY, for the use of Students and Practitioners. Third edition, enlarged and revised. In one large 8vo. volume of 880 pages, with 150 original illustrations Cloth, $5; leather, $6. TiRICHSEN (JOHN E.) THE SCIENCE AND ART OF SURGERY. A new American, from the eighth enlarged and revised London edition. In two large octavo volumes containing 2316 pages, with 984 illus. Cloth, $9; leather, $11. "HARQUHARSON (ROBERT). A GUIDE TO THERAPEUTICS. Fourth American from Fourth English edition, revised by Frank Woodbury, MD. In one 12mo. volume of 581 pages. Cloth, $2 50. "PINLAYSON (JAMES). CLINICAL DIAGNOSIS. A Handbook for Students and Practitioners of Medicine. Second edition. In one 12mo. volume of 682 pages, with 158 illustrations. Cloth, $2 50. "DLINT (AUSTIN). A TREATISE ON THE PRINCIPLES AND * PRACTICE OF MEDICINE. Sixth edition, thoroughly revised and largely rewritten by the Author, assisted by William H. Welch, M.D , and Austin Flint, Jr., M.D. In one large 8vo. volume of 1160 pages, with illustrations Cloth, $5 50 ; leather, $6 50. A MANUAL OF AUSCULTATION AND PERCUSSION; of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. Fifth edition, revised by James C. Wilson, M.D. In one handsome 12mo. volume of 274 pages, with 12 illus- trations. Cloth, $1 75. Just ready. A PRACTICAL TREATISE ON THE DIAGNOSIS AND TREAT- MENT OF DISEASES OF THE HEART. Second edition, enlarged In one octavo volume of 550 pages. Cloth, $4 00. A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- TION OF THE CHEST, AND THE DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS. Second and revised edition. In one octavo volume of 591 pages. Cloth, $4 50. MEDICAL ESSAYS In one 12mo. vol., pp. 210. Cloth, $138. ON PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY, etc. A series of Clinical Lectures. In one 8vo. volume of 442 pages. Cloth, $3 50. "pOLSOM (C. F.) An Abstract of Statutes of U. S. on Custody of the Insane. In one 8vo. vol. of 108 pp. Cloth, $1 50. Also bound with Clouston on Insanity. "POSTER (MICHAEL). A TEXT-BOOK OF PHYSIOLOGY. Fourth and revised American from the fifth English edition. In one large 12mo. vol. of about 925 pages, with about 300 illust. Preparing. LEA BROTHERS & CO.'S PUBLICATIONS. 7 "POTHERGILL'S PRACTITIONER'S HANDBOOK OF TREATMENT. Third edition. In one handsome octavo volume of 664 pages. Cloth, $3 75 ; leather, $4 75. pDWNES (GEORGE) . A MANUAL OF ELEMENTARY CHEMISTRY (INORGANIC AND ORGANIC). New edition. Embodying Watts' Physical and Inorganic Chemistry. In one royal 12mo. vol. of 1061 pages, with 168 illus., and one colored plate. Cloth, $2 75 ; leather, $3 25. pOX (TILBURY) and T. COLCOTT. EPITOME OF SKIN DIS- EASES, with Formulae. For Students and Practitioners. Third Am. edition, revised by T. C. Fox. In one small 12mo. volume of 238 pages. Cloth, $1 25. pRANKLAND (E ) and JAPP (F. R.) INORGANIC CHEMISTRY. In one handsome octavo vol. of 677 pages, with 51 engravings and 2 plates. Cloth, $3 75; leather, $4 75. pULLER (HENRY). ON DISEASES OF THE LUNGS AND AIR PASSAGES. Their Pathology, Physical Diagnosis, Symptoms and Treatment. From 2d Eng. ed. In 1 8vo. vol., pp. 475. Cloth, $3 50. QANT (FREDERICK JAMES). THE STUDENT'S SURGERY. A Multum in Parvo. In one square octavo volume of 845 pages, with 159 engravings. Cloth, $3 75. pIBBES (HENEAGE). PRACTICAL PATHOLOGY. In one very handsome octavo volume of about 400 pages, with about 75 illustra- trations. In press. piBNEY (V. P.) ORTHOPEDIC SURGERY. For the use of Prac- titioners and Students. In one 8vo. vol. profusely illus. Prepg. niBSON'S INSTITUTES AND PRACTICE OF SURGERY. In two octavo volumes of 965 pages, with 34 plates. Leather, $6 50. QOULD (A. PEARCE). SURGICAL DIAGNOSIS. In one 12mo. vol. of 589 pages. Cloth, $2. See Students' Series of Manuals, p. 14. pRAY (HENRY). ANATOMY, DESCRIPTIVE AND SURGICAL. ^ Edited by T. Pickering Pick, F.R.C.S. A new American, from the eleventh English edition, thoroughly revised, with additions, by W. W. Keen, M D. To which is added Holden's "Landmarks, Medical and Surgical." In one imperial octavo volume of 1098 pages, with 685 large and elaborate engravings on wood. Cloth, $6 ; leather, $7 ; very handsome half Russia, raised bands, $7 50. The same edition is also issued with veins, arteries, and nerves distin- guished in colors. Price, cloth, $7 25; leather, $8 25; half Rus- sia, $8 75. pRAY (LANDON CARTER). A PRACTICAL TREATISE ON THE U DISEASES OF THE NERVOUS SYSTEM. In one handsome octavo volume of about 600 pages. Preparing. QREEN (T. HENRY). AN INTRODUCTION TO PATHOLOGY AND MORBID ANATOMY. New (sixth) American, from the seventh London edition. In one handsome octavo volume of 540 pages, with 167 illustrations. Cloth, $2 75. Q.REENE (WILLIAM H.) A MANUAL OF MEDICAL CHEMISTRY. For the Use of Students. Based upon Bowman's Medical Chem- istry. In one 12mo. vol. of 310 pages, with 74 illus. Cloth, $1 75. 8 LEA BROTHERS & CO.'S PUBLICATIONS. GRIFFITH (ROBERT E.) A UNIVERSAL FORMULARY, CON- U TAINING THE METHODSOF PREPARING AND ADMINISTER- INGOFFICINAL ANDOTHER MEDICINES. Thirdand enlarged edition. Edited by John M. Maisch, Phar.D. In one large 8vo. vol. of 775 pages, double columns. Cloth, $4 50 ; leather, $5 50. Ci ROSS (SAMUEL D.) A SYSTEM OF SURGERY, PATHOLOGICAL, " DIAGNOSTIC, THERAPEUTIC AND OPERATIVE. Sixth edi- tion, thoroughly revised. In two imperial octavo volumes contain- ing 2382 pages, with 1623 illustrations. Strongly bound in leather,' raised bands, $15. A PRACTICAL TREATISE ON THE DISEASES, INJU- ries and Malformations of the Urinary Bladder, the Prostate Gland and the Urethra. Third edition, thoroughly revised and much condensed, by Samuel W. Gross, M.D. In one octavo volume of 574 pages, with 170 illus. Cloth, $4 50. A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR PASSAGES. Inone 8vo. vol. of 468 pages. Cloth, $2 75. GROSS (SAMUEL W.) A PRACTICAL TREATISE ON IMPO- TENCE, STERILITY, AND ALLIED DISORDERS OF THE MALE SEXUAL ORGANS. New (fourth) edition. Edited by F. R. Sturgis, M.D. In one handsome octavo volume of 165 pages, with 18 illustrations. Cloth, $1.50. HABERSHON (S. 0.) ON THE DISEASES OF THE ABDOMEN; AND OTHER PARTS OF THE ALIMENTARY CANAL. Second American, from the third English edition. In one handsome 8vo. volume of 554 pages, with illus. Cloth, $3 50. HAMILTON (ALLAN McLANE). NERVOUS DISEASES, THEIR DESCRIPTION AND TREATMENT. Second and revisededition. In one octavo volume of 598 pages, with 72 illustrations. Cloth , $4. HAMILTON (FRANK H.) A PRACTICAL TREATISE ON FRAC- TURES AND DISLOCATIONS. New (eighth) edition, revised and edited by Stephen Smith, A.M., M.D. In one handsome 8vo. vol. of 832 pages, with 507 illustrations. Cloth, $5 50; leather, $6 50. Just ready. HARE (HOBART AMORT). A TEXTBOOK OF PRACTICAL THERAPEUTICS, with Special Reference to the Application of Remedial Measures to Disease and their Employment upon a Rational Basis. With articles on various subjects by well-known specialists. In one handsome octavo volume of 622 pages. Cloth, $3. 75 j leather, $4.75. HARTSHORNE (HENRY). ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDICINE. Fifth edition. In one 12mo. volume, 669 pages, with 144 illustrations. Cloth, $2 75; half bound, $3. A HANDBOOK OF ANATOMY AND PHYSIOLOGY. In one 12mo. volume of 310 pages, with 220 illustrations. Cloth, $1 75. A CONSPECTUS OF THE MEDICAL SCIENCES. Com- prising Manuals of Anatomy, Physiology, Chemistry, Materia Medica, Practice of Medicine, Surgery and Obstetrics. Second edition. In one royal 12mo. volume of 1028 pages, with 477 illus- trations. Cloth, $4 25 ; leather, $5 00. HERMANN (L) EXPERIMENTAL PHARMACOLOGY. A Hand- book of the Methods for Determining the Physiological Actions of Drugs. Translated by Robert Meade Smith. M.D. In one 12mo. vol. of 199 pages, with 32 illustrations. Cloth, $1 50. HILL (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS PIS- ORDERS. In one 8vo. volume of 479 pages. Cloth, $3 25. LEA BROTHERS & CO.'S PUBLICATIONS. 9 TTILL.IER (THOMAS). A HANDBOOK OF SKIN DISEASES. 2d ed. In one royal 12mo. vol. of 353 pp.. with two plates. Cloth, $2 25. TTOBLYN (RICHARD D.) A DICTIONARY OF THE TERMS USED J " L IN MEDICINE AND THE COLLATERAL SCIENCES. In one 12mo. vol. of 520 double-columned pp. Cloth, $1 50 ; leather, $2. TTODGE (HUGH L.) ON DISEASES PECULIAR TO WOMEN, IN- 11 CLUDING DISPLACEMENTS OF THE UTERUS. Second and revised edition. In one 8vo. volume of 519 pages. Cloth, $4 50. TTOFFMANN (FREDERICK) AND POWER (FREDERICK B.) A 11 MANUAL OF CHEMICAL ANALYSIS, as Applied to the Examina- tion of Medicinal Chemicals and their Preparations. Third edition, entirely rewritten and much enlarged. In one handsome octavo volume of 621 pages, with 179 illustrations. Cloth. $4 25. ETOLDEN (LUTHER). LANDMARKS, MEDICAL AND SURGICAL. From Ihe third English edition. With additions, by W. W. Keen, M.D. In one royal 12mo. vol. of 148 pp. Cloth, $1. TTOLLAND (SIR HENRY). MEDICAL NOTES AND REFLECTIONS. From 3d English ed. In one 8vo. vol. of 493 pp. Cloth, $3 50. TTOLMES (TIMOTHY). A SYSTEM OF SURGERY. With notes and additionsby various American authors. Edited by John H. Packard, M.D. In three very handsome 8vo. vols, containing 3137 double- columned pages, with 979 woodcuts and 13 lithographic plates. Cloth, $18; leather, $21 ; very handsome half Russia, raised bands, $22 50. For sale by subscription only. A TREATISE ON SURGERY. Its Principles and Practice. A new American from the fifth English edition. Edited by T. Pickering Pick, F.R.C.S. In one handsome octavo volume of 1008 pages, with 428 engravings. Cloth, $6 ; leather, $7. TTORNER (WILLIAM E.) SPECIAL ANATOMY AND HISTOLOGY Eighth edition, revised and modified. In twolarge8vo. vols, of 1007 pages, containing 320 woodcuts. Cloth, $6. TJUDSON (A.) LECTURES ON THE STUDY OF FEVER. In one octavo volume of 308 pages. Cloth, $2 50. TTUTCHINSON (JONATHAN). SYPHILIS. In one pocket size 12mo. volume of 542 pagjs, with 8 chromo-lithographic plates. Cloth, $2 25. See Series of Clinical Manuals, p.- 13. TTYDE (JAMES NEVINS) . A PRACTICAL TREATISE ON DISEASES OF THE SKIN. New (second) edition. In one handsome octavo volume of 67fi pages, with 85 engravings and 2 colored plates. Cloth, $4 50 ; leather, $5 50. TONES (C. HANDFIELD). CLINICAL OBSERVATIONS ON FUNC- " TIONAL NERVOUS DISORDERS. Second American edition. In one octavo volume of 340 pages. Cloth, $3 25. TULER (HFNRY) A HANDBOOK OF OPHTHALMIC SCIENCE " AND PRACTICE. In one 8vo. volume of 460 pages, with 125 wood- cuts, 27 chromo-lithographic plates test types of Jaeger and Snellen and Holmgren's Color blindness test. Cloth, $4 50; leather, $5 50. TTING (A. F. A.) A MANUAL OF OBSTETRICS. New (fourth) edition. In one 12mo. volume of 432 pages, with 141 illustrations. Cloth, $2 50. 10 LEA BROTHERS & CO.'S PUBLICATIONS. gLEIN (E.) ELEMENTS OF HISTOLOGY. Fourth edition. In one pocket-size 12mo. volume of 376 pages, with 194 engravings. Cloth, $1 75. See Students' Series of Manuals, p. 14. j^ANDIS (HENRY G ) THE MANAGEMENT OF LABOR. In one handsome 12mo. volume of 329 pages, with 28 illus. Cloth, $1 75. T A ROCHE (R.) YELLOW FEVER. In two 8vo. vols, of 1468 pages. •^ Cloth, $7. . PNEUMONIA. In one 8vo. vol. of 490 pages. Cloth, $3. T AURENCE (J. Z.) AND MOON (ROBERT C.) A HANDY-BOOK OF OPHTHALMIC SURGERY. Second edition, revised by Mr. Laurence. In one 8vo. vol pp. 227, with 66 illus. Cloth, $2 75. T AWSON (GEORGE) . INJURIES OF THE EYE, ORBIT AND EYE- LIDS. From the last English edition. In one handsome octavo volume of 404 pages, with 92 illustrations. Cloth, $3 50. TEA (HENRY C). CHAPTERS FROM THE RELIGIOUS H1S- TORY OF SPAIN; CENSORSHIP OF THE PRESS; MYSTICS AND ILLUMINATI; THE ENDEMONIADAS ; EL SANTO NINO DE LA GUARDIA; BRIANDA DE BARDAXI. In one 12mo. volume of 522 pages. Cloth, $2.50. Just ready. SUPERSTITION AND FORCE; ESSAYS ON THE WAGER OF LAW, THE WAGER OF BATTLE, THE ORDEAL AND TORTURE. Third edition, thoroughly revised and greatly en- larged. In one handsome royal 12mo. vol. pp. 552. Cloth, $2 50. STUDIES IN CHURCH HISTORY. The Riseof the Temporal Power — Benefit of Clergy — Excommunication. New edition. In one handsome 12mo. vol. of 605 pp. Cloth, $2 50. AN HISTORICAL SKETCH OF SACERDOTAL CELIBACY IN THE CHRISTIAN CHURCH. Second edition. In one hand- some octavo volume of 684 pages. Cloth, $4 50. TEE (HENRY) ON SYPHILIS. In one 8vo volume of 246 pages. "^ Cloth, $2 25. TEHMANN (C. G.) A MANUAL OF CHEMICAL PHYSIOLOGY. In one 8vo. vol. of 327 pages, with 41 woodcuts. Cloth, $2 25. T EISHMAN (WILLIAM). A SYSTEM OF MIDWIFERY. Includ- ing the Diseases of Pregnancy and the Puerperal State. Fourth edition. In one octavo volume of about 800 pages, with about 225 illustrations. T UCAS (CLEMENT). DISEASES OF THE URETHRA. Preparing. See Series of Clinical Manuals, p. 13. T UDLOW (J. L.) A MANUAL OF EXAMINATIONS UPON ANAT- Jj OMY, PHYSIOLOGY, SURGERY, PRACTICE OF MEDICINE, OBSTETRICS, MATERIA MEDICA, CHEMISTRY, PHARMACY AND THERAPEUTICS. To which is added a Medical Formulary. Third edition. In one royal 12mo. volume of 816 pages, with 370 woodcuts. Cloth, $3 25; leather, $3 75. T YONS (ROBERT D.) A TREATISE ON FEVER. In one octavo Jj volume of 362 pages. Cloth, $2 25. AISCH (JOHN M.) A MANUAL OF ORGANIC MATERIA MED- ICA. New (fourth) edition. In one handsome 12mo. volume of 529 pages, with 258 beautiful illustrations. Cloth, $3. M LEA BROTHERS & CO.'S PUBLICATIONS. 11 TLfARSH (HOWARD). DISEASES OF THE JOINTS. In one 12mo. volume of 468 pages, with 64 illustrations and a colored plate. Cloth, $2. See Series of Clinical Manva Is, p. 13. JlJAY (C. H.) MANUAL OF THE DISEASES OF WOMEN. For the use of Students and Practitioners. New (second) edition, revised hy L S. Rau, M D. In one 12mo. volume of 360 piges, with 31 illustratir ns. Cloth, $1 75. TVOIGS (CHAS. D.) ON THE NATURE, SIGNS AND TREATMENT OF CHILDBED FEVER. In one 8vo. vol. of 346 pages. Cloth, $2. "M"ILLER ( J AMES) . PRINCIPLES OF SURGERY. Fourth American, from the third Edinburgh edition. In one large octavo volume of 688 pages, with 240 illustrations. Cloth, $3 75. "M"ILLER (JAMES). THE PRACTICE OF SURGERY. Fourth American, from the last Edinburgh edition. In one large octavo volume of 682 pages, with 364 illustrations. Cloth, S3 75. TVJORRIS (HENRY). SURGICAL DISEASES OF THE KIDNEY, 12mo., 554 pages, 40 woodcuts, and 6 colored plates. Cloth, $2 25. See Series of Clinical Mamials, p. 13. ]M"ULLER (J.) PRINCIPLES OF PHYSICS AND METEOROLOGY. In one large 8vo. vol. of 623 pages, with 538 cuts. Cloth, $4 50. JTEILL (JOHN) AND SMITH (FRANCIS G.) A COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE. In one handsome 12mo. volume of 974 pages, with 374 woodcuts. Cloth, $4; leather, raised bands, $4 75. JTETTLESHIP (E.) DISEASES OF THE EYE. New (fourth) Ame- rican, from fifth English edition. In one royal 12mo. volume of 500 pages, with 164 illustrations, test types and formulae and color blindness test. Cloth, $2. "M"ORRIS AND OLIVER ON THE EYE. In one 8vo. volume of about 500 pages, with illustrations. In press. QWEN (EDMUND). SURGICAL DISEASES OF CHILDREN. 12mo., 525 pages, 85 woodcuts, and 4 colored plates. Cloth, $2. See Series of Clinical Manuals t p. 13. pARRISH (EDWARD) . A TREATISE ON PHARMACY. With many Formulae and Prescriptions. Fifth edition, enlarged and thoroughly revised by Thomas S. Wiegand, Ph.G. In one octavo volume of 1093 pages, with 257 illustrations. Cloth, $5 j leather, $6. pARRY (JOHN S.) EXTRA-DTERINE PREGNANCY. ITS CLIN- L ICAL HISTORY, DIAGNOSIS, PROGNOSIS AND TREAT- MENT. In one octavo volume of 272 pages. Cloth, $2 50. pARVIN (THEOPHILUS). THE SCIENCE AND ART OF OBSTET- RICS. New (second) edition. In one handsome 8vo. volume of 701 pages, with 239 engravings and a colored plate. Cloth, $4 25 ; leather, $5 25. PAVY (F. W.) A TREATISE ON THE FUNCTION OF DIGESTION, ITS DISORDERS AND THEIR TREATMENT. From the second London edition. In one octavo volume of 238 pages. Cloth, $2. PAYNE (JOSEPH FRANK). A MANUAL OF GENERAL PATHOL- ogy. Designed as an Introduction to the Practice of Medicine. Handsome octavo volume of 524 pages with 153 engravings and 1 colored plate. Cloth, $3 50. 12 LEA BROTHERS & CO.'S PUBLICATIONS. pEPPEB (A. J.) FORENSIC MEDICINE. In press. See Students 1 Series of Manuals, p. 14. SURGICAL PATHOLOGY. In one 12mo. volume of 511 pages, with 81 illus. Cloth, $2. See Students 1 Series of Manuals, p. 14. >ICK (T. PICKERING). FRACTURES AND DISLOCATIONS. In one 12mo. volume of 530 pages, with 93 illustrations, Cloth, $2. See Series of Clinical Manuals, p. 13. URRIE (WILLIAM). THE PRINCIPLES AND PRACTICE OF SUR- GERY. In one handsome octavo volume of 780 pages, with 316 illustrations. Cloth, $3 75. )LAYFAIR (W. S.) A TREATISE ON THE SCIENCE AND PRAC- TICE OF MIDWIFERY. New (fifth) American from the seventh English edition. Edited, with additions, by R. P. Harris, M.D. In one octavo volume of 664 pages, with 207 woodcuts and five" plates. Cloth, $4; leather, $5. THE SYSTEMATIC TREATMENT OF NERVE PROSTRA- TION AND HYSTERIA. In one 12mo. vol. of 97 pages. Cloth, $1. pOWER (HENRY). HUMAN PHYSIOLOGY. Second edition. In one 12mo. volume of 396 pages, with 47 illustrations. Cloth, $1 50. See Stttdents' Series of Manuals, page 14. pURDY ON BRIGHTS DISEASE AND ALLIED AFFECTIONS OF •*" THE KIDNEY. Octavo, 288 pp , with 18 handsome illus. Cloth, $2. "DALFE (CHARLES H.) CLINICAL CHEMISTRY. In one 12mo. ^ volume of 314 pages, with 16 illustrations. Cloth, $1 50. See Studfnts' Series of Manuals, page 14. "DAMSBOTHAM (FRANCIS H.) THE PRINCIPLES AND PRAC- 11 TICE OF OBSTETRIC MEDICINE AND SURGERY. Inoneim- perial octavo volume of 640 pages, with 64 plates, besides numerous woodcuts in the text. Strongly bound in leather, $7. ■DEMSEN(IRA). THE PRINCIPLES OF THEORETICAL CHEMIS- TRY. New (third) edition, thoroughly revised, and much enlarged. In one 12mo. volume of 318 pages. Cloth, $2. "DEYNOLDS (J.RUSSELL). A SYSTEM OF MEDICINE. Edited* with Notes and Additions, by Henry Habtshorne, M.D. In three larga 8vo. vols., containing 3056 closely printed double-columned pages, with 317 illustrations. Per volume, cloth, $5 ; leather, $6; very handsome half Russia, $6 50. For sale by subscription only . ■RICHARDSON (BENJAMIN W.) PREVENTIVE MEDICINE. In one octavo vol., of 729 pp. Clo., $4; leather, $5. pOBERTS (JOHN B). THE PRINCIPLES AND PRACTICE OF . MODERN SURGERY. In one odavo volume of 780 pages, with 501 illustrations. Cloth, $4 50; leather, $5 50. pOBERTS (JOHN B.) THE COMPEND OF ANATOMY. For use in the Dissecting Room and in preparing for Examinations. In one 16ino. volume of 196 pages. Limp cloth, 75 cents. "ROBERTS (WILLIAM). A PRACTICAL TREATISE ON URINARY AND RENAL DISEASES, INCLUDING URINARY DEPOSITS. Fourth American, from the fourth London edition. In one very handsome 8vo. vol. of 609 pages, with 81 illustrations. Cloth, $3 50 # LEA BROTHERS & CO.'S PUBLICATIONS. 13 "DOBERTSON (J. McGREGOR). PHYSIOLOGICAL PHYSICS. In one 12mo. volume of 537 pages, with 219 illustrations. Cloth, $2 00. See Students' 1 Series of Manuals, p. 14. "DOSS (JAMES). A HANDBOOK OF THE DISEASES OF THE ■" NERVOUS SYSTEM. In one handsome octavo volume of 726 pages, with 184 illustrations. Cloth, $4 50 ; leather, $5 50. OAVAGE (GEORGE H.) INSANITY AND ALLIED NEUROSES, ° PRACTICAL AND CLINICAL. In one 12mo. volume of 551 pages, with 18 typical illustrations. Cloth, $2 00. See Series of Clinical Manuals, p 13. OCHAFER (EDWARD A.) THE ESSENTIALS OF HISTOLOGY, *^ DESCRIPTIVE AND PRACTICAL. For the use of Students. In one handsome octavo volume of 246 pages, with 281 illustrations. Cloth, $2 25. nCHMITZ AND ZUMPT'S CLASSICAL SERIES. In royal 18mo. ° ADVANCED LATIN EXERCISES. Cloth, 60 cents ; half bound, 70 cents. SALLUST. Cloth, 60cents; half bound, 70 cents. NEPOS. Cloth, 60 cents; half bound, 70 cts. VIRGIL. Cloth, 85 cents; half bound, $1. CURTIUS. Cloth, 80 cents; half bound, 90 cents. OCHREIBER (JOSEPH). A MANUAL OF TREATMENT BY MAS- ° SAGE AND METHODICAL MUSCLE EXERCISE. Translated by Walter Mendelson, M.D., of New York. In one handsome octavo volume of 274 pages, with 117 fine engravings. Cloth, $2 75. OEILER (CARL). A HANDBOOK OF DIAGNOSIS AND TREAT- ° MENT OF DISEASES OF THE THROAT AND NASAL CAV- ITIES. New (3d) edition. In one very handsome 12aao. volume of 373 pages, with 101 illustrations, and 2 beautifully colored plates. Cloth, $2 25. OENN (NICHOLAS). SURGICAL BACTERIOLOGY. New (second) edition. In one handsome octavo volume of 268 pages, with 13 plates, 9 of which are colored, and 9 engravings. Cloth, $2 00. Just ready. OERIES OF CLINICAL MANUALS. A series of authoritative mono- graphs on important clinical subjects, in 12mo. volumes of about 550 pages, well illustrated. The following volumes are now ready : Broadbent on the Pulse ($1 75) ; Yeo on Food in Health and Disease ($2) ; Ball on the Rectum and Anus ($2 25) ; Carter and Frost's Ophthalmic Surgery($2 25); Hutchinson on Syphilis ($2 25); Mar^h on Diseases of the Joints ($ 2) ; Morris on Surgical Diseases of the Kidney ($2 25) ; Owen on Surgical Diseases of Children ($2) j Pick on Fractures and Dislocations ($2) ; Butlin on the Tongue ($3 50); Savage on Insanity and Allied Neuroses( $2) ; and Treves on In- testinal Obstruction, ($2). The following is in press: Lucas on Diseases of the Urethra. For separate notices, see under various authors' names. IMON (W.) MANUAL OF CHEMISTRY. A Guide to Lectures and Laboratory work for Beginners in Chemistry. A Text-book specially adapted for Students of Pharmacy and Medicine. New (2d) edition. In one 8vo. volume of 480 pages, with 44 wood- cuts and 7 plates showing colors of 56 tests. Cloth, $3 25. S 14 LEA BROTHERS & CO.'S PUBLICATIONS. S KEY (FREDERIC C.) OPERATIVE SURGERY In one 8vo. vol. of 661 pages, with 81 woodcuts. Cloth, S3 25. qLADE(B.D.) DIPHTHERIA; ITS NATURE AND TREATMENT. Second edition. In one royal 12mo. vol. pp. 158. Cloth, $1 25. qMITH (EDWARD). CONSUMPTION; ITS EARLY AND REME- ° DIABLE STAGES. In one 8vo. vol. of 253 pp. Cloth, $2 25. OMITH (J.LEWIS). A TREATISE ON THE DISEASES OF IN. ° FANCY AND CHILDHOOD. Seventh edition, revisedandenlarged. In one large 8vo. volume of 881 pages, with 51 illustrations. Cloth, $4 50 ; leather, $5 50. Just ready. OMIXH (STEPHEN). OPERATIVE SURGERY. Second and thor- oughly revised edition. In one very handsome 8vo. volume, of 892 pages, with 1005 illustrations. Cloth, $4 ; leather, $5. OTILLE (ALFRED) CHOLERA, ITS ORTGIN, HISTORY, CAUSA- ° TION, SYMPTOMS, LESIONS, PREVENTION AND TREAT- MENT. In one handsome 12rao. volume of 163 pages, with a chart showing routes of previous epidemics. Cloth, $1 25. nTILLE (ALFRED). THERAPEUTICS AND MATERIA MEDIC A. ^ Fourth revised edition. In two handsome octavo volumes of 1936 pages. Cloth, $10; leather, $12; very handsome half Russia, $13 STILLE (ALFRED) AND MAISCH (JOHN M.) THE NATIONAL DISPENSATORY: Containing the Natural History, Chemistry, Pharmacy, A^ti ns and Uses of Medicines. Including those rec- ognized in the latest Pharmacopoeias of the United States, Great Britain and Germany, with numerous references to the French Codex. New (fourth) edition, revised and enlarged with an Appen- dix. In one magnificent imperial octavo volume of 1794 pages, with 311 accurate engravings on wood. Cloth, $7 25 ; leather, raised bands, $8 ; very handsome half Russia, raised bands and open back, $9. Also, furnished with Ready Reference Thumb letter Index for $1 in addition to price in any of the above styles of binding. STIMSON (LEWIS A.) A TREATISE ON FRACTURES AND DISLOCATIONS. In two handsome octavo volumes. Vol. I., Frac- tures, 582 pages, 360 beautiful illustrations. Vol II., Dislocations, 540 pp., 163 illustrations. Complete work, cloth, $5 50; leather, $7 50. Either volume separately, cloth, $3 ; leather, $4. A MANUAL OF OPERATIVE SURGERY. New edition. In one royal 12mo. volume of 503 pages, with 342 illustrations. Cloth, $2 50. STUDENTS' SERIES OF MANUALS. A series of fifteen Manuals by eminent teachers or examiners. The volumes are pocket-size l2mos. of from 300-540 page?, profusely illustrated, and bound in red limp cloth. The following volumes may now be announced : Bruce's Materia Medica and Therapeutics (fourth edition), $1 50; Treves' Manual of Surgery (monographs by 33 leading surgeons), 3 volumes, each $2 00 ; Bell's Comparative Physiology and Anatomy, $2 00; Robertson's Physiological Physics, $2 00 ; Gould's Surgical Diagnosis, $2 00; Klein's Elements of Histology (4th edition), $1 50; Pepper's Surgical Pathology, $2 00 ; Treves' Surgical Ap- plied Anatomy, $2 00 ; Power's Human Physiology, second edition, $1 50; Ralfe's Clinical Chemistry, $1 50; and Clarke and Lock- wood's Dissector's Manual, $1 50. The following is in press : Pep- per's Forensic Medicine. For separate notices, see under various authors' names. STURGES (OCTAVIUS). AN INTRODUCTION TO THE STUDY OF CLINICAL MEDICINE. In one 12mo. vol. Cloth, $1 25. LEA BROTHERS & CO 'S PUBLICATIONS. 15 TAIT (LAWSON). DISEASES OF TVOMEN AND ABDOMINAL SURGERY. In two handsome octavo volumes. Vol I. contains 546 pages and 3 plates. Cloth, $3 00. Vol. II. In Press. TANNER (THOMAS HAWKES) . A MANUAL OF CLINICAL MED1. CINE AND PHYSICAL DIAGNOSIS. Third American from the second revised English edition. Edited by Tilbury Fox, M. D. In one handsome 12mo. volume of 362 pp., with illus. Cloth, $150. ON THE SIGNS AND DISEASES OF PREGNANCY. From the second English edition. In one 8vo. volume of 490 pages, -with four colored plates and numerous woodcuts. Cloth. $4 25. TAYLOR (ALFRED S.) MEDICAL JURISPRUDENCE. Eighth American from tenth English edition, specially revised by the Author. Edited by John J. Reese, M.D. In one large octavo volume. ON POISONS IN RELATION TO MEDICINE AND MEDICAL JURISPRUDENCE. Third American from the third London edi- tion. In one octavo volume of 788 pages, with 104 illustrations. Cloth, $5 50; leather, $6 50. TAYLOR (ROBERT W.). A CLINICAL ATLAS OF VENEREAL AND SKIN DISEASES. Including Diagnosis, Prognosis, and Treatment In eight large folio parts, measuring 14 x 18 inches, and comprising 213 beautiful figures on 58 full-pge chromo-litho- graphic plates, 85 fine engravings, and 425 pages of text. Com- plete work, just ready. Price per part, sewed in heavy embossed paper, $2 50. Bound in one volume, half Russia, $27; half Turkey Morocco, $28. For sale by subscription only. Address the Pub- lishers. Specimen plates by mail on rece ; pt of ten cents. THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- EASES. Being the sixth edition of Bumstead and Taylor. In one verv handsome 8vo. volume of about 900 pages, with about 150 en- gravings as well as chromo-lithographie plates. Preparing. THOMAS (T. GAILLARD). A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Fifth edition, thoroughly revised and rewritten. In one large and handsome octavo volume of 810 pages, with 266 illustrations. Cloth, $5 ; leather, $6; very hand- some half Russia, $6 50. THOMPSON (SIR HENRY). CLINICAL LECTURES ON DISEASES OF THE URINARY ORGANS. Second and revised edition. In one octavo volume of 203 pages, with illustrations. Cloth, $2 25. THOMPSON (SIR HENRY). THE PATHOLOGY AND TREAT- MENT OF STRICTURE OF THE URETHRA AND URINARY FISTULiE. From the third English edition. In one octavo vol- ume of 359 pages, with illustrations. Cloth, $3 50. TIDY (CHARLES MEYMOTT). LEGAL MEDICINE. Volumes I. and II. Two imperial octavo volumes containing 1193 pages, with 2 colored plates. Per volume, cloth, $6 ; leather, $7. TODD (ROBERT BENTLEY) , CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In oneSvo. vol. of 320 pp., cloth, $2 50. TREVES (FREDERICK). A MANUAL OF SURGERY. In Treatises by 33 leading surgeons. Three 12mo. volumes, containing 1866 pages, with 213 engravings. Price per set, $6. See Students 1 Series of Manita Is, p. 14. SURGICAL APPLIED ANATOMY. In one 12mo. volume of 540 pages, with 61 illustrations. Cloth $2 00. See Students' 1 Series of Manuals, page 14. INTESTINAL OBSTRUCTION. In one 12mo. volume of 522 pages, with 60 illustrations. Cloth, $2 00. See Series of Clinical Manuals, p. 13. TUKE (DANIEL HACK). THE INFLUENCE OF THE MIND UPON THE BODY. Second edition. In one handsome 8vo. vol. of 467 pages, with 2 colored plates. Cloth, $3. 16 LEA BROTHERS & CO.'S PUBLICATIONS. VAUGHAN (VICTOR C), and NOVY (FBED'K G.) PTOMAINES AND LEUCOMAINES, OR PUTREFACTIVE AND PHYSIO- LOGICAL ALKALOIDS. New (second) edition. In one handsome 12mo. volume of about 325 pages. Preparing. VISITING LIST. THE MEDICAL NEWS VISITING LIST for 1891. Four styles : Weekly (dated for 30 patients) ; Monthly (undated, for 120 patients per month) ; Perpetual (undated for 30 patients each week) ; and Perpetual (undated for 60 patients each week). The 60 patient book consists of 256 pages of assorted blanks. The first three styles contain 32 pages of important data, thoroughly revised, and 176 pages of assorted blanks. Each in one vol., price, $1.25. With thumb-letter index for quick use, 25 cents extra. Special rates to advance-paying subscribers to The Medical News or The American Journal, or both. Seep. 1. WALSHE (W. H.) PRACTICAL TREATISE ON THE DISEASES "' OF THE HEART AND GREAT VESSELS. 3d American from the 3d revised London edition. In one 8vo. vol. of420 pages. Cloth, $3. WATSON (THOMAS). LECTURES ON THE PRINCIPLES AND " * PRACTICE OF PHYSIC. A new American from the fifth and en- larged English edition, with additions by H. Hartshorne, M.D. In two large 8vo.vols. of 1840 pp., with 190 cuts. Clo., $9; lea., $11. WELLS (J. SOELBERG). A TREATISE ON THE DISEASES OF THE EYE. In one large and handsome octavo volume. WEST (CHARLES). LECTURES ON THE DISEASES PECULIAR " TO WOMEN. Third American from the third English edition. In one octavo volume of 543 pages. Cloth, $3 75 ; leather, $4 75. ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILDHOOD. In one small 12mo. vol. of 127 pages. Cloth, $1. WILLIAMS (CHARLES J. B. and C. T.1 PULMONARY CONSUMP- " TION: ITS NATURE, VARIETIES AND TREATMENT. In one octavo volume of 303 pages. Cloth, $2 50. WILSON (ERASMUS). A SYSTEM OF HUMAN ANATOMY. A new and revised American from the last English edition. Illustrated with 397 engravings on wood. In one handsome octavo volume of 616 pages. Cloth, $4; leather, $5. THE STUDENT'S BOOK OF CUTANEOUS MEDICINE. In one handsome royal 12mo. vol. Cloth, $3 50. WINCKEL ON PATHOLOGY AND TREATMENT OF CHILDBED. With additions by the Author. Translated by James R. Chad wick, A.M. , M.D. In one handsome 8vo. vol. of 484 pages. Cloth, $4. WOHLER'S OUTLINES OF ORGANIC CHEMISTRY. Translated from the 8th German edition, by Ira Remsen, M.D. In one 12mo. volume of 550 pages. Cloth, $3 00. WOODHEAD (G. SIMS). PRACTICAL PATHOLOGY. A Manual for Students and Practitioners. In one beautiful octavo vol. of 497 pages, with 136 exquisitely colored illus. Cloth, $6. YEAR-BOOK OF TREATMENT FOR 1891. A Critical Review for Practitioners of Medicine and Surgery. In contributions by 20 well-known medical writers. 12mo.. of 485 pages. Cloth, $1 50. In combination with The Medical News and The American Journal of the Medical Sciences, 75 cents. See page 1. YEAR-BOOK OF TREATMENT FOR 1886, 1887 AND 1890. Similar to above. 12mo., 320-341 pages. Limp cloth, $1 25. TEO (I. BURNEY) ON FOOD IN HEALTH AND DISEASE. In one 12mo. volume of 590 pages. Cloth, $2. Just ready. See Series of Clinical Manuals, p. 13.