(Eolumbta MmtrrrsUy CflUrgF of JbgstrtanB m^ ^itrgr0nfi bu Ylf\rs. ,. .C.,°B....Qiu.-Tilhe^.r, .♦; •-. .-: ( ''\>^--'. .Cu"f»» i:*^. f?^ *-Ai^ iV «:Ai=^' fKt'V •6. £-^...^ *^.^^^^^ A MANUAL OF MINOR SURGERY AND BANDAGING. SURGICAL WORKS. PUBLISHED BY LINDSAY & BLAKISTON, PHILADELPHIA. HEARS (J. EWINCt), M.D, PEACTICAL SURGERY. Including Surgical Dress- ings, Bandaging, Amputation, etc., with 227 Illustrations. Price, $2. HEWSON (ADDINELL), M.D. EARTH AS A TOPICAL APPLICATION IN SURGERY. Being a full Exposition of its use in Cases requiring Topical Ap- plications. With Illustrations. Price, $2.50. SWAIN (WILLIAM PAUL), F.R.C.S. SURGICAL EMERGENCIES. Containing Concise Descriptions of Various Accidents and Emergencies, with Directions for their Immediate Treatment. With Illustrations. Price, $2. HEATH (CHRISTOPHER), F.R.C.S. A GUIDE TO SURGICAL DIAGNOSIS. For Practitioners and Students. 12mo. Cloth. Price, $1.50. NOERIS (GEORGE W.), M.D. CONTRIBUTIONS TO PRACTICAL SURGERY. Including numerous Clinical Histories, etc. Price, $4. PRINCE (DAVID), M.D. PLASTIC AND ORTHOPEDIC SURGERY. Contain- ing a Report on the Condition of, and Advance made in. Plastic and Orthopedic Surgery, etc., and numerous Illustrations. Price, $4.50. TOLAND (H. H.), M.D. LECTURES ON PRACTICAL SURGERY. Second Edi- tion. With Additions and numerous Illustrations. Price, in Cloth, $4.50, i n Leather, $5. CLAY (CHARLES), M.D, A COMPLETE HANDBOOK OF OBSTETRIC SUR- GERY. With Rules of Practice in Every Emergency, and numerous Illustra- tions. Price, $2. AGNEW (D. HAYES), M.D. THE LACERATIONS OF THE FEMALE PERI- NiEUM, AND A^ESICO-VAGINAL FISTULA. Their History and Treatment, with numerous Illustrations. Price, $1,50. A MANUAL OP MINOR SURGERY AND BANDAGING. By CHRISTOPHER HEATH, F.R.C.S., SUEGEON TO TTNIVERSITY COLLEGE HOSPITAL AND HOLME PROFESSOR OF CLINICAL SCEGEEY IX UNIVERSITY COLLEGE, LONDON ; HONORARY FELLOW OF king's COLLEGK SIXTH EDITION. REVISED AND ENLARGED. WITH ONE HUNDEED AND FIFTEEN ILLUSTEATIONS. PHILADELPHIA: LINDSAY & BLAKISTON. 18 80. !-, V' / \sso PREFACE TO THE SIXTH EDITION. In preparing a sixth edition of tliis Manual, I have care- fully revised every page, and have made such alterations as further experience and the progress of surgery have ren- dered advisable. I have however endeavored, as far as pos- sible, to maintain the original character of the book, which made no pretension to be a systematic work, but was ad- dressed to the wants of beginners. Several new woodcuts have been added, and I have to thank Mr. MacCormac for the use of some which appeared in his Ambulance Surgeon. I trust that the present edition will be found not less useful to the student and young practitioner than its predecessors. Christophep*, Heath. 36 Cavendish Squake, W. January, 1880. PREFACE TO THE FIRST EDITIOX. In writing the following pages, m}^ object has primarily been to offer to those .young surgeons, who are holding the responsible post of house-surgeon or dresser in the various hospitals and dispensaries, some hints on the treatment of the numerous accidents and emergencies daily coming under their care. Having myself filled tbe offices of dresser and house-surgeon to a metropolitan hospital, and having, more- over, been a constant attendant at two such institutions since that time, I venture to hope that the suggestions here incorporated will be found serviceable. It has been my endeavor to avoid, as far as possible, the repetition of mat- ter which will be found at greater length in the various handbooks of surgery, and rather to call attention to those minor points which are imparted only by oral instruction, or are simply imitated from one's predecessors. Although, for convenience, specially addressed to house- surgeons, I am not without hope that these suggestions may be found serviceable by any who are anxious to gain a knowledge of the smaller details of surgery, which, after all, tend greatly to the success of surgical practice; and particularly by those who may not have had the opportunity of residing for a time within the walls of an hospital. VIU * PREFACE. In the chapters on "Bandaging" and "Apparatus" I have endeavored to avoid unnecessary complexity, at the same time, however, alluding to most of the appliances in common use in the metropolitan hospitals, the greater num- ber of which I have visited with this special object in view. The illustrations are all new and original, being careful copies, by Mr. Swain, of Bouverie Street, from photographs taken for the purpose, under my own superintendence. I have to thank numerous friends for kind suggestions and assistance, and specially Dr. Anstie, for revising the chapter on " Chloroform," and Dr. Buzzard for his artistic assistance with regard to some of the illustrations, and for selecting the pharmacopceial formulae at the end of the work. Christopher Heath. CONTENTS. INTKODUCTIO:^. Relation of House-Surgeon to Dressers, Visiting Surgeon, Secretary, and Matron, Chaplain, Students— Nurses— In-patients— Diet— Medi- cine — Fresh air— Accidents— -Certificates — Law — Care of own health, 17-27 CHAPTEK I. Haemorrhage — General treatment — Haemorrhage from accidents — Scalp wounds— Wounds of face— Cut lip— Bleeding from nose ; from ear — Bitten tongue— Teeth knocked out — Cut throat — Euptured frsenum — Stabs— Wounds of arteries— Wound of palmar arch— Wounds of veins— Hsemorrhage from disease — Epistaxis — Syphon-tube — Nasal douche — Haemorrhage from rectum ; from bladder — Bloody urine — Euptured varicose veins — Ulceration and sloughing — Haemorrhage after surgical operations; after extraction of teeth — Haemorrhagic diathesis; from the tonsils— Leech-bites— Intermediary haemorrhage — Hemorrhage after incisions— Secondary haemorrhage— Haemorrhage after lithotomy— Tube en chemise — Elastic tampon — Appliances for arresting haemorrhage; pressure; tourniquets — Esmarch's band; forceps ; ligature — Method of tying ; catgut ligature- Acupressure — Torsion, 28-58 CHAPTEE II. Wounds : contused and lacerated ; after-treatment of— Wound of cornea ; of sclerotic — Liebreich's eye-bandage : over shin ; of joints — Bruises and contusions — Sprains — Strains — Euptured tendo Achillis — Ma- chinery accidents — Burns and scalds— Scalds of glottis— Injuries from firearms and gunpowder — Gunshot injuries — Bites and stings — Sus- pended animation— Marshall Hall's, Sylvester's, and Howard's meth- ods — Concussion and compression — Diagnostic table of—Foreign bodies in eye — Lime in eye — Foreign bodies in ear or nose, larynx, trachea, oesophagus, bladder, urethra, rectum, and vagina, . 59-87 X CONTENTS. CHAPTEK III. Eetention of urine : from spasmodic stricture ; from permanent stricture ; from enlarged prostate ; from paralysis of bladder ; from calculus — Retention in female — Extravasation of urine — Washing out bladder — ■ . Washing cathetei's — Paraphimosis^Strangulated hernia — Diagnostic table of — Prolapsus ani— Rape, . . . . . . 88-104 CHAPTER IV. Immediate treatment of cases of poisoning — Alcoholic poisoning : diag- nosis from apoplexy; treatment — Opium poisoning; treatment — Ox- alic acid ; treatment — Hydrocyanic acid and the cyanides — Mineral acids; treatment — Caustic alkalies ; treatment — Carbolic acid, 105-110 CHAPTER Y. Minor operations — Laryngotomy — Tracheotomy: tubes for; pilot tro- car — Paracentesis — Aspiration — Venesection — Bleeding from jugu- lar vein; from temporal artery — Incisions into inflamed parts — Ab- scesses — Antiseptic treatment of abscess — Whitlows — Introduction of eyedrops — Plugging the nares — Removal of polypus nasi — Puncture of tonsil — Removal of tonsil — Spray-producer — Local ansesthesia— Amputation of fingers ; of toes — Use of stomach-pump — Introduction of rectum-tube and bougie — Rectal abscess — An inflamed pile — Cir- cumcision — Tapping hydrocele — Ingrowing toe-nail — Seton — Issue — Cupping — Application of nitric acid — Subcutaneous injection — Vacci- nation and preservation of lymph, 111-147 CHAPTER VI. Operating theatre — Esmarch's bloodless method — Removal of patient — Light in theatre — Patient's bed — Treatment after operations — Delir- ium tremens — Antiseptic system — Steam spray-producer — First dress- ing after operations — Slinging stumps — Bed-sores — Filling a water-bed — Administration of chloroform — Nitrous oxide gas — Ether, 148-175 CHAPTER VII. Dressings : dry ; Gu Erin's cotton- wool ; water ; absorbent — Antiseptic dressing — Boracic acid dressing — Drainage-tubes — Evaporating dress- ing — Irrigation — Ointments — Poultices — Strapping : to strap a limb ; to strap a joint — Scott's dressing; to strap a testicle; to strap a breast, . . . 176-194 CONTENTS. XI CHAPTEK VIII. Bandages : rolling machine ; spiral ; figure-of-eight ; for leg ; for ankle ; for knee — Spica of groin ; both groins ; for breast ; both breasts ; for finger ; penis ; for all fingers ; thumb ; arm ; axilla ; for head ; Cape- Kne ; for stump ; J bandage ; many-tailed — Handkerchiefs — Slings — To tie in catheter; five methods — Lithotomy-tie — Ankle and wrist straps — Retractors, 195-234 CHAPTER IX. Fractures ; diagnosis — Simple fractures ; dislocations accompanying fractures ; compound fractures ; setting fractures — Nelaton's and Bry- ant's lines — Apparatus : splints ; pads ; splint-room ; gutta-percha, leather, leather-felt ; poro-plastic ; immovable apparatuses, starch, chalk and gum; plaster of Paris; Sayre's plaster jacket; plaster of Paris splints ; glue bandage ; paraffin bandage ; silica bandage ; sand- bags, ■ . . . . . 235-249 CHAPTER X. Special fractures : of skull ; of base of skull ; spine ; pelvis ; nasal bones ; lower jaw; ribs; clavicle — Ellis's apparatus for: humerus — Stromey- er's cushion : forearm — Colles's — Gordon's splints : metacarpal bones ; phalanges ; thigh ; application of long splint ; double-inclined plane ; extension by straps of plaster ; extension by weight ; elastic extension — Thomas's splints for hip and knee; patella; tibia; fibula — Pott's fracture : foot — After-treatment of fractures, . . . 250-284 CHAPTER XI. Dislocations: clove-hitch — Dislocation of jaw; clavicle; humerus — Diag- nosis of injuries of shoulder — Dislocation at elbow ; at wrist — Injury of arm in children — Dislocation of phalanges — Levis's apparatus for reducing : '' the Siamese link ;" femur ; at knee ; at ankle — Treatment after excision of joints ; shoulder ; elbow — Mason's splint for : wrist ; hip ; hammock-swing ; knee — Eben Watson's splint : ankle, 285-304 CHAPTER XII. Case-taking: importance of; order of particulars; history of case; de- scription of case ; diagnosis and treatment ; progress ; pulse, respira- tion, temperature; result — Case-books: table for reporting a surgical case, 305-313 Xll CONTENTS. CHAPTER XIII. Post-mortem examination : of head ; to remove the brain ; to open the orbit; to remove temporal bones ; to remove spinal cord; chest and abdomen; thorax; heart; larynx; abdomen; to remove the urethra and bladder ; post-mortem wounds — Average weights of organs, 314-326 PhARMACOPCEIAL FORMULiE OF THE LONDON HOSPITALS, . . 327 Hospital Diet Tables, 336 Index, .337 LIST OF ILLUSTEATIONS. PAGB 1. Siphon-tube, 40 2. Nasal douche, 42 3. Lithotomy tube en chemise, ....... 48 4. Lithotomy tampon, ........ 49 5. Eeef-knot and "'granny," 53 6. Mode of tying a ligature, ....... 53 'J, " " " 54 8. " " " 55 9. Case for cat-gut ligatui'es, 56 10. Torsion of arteries, 57 11. Split plaster, 60 12. Elastic plaster, 60 13. Liebreich's eye-bandage, 63 14. Sylvester's method of artificial inspiration, .... 77 15. " " " expiration, .... 78 16. Angular forceps, . 83 17. Horsehair probang, closed, 86 18. " " open, ....... 86 19. India-rubber bottle, 97 20. Mode of securing tracheotomy tube, 115 21. Durham's tracheotomy tube, . 117 22. " " 117 23. Pilot trocar for tube, . .117 24. Venesection, • . 121 25. Mode of holding lancet, 121 26. Bandage after venesection, 122 27. Eye-drop bottle, 127 XIV LIST OF ILLUSTRATIONS. PAGE 28. Guillotine for tonsil, . 130 29. The spraj-producer, .... . 131 30. Dr. Brakenridge's instrument, . . . 131 31. Amputation of finger, .... . 133 32. " " by oval method, . . 134 33. Spoon reflector for candle, . 152 34. Steam spraj-producer, . . 156 35. Dressing for stump, .... . 163 36. Sling for stumps, ..... . 165 37. Suspension of arm. . 165 38. Strapping leg, . 189 39. " knee and ankle, . 190 40. " testicle, . . . . . 192 41. " ''.... . 192 42. " breast, .... . 193 43. Bandage rolling machine, . . . . 196 44. " spiral, . . . 198 45. " figure-of-eight, . . 198 46. " for leg, .... . 199 47. " for knee, . . . . ^ . 200 48. " " . 200 49. " spica, for groin, . 201 50. " for both groins. . 202 51. " for breast, . 203 52. " for both breasts, . 204 53. " for finger, . 205 54. " for all the fingers, . . 206 55. " for thumb, ... . 207 56. " for arm, .... . 208 57. " for axilla, . , . . 209 58. " for head, ... . 210 59. . " " .... . 211 60. " capeline, . . . ' . . 212 61. " " .... . 213 62. " for stump, . : . 214 63. " sling for hand. . 217 64. " sling for arm, . 217 65. " method of tying in catheter, . 220 6Q. " Thompson's method of tying ii 1 catheter, . 220 67. Lithotomy tie, .... . 221 . .222 LIST OF II.LUSTB AXIOM'S. XV 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87, 89. 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101. 102. 103. 104. 105. 106. 107. 108. 109. 110, Lithotomy straps, . Diagnostic lines about hip-joints, Leather splint for hip-disease, Sayre's tripod and suspender. Bandage for fractured jaw, . " for fractvired clavicle, Sayre's plaster for fractured clavicle, Ellis's apparatus for fractured clavicle, Splint for fractured humerus. Bandage and sling for fractured humerus, Three splints for " Stromeyer's cushion, " '^ apjdied, Splints for forearm, Splint for Colles's fracture, . 88. Gordon's splint for Colles's fracture, " " applied, . Long thigh splint applied. Double thigh splints for children. Extension of fractured thigh by weight, Pulley for weight extension, Buckston Browne's thigh extension. Extension of fractured thigh by elastic Thomas's splint for hip disease, " " for the knee and foot, " " applied. Wood's splint for fractured patella, Maclntyre's splint, Salter's cradle. Splints foHeg, Cline's leg-splints, . Clove-hitch, Forceps for dislocated fingers, Levis's apparatus for dislocated fingers Mode of reducing dislocation of foot. Mason's splint for excised elbow, band PAGE 223 230 234 241 253 255 256 257 257 258 259 260 260 261 262 263 263 265 266 267 269 270 271 271 272 273 274 275 276 276 277 279 , 280 , 281 . 282 , 286 . 287 . 293 . 293 . 295 . 297 XVI LIST OF ILLUSTEATIONS. PAGE 111. Extension of hip by weight, 299 112. Hammock-swing, 299 113. Splint for excision of knee, . . . . . . . 300 114. Evan Watson's excision splint, 302 115. Method of slinging limbs, 303 MINOR SURGERY. INTRODUCTION. The office of house-surgeon to a public hospital is one of the most responsible posts a young surgeon can occupy, and, at the same time, its value in giving him both expe- rience and confidence can be scarcely too highly estimated. Before, however, entering upon the more purely surgical duties of the house-surgeon, it may be well to say a few words on his relation to the other officials of the establish- ment, to the patients, and to the public. Beins resident, the House-Surgeon has the entire charge of all the surgical in-patients during the absence of the prin- cipal medical officers, and under his care also come all the casualties which may occur between the regular visits. This rule is modified in some hospitals by the fact that the Dressers are held responsible for the welfare of both in- patients and casualties, the house-surgeon occupying merely the post of a supervisor, who can be appealed to in the event of any special emergency; but, for brevity's sake, in the following pages the term House-Surgeon is employed to signify the responsible and acting officer. It is obvious that the above arrangement must modify materially the relative positions of house-surgeon and dresser : in the one case the dresser being entirely subordi- nate, while in the other he acts in a great degree on his own responsibility. It is not within the scope of this work, how- ever, to enter into these minulise^ which are sufficiently reg- ulated by the traditions prevalent in each institution. 2 18 MINOR SURGERY. The relation of the house-surgeon to the Yisiting-Sur- GEON varies also in different institutions, and with different individuals. Some visiting-surgeons wish to do everything themselves, and are very wroth if a house-surgeon has opened an abscess or tightened a bandage ; while others allow their subordinates considerable liberty, provided the patients suffer no harm. Here, again, tradition and obser- vation during student-life will enable the house-surgeon to keep clear of all collision with his superior officers ; and he is certainly bound to respect the reasonable prejudices of each surgeon with regard to the details of his practice, and not to attempt to bring the practices of two or three indi- vidual surgeons to one uniform level, by which all possibility of comparison would be lost. It is most important, both for his own comfort and for the welfare of the patients, that the house-surgeon should keep on good terms with the non-medical portion of the establish- ment, ordinarily represented by a Secretary and a Ma- tron. These latter officers being permanent, and often of long standing, have frequently considerable power with the committee and governors at large, and have unfortunately also occasionally very strong views with respect to the manner in which the house-surgeon's duties are to be con- ducted ; and it is sometimes difficult to venture in the least degree from the beaten track, even in a good direction, without offending their prejudices. A gentlemanly bearing and the exercise of proper tact will, however, often enable a house-surgeon to overcome difficulties at first sight insup- erable, and it will generally be found tlmt when a house- surgeon has got into "hot-water" with the officials, it has been owing to some false step or want of courtesy on his own part. Should the house-surgeon find, however, that he is interfered with in the proper discharge of his duties by any one, he is bound to state the facts to the superior medical officers, that the matter may be at once investigated and set right ; for if any encroachment be permitted, the next occu- INTRODUCTION. 1 9 pant of the office may be still more harassed in the proper fulfilment of his charge. It is to be hoped that the house-surgeon will never inter- fere with the duties of the Chaplain, seeing that the spiritual care of the sick is not within the house-surgeon's province; the only difficulty at all likely to arise in this quarter is the tendency of some chaplains to prolong their visits to the wards to the inconvenience of the dressers and others ; but this can be easily remedied by a proper representation of the fact. The house-surgeon is bound to respect the pri- vacy of a ward when prayers are being read, except in the case of accident or sudden emergency, when everything else must yield to the necessities of the case. Since most hospitals have medical schools attached to them, the house-surgeon may be of the greatest possible service to the Students, b}'^ encouraging their visits to the wards, and by taking the trouble to give a little clinical in- struction in making his rounds. This will prepare himself also for more formal clinical teaching, should he ever occupy the position of surgeon to an hospital ; and since to teach is to learn, he can have no better way of improving himself in the practice of his profession. It would be well also if the house-surgeon would bear in mind the necessity for clinical observation, and take care that, when possible, the students should be summoned to witness any operation or remark- able accident which may occur at other than the regular hour of the surgeon's visit. With this view, also, the house- surgeon might possibly be self-denying enough not to reduce all dislocations, etc., instanter, when an hour's delay would not be of the smallest consequence to the patient and would allow the students to see an accident such as they may be soon called upon to attend in private, and to witness its ap- propriate treatment at the hands of the visiting-surgeon. The house-surgeon must of course guard his patients against the meddling of inexperienced students, and have due regard 20 MINOR SURGERY. also to the comfort and privacy of the wards, especially those occupied by female patients. As the well-doing of the patients depends in no inconsid- erable degree upon the good understanding between the house-surgeon and the Nurses, its maintenance should always be aimed at. Nurses often have views of their own with regard to treatment of cases, which, if kept within proper bounds, may be of considerable service, for the inexpe- rienced house-surgeon may not unfrequently gain useful liints from an intelligent woman who has been for years in the wards of a hospital; he must be careful, therefore, not to disgust his subordinates, in the first blush of office, by any sweeping revolutions or startling novelties. B}^ an in- variabl}^ courteous, and at the same time firm, behavior, the house-surgeon will soon gain the confidence of nurses who would, perhaps, prove insubordinate to a vacillating and rude officer, of even greater professional abilities. Two difficulties which are to be guarded against with respect to the nurses are, the tendency they have (in order to save trouble) to do all the dressing themselves, instead of leaving them for the proper dressers, and the exhibition of favor- itism to certain patients. To obviate the former the dresser must be careful to attend in proper time, so that the gen- eral business of the ward is not delayed ; and the latter must be judiciously checked, or if necessary, may be pre- A^ented by transferring the patient to another ward. It can hardly be necessary to deprecate in the strongest terms any undue familiarity between the house-surgeon and the nurses or female patients, which no one who has any proper sense of honor would allow himself to indulge in for a moment. The In-patients are in most hospitals admitted under the surgeon of the week or day on which they may happen to apply, but invariably any case sent specially to any in- dividual surgeon is admitted under his particular care, and the house-surgeon should be careful to attend to this, as the infringement of the rule generally creates some ill-feeling. INTRODUCTION. 21 The division of the beds among the several surgeons will var}^ in different institutions, and there is generally an un- derstood " give and take " arrangement which obviates all overcrowding. Unless evidently perfectly clean, or unless the severity of the injury or disease prevent it, all in-patients should have a warm bath before being put into bed, and even when the bath is not available, as much diit as can should be removed by the nurse with soap and water. Except in the case of some very sudden emergency, a patient should never be put into the bed occupied by another without the linen having been changed, and, if at all soiled, the blankets also. (In all hospitals the rule is, that when a death has occurred the whole of the bedding should be changed.) The allowance of clean linen to each l)ed varies verj' considerably in differ- ent institutions, and a change will be required much more frequently in some cases than in others ; but where the al- lowance is small, a neat appearance can be given to the beds by always placing a clean sheet first atop of the patient, and after a day or two shifting it to underneath him, and re- placing it by another clean one, and so on. The house- surgeon should not consider the details of the bed of a patient as ivfra dig.^ since his progress may materially depend upon his comfort in it. It will often make all the difference between a good and a sleepless night to a weary patient, if all crumbs, etc., are carefull}^ swept out of the bed, and the sheets are thoroughly smoothed and tucked in on each side. With regard to Diet, the house-surgeon has more liberty in some hospitals than in others, but should alwa3's endeavor to avoid extravagance, and particularly the continuance of large quantities of stimulants or extras after the necessity for their administration is past. A table of the diet-rolls of some of the metropolitan hospitals will be found at the end of this book. Some little skill will be necessary in order to suit the capricious appetite of a failing patient, and there is 22 MINOR SURGERY. ordinarily no diflScultj'^ in obtaining special niceties for sucli cases, on making a representation of the facts to the matron or steward. In the matter of Medicine, the house-surgeon should, as a rule, not commence a course of treatment without the sanction of the visiting-surgeon, and should he be obliged to make any alteration in the surgeon's absence, must be careful to inform him, at his next visit, otherwise neither surgeon nor patient will have fair play. Even in cases where no medicine is required, it satisfies the patient's mind to have something on the medicine-card, and hence '^ R. Haust. Sennse co., f ^jss. pro re nata," is a useful prescription. Fresh air is, perhaps, more necessarj^ than medicine for surgical patients, and the house-surgeon should see that the ventilation of the wards is properly carried out, and, if pos- sible, that the windows are opened at certain periods of the day. Attention must, however, be paid to the state of the atmosphere and direction of the wind, for if, with a bitter east wind, windows facing that way are opened, the patients will often suffer severely from catarrh or erysipelas. Win- dow-sashes which direct the current of air upwards, can often be opened when the ordinar}^ draughty windows would do much harm to the patients. The use of disinfecting lotions, etc., will do away with much of the offensive odor of un- healthy wounds, and, if necessary, cloths may be hung round a patient's bed soaked in some disinfecting fluid, which may also be sprinkled on the floor. A pill-box, perforated with pin-holes, and filled with metallic iodine, is found in the cancer wards of the Middlesex Hospital to be a most eflfect- ual deodorant when affixed to each patient's bed ; and at Guy's Hospital, Dr. Steele has contrived a revolving jack- towel in miniature, one end of which passes through a trough containing a solution of carbolic acid, which is thus con- stantly evaporated in the neighborhood of offensive or con- tagious cases. The water-closets and urinals in connection with the wards should be occasionally inspected, to see INTEODUCTION. 23 that they are perfectly sweet, and when the bed-pan is em- ployed it should contain a little disinfecting fluid or powder. and be emptied immediately after being used. Those pa- tients who are able to do so sho.uld be encouraged to go out into the fresh air, and all who are able should be up during the daytime, and, if not strong enough to be thoroughly dressed, may lie outside the bed with advantage. The prevailing custom of constantly scrubbing the floors of the wards with soap and water has a decided tendency to maintain a moist, unhealthy atniosphere, particularly in the winter months. The practice of polishing and dry-rub- bing the floor would be a great improvement, and is said (e. g. at Birmingham) to have a direct tendency to reduce the mortality from erysipelas, etc. The house-surgeon should make an invariable rule of seeing all cases of Accident as soon as he is called to them. In by far the majority of cases a few minutes' delay would be of no consequence ; but as it is impossible to sa}' when the highl^^ urgent cases may occur, the house-surgeon — having due regard to public opinion and the verdict of a coroner's jury — should always give his immediate attendance. The decision as to the necessity for the admission of a case of accident is sometimes a matter of difficulty, and will be influenced a good deal by the number of vacant beds, etc., but in doubtful cases it is much better to err on the safe side, and take in a patient for a day or two, than to run any risk of mischief occurring during treatment as an out-patient. This is especially advisable in an}^ case brought by the police, and likely to be the subject of legal investigation. Cases present themselves occasionally at hospitals which are obvi- ously unfitted for admission, either from being incurable, or from the fact that they are suflfering from want rather than disease. These, if summarily dismissed, may be bandied about between workhouse officials, until (as has positively occurredj the unfortunate sufferer has died of inanition in the street. A coroner's jury, finding that admission was 24 MINOR SURGERY. refused to a patient in a dying condition, will naturall}^ lay the onus upon the house-surgeon, whom it behooves, there- fore, to take some little pains to avoid such a misfortune by calling the attention of the lay officials to the case, when they will at least give some nourishment to the applicant before he is dismissed, and possibly take steps to secure his immediate admission into a suitable asylum. A house-surgeon is a good deal pestered for Certificates of illness for clubs, etc., and should be provided with printed forms, which can be readily filled up. Caution should be exercised in giving certificates to the police (except when a patient is unable to appear), since the house-surgeon may lose a fee by not having appeared in person at a police- court. The following are the principal points of Law affecting the house-surgeon. The house-surgeon cannot claim any fee for evidence at an inquest upon a patient who died in the hospital, and it is sometimes a nice point to decide whether a death took place outside the hospital doors or not. If the subject of the inquest was brought in dead, the house-surgeon is en- titled to one guinea for giving evidence, and one for the post-mortem examination, provided the coroner has given an order for it to be made ; and the house-surgeon should be careful not to give evidence without receiving a summons in due form, and particularly not to make a post-mortem without a written order, or he will forfeit his fees. The house-surgeon must give evidence before a magistrate, if summoned, and there is no fee allowed unless the case be sent for trial, when half a guinea will be allowed for each da3^'s attendance at the police-court, and it is as well to ask the magistrate to enter the attendance at the police-court upon the depositions, so that there may be no mistake after the trial. Although the magistrate has no power to give a fee for evidence on a case which is not sent for trial, the fee of a guinea may usually be obtained by writing a formal INTRODUCTION. 25 letter to the Secretary of State for the Home Department, Whitehall, stating the circumstances, when in a few days, probably, an order will be received for payment of the fee. At assizes or sessions the house-surgeon is bound to attend on the day he is summoned, and to wait until he is called on, and is allowed a guinea a day for such attendance, and reasonable travelling expenses if he has to go any distance. The fees (including those due for the police-court) are paid as soon as the trial of the case is concluded. In civil actions the fee will vary according to the liberality of the attorney, but will never be less than a guinea a day and travelling expenses ; when served with a subpoena to attend, the house-surgeon should receive current coin of the realm sufficient to defray his travelling expenses, or is not bound to pay any attention to it. When there is doubt of the respectability of the parties, it is well to insist upon having the fee before giving evidence ; or if the attorney re- fuse this, the house-surgeon should appeal to the presiding judge before being sworn, when the judge will direct that the usual fees should be paid : if this is not done, the house- surgeon is at libertj' to decline to give evidence. By taking this course of appealing to the judge, the author succeeded once in obtaining the fees for giving evidence in an " attor- ney's action," when a medical friend, who neglected the pre- caution, failed to obtain any remuneration.* In order that a house-surgeon may fulfil his duties effi- ciently, it is essential that he should be careful of his own health. The labor, anxieties, and foul air of an hospital produce an effect upon the strongest constitution in a few weeks, and unless the house surgeon take proper care of himself he will very soon be disabled. A daily cold bath and a daily walk are the great means for maintaining the * The house-surgeon may advantageously study the " Abstract of the principal laws affecting the medical profession," contained in the "Medical Directory." 26 MINOR SURGERY. health and spirits ; the walk, particularly, is essential, and is very apt to be shirked, either from want of energy or from over-anxiety for the welfare of the cases. This over-anxiety is not only injurious to the house-surgeon himself, but is bad for the patients also, since it leads to over- frequent visits to the wards, constant change of treatment, and a general state of worry. The house-surgeon should be satisfied with the consciousness of having done his best for his patients, and must be content to leave the result in other hands ; and though, no doubt, it is annoying to lose patients in whom a great interest has been taken, it is one of the inevitable drawbacks of medical practice. A good night's rest is most important for the house- surgeon ; but where he is in sole charge of the hospital, its attainment is A^ery precarious. On Saturday nights it is, perhaps, of very little use for a house-surgeon to retire early, since the number of broken heads, etc., is generally large at that time ; but on other nights there can be no object in sitting up to unreasonable hours, and even half an hour's sleep in bed is better than twice that time in an arm-chair. When the house-surgeon is called up in the night, it will be well for him to take the opportunity of visiting one or two of the wards occasionally, to see that the night nurses are on the alert, and to soothe any sleepless patient. In order that the house-surgeon should get through the hard work, both mental and bodily, of his office, it is essen- tial that he should be liberally fed. Committees are not aware sometimes of the hardships they inflict by penurious- ness with regard to the medical officers' table ; and, un- doubtedly, a house-surgeon who does his work thoroughly^ requires '' meat three times a day." The first symptom of " knocking up " is an inability to eat breakfast, which is a most important meal for the house-surgeon, as he has all his rounds to make immediately afterwards, and should there- fore be taken in good time, and without the hurry incident to late rising. This is soon followed b}^ a relaxed sore throat INTRODUCTIOi^^. 27 (hospital sore throat) and a general feeling of depression. An extra allowance of fresh air, by either walking or driving, a conple of glasses of wine, and the internal administration of bark and mineral acids, are the remedies for this state of things ; and unless they are soon had recourse to, the house- surgeon may have to throw up his appointment altogether and seek for health and strength in country air. 28 HEMORRHAGE. CHAPTER I. HEMORRHAGE. HAEMORRHAGE from various sources is one of the affections which the house-surgeon is called upon to treat most fre- quently-. Its amount may vary from what is termed '' tri- fling " to " alarming," but it may be of service to the young surgeon to say that there is, probably, no haemorrhage from the external surface of the body which cannot be arrested, at least temporarily. The ligature ani pressure are the two means of arrest in most common use, although the latter (in its varied forms) is not so fully appreciated as it deserves ; but recourse must be had occasionally to escharotics and styptics of various kinds, of which the actual cautery is the most potent. The position of the wounded part has consid- -erable influence on haemorrhage, and should therefore be fully attended to, since, for example, it is obvious that blood will flow more readily from a limb which is allowed to hang down, than from one which is raised to, or above, the level of the heart. The after-treatment of cases of haemorrhage, both as respects the wound and the general condition of the patient, is of the greatest importance. Supposing an artery to have been tied on a bleeding surface, no surgeon would think of removing the ligature on the following day ; but if pressure alone has been applied to the wound, it must be still more necessary not to interfere rashly with the dressings, and so disturb the natural process of occlusion of the injured ves- sel. If the haemorrhage do not recur, there can be no neces- sity for removing the pads, etc., until they are loosened by suppuration commencing in the wound, although it may be Htemokrhage. 29 advisable to relax the bandages (of necessity tightly applied in the first instance) after a few hours. Perfect rest of the wounded part, and, if possible, an elevated position, are absolutely necessary for successful treatment, while at the same time the whole system must be broug};^t into a condi- tion most likely to conduce to the formation of clot in the vessel, and the rapid granulation of the wound. The constitutional treatment of cases of severe hgemor- rhage is one of the most anxious cares of the surgeon. On the one hand there is the immediate danger of the patient's death from exhaustion, and on the other, the fear that by over-stimulation the haemorrhage may be agaiji induced with equally dangerous effect. It is in these cases that opium is of the greatest service. From one-half to one. grain, in frequently repeated doses, will do much to calm the patient's nervous system, and mitigate the injurious effects of loss of blood. Stimulants may be cautiously ex- hibited, provided surgical means have been taken to arrest entirely the flow of blood ; but where, from the nature of the injury, that has been impossible, it would be destruction to the patient to excite immediately the action of the heart, and thus destroy nature's means of arrest. A previously healthy patient will survive a state approaching syncope for many hours, and ultimately make a perfect recovery, while early and injudicious stimulation would have hurried him uncontrollably to the grave. Reaction after hemorrhage is not usually of a violent character, but, if necessary, may be treated by gentle purgation and small doses of digitalis ; tartar emetic can be but rarely required. Among the debilitated patients one meets with in hospital practice, anaemia is the difficulty which stands in the way of recovery from a wound. It is in these cases, when the blood seems scarcely able to coagulate, and there is a constant oozing from the wounded surface, that the preparations of iron in frequent doses have such a haemostatic effect. Of these the Tinctura Ferri Perchloridi seems the best medi- 30 H^MOEEHAGE. cine for the purpose, and this, together with small and re- peated doses of wine, and a light, dry diet, will materially assist in the recover}' of the patient. Haemorrhages may be conveniently divided into those which are caused by accident, and those which result from disease or follow surgical operations. HEMORRHAGE FROM ACCIDENTS. Scalp wounds are very common in hospital practice, and from the vascularity of the part generally bleed freely. If no large artery (temporal or occipital) is wounded, pressure alone will be sufficient treatnaent, and this is best applied by putting the edges of the wound in apposition (without stitches), placing a pad of dry lint upon them, and apply- ing a bandage firmly over the cranium, with a turn or two under the chin to keep everything tight (Chap. viii). The hair in the neighborhood of the wound should be cut close, and the immediate edges shaved, so that both the extent of the injury may be clearly seen, and the apposition of the edges may not be interfered with. Should one of the ar- teries be divided, so that the ends are able to retract, pres- sure will still usuall}'- suffice ; but if the vessel only be wounded, it should be thoroughly divided with a lancet before the edges of the wound are brought together. It is very difficult to apply a ligature on the scalp ; and if an artery continue to spout, a good plan is to transfix the edges of the cut and the mouth of the vessel with a hare-lip pin, over which a twisted or figure-of-8 suture can be passed so as to hold the parts in apposition and arrest the bleeding. The pin should be withdrawn in forty-eight hours. Scalp wounds may of course be accompanied by fracture of the skull, which should therefore be borne in mind, and the haemorrhage in these cases may come from within the skull, and be beyond the surgeon's control. HiEMOERHAGE FROM ACCIDENTS. 31 Wounds of the face bleed freely, and frequently require a ligature, though pressure can be very well adapted to the parts about the jaws. Collodion will frequently arrest the haemorrhage from small cuts, if applied in the following way : Grasp the part wounded between the fingers and thumb, so as to blanch it, clean the wound, and put the edges in apposition, drying them thoroughly with a soft rag. Then paint on the collodion, making it cover the skin for some distance around the wound ; let a firm hold be maintained until the collodion is perfectly dry, and then having allowed the parts to resume their proper position, paint another coat over all. The Collodium flexile of the British Pharmacopoeia is more tenacious than, and not so rigid as the common collodion, and is therefore more con- venient for surgical purposes ; a very good form of collodion is ma'de by dissolving guttapercha in chloroform with a gentle heat. To attempt to paint collodion on a wet sur- face, or while the blood is running, is worse than useless, and the same may be said of the application of adhesive plaster under similar circumstances, if warmed in the ordi- nary way ; but, if immersed in hot water, and carefully ap- plied with a little pressure with a cloth, the plaster will be found to adhere, and to control the haemorrhage to some extent. If adhesive plaster be applied during the process of granulation, it is best done in a number of narrow strips across the wound, each strip slightly overlapping the pre- ceding one. Sutures will sometimes be required in wounds of the face, in order to diminish the width of the scar, and if so, very fine silk, or fine metallic sutures are the best. Cut Lip. — Either lip may be cut through by a blow or fall upon the teeth, and the haemorrhage from the divided coro- nary artery is generally profuse. The introduction of a hare-lip pin and the application of a twisted silture form the best treatment ; but care must be taken to pass the pin sufficiently deeply in the substance of the lip to transfix, or 32 H^MORKHAGE. at least go close to, the bleeding orifices of the artery, other- wise haemorrhage ma_y still go on into the mouth. Unless a piece should have been cut (or bitten) out of the lip, there will be no difficulty in properly adapting the edges of the wound, but the surgeon should bear in mind, as in the opera- tion for hare-lip, that his proper guide is not the red border of the mucous membrane, but the line where the mucous membrane joins the skin. Collodion may be usefully applied over the twisted suture when the ends of the pin have been cut off. Two da3's are generally sufficient for the pin to remain in the lip, but the scab should be left untouched until it drops off spontaneously. Bleeding from the nose^ the result of a blow, is generally slight, and may be alleviated by the application of cold water, although the usual position assumed by the patient, that of bowing the head over the basin, is little calculated to assist in its arrest. It is much better to make the patient sit erect and hold a sponge to the nose, or in slight cases snuff up the cold air, which will often prove sufficient. Bleeding from the ear after a blow, is generally caused hy slight rupture of the lining membrane of the meatus, and must not be taken as a symptom of fractured skull, unless it is in large quantity', or is accompanied by other evidence of injury. Bitten tongue may give rise to severe haemorrhage if the wound happen to be in the thickness of that organ. Liga- tures are of little avail, as the}^ almost invariably pull off, and if cold does not arrest the flow of blood, torsion or the actual cautery should be applied to the bleeding points. Sutures are difficult to apply, and are of very little use in wounds of the tongue; and unless the piece is nearly sev- ered from its connections, so that the surfaces of the wound HEMORRHAGE FROM ACCIDEXTS. 33 are unlikely to come into apposition, it is better to trust to nature and the healing powers of the saliva. Teeth knocked out seldom give rise to severe haemorrhao-e of any duration, and cold water forms the best treatment. If the tooth (particularly an incisor) is sound, an attempt should be made to replace it in the socket, as it may possi- bly' become again attached. A piece of silk should bind it to the neighboring teeth, in order to keep it in position. Cut Throat. — If the large vessels of the throat are divided by the knife, immediate death will ensue before the suro-eon is called; but this is not a common occurrence, for attempts at suicide being generally made in the space between the hyoid bone and thyroid cartilage, the incision does not go near the carotid arteries. There is often sharp haemor- rhage at first from two or three small arteries if the incision is severe, but this may easily be arrested by ligatures or torsion, if the cold air has not already been sufficient to stop the bleeding. The incision will vary considerably both in size and depth ; an incision "from ear to ear" may be only skin deep, while another of smaller extent may have divided the trachea, and even the oesophagus. The patient is o-en- erally in a very depressed condition, partly the result of loss of blood, but mainly owing to the mental condition which gave rise to the attempt, aggravated occasional!}' by bodilv want. In this case it may be advisable to administer at once a small quantity of nourishment, such as a couple of tablespoonfuls of beef-tea and one of brandy, and repeat it at short intervals. If the pharynx is uninjured this can be readily swallowed, but if it is wounded (it is very seldom entirely divided) the stomach-pump must be used, the tube being introduced with great care, and the finger, if neces- sary, inserted in the wound to insure its taking the right direction. No Sutures Musi he Placed in a Cat Throat. — This is im- 3 34 H^MOEEHAGE. portant, as the friends of a X)atient are always very anxious to have the throat " sewn up," but such a practice is very dan- gerous, as it would cause any blood which might be effused to enter or press upon the windpipe, and b}^ retaining blood or pus witliin the wound, would prevent its granulating from the bottom. There is no objection to closing a mere skin- wound in the throat ; and even in deep cuts, the angles of the wound which are of this character ma}^ be safel}^ brought together. The position of the patient is the great thing for effecting a cure. If the first faintness has gone off and all haemor- rhage has ceased, the patient's shoulders should be raised by pillows, so as to make the head bow forward, and if the necessity for this position be explained to him, it will be found sufficient, provided the patient is sane. In insane or unruly cases, it will be better to carr}^ a bandage round the forehead, and bring the ends from the temples down to a waistband in front. The great danger in ca^es of cut throat, after the imme- diate consequences of haemorrhage and shock are passed, is inflammation of the lungs and air-passages, owing to the entrance of cold air through the wound. This is best ob- viated by the application of hot moist flannels, folded and laid lightly over the wound, and renewed as often as they become cold or dry. The flannels tend to help the granu- lating process, and after a day or so the patient can be taught to apply them himself so long as they are neces- sary. Great care must be taken to support the patient's strength during the first few hours after the injury, by the administration of food and stimulants by the mouth, if pos- sible, or if not, by enemata per rectum. Ruptured Fraenum. — Patients have been known, on sev- eral occasions, to apply at an hospital faint from loss of blood caused by a rupture of the frdenum preputii. Since the continued bleeding depends upon the fact that the little HiEMORRHAGE FROM ACCIDENTS. 35 artery of the frasnum has only been partiall}'^ divided, the obvious treatment is to snip it across with a pair of scissors, when the hgemorrhage will cease imraediatel3^ Stabs may be inflicted in various parts of the bod}', and give rise to a varying amount of hsemorrhage. {n.) Stabs in the throat may be treated on the same prin- ciples as cut throat, viz., to stop the bleeding and let the wound heal from the bottom without stitches. A complica- tion which may arise in stabs of the throat is where tlie knife has perforated the trachea, and emphysema is pro- duced, owing to the wound not being sufficiently large or direct for the air to escape through it. A pad of lint and a bandage, gently applied, form the best treatment, and the emphysema is generally but slight, and will gradually dis- appear. (6.) Stabs 171 the chest may produce haemorrhage by wound- ing (rarel}^) an intercostal artery, or the lung. An intercos- tal artery may be twisted or tied, and seldom gives much trouble. Wound of the lung (generally shown by bloody expectoration) ma}'' be immediatel}^ fatal from haemorrhage, the blood either pouring from the mouth or choking the lung, or more rarely filling the pleura and compressing the lung. The great object is the immediate arrest of the haemorrhage, by the inhalation of the vapor of turpentine sprinkled on a handkerchief, the application of cold both to the surface of the chest and by swallowing ice, and lastly by venesection, if necessary. Venesection for this purpose should be performed while the patient is supported in the erect posture, and the blood should be drawn from a large aperture, so as to induce a fainting condition as rapidly as possible, and care must be taken that the patient be not al- lowed to recover his heat and rapid circulation too soon, or the haemorrhage ma_v recur. An early opportunity^ should be taken of administering one of those drugs which have a haemostatic tendency (e. (/., Plumbi Acetatis gr. j, in pil. ; or Acidi Gallici, gr. v) in repeated doses. 36 H^MOREHAGE. (c.) Stabs in the abdomen may give rise to ligemorrliage from wounding vessels in the parietes, and these can be easily secured ; but apparently slight wounds may perforate the peritoneum and wound the intestines, giving rise to in- ternal haemorrhage. Simple wounds of the parietes should be closed with plaster or sutures, and collodion painted over all, so as to exclude the air. The sutures should be made to go through the edges of the cut peritoneum so as to se- cure its early union by adhesion, and had better be of silk, as they bear a greater strain than the wire ones, and are more easily withdrawn. Intestines, if wounded and ex- posed, should be stitched up with fine silk and continuous suture, provided the mucous membrane has not already pro- truded through, and so filled up the wound. Whatever the injury, the sooner the patient is got fully under the influence of opium the better, so as to guard against peritonitis. Wounds of arteries require varied treatment according to the size of the vessel and the kind of injury inflicted. For- tunately, these injuries occur mostly in the extremities, where pressure can be readily adapted to the limb, and it is to pressure alone that recourse should be had in many of the wounds of small vessels. Whenever there is sharp haemorrhage, probably arterial, from a wound; pressure should be immediately made upon the main artery with the fingers so as to stop the bleeding temporarily. This immediately relieves the anxiety of the patient and friends, and also permits a careful examination and cleansing of the wounded part with cold water. If this is done deliberately, and the wound is further exposed for a few minutes to the air, possibly, on the relaxation of the pressure above, no further haemorrhage will take place. Should it return, however, careful inspection should be made to discover the bleeding point. Supposing this pos- sible, which is not always the case, and a bleeding orifice to be discovered, if of large size, a ligature may be applied, or HJ5MORRHAOE FROM ACCIDENTS. 37 if small, it may be twisted, or pressure may be adapted in the following manner: An assistant again holding the main artery, and the wound having been again thoroughly cleansed, the surfaces should be laid together and a pad of dry lint placed over the wound and adjacent skin, so as to press the cut surfaces closely togetlier. A bandage, carried first round the limb for some distance below the wound, should be applied tightly over the pad, and then be carried a short distance above the wound, additional pads being placed, if considered necessary, along the course of the principal arteries, so as to exert pressure upon tliem. Should bleeding again occur, graduated presaure ma}' be used in the following waj' : The main arter}' being held as above described, the wound is to be laid open, and a small pledget of folded lint placed at the bottom; on this another pledget rather larger, and so on until the lint is an inch thick above the skin, pressure with a bandage being then exerted on the whole, with the same precautions as before. The addition of a piece of cork or of a small coin wrapped in lint renders the graduated compress firmer and more effectual. The disadvantage of this otherwise very effective method is, that the wound must necessarily be allowed to granulate from the bottom, thus occupying a longer time in healing, and leaving a larger scar. The position of the limb after the application of pressure is of the greatest importance ; thus the hand should be raised b}' a sling to the opposite shoulder so as to flex the elbow, while the foot and leg should be supported above the level of the body by means of pillows. (It is never sufficient simpl}-^ to tell a patient to keep a wounded or inflamed arm in a sling, for the limb is then generally allowed to hang down, but the surgeon should himself see that the hand is raised to the opposite shoulder.) The above directions are only applicable to wounds in- volving the smaller arteries of the limbs. In cases of injury of the main trunks, the profuse haemorrhage should be in» 38 H^MOREHAGE. stanth^ controlled by pressure of the finger upon the artery above the wound, until a tourniquet can be applied, which, although it arrests the rush of arterial blood, will very prob- ably still leave a strong current of dark-colored blood ebbing out of the wound. This blood, which may come from the lower end of the wounded artery, from the vein, or from both, will be immediately controlled b}'" another tourniquet placed below the wound, until the assistance of the visiting surgeon can be obtained, since operative interference of some kind will certainly be required. Patients who have received, a few days before, a wound of the principal artery, whicli has been treated by band- aging, are occasionally brought to an hospital on account of a continual oozing, or perhaps a sudden gush of blood ; and on examination a tumor is found in the limb, with a small orifice from which the blood emerges. The house- suro;eon is to be cautioned a2:ainst interferinir with such a case further than to put a tourniquet on the artery; for the tumor is probably a false aneurism of large size, and will require an operation of no small moment for its cure. Wounds of the palmar arch are sometimes laid great stress upon, as if their treatment differed in any way from that of wounds of arteries generally. A tourniquet should be temporarily applied while the wound is examined, and if no bleeding vessel can be conveniently tied or twisted, recourse must be had to pressure, which may generally be relied on, provided the parts are not interfered with and the dressings disturbed too earl^^ The fingers and thumb should be carefully bandaged, and a firm graduated compress hav- ing been applied to the bleeding point, the hand and arm should be firmly bound upon a back splint, and it may be well, as an additional precaution, to make pressure upon the radial and ulnar arteries at the wrist with pieces of elastic catheter wrapped in lint beneath the bandage. The elbow HAEMORRHAGE FROM DISEASE. 3d is then to be fully flexed and the hand bound up to the op- posite slioulder. Wounds of veins give comparatively little trouble, and the haemorrhage is readily arrested by pressure, if the vein is of moderate size. A ligature may occasionally be required on a large vein, and may be applied without much appre- hension as respects phlebitis, etc. HAEMORRHAGE FROM DISEASE. Bleeding tnay occur from vascular or malignant growths on the surface of the body, and, from the low condition of the patient, it may be highly desirable that as little blood as possible should be lost. As the source of the haemor- rhage is generall}^ rather a surface than any one bleeding vessel, the ligature is seldom applicable, and from the na- ture of the case pressure can hardly be applied ; haemostatics therefore must be employed, such as the Liquor Ferri Per- chloridi fortior, the Liquor Ferri Pernitratis, the solid Ni- trate of Silver, and Nitric Acid, or, in extreme cases, the actual cautery. In dealing with vascular growths, it will be advisable to surround the mass with a ligature, and tie it by one of the numerous methods described in surgical works, or more simply by passing a needle or hare-lip pin beneath the bleed- ing tissue, and then carr3dng a thread around it. Epistaxis, or haemorrhage from the nose, of spontaneous and constitutional origin, may be treated locally by the ap- plication of cold to the head and face, by the inhalation of vapor of turpentine, or by the use of powdered alum as a snuff. In severe cases, plugging of the nostrils may be required. The method of washing out the nose advo- cated by Dr. Thudichum, offers great advantages in the treatment of epistaxis. It is based upon the physiological 40 H^MOERHAGE. fact, that when a patient breathes through the month alone, the soft palate so effectually shuts off the posterior nares that fluid ma}^ be injected into one nostril, and will pass round the septum and out of the other nostril without enter- ing the mouth. A special apparatus has been devised for this purpose, but the plan can be readily carried out by means of a double-action india-rubber bottle or enema ap- 23aratus ; or still more simplj^ by attaching a rectum-tube to Fig. 1. /fW =— =k\ /G ^"l\ I r •■■• \ P I C \ &.' / a common water-tap, by which the force of the stream can be readily moderated. The most convenient form of apparatus, and one which has been emploj-ed by the author with advantage in the treatment of ozsena, is the simple vaginal douche, contrived by Dr. Rasch, and shown in Fig. 1. It consists simply of HAEMORRHAGE FROM DISEASE. 41 a stout india-rubber tube, five or six feet long, with a per- forated weight (a) at one end, so grooved that water can pass through it when standing on a flat surface. At the other end is an ordinary gum-elastic enema nozzle, which maj'^ be perforated with more than one hole if preferred. In using the instrument, it is only necessary to have an ordi- nary bedroom ewer filled with water, when the weighted end is dropped into it, and the tube " payed in " for two or three feet and left for a couple of minutes. The ewer being then raised upon a chest of drawers, or some convenient eleva- tion, the tube is squeezed below the level of the water (c) and drawn over the tip of the ewer (c'), when, being con- verted into a siphon, the water immediately begins to flow alona: it. Perfect control can be exercised over the water by the pressure of the finger and thumb of the surgeon, whilst tlie patient places his head over a basin and has the nozzle inserted into his nostril. On permitting the flow of the water, a stream is immediately established between the nostrils so long as the mouth is kept open, and the current can be reversed, arrested, or diminished with the greatest readiness. A more portable form of nasal douche consists of an india- rubber tube, weighted and fitted with a metal mount to pre- vent collapse against the edge of a tumbler. The other end is fitted with an india-rubber teat, which effectually plugs the nostril so that water can be sniffed up when the other nostril is closed. The tumbler being raised, the siphon action is then complete, and the water flows out of the op- posite nostril, provided the patient keeps his head forward and his mouth open. The tube should be made to slip through the mount so that the length of the weighted end can be adjusted to the depth of any tumbler or jug (Fig. 2). The instrument may then be conveniently employed for irrigating or cleansing wounds, especially about the nose or mouth, or may be used 4 42 HEMORRHAGE. for feeding helpless patients, either by suction through the teat, or by the siphon action. Fig. 2. Hsemorrhage from the rectum^ if venous, is generally the result of gorged hoemorrhoidal veins, and may be treated by enemata of cold water, or some astringent decoction, such as the Decoctum Quercus. If arterial and severe, the bleeding point may be touched with nitrate of silver or the actual cautery through a speculum, the rectum being after- wards carefully plugged with lint, to which a string should be attached to prevent its getting out of reach. Careful after-treatment will be requisite to relieve the loaded con- dition of the vessels, and probabl}^ an operation for the cure of the piles. Hsemorrhage from the bowel in children is not unfrequently caused by a polypus in the rectum, HEMORRHAGE FROM DISEASE. 43 which will require removal before the affection will be cured. Haemorrhage from the bladder may result from disease of its coats, or from the presence of a stone. The injection of cold water through a catheter will generally suffice, the instrument being retained in the urethra, so as to allow any blood which may flow to escape at once, and not coagulate in the bladder. In severe cases, weak astringent solutions may be injected, and ice be placed in the rectum and about the pubes. The internal administration of Gallic Acid and Tincture of Iron may be employed in these cases, but the most effectual remedy is turpentine in ten minim doses sus- pended in mucilage. An early opportunity should be taken to ascertain the presence of a calculus by means of the sound, and if it exist, the patient had better be at once ad- mitted into the hospital, or very possibly, the haemorrhage having ceased, he may never appear again for the necessary treatment. The following will assist the house-surgeon in arriving at a correct diagnosis as to the source of bloody urine. If the blood come from the kidney, it will be thoroughly mixed with the urine, rendering it of a smoky color if in small quantity, or dark red if more abundant. When the haemor- rhage is from the bladder, the first portion of the urine may be pretty clear, and the blood will be clotted and more abundant as the organ contracts. If from the urethra alone, it will be found that the first gush of urine is mixed with blood, but that afterwards it is clear, being again bloody at the last, when possibly a few drops of nearly pure blood may be ejected. Blood from the urethra, if in quantity, will trickle out before any effort at micturition is made. Ruptured varicose veins in the lower extremities give rise to dangerous haemorrhage. The patient may be unaware of the accident, and fall down in a fainting condition, 44 HEMORRHAGE. which may rapidly become fatal if not attended to. Pressure upon and below the wound immediately stops the bleeding, but the limb should be carefully supported in an elevated position for some time after the accident, to pre- vent its recurrence. The veins of the labia sometimes o-ive way in pregnant women: cold, the horizontal position, and pressure, form the appropriate treatment. Ulceration and ploughing may give rise to A^ery severe and even fatal haemorrhage by opening into a large vessel. Here the temporary arrest by pressure on the main trunk, and the subsequent adoption of the treatment proper for wounds of arteries (p. 36), must be had recourse to; although in some localities, as in the throat after scarlet fever, etc., the haemorrhage is beyond the surgeon's control, and will prove fatal. HAEMORRHAGE AFTER SURGICAL OPERATIONS. Hsemoi^rliage after extraction of teeth is sometimes troublesome, particularly in feeble patients. It is best treated by careful and forcible plugging with a strip of lint soaked in some st3'ptic, which is to be thrust bit by bit into the socket until it piojects beyond the neighboring teeth; the pressure of the opposite jaw, maintained b}^ a bandage under the chin, will then keep it sufficiently tight. In children, the subjects of an hereditary tendency to bleed {heemorrhagic diathesis), considerable trouble may be experienced in arresting haemorrhage from this cause. The lint should be steeped in the Liquor Ferri Pernitratis, and the patient should take full and repeated doses of Tinctura Ferri Perchloridi with dilute Hydrochloric Acid. Hseniorrhage from the tonsils may follow either the punc- ture of an inflamed tonsil, or the removal of one which is chronically enlarged ; and the former is naturally the more HEMORRHAGE AFTER SURGICAL OPERATIO^^S. 45 severe accident. The blood comes only from the branches of the artery to the tonsil, and never from the internal carotid ; and if gargling with iced water fail to arrest the hsemorrhage, the Tinctura Ferri Perchloridi, or, still better, the Liquor Ferri Perchloridi, or Liquor Ferri Pernitratis (B. P.) may be almost certainly depended upon to effect it. The fluid should be applied by means of a small sponge or piece of lint, attached to a piece of stick, and must be held firmly against the bleeding point for some minutes. In bleeding from the tongue and back of the throat, great advantage may be derived from the use of one of the "spray producers " in common use, emploj'ing as a stj'ptic the Glj'cerinum Acidi Tannici (B. P.) in the proportion of one to six parts of water, or the Styptic Colloid of Dr. Richardson. Or the patient may advantageously swallow slowly a tea spoonful at a time of the following solution, recommended by L)r. Morell Mackenzie: Acidi Tannici, gr. 360; Acidi Gallici, 180; Aquse, f^j. Leech-bites give trouble occasionally; and should cold and pressure fail to stop the bleeding, a fine-pointed stick of nitrate of silver may be inserted into each wound. As a last resource, a needle or hare-lip pin may be inserted through the skin so as to transfix the bite, and a twisted suture be placed over it. Intermediary hdemorrhage is that occurring soon after an operatiofi, and before inflammatory action has supervened. Small vessels, which did not bleed at the time of the opera- tion, may begin to do so on the patient's becoming warm in bed, and the bandages, etc., will become more or less stained with blood. This need occasion no alarm, unless the blood soak completely through, and begin to drip away from the dressings, when immediate steps must be taken for its arrest. In the case of a stump after amputation, for in- stance, the soaked dressings should be removed, and the 46 HEMORRHAGE. stump raised and exposed to a current of cold air, while gentle pressure is made upon the main artery with the finger or a tourniquet. If these measures arrest the bleed- ing, fresh cold dressings may be applied; but the limb had better be elevated, and the pressure gentl}'^ maintained for a few hours, to avoid its recurrence. If this treatment should not succeed, the sutures must necessarily be divided and the surfaces of the wound separated, in order that a ligature may be applied to the bleeding point ; or if, from au}^ reason, that is impracticable, a line-pointed actual cautery ma}^ be had recourse to as a last resource. In the practice of those surgeons who leave the flaps of amputa- tions apart for a few hours, intermediar}^ haemorrhage is much less likely to occur; should there be any oozing, however, care must be taken to remove with a soft sponge any clot which may have formed, which would prevent the immediate cohesion of the flaps which it is desired to obtain. Intermediarj^ haemorrhage after other operations is often more troublesome to treat than after amputation ; for ex- ample, in resection of the knee-joint an oozing may take place, but as no large vessel has been divided, and perfect rest is essential for the success of the operation, a house- surgeon should avoid opening up the wound and displacing the bones to look for a small vessel, which pressure and time would probably treat more satisfactoril3\ The same may be said of compound fractures, etc. Ssemorrhage after Incisions into Inflamed Parts. — In- cisions will often bleed profusely after a warm poultice is applied, as is the general custom in cases of erysipelas, carbuncle, etc., and the patient may lose more blood than is either necessary or advisable. The warm poultice must be immediately taken off and the clotted blood removed, after which strips of lint should be laid in each incision so as to fill it to the surface, and a pad of lint be placed over all ; a bandage should then be lightly applied, and the HEMORRHAGE AFTER SURGICAL OPERATIONS. 47 limb, if possible, kept in an elevated posture. In three or four hours the bandage and pad ma}- be safely removed, and the poultice reapplied over the strips of lint, which should be allowed to remain undisturbed until loosened by suppuration. Secondary hsemorrhage may occur in any wound when a ligature comes away, from the vessel not having become occluded, or it may result from sloughing having opened up vessels not previously implicated. Another and more formidable variety is where ligature of an arterial trunk has been performed, and hsemorrhage occurs at the time when, or soon after, the ligature comes away. Immediate arrest of the haemorrhage by pressure upon the main artery is, of course, the first object, and then, should the surfaces of the wound or stump be only partially united, an effort may be made to place a ligature upon the bleeding vessel; when, however, as is often the case, the greater part of the wound has healed, the assistance of the visiting surgeon should be at once obtained, since it will be a question whether the adhesions should be divided and the wound reopened, or a ligature placed upon the main artery higher up in the limb. Even in cases when the vessel can be reached, it is often impossible to isolate it from the surrounding tissues ; and the only method of proceeding is to carry a thread as close round the vessel as may be, by means of a sharp-pointed aneurism needle, and to tie it and the surrounding struc- tures en masse. In secondary hsemorrhage after ligature of an arterial trunk, two tourniquets will probably be required, one above, the other below the bleeding point, since the already re- established circulation will bring a full current of blood to the lower end of the vessel. Here one of two operations will be required — either to dissect out and tie the vessel at the bleeding point or immediately above, or to place a fresh ligature on the main trunk nearer the heart; and the as- 48 H^MOERHAGE. sistance of the superior officer must be immediately ob- tained.* In all cases in which secondary hsemorrhage may possibly occur, it is a useful precaution to mark with ink the spot where pressure should be applied ; and both the nurse and the patient should be shown how to make pressure with the finger in case of an3^ sudden emergenc}^ When there is any real probability of haemorrhage occurring, a tourniquet should be kept constantly but loosely applied to the limb, so that it may be put in action at a moment's notice. Haemorrhage after lithotomy may be both intermediary Fig. 3.t and secondary. There is often a little oozing of blood after the patient is put to bed, which may be checked by bring- * Consult Fergusson's *' Practical Surgery," p. 418 ; and see case of secondary hsemorrhage after ligature of both femorals, Lancet, 6th June, 1857. t Taken by permission from Thompson on " Lithotomy and Lithotritv." H^MOREHAGE AFTER SURGICAL OPERATIONS. 49 ing the thighs together with a turn of bandage, and exposing the perinffiura to the cold air; but occasional!}'' there is a sharp flow of arterial blood a few hours after the operation, sufficient to blanch the patient if he is very young. If the bleeding vessel can be seen, it should be tied or twisted; and if not, cold water may be injected per urethram and allowed to run through the wound, and ice can be placed in the rectum. The most effectual method of checking haemor- rhage, both at the time of and after the operation, is to plug the wound around a tube en chemise passed into the bladder. This gum elastic tube, of from six to eight inches Fig. 4. in length and half an inch in diameter, is perforated with holes at one end, and fitted with two rings at the other. A sort of petticoat is formed around the tube by pushing it through a hole in the centre of a square piece of calico, which is then to be firmly tied around it about an inch from the end, as seen in Fig. 3. Into this a quantity of lint or cotton-wool can be introduced when the tube is in situ^ and thus the wound is effectually plugged without risk of foreign bodies entering the bladder, and the whole can be with- drawn with the greatest ease. The strings attached to the rings pass in front of and behind the body of the patient, and are fastened to a band round his waist. If the rings are wanting, the strings can be effectually attached to the 50 H^MOERHAGE. tube (or a common catheter for children) with clove- hitches. Mr, Bnckston Browne's ingenious elastic lithotomy tampon (Fig. 4) is a more efficient and cleanly apparatus, being made entirel}'' of india-rubber, with a movable muslin cover, which prevents overdistension. Being introduced into the wound in a collapsed condition, the ball is distended with air, so as effectually to arrest haemorrhage, while the centre tube allows of the escape of urine. APPLIANCES FOR ARRESTING HAEMORRHAGE. Pressure with the finger, if applied on the proper spot, is alvvaj's sufficient to stop the current of blood in an artery. If possible, pressure should be made against a bone, and not against muscles, which offer but sliglit resistance ; thus the femoral artery should be compressed upon the edge of the pubes, and the brachial against the humerus. The sub- clavian can be compressed above the clavicle against the first rib with the thumb, or, what is better^ the handle of a door-key wrapped in lint. Tourniquets are of several kinds. The ordinar}^ one, or Petit's, is the least likely to slip, but has the disadvantage of impeding the venous circulation, and is therefore inappli- cable for lengthened use. The pad placed upon the strap of this instrument is generall}' too small, and had better be removed its place being supplied by a small roller about an inch and a half wide, which should be placed under the strap of the instrument, and over the artery. It will be found most convenient to place the screw of the instrument on the outer side of the limb, except in the case of the pop- liteal artery, where it should be placed directly over the knee. The buckle of the strap often gets drawn up close to the brass work, and would impede the action of the screw ; care should therefore be taken that a few inches of strap APPLIANCES FOR ARRESTING HEMORRHAGE. 51 intervene before the instrument is applied. It will be found impossible to apply this instrument so high upon the femoral artery as either tlie finger or other forms of tourniquet ; neither is it applicable to limbs which have two main arteries. Esmarch^H bandage and cord are very effectual means for rendering a limb bloodless previous to an operation. The elastic bandage, rolled like an ordinar}'' bandage, is to be applied firmly from the toes or fingers to a point well above the seat of operation, any open sore being protected with a piece of oil-silk. The elastic cord is then wound twice or thrice round the limb over the highest turn of the b«,ndage, being pulled as tight as can be conveniently done, so that the elastic tension may be complete. On removing the bandage, the limb will be found blanched and pulseless, and will remain so as long as the cord is tight. In the case of an amputation, the main arteries will be secured before the cord is loosened, but an assistant should always be ready to compress the main vessel with his thumb, so as to prevent loss of blood while the smaller arteries are being secured. In the case of an operation for necrosis, the wound should be packed with lint and a bandage ap- plied before the cord is loosened, so as to obviate almost entirel}' all loss of blood ; but caution must be exercised lest the bandage be applied so tightly as to prevent the return of blood into the limb, and thus endanger its vitality. For fingers, an ordinarj^ india-rubber ring, or, better, a round '' umbrella-ring," may be used, and, if rolled up the finger from tip to base, renders the operation bloodless. A similar ring may be conveniently used for the penis in cases of circumcision, or one of larger size for the limbs of infants or young children. Signoroni^s tourniquet is chiefly applicable to the upper part of the femoral artery, the hollow pad being applied to 52 HEMORRHAGE. the outer and back part of the limb, and the convex one screwed down upon the vessel. This is a very effective instrument in this position, provided the bedclothes are prevented from touching it ; but in other positions it will be found difficult of application, and very liable to slip off. There are two or three varieties of field-tourniquet, con- sisting essentiall}^ of a strap, buckle, and pad, which can be readily applied ; or, in case of sudden emergency, a tourni- quet may be improvised out of a handkerchief tied firmly round the limb, and a stick twisted in it to keep up pressure. Forceps are the best instruments for seizing a bleeding vessel, and of all the varieties which have been invented, a pair of ordinary dissecting forceps, broad and well serrated at the extremities, is the best for the operator, who readily seizes the vessel, and, probably, a small amount of tissue with it; but it is not so convenient for tying the ligature upon as the artery forceps made to meet at a sharp point. The spring of the forceps should not be too feeble, since it materially assists in catching a bleeding vessel to have a sligiit resistance in the instrument. Coxeter's catch artery forceps is a ver}' useful instrument, especially for picking up a vessel close to bone, but it has the disadvantage tiiat it transfixes the tissue it grasps, and may thus inflict an injur}'^ upon the coats of a large artery when the attempt is made to seize a small branch cut short. The ligature should be of hemp or silk (of which the former is preferable), or of carbolized catgut, if strict anti- septic precautions are to be adopted in the after treatment; and a little study of the best and most rapid way of tying a ligature will amply repay the house-surgeon. The object is to tie a "reef-knot," which is certain to hold, and not what is nautioally termed a " granny," which is very likely to slip. The difference between the two knots will be best APPLIANCES FOR ARRESTING HEMORRHAGE. 53 appreciated by the diagrams (Fig. 5), where the reef-knot is marked A, and the granny B. Fig. 5. It will be observed that in the "reef" both the ends of the threads pass either over or under the corresponding loop, while in the "granny" one thread is over and the other under; the result of which is tliat the loops are not so Fig. 6. flat, and, when pulled tight, do not come so closely together or hold so firmly as in the true "reef-knot." Any one can satisfy himself of this in a moment by tying the two knots on a piece of string, and comi)aring them. The secret of 54 HEMORRHAGE. invariably tying a " reef-knot " is to make the same thread uppermost or undermost both in the first and second t3^ing. This can be, and is, accomplished by many surgeons by changing hands after the first tying, which always looks awkward, and wastes time. A much better method, but one which requires a little practice to learn thoroughly, is the following: The ligature, which should be sixteen inches long, is to be held in the palm of the (right) hand Fig. 7. between the thumb and forefinger; the end is then to be thrown round the forceps closely and caught with the left hand ; the right hand is now brought under the end in the left, when that end is to be crossed over the right thumb and inserted between the third and fourth finger of the right hand (Fig. 6) ; the left hand at the same moment seizes the other end, and thus an interchange is effected, and the ends of the threads are drawn out as is being done in Fig. 1. There will now be no difficult}^ in drawing the knot thus formed tight with the forefingers, or, if preferred, with the thumbs (Fig. 8). To complete the knot by making another tie, the same manoeuvre is to be effected, taking care always APPLIANCES FOR ARPvESTING HEMORRHAGE. 55 to begin with the opposite iiand to that which began before. It is quite immaterial which hand begins the first part of the knot, so long as the opj^osite one always begins the second part; and in this way, with a little practice, the reef-knot may be unerringly tied with the greatest rapidit3^ Some people may- possibl}' think that the above directions more resemble those for the performance of a conjuring trick than a surgical operation ; but it is surely well worth Fig. 8. a surgeon's while to attain the greatest possible dexterity in the use of his fingers, both for his own and his patient's sake. In whatever way the knot is made, great care should be exercised not to tie the forceps in, while drawing it close ; to avoid which accident, the best way is to keep the loop flat upon the wounded surface, and, as it is drawn tight, to pre- vent it slipping up with the forefinger on each side. In pulling the ends of the thread, they should be drawn down- wards as much as possible, i. e., towards the wound, since otherwise tlie ligature may very possibly be pulled off re- 56 HEMORRHAGE. peatedly. Although the manner in which the ligature is tied is of the greatest importance, still much depends upon the way in which the forceps seize the vessel and hold it after- wards. Except in the case of the large vessels which have a distinct sheath, it is impracticable to attempt to seize merely the bleeding orifice, but a certain amount of sur- rounding tissue must necessaril}' be grasped, and tied in by the ligature; and it will much facilitate the operation of tying, if the holder of the forceps draws them slightly away from the side on which the knots are being made, at the time the ligature is being applied. When the tenaculum is used to seize the vessel, the same method of applying the ligature Fig. 9. should be employed, but care must be taken to make the knots beneath the instrument, and not over it so as to pre- vent its being withdrawn. The cat-gut ligature is made of three sizes, No. 1 being the smallest, and should be kept in carbolic oil. Stoppered bottles are better than those with corks for holding the ligatures, but for an operating-theatre reels should be provided which can rotate in a trough of carbolic oil (Fig. 9). Acupressure, as originally devised by Sir James Simpson, had for its object the arrest of haemorrhage by means of a hare-lip pin, which was made to exert pressure upon a bleed- ing vessel, by compressing it against a bone or the surround- APPLIANCES FOR ARRESTING H^MORRRAGE. 57 ing tissues ; but has also been modified bj' using needles in combination with wires. The pin is to be applied on the surface of the wound, and is to pass over the open mouth of the vessel, so as to compress it, or maj' be made to twist the vessel by being rotated before the point is fixed into the tis- sues. Wherever it is inserted the extremity must be left at the surface of the body, in order that it may be withdrawn in from four-and-twenty to sixty hours, after the vessel has become occluded by natural processes. The method with the wires consists in passing a sewing needle (to the eye of which a wire is affixed) beneath the bleeding vessel, and over its point a loop of iron wire, which passes across the Fig. 10. vessel and is secured with a twist around the shaft of the needle. In order to remove this, it is only necessary to un- twist the wire, and to withdraw the needle b}^ means of the wire attached to it, when the loop of the secured wire will become disengaged and can be withdrawn. The advantage claimed for these methods is that the irritation caused by a ligature is avoided, the metallic needle producing no such effect, and being withdrawn at so early a date, it offers no impediment to the wound's healing by first intention. It has been found in practice, however, that the presence of the needles is so inconvenient, that their use has not become general, even those who adopted the method of acupressure having in many instances preferred that of torsion. 58 H^MOERHAGF. Torsion of arteries is an old practice which has recently been revived and a good deal employed. It consists in grasping the mouth of a cut artery with broad serrated for- ceps, which have a sliding button or catch, by which the vessel is secured whilst it is twisted two or three times by the fingers of the operator ; this is termed "free torsion." " Limited torsion," which is applicable only to large vessels, consists in drawing the vessel out of its sheath with one pair of forceps, whilst with another pair it is grasped trans- versely about half an inch from the extremity, which latter is then twisted as shown in the illustration from Fergusson's Surger}^ (Fig. 10). The emplo^'ment of torsion is not so easy as the application of a ligature, as it is necessary to seize the mouth of the vessel fairly and alone in order to obtain a good result. Hence, more care and time are re- quired in the operation than in merely picking up vessels with some of the surrounding tissue before the ligature is applied. It is no doubt an advantage, however, to get rid of the ligatures in a wound if it is hoped to heal it by first intention, but when the vessels are extensively diseased it w^ould not be safe to resort to torsion. WOUNDS. 59 CHAPTER II. WOUNDS, CONTUSIONS, BURNS, ETC. Wounds present an endless variety both of shape and position. The treatment of some of these has necessarily been included in the observations upon haemorrhage, which is one of their constant accompaniments. Respecting wounds generally, it will be sufficient to say that the sur- geon's object is to heal them by iBrst intention, if possible, and that this result may be ordinarily looked for in the case of clean incised wounds, whilst it is least likely to occur in crushed or torn issues. Dr\' dressings, with moderate pres- sure and support, have a direct tendency to aid the process of rapid healing, and thej^ form therefore the appropriate treatment of incised wounds. Should any dirt or foreign body have entered the wound, it must be carefully removed with a sponge and cold water; but if there is no reason to imagine such an event to have occurred, it is cruel and un- necessary to insist upon probing a wound simply to satisfy a morbid curiosity as to its depth, with the possibility of exciting anew the haemorrhage, which has been arrested by natural processes. A small pad of lint will probably be sufficient to keep the edges of the wound in apposition be- neath a carefully applied bandage; but if not, a pad may be placed on each side of the inuision so as to exert pressure on the deeper parts, the surface being covered with a small additional piece. Strips of adhesive plaster may be applied to hold the edges together, but in that case they should be cut long enough to take a hold upon the skin some inches beyond the actual wound. After the operation for hare-lip, or in other cases of wound where traction is required, it will be found 60 WOUNDS. convenient to use two straps of plaster of different widths, passing the narrow one through a transverse slit in the wider one, and splitting the ends of the plaster so as to obtain a good hold on the tissues (Fig. 11). Or if elastic tension is desirable, a common india-rubber ring may be inserted be- tween two pieces of plaster cut and folded as in Fig. 12. In Fig. 11. Fig. 12. the case of the extremities, it may sometimes be advisable to carry a long strip of plaster round the limb, making the ends cross over the wound in order to exert pressure upon the tissues. Sutures are requisite in large wounds, and in cases where the skin retracts so that without them the cut surfaces do not come into apposition. They should be of silk or fine wire, which latter excites little or no irritation in the tissues, and can therefore offer no impediment to union by first intention ; or on the face may be of fine cat-gut or horse- hair, which dissolve away spontaneously. Contused and lacerated wounds^ particularly those in which a large portion of skin has been destro3^ed, can only be expected to heal by granulation, and they may therefore be appropriately treated from the first with '' water-dress- WOUNDS. 61 ing," unless it is thought well to employ Lister's dressing, in the hope of leading to organization of tlie blood-clot in the wound. It is in these wounds that foreign bodies may generally be expected, and care should therefore be taken to cleanse them as far as can be readily effected ; but any little remainder of dirt, etc., will be certainly thrown off by the process of suppuration. Strapping, and careful but light bandaging, are v^erj'^ serviceable in these injuries ; but sutures are of little use unless the wound is very extensive. In fact, the house-surgeon will have to guard against allow- ing a wound to heal at the surface while suppuration is going on in the deeper parts. The after 'treatment of wounds coT^&\sis mainly in atten- tion to three points, viz., rest, cleanliness, and temperate living. The first must be attained by confinement to bed in severe cases, or at least cessation from employment, and, if necessary, the use of a sling, etc.; the second is for tlie house-surgeon to see to at each dressing of the wound ; while the third can generally only be hoped for in patients under the surgeon's eye in the wards of an hospital. Cases in which union by first intention is hoped for should not have the first dressings disturbed before the third or fourth day, provided there is no pain or throbbing complained of, and the dressing should be soaked off with tepid water, to avoid tearing open the edges of the wound. Should the edges be found united throughout, and no swelling or redness indicate the presence of pent-up matter, a piece of drj^ lint and a bandage should be again applied, to give support, and in a few days a perfect cure will be effected. It not unfrequently happens, however, that pain and throbbing indicate the presence of pent-up fluid, and it is surprising how much inconvenience a mere bead of matter will occasion. In such a case it is unnecessary to tear open the whole of the wound, for if with a probe a small opening be made at one end of it, a little pressure 62 WOUNDS OF THE CORNEA. will cause the fluid to exude, to the patient's immediate relief, and the lint and bandage can then be re-adapted. Supposing the effort to induce healing by first intention to fail^ the wound will become converted into a granulating one, and be treated according^. Granulating wounds are best treated with water-dressing, some stimulating lotion being used in addition, when necessary. When there are sloughs to come away, linseed-meal poultices may be advisable for a time, but should not be prolonged so as to make the granulations weak and flabby. In dressing a granulating sore, care should be taken to cut a piece of lint just the size of the wound ; over that should be placed a piece half an inch larger in each direction, and on that again the oil- silk or thin gutta-percha, which should again slightly over- lap it, the whole being retained b}^ strips of plaster or a light bandage. Although cleanliness, as regards the dress- ings, etc., is of the greatest moment, the surface of a sore should not be interfered with more than to sponge off, gently, any superfluous matter, for a certain amount of pas is absolutely necessary for its progress. Wound of the cornea is too frequently accompanied by prolapse of the iris. If seen immediately after the acci- dent, an attempt may be made to restore the iris by dilating the pupil with the solution of sulphate of atropine (gr. ij ad f^j), a few drops being placed in the eye, and some smeared around the orbit. A strip of plaster should be placed over the lids, so as to keep them closed ; and the patient should wear a shade over both eyes, and entirely abstain from using them. If there is pain, iced water applied on lint over the eyes will relieve it. It is seldom that a case is seen so instantaneously as to be benefited by the treatment with belladonna, and the small prolapse will soon shrink up, and can be clipped off in a few days with a sharp pair of scissors. A wound of the sclerotic is always more serious than one of the cornea, and ma}^ immediately destroy sight. WOUKDS OVER THE SHIN. 63 When the wound is small, an attempt should be made to bring about healing by drawing the edges together with a fine silk stitch. Liebreich's eye bandage (Fig. 13; will be found serviceable after injuries as well as after operations upon the eye. The bandage consists of a linen or knitted cotton band, A^ from 10 to 10|- inches in length, and 2^ inches in width, at either end of which are attached tapes to keep it in position on the head. The tapes should be 1 inch in width. One tape, 5, IH to 12 inches in length, extends across the top of the head from ear to ear, and terminates in a loop, through which the second tape, CD, passes, as in the woodcut. Fig. 13. To apply the bandage : The patient having been told to gently close the lids of both eyes, a small square of linen is laid over each, upon which are placed small pads of cotton wool or charpie. The bandage, which had been previously fitted to the head, is now drawn across the eyes and fastened on the temple opposite to the eye which has sustained the injury. Wounds over the shin often give trouble, if neglected. Collodion and absolute rest form the best treatment ; and as the}' are frequently accompanied by a bruise of the sur- rounding parts, the tincture of Arnica montana may be usefully painted around, but not upon, the wound. Curtis's 64 * WOUNDS OF JOINTS. "Pasma," or the oxide of zinc powder, may be advantage- ously dusted on these wounds. Wounds of Joints. — Wounds of joints, if not obvious at first, are soon made evident by the escape of synovial fluid, which trickles out, and can easily be distinguished from blood by its light color and tenacity. Unless antiseptic treatment is available, closure of the wound is of the first importance, provided no foreign bod}' be left in the synovial cavit}^ In the case of punctures or small incisions, collo- dion forms the best application, the same precautions being used as in cuts on the face. (See p. 31.) In the absence of collodion, white of egg is not a bad application ; and plaster should be used to support the parts, and prevent the wound being dragged open. When the wound is so large as to require the application of stitches, care should be taken not to insert them through the S3'novial membrane, and col- lodion may be advantageously applied over them. Perfect rest and the application of cold are the best preservatives against inflammation of the joint ; and a splint should there- fore be applied to the limb, which must be kept, if possible, in an elevated position. The posture which is easiest, and which relaxes all the parts most, must be the best at first, but, should inflammation come on, care must be taken to place the limb in a position in which it may be ultimately useful, should the motion in the joint be lost or impaired. Irrigation with cold water is the readiest and most certain method of applying cold to a wounded joint. In the anti- septic treatment of a wounded joint, it would be necessary to wash out the cavity with a solution of carbolic acid (1 in 40), to insert a drainage-tube through the wound, and to appl}^ the gauze dressing with all the details described under " Antiseptic Dressing." A bursa over a joint, when opened, pours out a fluid closely resembling synovia, which might be considered diagnostic of injury to the articulation; but BRUISES AND CONTUSIONS. 65 the cautious introduction of a probe would at once decide the question of its origin. Bruises and contusions form a considerable portion of out- patient practice. They present every possible variety, and it is generally from fear of some more severe lesion having occurred, rather than for the treatment of the bruise itself, that the patient applies to the house-surgeon. A careful examination is essential in all cases of contusion, lest some injury should be overlooked; and when, as sometimes will occur, it is found impossible, owing to the swelling, to ar- rive at a definite conclusion, it is better to err on the safe side, and treat the case for the more severe injury (e. g., fracture), than to commit an error which may be of lasting importance to the patient, by ignoring the possibility^ of its occurrence. Cold is the best application for a bruise, and this may be applied in any way most convenient — by irrigation, the ap- plication of an ice-bag, or the use of an evaporating lotion. The following is a useful formula for an evaporating lotion : R. Spiritus Vini rectificati, Liquoris Ammonise Acetatis, aa, . f ^j Mist. Campliorse, .... f5xiv. Misce ; and care should be taken to instruct the patient to allow it to evaporate^ and not to cover the rag on which it is applied. The tincture of arnica has been highly recommended in all cases of bruise, and, when used undiluted, appears to have considerable power both in alleviating pain and inducing absorption of the effused blood. In some persons with irri- table skin, the pure tincture is apt to produce a form of erysipelas, and it is well, therefore, to be cautious in its em- ployment on the first occasion. There is one form of bruise which requires special notice, and that is, where a circumscribed swelling is produced on tlie head by a blow, giving an appearance resembling de- 6 QQ CONTUSIONS. pressed fracture of the skull, owing to the circumferential swelling of the integuments. Since this affection is fre- quently conjoined with cerebral symptoms, — concussion, more or less severe, — it becomes of importance to make a correct diagnosis ; and careful manipulation will generally prove that the appearance of depression is deceptive, while the presence of fluctuation in the centre will, in many cases, assist in arriving at the truth. A bladder, or better a flat- bottomed india-rubber bas:, of ice to the head is the best treatment. In large subcutaneous effusions of blood in a limb it may be occasionally advisable to tap the swelling with a fine aspirator-needle, and draw off the uncoagulated blood ; but this should never be done in a recent case, as it will only lead to further effusion from the ruptured capil- laries. Contusions are best treated by rest and opiate applica- tions. Bed is the great panacea; but if this is not attaina- ble, rest of the limb, by means of a sling or otherwise, sliould be enjoined. In contusions of the chest, even where there is no suspicion of a broken rib, a broad flannel bandage, firmly applied, gives great relief by restraining the intercos- tal muscles; and on the same principle a bandage may be applied to a limb. Soap liniment, with a little laudanum in it, is a good application in most cases ; or the belladonna liniment (B. P.) sprinkled upon lint, and covered with oil- silk, will be found useful. Where a patient is shaken and bruised all over by a fall from a horse, etc., a warm bath gives great relief, provided he is not faint. In any case of contusion about the abdomen, and particu- larly if the injury has been inflicted by a carriage-wheel, the house-surgeon should immediatel}' pass a catheter, which must be retained if there are symptoms of injury to that vis- cus or to the urethra, such as bloody urine or pain over the pubes. The early attendance of the surgeon should be re- SPKAINS AND STRAINS. 67 quested to any case in which rupture of the bladder may be suspected, and care should be taken in these cases not to overlook a fracture of the pelvis without displacement. Sprains^ though apparently trivial, should never be neg- lected, since they too frequently lead to joint-disease. Al- though, in most cases, it is onU' the ligamentous tissues which suffer, yet occasionally small prominences of bone are wrenched off, or, in youth, the epiphyses may be torn awa}'. In all cases of sprain, therefore, a thorough but gentle ex- amination of the joint should be made : and if this is impos- sible from the pain produced, chloroform should be had recourse to, rather than that an error in diagnosis should be committed. Unless seen immediately, the swelling is often so great as to mask the nature of the case, and no opinion should be pronounced until a tliorough examination can be made. The local abstraction of blood b}' leeches is of great ben- efit in violent sprains, and the bleeding may be encouraged by hot baths or the application of linseed poultices. Sub- sequently, support of the affected joint is of the greatest im- portance, and this may be effected by careful bandaging, or, still better, bj' strapping with adhesive plaster, which has the advantage, not only of supporting, but of rendering the joint motionless, much more effectually than the band- age. Strapping may, in most cases, be applied within thirty- six hours of the injury, and thus the patient will be enabled to get about with comparative comfort. Stimulating fric- tions are useful in the later stajjes. es Strains generally mean some rupture of muscular or ten- dinous fibres, although sometimes the term is vulgarly ap- plied to a hernia. Time is the only cure for ruptured tissues, and all the aid the surgeon can give is to approximate the extremities of the torn fibres, and support them by a band- age, so that they unite as rapidly as possible, and also that 68 MACHINERY ACCIDENTS. no subsequent weakness may result from the tissues being lengthened. Cold applications will be useful in relieving the pain, and will assist in inducing the absorption of any effused blood. Buptured tendo Achillis may be conveniently mentioned here. It generally results from some unwonted exercise on the part of an elderly person, who drops suddenly to the ground. A snap is sometimes heard, and the rupture can be felt with the finger. The treatment consists in attaching a strap to the heel of a slipper, and fastening it above the knee, so as to point the toe thoroughly and slightly flex the knee. Ruptures of the fibres of the muscles of the calf ma}^ be treated in the same manner, or by raising the heel of the boot. Machinej^y accidents present every variet}^, from simple fractures or incised wounds, to total disorganization of a limb. The haemorrhage, if au}^, should be arrested, and the parts be brought as nearly as possible into their normal relations to one another, stitches being inserted when necessary ; and even where there is no fracture, the appli- cation of a splint to a crushed limb will often be of the greatest service. Amputation should not be thought of while there is any hope of saving a limb, since it is extra- ordinary how well severe machinery accidents turn out, owing to the previous good health of the patients. When a portion of a limb has been torn off, amputation higher up will probably be necessary in order to obtain sufficient soft tissue to form a stump. But for this, the advice of the visiting surgeon should always be obtained. Extraordinary scalp wounds are sometimes produced b}'' the long hair of women becoming entangled in machinery, and the scalp being consequently torn off the head, partially or completely. If only partially removed, the scalp should be carefully sponged and replaced, if possible, without the Buiijss aind scalds. G9 use of stitches, and with dry dressings. The " capeline " bandage (cliap.viii) will be found a very useful application in these cases, and will often insure healing by first inten- tion. Wiien the whole scalp has been torn off, water-dress- ing forms the best application, and the surface will proceed to granulate, provided the patient's strength is sufficient to bear up against the shock and exhaustion. The house-surgeon may be summoned to a manufactory to *'cut out" a sufl[erer from machinery, which it is found impossible to remove without doing further damage. No precise rules can be laid down for such proceedings, but the chief points are to guard against haemorrhage, and to remove as little of the body as possible ; Init the amputation should be done so as to avoid a second operation. When a limb, and particularly the arm and hand, has been crushed by machinery, and it is resolved to give it a chance of recovery, a most excellent mode of treatment will be found in irrigation with tepid water. The constant flow of water keeps the complicated wound thoroughly clean, modifies the inflammation, and has a direct tendency to effect a cure. Poultices may be advisable for a short time, to favor the separation of sloughs ; but, if employed, care must l)e taken that the matter has a free discharge, or pytemia will very possil)ly result. When granulation has commenced, the ordinary treatment of wounds is all that is required, viz., cleanliness, support, and slightl}'^ stimu- lating lotions, together with proper attention to the pa- tient's "general health. Burns and Scalds. — In severe cases, the constitutional treatment is of more immediate importance than the appli- cation of local remedies. The patient is suffering from "shock " in its most aggravated form, and is to be treated accordingly. He should be wrapped in a warm blanket and placed near a fire, while some warm brand}^ and water is administered. When the warmth of the body is thoroughly 70 BUENS AND SCALDS. restored, attention may be directed to the local injury, and dressings may be applied to one limb at a time, the rest of the body being carefully covered up. In the case of burns of the trunk in children (and in adults, too, if conveniences a^re at hand), immersion in a warm bath, the temperature of which must be carefully maintained, will ease the pain and float of!' the charred remnants of the clothes, leaving clean surfaces for the application of dressings. If the ''continuous bath" can be emplo3^ed, the patient may, with advantage, remain in it until cicatrization is complete. In superficial burns (l e., where only tlie cuticle is destroyed), and in scalds, a read}^ application is a mixture of collodion and castor-oil (two parts to one), which should be painted with a small brush all over the injured surface; or the gutta-percha collodion may be used pure ; or solution of nitrate of silver (fifteen grains to the ounce) may be painted over the whole surface, tlius producing a protecting eschar; or a saturated sohition of bicarbonate of soda may be em- ployed. When vesicles have been produced, tliey should be snipped with a sharp pair of scissors, the serum being gently evacuated with a piece of cotton-wool, and the ni- trate of silver lotion or the collodion mixture applied over them. This mixture ma}^ be convenientW kept ready-made in a well-stoppered (or l)etter, a capped) bottle, in the sur- gery; and its application, although painful for the moment, will be found to give immediate relief to the smart of the injury. No other dressing should be put over the collodion, which should be repeated once or twice as it dries. If the injury is quite superficial, the skin will probably cicatrize before the scab drops off; but if too severe for that, healthy granulations will spring up, which are best treated with water dressing. Cotton-wool (or, what is better and cheaper, the common white cotton wadding, split open) is a favorite and useful application both for burns and scalds. It should be carefully wrapped around the injured part, and maintained in position by bandages. It certainly AFTER-TREATMENT OF BURNS. 71 soothes the pain rapidl}', but has the disadvantage of stick- ing to the raw surface, from which it should be allowed to separate by suppuration, assisted b}^ a poultice, if neces- sai*y. Carr-on oil (equal parts of lime-water and linseed oil — liniraentum calcis) is an exceedingly nasty application, though a favorite with many surgeons. Lint soaked in it is placed over the burnt part, and in badly-charred cases it is, perhaps, as good an application as any, though its offen- sive odor is a great drawback. The boracic acid ointment has the advantage of combining an antiseptic with a greasy dressing, and is largel}' employed in University College Hospital. At the London Hospital, where the cases of burns are very numerous, the universal treatment is the application of zinc ointment on lint, fomentations being applied over the dressings for the first few hours. The after-treatment of hurns^ both local and constitu- tional, is of the greatest importance. If the injury be at all severe, hot bottles should be applied to the feet, and some form of sedative, even in young children, will be ad- visable, both to relieve pain and procure sleep ; and this may be necessary for some days after the accident. In very extensive burns, it may be advisable to administer chloro- form for the first few dressings. Subsequently, ample nourishment, and probably stimulants, will be necessary to counterbalance the drain upon the system caused by the profuse suppuration. As respects the wound itself, our object is to get it into a state of health}' granulation as quickly as possible, and for this purpose — so soon as the first applications are removed — water-dressing may be ap- plied, with or without myrrh or some other lotion ; or the zinc ointment may be used, if preferred. When a highly- sensitive surface — such as the face — has been extensively burned, the ointment should be preferred, as it adheres less to the surface. In these cases the dressing should be 72 SCALDS OF THE GLOTTIS. changed as seldom as ma}' be, and, if possible, under t-lilo- roform. A poultice can only be useful in expediting the detachment of eschars, and should not be employed after- wards, as it will provoke suppuration. To prevent contraction during and after the cicatrization of burns is one of the house-surgeon's most difficult tasks, and will tax his ingenuity to the utmost. Extension of the cicatrix must be constantly kept up by the use of splints if the injury is on the limbs, or by laying the patient flat in bed, or even with the head overhanging the bed, if the burn is on the neck. In these cases strips of plaster may be most usefully employed to stretch the cicatrix, and if the patient's head is shaved, the scalp will be found to afford a firm attachment for them. Of the various mechanical appa- ratuses which have been contrived for stretching the cica- trices of the neck, the onl}'^ one which is really effective is that which exerts pressure in both directions, and pulls the skin down over the clavicles by means of a collar, at the same time that the chin is raised. Those screws which only get their purchase from a waistband, and therefore only act in one direction, are worse than useless. Bad burns are often months in an hospital, and as they are by no means favorite cases with either dressers or nurses, it behooves the house-surgeon to exercise a sharp surveillance, and to see that they are properly attended to, or he will find that with all his care the patient will become crippled by contractions. Scalds of the glottis require special notice and treatment. The patient is generally a child, who has attempted to drink boiling water from the spout of the tea-kettle, and has con- sequently injured the mouth, fauces, and upper part of the larj-nx more or less severel3^ The symptoms of d^'^spnoea will vary according to the time which has elapsed since the accident, and the amount of damage done. If the little patient is evidently in articulo from want of breath, the INJURIES FROM FIREARMS AND GUNPOWDER. 73 house surgeon had better perform laryngotomy at once; but if the symptoms are not of such extreme urgency, the operation should be deferred, for a time at least, in order to try the effects of treatment. The first thing is to place the patient in a warm and moist atmosphere, and this can be contrived by })lacing an ordinary surgical cradle over him and under the bedclothes, or a piece of Mackintosh cloth, and then bringing the steam of a kettle beneath the canopy thus formed. Care must of course be taken that the temperature be not raised above 80^, or the patient will be suffocated and parboiled. Relief may also be attempted by scarifying the back of the throat, epiglottis, etc., which has been known to be of great service in some cases. As regards medicines, antimony and ipecacuanha appear to offer the best chance of success, and the}' may be most conveniently administered in the form of the wines. Large doses of either (and antimony by preference), according to the child's age, may be given, and frequently repeated, until the breathing is relieved. Yomiting is not to be wished for, and will seklom be produced. Mercur}'^ may be combined with the antimony, and, to be of an}- service, must be administered in heroic doses, and frequently; but should the breathing become more embarrassed, the operation of laryngotomy or tracheotomy must at once be had re- course to. It) juries froYR Firearms and Gunpowder, — Gunpowder will inflict damage according to the mode in which it is exploded, rather than the actual quantity ignited. Loose powder scorches and burns the surface of the body severely, and, from the mode in which it ''flares up," is very apt to injure the eyes and burn the hair off the head. The treatment of such injuries differs in no essential particulars from that of burns generally. Compressed powder shatters and destroys b}'' the force of the explosion, in addition to the damage done by the flame. A firework exploding in the hand, the bursting of a gun, or, still more commonly, of a powder- 74 INJURIES FROM FIREARMS AND GUNPOWDER. flask held over a light, will shatter the hand very severely. On admission to the hospital, the haemorrhage, if still exist- ing, should be arrested by ligature or otherwise, and the state of the hand be carefully examined. In the case of children or adults without much self-control, it may be ad- visable to administer chloroform at once, and do what is necessar}' while the patient is under the influence of the anaesthetic. If fingers are blown off, the adjacent tissues should be drawn together as far as may be, to form a stump ; or it may be well, particularly in the case of patients of the better class, to remove at once the head of the metacarpal bone, so as to improve the after-appearance of the. hand. Although severely torn, and even fractured, a finger should never be hastily amputated, since, with careful dressing and support on a splint, apparently despei'ate cases do well eventuall3\ If onl}^ one finger can be preserved, it should be saved ; and what is said of a finger applies wuth double force to the thumb, without which the hand loses the greater part of its powers, and presents a most unsightly appear- ance. Gunshot injuries may be immediately fatal from haemor- rhage, or from injury inflicted on a vital part. A bullet and a charge of shot at a short distance will each produce a sino-le wound, the edofes of which are inverted; whereas if 7 ' the missile emerge from the body, the edges of the last opening are, as a rule, everted. A charge of shot from a distance is so much scattered as to do little more than "pepper" the patient, the pellets lodging in the skin, from which they are readily extracted ; Uut if fired pretty close, the charge does more harm than a bullet, tearing the soft tissues and spreading through them so as to render extrac- tion of the shot impossible. Even '' l>lank cartridge," if fired within a few yards, may inflict serious injury; the wad striking and bruising the face, or even rupturing the eyeball, and the grains of unburnt powder being lodged in the skin. BITES AND STINGS. 75 These should be extracted at once as far as possible with the point of a needle, or an indelible blue mark will be left on the part affected. The primary treatment of gunshot wounds does not differ in any way from that of wounds generally; but as in the after-treatment, the extraction of the bail, etc., many im- portant questions become involved, it will be well for the house-surgeon to obtain the advice of the visiting surgeon at an early date, more particularh' since gunshot injuries almost always lead to legal inquiries in some form or other. The treatment of wound of the lung by firearms is the same as in the case of stabs. (See p. 35.) Bites of Animals, and Stings. — The dog is the animal whose bite is most commonly met with, though occasionally the cat, rat, or horse inflict injury in this way. The fear cf hydrophobia is always present in the mind of a patient who has been bitten, and the house-surgeon should not lose sight of the danger, although the frequency of its occurrence is greatly exaggerated. When, as often happens, the dog has merely snapped, and perhaps grazed or only marked the skin, no treatment is really required, though it may be ad- visable to give the patient scnie evaporating lotion as a placebo, together with a few words of assurance as to his safety. Where a wound is actually inflicted, if recent, it may be cauterized with nitrate of silver; or, if there are really any suspicions as to the state of the animal, it will be only safe to give the patient choloroform and excise the edges of the wound, taking care to go quite to the bottom, or where this is impossible, the actual cautery will form an efficient substitute. Both patient and animal should be kept under surveillance for some weeks, if possible, in order that any symptoms may be treated as early as possible. The bite of a cat is even more dangerous than that of a dog; but that of the horse is only important on account of the se- 76 SUSPENDED ANIMATION. vere local injury generally inflicted when this animal in- dulges his biting propensities. The sting of the adder is the only common accident of tl»e kind met with in this country. The treatment consists in tying a ligature tightly round the limb above the wound, in order to prevent absorption of the poison, and subsequently in the extraction of the poison by sucking the wound or ap- plying cupping glasses, after which a poultice is the best application. The vital powers are severely and rapidly de- pressed by the absorption of the poison, and must be sup- ported by the free administration of ammonia, ether, brandy, etc. In the rare cases in this countr}^ of bites by tropical serpents, the rapid administration of diffusible stimulants and the use of artificial respiration form the appropriate treatment. Suspended Animation (hanging, drowning, etc) — Drown- ing is the most common cause of suspended animation, though cases of hanging and suffocation from noxious gases^ occasionally occur. In all cases the object is the same, viz., to restore the action of the heart, which may be most readily accomplished by resorting to artificial respira- tion, combined with friction to the trunk and extremities. The Marshall Hall method of artificial respiration, as it is called, consists in laying the patient on his face with the right aim doubled under the forehead, so as to prevent ob- struction of the mouth, which should be seen to be open. The assistants, grasping the left shoulder and hip, should then turn the patient on his side, and half-way on to his back, when the motion is to be reversed, and the patient placed again in the prone position. This Series of manoeu- vres should be repeated from sixteen to twent}' times a minute, and the difficulty in practice is to prevent the too rapid movements of over-zealous assistants. Another and more effectual method (Dr. Sylvester's) is as follows: Tlie mouth being cleared of any dirt or saliva SUSPENDED ANIMATION. 77 which may be in it, the tongue should be drawn forward and held with the finger and thumb or a pair of forceps; or secured with a piece of ribbon or an elastic band, passed over the tongue and under the chin. This drawing forward of the tongue is very important, as it opens the windpipe, and must never, therefore, be omitted. The patient being laid on his back, with the shoulders and head slightl}' raised, Fig. 14. the operator then kneels behind his head, grasps the arms just above the elbows, and draws them steadily and gently upwards (Fig. 14) until they meet above the head. By this means the ribs are elevated by the pectoral muscles, and in- spiration is produced. The arms are then to be brought down to the side of the chest, which they are to compress in a slight degree (Fig. 15) so as to imitate expiration. These movements are to be repeated as slowly as in the other method, and they give a more complete change of air to the lungs. Dr. Howard, of New York, has introduced a third method, which in his large experience of the treatment of drowned persons has given most satisfactory results. He lays great 78 SUSPENDED ANIMATION. stress upon emptying the stomach of its contents, so as to free the diaphragm from pressure; and for this purpose places the patient on a firm roll of clothing, so that the head may be lower than the trunk. Pressure upon the stomach being then made, its contents are readily ejected. The mouth being then cleared, the tongue is to be seized with a piece of rag b}^ the fingers of an assistant and drawn out at FiCx. 15. one corner of the mouth, and the arms of the patient are to be drawn well above his head and held there crossed. The operator then kneels astride the patient, and fitting the fingers of both hands into the lower intercostal spaces of each side, forcibly compresses the lower ribs by bowing for- ward over the patient's bod}^ In this way expiration is produced by acting on the most mobile portion of the tho- rax ; and the elastic recoil of the ribs, upon the operator loosing his hold, is sufficient to produce inspiration. Whichever method is preferred should be put in force without a moment's delay, and be persevered in without in- termission for not less than half an hour. Friction with warm towels may be had recourse to in addition, the direc- CONCUSSION AND COMPRESSION. 79 tion of the rubbing being as far as possible towards the heart. The galvanic battery, or the more convenient electro- magnetic machine, ma}^ be had recourse to in desperate cases, but is rarely of much service. The poles may be ap- plied over the base and apex of the heart, or better, over the {)hrenic nerve at the root of the neck and over the diaphragm ; but the artificial respiration must never be relaxed, as upon it the chief reliance is to be. placed {vide Chapter on Clilo- roform). In cases of hanging, and occasionally of drowning, the face is turgid, and the head evidently enormously con- gested; and under these circumstances it will be justifiable to take blood from the external jugular vein or from the tem- poral artery. When symptoms of recovery begin to show themselves, stimulating enemata of wine or brandy ma}^ be useful; but the house-surgeon must be careful not to administer stimu- lants by the mouth until animation is fully restored, lest they pass into the lungs and so suffocate the patient. In cases of apparent death from chloroform, carl)onic acid, etc., all the above measures may be adopted ; and in addition (particularly in the case of chloroform), dashing with cold water, to produce a forcible inspiration, should be imme- diately had recourse to. Concussion and Compression. — When a patient is brought into the hospital in an insensible state, the result of a blow on the head, it becomes of immediate importance to deter- mine the cause of that condition. The house-surgeon should make a careful examination of the head to see if there is any external injur\", and institute inquiries as to the nature of the blow and its probable seat. If there is no injury to the head, or at most only a scalp wound, if the patient can be partially roused by bawling at him, and if his skin is cool and the pupils contracted, he may pretty safely be cousid- 80 CONCUSSION AND COMPRESSION. ered to be laboring under concussion. If, on the contmry, he is perfectl}^ senseless, if the breathing is labored and ster- torous, and the pupils are unequal and dilated, it raay be looked upon as a case of compression. The diagnosis will be confirmed b}^ any severe external damage to the head, and particularly by any fracture or depression of the skull. The pulse will not be of much service as a diagnostic aid immediately after the accident; but in a few hours will vary materially in the two affections, — in concussion being feeble and irregular, in compression becoming full and slow. It must be carefully borne in mind, that cases of apparently simple concussion ma}^ become converted, at an}' moment, into examples of compression, the result of intracranial haemorrhage, and this will be generally indicated by the supervention of stertorous breathing. The primary treatment of both affections is the same, viz., to place the patient in bed, have the head shaved, and insure perfect quiet by the exclusion of all visitors. In concussion, if the depression of system is not already too great, cold may be applied to the head in the form of evap- orating lotions or a bladder of ice ; but if the patient is very prostrate, these should be omitted, and hot bottles be ap- plied to the feet, and mustard poultices to the calves of the legs. A patient may be for hours in a perfectly tranquil condition, and, so long as his pulse keeps steady and the breathing regular, this need excite no alarm ; but should the pulse decline, or symptoms of compression from effused blood come on, the advice of the visiting surgeon must be obtained without delay. In cases of compression, the visiting surgeon should be immediately summoned, since operative proceedings, to be of any service, must be had recourse to at as early a period as possible ; and even should none be advisable, the treat- ment of these cases requires all the suggestions of long experience. CONCUSSION AND COMPRESSION. 81 Comparative Table of Symptoms of Concussion and Com- pression OF the Brain (from Gross). Conctission. 1. The symptoms are immedi- ate, coming on instantly after the infliction of the injury. 2. The patient is able to answer questions, though with difficulty, and usually only in monosyllables, such as yes or no. 3. Special sensation is still going on, the patient being able to hear, see, smell, taste, and feel. 4. The respiration is feeble, im- perfect, and noiseless. 5. The pulse is weak, tremulous, intermittent, and preternaturally frequent. 6. There is nausea, and some- times vomiting. 7. The bowels are relaxed, and there are sometimes involuntary evacuations. 8. The power of deglutition is impaired, but not abolished. 9. The bladder retains the power of expelling its contents, but some- times, owing to the weakness of its sphincter, the water flows off invol- untarily. 10. The voluntary muscles, al- though much weakened, are still able to contract, there being no paralysis. Compression. 1. An interval of a few minutes, or even of a quarter of an hour, sometimes elapses if the compres- sion is caused by extravasation of blood. 2. The power of speech is totally abolished. We may halloo in the patient's ear as loudly as possible, and yet there will be no response. 3. Special sensation is destroyed. 4. The respiration is slow, la- bored, stertorous, and performed with a peculiar blowing sound. 5. The pulse is labored, soft, ir- regular, and unnaturally slow, often beating not more than 50, 55, or 60 strokes in a minute. 6. The stomach is quiet and in- sensible to ordinary impressions, even to emetics. 7. The bowels are torpid, and are with difficulty excited by the action of purgatives. 8. Deglutition is impossible, and sometimes does not return for sev- eral days. 9. The bladder is paralyzed, and therefore incapable of relieving it- self, the surgeon being obliged to use the catheter. 10. There is always paralysis on one side of the body, generally op- posite to that of the compressing cause. 82 FOREIGN BODY IN EYE. Concussion. Compression. 11. The pupils are usually con- 11. The pupils are widely di- tracted and somewhat sensible to lated, and unaffected by light, the light ; the lids are open and mov- lids being closed and immovable, able. 12. In concussion, the mind is 12. In compression, the mind is in a state of abeyance ; it is weak absent, and the patient is comatose, and confused, but not abolished. FOREIGN BODIES. Iti Eye. — foreign bodies lodged on the conjunctiva may vaiy from a small particle of dust to a splash of molten lead sutficient to cover the cornea. Immediate removal is abso- lutely necessary in all cases, and this is accomplished by everting the lids over a probe, when the foreign body may be removed with a pair of forceps, or brushed out with a camel's-hair penciL When a particle of metal, or some similar foreign body, has become imbedded in the cornea, it may be difficult to catch sight of it ; and the house-surgeon should place the patient between himself and the light, and look along the cornea, when, even if the foreign body does not project, he will be able to mark the abrasion of the epi- thelium, and very probably catch the refracted image of the object. The little " spud " made for the purpose, or a broad needle, will be required to dig the foreign body out of the cornea; and when this has been accomplished, a drop of castor oil placed between the lids will give immediate relief to the pain. When a particle of metal has been removed, or has possibly worked its way out spontaneously, there will often be left a slight stain, which will not require any special treatment. The magnifying-glass will serve to establish its nature. In many cases, particularly in children, the spasm of the eyelids is so great that it is impossible to examine the eye, much less to remove a foreign body ; and it is advisable, therefore, to have recourse to chloroform at once, b}^ which means the difficulty is immediatel}' overcome. FOREIGN BODY IN EAR OR NOSE. 83 Lime in the eye produces most serious mischief, unless immediately removed. This should be done with a dry camel's-hair brush, and then the eye should be thoroughly washed with vinegar and water, or very dilute acetic acid, so that any remaining lime may be converted into a harm- less salt. It is well to warn the patient and friends that the injury is of a serious nature, so that they may be prepared for the opacities which will probably be left, notwithstandino- early treatment. Foreign Body in Ear or Nose. — Generally a bean, pea, or small stone, pushed in by the child itself, constitutes the Fig. 16. obstruction, and can in many cases be removed at once with a pair of small forceps, of which the angular ones shown in Fig. 16 are very convenient for the purpose; or with the scoop; or even more readily with a simple loop of silver wire slipped around it. If the house-surgeon should not succeed at once (and he should be careful not to do any damage by poking about too much), recourse must be had to the syringe and warm water. The syringe should be of good size ; but as the surgeon's object, particularly in the 84 FOREIGN BODIES. case of the ear, is to expel the foreign body by the return current of water, it is important not to use a syringe with a nozzle so large as to plug the meatus ; and care should be taken to direct the water down to the membrana t3^mpani along the roof of the canal, so that the return current may be as forcible as possible. In the case of the nostril, the foreign body may often be conveniently pushed back into the fauces witli a probe or small bougie. There is one caution necessary respecting the use of the syringe, which is, that when the foreign body is known to be of a vege- table nature, syringing, if used, must be persisted in until the body is removed at the same sitting, lest, if left to an- other time, the moisture should cause the body to swell, and so impede its ultimate removal. Foreign body in larynx produces s3'mptoms of alarming urgency, the patient being often brought to the hospital black in the face, and apparently moribund. The house- surgeon should immediately thrust his finger down the throat, in order to feel and displace any body, such as a lump of meat, etc., which ma}'^ be obstructing the glottis ; and if this is not feasible, an opening should be instantly made in the crico-thyroid membrane, so as to admit air to the lungs. Laryngotomy is here recommended instead of trache- otomy, in the belief that, in these very urgent cases, the few moments' delay necessary for the performance of the latter operation, and particularly in somewhat inexperi- enced hands, is of the most vital importance ; and besides, these ver}"^ urgent symptoms are generally found in cases where the foreign body is impacted in the glottis, and has not passed into the trachea at all. Should tracheotomy be subsequentl}'^ necessary for the extraction of the foreign bod}-, the previous operation will be of no importance, and will offer no impediment to its due performance. FOREIGN BODY IN OESOPHAGUS. 86 The urgent s3'mptoms of suffocation having been thus relieved, — aided, it may be, by artificial respiration, — care- fid attempts should be made to ascertain the position of the obstruction; and if, as maybe expected, it is discovered fixed between the vocal cords, efforts may be made to dis- place it by inverting the child and slapping its back pretty sharply, or b}^ gently introducing an elastic catheter from below. When the foreign body has passed into the trachea, inversion of the patient, etc., may be tried, provided laryn- gotomy has been performed ; for if this has not been done, the bod}' may get impacted between the vocal cords, and necessitate an instant operation. In those cases which are brought to the hospital for various degrees of dyspnoea, the result of a foreign body in the trachea or bronchi, the house-surgeon is not justified in interfering unless there is great urgenc}', but should summon the assistance of his senior officers, since these cases often require the most dex- terous treatment, and throw a heavy responsibility on the operator. Foi^eign Body in CEaopliagus. — Large masses of solid food occasionally get fixed in the oesophagus ; but most com- monly the foreign body is a bone (generally a fish-bone), or, in rare instances, a set of artificial teeth. If the foreign body is one which can be readily digested, or at least will pass through the intestinal canal without difficulty, the best treatment is to push it down into the stomach with a bougie or stomach-pump tube. When, however, a fish-bone is fixed in the mucous membrane, — as can generally be ascertained by the pricking sensation experienced by the patient, — an attempt should be made to dislodge it. A long forefinger, thrust well down the throat, may be made to hook up such an obstacle with the nail, supposing it is still in the pharynx ; but if lower down, one of the numerous forms of probang must be used for the purpose, of which the ingenious horse- 86 FOREIGN BODY IN URETHRA. hair probang, shown shut, for introduction past the foreign body, in Fig. 17, and open, for its withdrawal, in Fig. 18, is probably the safest and best ; or recourse may be had to long curved forceps, which require, however, very careful Fig. 17. manipulation. The removal of artificial teeth from the oesophagus is an operation of great nicety, and one which the house-surgeon had better relinquish, if he does not suc- ceed at the first trial with the long forceps, lest he do irrep- arable damage to the gullet, or render the extraction im- possible except by oesophagotomy. Foreign Body in Urethra. — A piece of gutta percha bougie is the most common example of foreign body in the Fig. 18. urethra, and the house-surgeon should be very careful, both in examining its position and attempting its removal, not to push it farther down the canal. The foreign body can sometimes be expelled by careful manipulation along the urethra; but if this is unsuccessful, attempts may be made to withdraw it with a slender pair of forceps, the finger being kept carefully upon the urethra behind the obstruc- tion, so as to prevent its being carried on into the bladder. Should the house-surgeon not succeed in his attempts, the FOREIGN BODIES IX RECTUM AND VAGINA. 87 case should be submitted to the surgeon's opinion without delay. Hair-pin in Bladder and Urethra. — Cases have frequently occurred of young women introducing a hair-pin into the urethra, which has slipped into the bladder, and required removal b}^ the surgeon. Tiiis can best he accomplished with ordinary pol3'pus or dressing forceps, if the urethra be rapidly dilated, under chloroform, with the forefinger in- sinuated along a director passed into the canal. The finger can turn the foreign bod}' to tlie most convenient position for removal, and no permanent incontinence is likely to follow the proceeding. Owing to the short length of the female urethra, a hair-pin never becomes fixed in it so as to require surgical interference ; but a case has occurred of a hair-pin introduced into the male urethra slipping from the patient's grasp, and requiring removal by the surgeon. It is impossible to withdraw a hair pin with forceps under these circumstances, because one or both ends of it will lacerate and become entangled in the mucous membrane ; and, there- fore, the better plan is to introduce a small tube (a silver probe-case for example), and having grasped the pin throngh the walls of the urethra so as to bring the ends together, to slip the tube over them, after which the pin can be readily withdrawn. Foreign Bodies in Bectum and Vagina. — These cases are seldom of recent occurrence, and would not, therefore, re- quire immediate treatment by the house-surgeon. In any recent instance recourse may be had to suitable forceps; but should they not succeed, the case ma^^ be very well put aside until the suro-eon's visit. 88 DETENTION OF UEINE. CHAPTER III. RETENTION AND EXTRAVASATION OF URINE, HERNIA, ETC. Retention of Urine. — The cases of retention which the house-surgeon is called upon to treat are mostly of the spas- modic class, and result from some recent excess on the part of the patient ; occasionally, however, patients apply at an hospital with retention from other causes, viz., permanent stricture, enlarged prostate, or stone in the bladder. Since the lower classes are generally reluctant to ask for assist- ance which may involve some personal suffering, a patient with retention ordinarih^ only applies at an hospital when the agon}' of his distended bladder becomes unbearable, and his immediate relief, therefore, by the catheter is of the first importance. The use of opium and the warm bath, etc., is only so much time wasted if the S3'mptoms can be imme- diately relieved by the passing of a catheter, although, if this be impossible, they may afterwards be useful assistants in the treatment. Before entering upon any treatment, in- quiry should be made of the patient (if sober) as to his ordi- nary powers of micturition, and the existence or not of a permanent stricture of some standing ; but too much faith must not be placed on the statements of patients respecting the size of the stream passed, in which they commonl}^ ex- agoferate. Spasmodic Retention. — Supposing no stricture to have existed, an attempt may be made to pass Nos. *7 or 8 silver or elastic catheters ; but even should a stricture be acknowl- edged, it is better to begin with at least Nos. 4 or 5. Of the positions for passing the catheter, those of standing or of lying down, the latter is to be preferred, as giving the RETENTION OF URINE. 89 surgeon more control over the patient by preventing his drawing back, and also by doing away witii that most un- necessary manoeuvre, tlie tour de maitre. The practice va- ries, of course, in different hospitals ; but every surgery sliould be furnished with a couch or table for a patient to recline upon, if desired. A good-sized catheter having been selected, should be thoroughly warmed, either by friction with a towel or by putting it up the sleeve in contact with the arm, and it should then be well oiled for at least two- thirds of its length. Standing on the left hand of his recumbent patient, the surgeon gently stretches the penis with the left hand, while with the right the catheter is in- serted. With very slight force, almost b}- its own weight, the catheter should pass along the canal, the handle being directed along the left groin but gradually getting into the median line, until an obstruction is met with. Against this, gentle pressure with the end of the catheter should be made for some minutes, when, if the stricture be spasmodic, a gradual jielding will be distinctl}^ felt, and in a few moments more the instrument will probably enter the bladder. This, the best possible result, can only be looked for in uncompli- cated cases, where the urethra has been previously health}'. Should there be in addition some degree of permanent stric- ture, a smaller instrument may be tried, although the very small sizes are unsuited to cases of spasmodic retention, and are apt to cause haemorrhage and other mischief. Some- times when a catheter will not pass a stricture, if it be pressed against it for a time and then suddenly withdraw^n, the urine will flow, and thus the retention will be relieved. Should tlie house-surgeon not succeed in these first attempts, he must be guided in his further treatment by the condition of his patient. If the distress is not great and appliances are at hand, a w^arm bath may be administered, and thirt}^ or forty minims of laudanum given internally, the probability being thtit, after the patient has been a quarter of an hour in the bath, the urine will pass of its own accord, or that a 90 RETENTION OF URINE. catheter will then be readily introduced. Should the dis- tress of the patient be urgent, however, it is better to ad- minister chloroform at once, and to use a catheter (Nos. 6 or 7) with the same precautions as are mentioned above, when the instrument will generally be found to pass with facility. Should this fail, there are still the warm bath, laudanum, and fomentations to fall back upon. Permanent stricture^ when giving rise to retention, is much more difficult to treat. Although, according to the patient's account, he has not been able to pass a stream for weeks, it is better to commence proceedings with a No. 4 silver catheter. The patient lying down, this should be carefully passed until it meets with an obstruction, when the left hand should be passed along the urethra externally, to feel if there is any corresponding thickening at this point. The obstruction will generally' be found in the region of the bulb at the back of the scrotum ; and an endeavor should be made to guide the instrument through it, partly with the right and partly with the left hand. Not succeeding with No. 4, a series of cautious attempts with successively smaller instruments should be made, the left hand being still kept upon the urethra to serve as a guide for the median line, which it is, of course, most important to maintain, so as to avoid the formation of false passages. Even if a catheter pass an obstruction at the bulb, it may fail to reach the bladder, and the operator will find that he is unable to depress the end of the instrument. Under these circumstances, the left forefinger should be inserted into the rectum, to feel if the catheter has taken the course of the urethra ; and if it be felt on one side of the middle line, it should be at once withdrawn from the false passage, and fur- ther efforts be made to carry it on in the proper direction, guided by the finger still retained in the bowel. Even when no false passage has been made, an instrument will some- times meet with an obstruction just at or about the triangu- PERMANENT STRICTURE. 91 lar ligament, and the finger in the rectum will be able often to help it over the difficulty. Should the patient be unruly, or unable to bear the pain of these attempts, it will be well to put him under the influence of chloroform, although but little direct effect can be produced upon the stricture b}"" that agent. An elastic catheter, and particularly one of the French instruments with an olive-shaped extremity, will sometimes succeed in getting through a stricture where a metal instrument has failed, either without a stilette, or when used as follows: A good curve having been given to it by means of the stilette (which should be retained), it may be passed down to the stricture, and efforts may be made to push it through; if these fail, tiie stilette alone may then be withdrawn, and the attempt renewed, when the catheter may possibly find its wa}' through a tortuous passage, and enter the bladder. Whatever instrument happens to reach the bladder, should be retained and tied in until, at least, the case has been seen b}^ the visiting surgeon ; for if withdrawn at once, the retention may again occur, and treatment be- come necessary, possibW with a less successful result. When no eff'orts of the house surgeon suffice to relieve the bladder, the assistance of the senior officer should be re- quested without delay ; for if the distension be already great, a small further increase ma^^ cause the urethra to give way, and produce extravasation with its unfortunate results. In cases of retention of short duration, where there is little pain and the surgeon's visit may be soon expected, a dose of opium may be given and the delay allowed ; but bad cases should never be permitted to remain for hours unrelieved. It is no part of the plan of this work to discuss the treat- ment to be adopted by the visiting surgeon, which will vary according to both the individual surgeon and the nature of the case ; but should a house-surgeon be thrown upon his own resources, and be left to treat a case of retention on his own responsibilit}', he is strongly recommended to tap the 92 RETENTION OF URINE. bladder through the rectum, or above the piibes, in the latter case employing the aspirator. Enlarged prostate gives rise to retention only in old people, and the increase in the size of the gland can be readily detected through the rectum. Since the chief ob- struction to the flow of urine is usuall}^ the central projection from the floor of the urethra, it will be necessary to use a prostatic catheter, i. e., a large silver instrument, rather lono^er than usual and with a o-reater curve. Should this not pass readily, a large elastic catheter, without a stilette, may be used, or one of the French instruments made with a bend or elbow near the extremity {sonde coude). It is a great mistake to use small, short instruments in these cases, since they only perforate the prostate, giving rise to hemorrhage, and never reach the bladder at all. -Paralysis of the bladder from overdistension (atony of bladder) must not be confounded with retention caused by stricture. The obvious treatment is to relieve the overdis- tended viscus b}- means of a large catheter; and if the house- surgeon follow the above rule of always beginning with a good- sized instrument, he can hardly fall into the error of making false passages in a previously healthy urethra. If any doubt should exist as to whether the catheter has entered the blad- der or not, it will be immediately solved by throwing in a little warm water with the india-rubber bottle. This will, of course, distend an empt}^ bladder, but will not enter at all if the instrument has not (as is most probable) reached the viscus, and a longer catheter should be at once employed. Overdistension of the bladder gives rise also to another symptom, viz., an overflow or involuntary dribbling away of urine; and this must not be confounded with the want of power over the neck of the bladder by which the viscus is alwa3'S kept empty. The diagnosis is easily made by per- RETENTION OF URINE. 93 cussing the region of the bladder, and noticing the extent of dulness ; and the rational treatment is to pass a catheter. Beteidion from calculus occurs usually only in children, and may often be overcome by making the child lie on its back during micturition ; if this does not succeed, a cathe- ter suited to the size of the urethra may be readily intro- duced. In such cases an early opportunity should be taken to determine the presence of a stone, in order that appro- priate treatment ma_y be undertaken. A small calculus may become impacted in the urethra of a child, and thus produce retention either partial or com- plete. Frequentl}^ the calculus is arrested just within the meatus, and can be extracted with a small scoop ; but if far- ther down, urethral forceps must be employed. If the house- surgeon is unsuccessful in his attempt to extract the calcu- lus in this manner, the visiting surgeon should he summoned to cut down upon it without delay, since an impacted cal- culus may give rise to extravasation of urine by causing ulceration through the urethra. The same rules would apply to a piece of calculus im- pacted in the urethra after lithotrity, though in that case, if the fragment is near the bladder, an attempt may be made to push it back into that viscus with a large catheter or bougie. Retention in the female occasionally requires the use of the catheter, though, since it is generally an hysterical symptom, the use of instruments, etc., should be avoided as much as possible. The patient should never be exposed for the passage of a catheter, but she should be placed on her back with her knees drawn slightly up. Standing on the right of the patient, the surgeon will next pass the left hand between the thighs, and place the forefinger just at the orifice of the vagina. An elastic catheter can then he readily introduced with the right hand, and being made to glide 94 EXTRAVASATION OF UBINE. over the forefinger of the left, will almost infallibly enter the urethra, being felt through the wall of the vagina im- mediatel}'- beneath the arch of the pubes as it passes to the bladder. The so-called tubercle at the orifice of the uretlira is generally imperceptible, and likely to be confounded with the clitoris ; and it is therefore safer to disregard it alto- gether, and to proceed as suggested above. Extravasation of urine may occur either from the urethra giving way after prolonged distension of the bladder, or may be caused by the unskilful use of the catheter having made a hole in the urethra. Occasionally the urethra is ruptured by direct violence, such as a fall astride a piece of timber, or is torn in cases of injury to the pelvic bones from any crushing force. In any case the result is the same; the urine gets into the areolar tissue of the scrotum and penis, which it distends, and, if unrelieved, will find its wtvy over the pubes and into the groins of the patient. If seen early, the distension will simulate that of ordinary oedema, but in a very few hours the skin becomes scarlet, and then dusky; black sloughs show themselves at various points, and an erythematous blnsh spreads for some distance towards the abdomen. A house-surgeon should not treat a case of extravasation on his own responsibility if he can obtain the assistance of a senior officer at once; but he is not justified in waiting more than a short time for this. If oblio;ed to act on his own responsibility, he should have the patient held in the lithotom}^ position, and make free incisions on each side of the median line into the distended perin^eum, scrotum, and penis, and wherever the urine appears to have found its way. Tliese incisions ueed not be very deep, so long as they give exit to the infiltrated urine, which will be easily recognized by the peculiar smell. Any small vessels which may bleed should be at once twisted or tied, as it is im- portant that the patient should not lose any blood. In cases EXTRAVASATION OF URINE. 95 wliere the extravasation is o;reat, and the necessaiy incisions evidently give free exit to tlie urine contained in the blad- der, it is better to abstain altogether from passing a cathe- ter along the torn urethra for a few daj's, until the parts have become more healthy, since the urine will run away through the incisions as readily as through the wound made in lithotomy. When, however, the extravasation is small, and, perhaps, only one-sided, and the incisions are there- fore not large or deep, it will be necessary to get an instru- ment into the bladder, in order that no more urine ma}'' be effused ; and the house-surgeon should therefore make care- ful attempts to introduce a catheter, using both elastic and metallic instruments for that purpose ; and he will often be able to succeed, even in cases of old stricture, the effect of the effusion being to relax slightly the strictured parts. An instrument having been introduced, should be tied in, and light linseed-meal poultices should then be applied to the pubic region, and frequently changed, while measures should be taken to secure the constant flow of urine throuo^h the catheter, if one has been introduced, either by adapting some form of urinal to it, or by frequently removing the stilette. If, however^ the house-surgeon should find himself unable to introduce a catheter, he must await the arrival of the visiting surgeon, who has l)een already summoned, and who will either lay the urethra open through the perina'um, and pass a catheter into the bladder, or, which is probably safer, will tap the bladder through the rectum. The house- surgeon is warned against undertaking the operation of opening the urethra on his own responsibilit}', since none is more difficult to complete satisfactorilj^ ; and the patient being already in a dangerous condition, the possible fatal result may be attributed to his interference. A patient suffering from extravasation of urine is always in a depressed condition, and will require very careful after- 96 WASHING OUT THE BLADDER. treatment, with plenty of nourishment and some stimulants, at all events at first. Since false passages are occasionally made by the best surgeons, extravasation may occur in a patient already in the hospital and under treatment for stricture, and the house-surgeon should not mistake the erythematous blush and slight oedema which mark the accident for an attack of erysipelas. The same remark applies to extravasf^tion in children, caused by impaction of a stone in the urethra. Washwg out the bladder is an operation generally in- trusted to the house-surgeon, and its careful performance is a matter of great importance, both in cases of diseased bladder, and in cases of paralysis, the result of injury to the spine, or from other causes. When it is simply desired to wash out an}^ accumulation of mucus or sediment from the bladder, a good-sized elastic catheter with a large eye is the best instrument; or when any particles of earthy de- posit may be expected, the very large-eyed catheter used after lithotiitv will be of advantaj^e. The catheter havinsr been introduced with the greatest care (and more particu- larly so in cases of paralysis, where sensation is wanting), the bladder should be thoroughl}' emptied, pressure with the hand being made over the pubes, if necessary, to assist the expulsion of the contents. In doing this with an elastic catheter, it is well to bear in mind that the wall of the bladder, as it contracts, is apt to press against the eye of the instrument and obstruct the flow of urine, and that this is easily remedied by drawing the instrument out for an inch or so, when the event happens. The simplest, and therefore best, injecting apptiratus is a small india-rubber ball, with nozzle and pipe, and bullet-valves (Fig. 19). Tiie ivory nozzle at the end of the india-rubber pipe maj' be either inserted into the catheter, or, the nozzle having been removed, the pipe itself may be fitted over the end of the instrument, if the size will allow it. The onlj- precaution WASHING OUT THE BLADDER. 97 necessaiy to observe in eraplo3'ing this little apparatus is to kee[) it upright when in use, since tliat position alone en- ables tlie i)ullet- valves to act properl}-. A shake will occa- sionally' be requisite, if the liullet gets fixed for a moment, but the house-surgeon should beware of ofllcious assistants unscrewing the joint and letting the bullet drop out. The bottle should be filled with tepid water before it is attached to the catheter, so as to avoid the injection of air, and then, b}^ a series of gentle squeezes, as much tepid water as may Fig. 19. be desirable can be readily thrown into the bladder. This water should be allowed to run out into a fresh vessel, and the injection ma}' be repeated as often as necessar3\ In some cases the use of a double catheter may be de- sirable ; but the same bottle can be used with it, unless the more cumbrous metallic syringe is for any reason preferred. Medicated injections generally require a gilt catheter; but, if weak, they will not do any serious damage to the india- rubber bottle, which must, of course, be carefullj'^ washed after being so used. Probably the best injection for restor- ing a health}' condition of the urine is a solution of sulphate of quinine, gr. ij ad aquse fjj, with two minims of dilute sul[)huric acid. 98 PARAPHIMOSIS. Washing Caihefers. — It Is very important that catheters, and particularly the smaller sizes, should be carefull}^ cleansed after being used. The house-surgeon should not leave this to a nurse, but should either do it himself, or see that a dresser thorougldy washes each instrument. The best way is to let the catheter lie for a few seconds in the water, and then to hold it up with the handle or rings downwards, by which means Siuy blood, etc., is at once washed out in the readiest way. This should be repeated once or twice, and then the operator may blow through the instrument into the water, so as to make sure that the eyes are clear. After being di'ied with a towel, the catheter should again be blown through, so as to dry the interior, and the proper stilette be immediately inserted. The common method of blowing down a catheter before washing it out, simply drives any clot of blood, etc., down to the eyes, and makes its extraction nearly impossible. In order to obviate all possibility of contagion bj' means of catheters, it is well to use a weak solution of carbolic acid for washing all urethral instruments, and to employ carbolic oil (gr. X ad f^j) for lubricating them prior to use. Paraphimosis. — Boys are sometimes brought to an hos- pital on account of the foreskin having got behind the glans penis, so that they are unable to return it, and the disorder will be met with in men as a not uncommon accompaniment of gonorrhoea. If the case is seen early, reduction is readily effected ; but if oedema and even ulceration have supervened, it is by no means an easy task, but one wliich may be inva- riably accomplished in the following way: The patient should be placed upon a couch, and the operator, grasping the foreskin with the fingers of both hands (a towel inter- vening), should squeeze the blood and serum out of it as much as possible. The thumbs are then to be placed against the glans, and made to compress it in the same way, after which endeavors should be made to draw the foreskin for- STRANGULATED HERNIA. 99 wards, and at the same time to push the glans in with the thumbs. After a few minutes' steady traction, the parls will assume their proper position, unless the foreskin has become ulcerated and its surfaces agglutinated together. Water-dressing should afterwards be applied around the penis, which must be supported by a bandage. A few punctures on the swollen prepuce, and the applica- tion of a piece of elastic webbing or india-rubber band tightly round the part for a few minutes, will be found to tend greatly to remove the swelling; and in cases where the congestion of the organ rather than the amount of oedema is the cause of difficulty in effecting reduction, the application of a stream of cold water from an ordinary tap for a quarter of an hour will much facilitate the proceeding. Appearances closely resembling paraphimosis are some- times caused by a child having tied a thread round the penis, either in play, or with the view of obviating punish- ment for wetting his bed. In these cases the thread be- comes so imbedded in the swollen tissues as to require great care for its discovery and division. Strangulated Hernia.— It is the exception, rather than the rule, for patients to apply at an hospital odensibly for relief of a strangulated hernia. Having, probably, never been warned upon the subject, they regard the rupture as of secondary importance, and apply for relief of the consti- pation, pain, or sickness, consequent upon strangulation. In all cases, therefore, of pain in the abdomen with constipa- tion, it is well to direct attention to the possible existence of a rupture, since the patient seldom or never volunteers the information. If there is the slightest suspicion in the house-surgeon's mind, nothing but actual manipulation should satisfy him, since a hernia of small size may exist without the patient's knowledge ; or, although he may ac- knowledge to a rupture on one side, he may ignore one on the other, which may possibly be strangulated. Hernise which become strangulated are generally of old 100 DIAGNOSIS OF STIIAKGUI.ATED HERNIA. standing, which some exertion has increased in size, since which time the patient has been unable to return the bowel; but a hernia may be produced and strangulated at one and the same time by violent exertion, or by some crushing force. Thus, after the peace illuminations of 1856, a woman lost her life from a strangulated femoral hernia, produced and strangulated by the pressure of the crowd, the tumor, which was of small size, being mistaken at first for an enlarged gland. The diagnosis of strangulated hernia is often very diffi- cult, both in the inguinal and femoral varieties, it being in the former confounded with other scrotal tumors, and in the latter with enlarged glands. The scrotal tumors most likely to be confounded with strangulated hernia are hsematocele and inflamed testicle; and the following table may assist the house-surgeon in distinguishing them, though it must always be remembered that hernia may coexist with other tumors : Strangidated Hernia. Suddenly produced by some ef- fort of the patient; or, if her- nia existed before, strangu- lated in that way. Pain in groin and about abdo- men, with considerable con- stitutional depression and anxiety of countenance. Tumor tense, and giving the sensation of intestine to the hand when manipulated. Skin normal. Impulse on coughing to be felt along the groin, in which there is more fulness than usual, but ceases abruptly at the point of strangulation. Percussion over tumor gives a clear sound unless the protru- sion is omental. Vomiting probably present and continuous. Te.sticle to be felt below and behind hernia. Hcematocele. Suddenly produced by some external violence. Pain in scrotum and con- stitutional disturbance slight after the first few minutes. Tumor tense and heavy, pyriform in shape, but not translucent. Skin discolored. No impulse in groin, which is perfectly normal. Orchitis. Gradually developed after gonorrhoea or a blow. Pain in scrotum and along the cord to the loins. Feverish disturbance of sys- tem. Tumor excessively tender to the touch ; cord thickened. Skin reddened. No impulse on cough- ing. Percussion yields a dull Percussion yields a sound. dull sound. Vomiting immediately fol- lowing the accident, but not continued. , Testicle not to be felt. Nausea and faint- ness, but seldom vomiting. Testicle enlarged and tender. STRANGULATED HERNIA. 101 Having ascertained the existence of a hernial tumor, it will he the duty of the house-surgeon to inquire very par- ticularly as to the probable duration of the strangulation, the symptoms to vviiich it has given rise, and the amount of tenderness present in the part. A very few minutes only need be thus occupied, but the after-treatment will be guided very much by the knowledge thus gained ; for, should the hernia be of only recent strangulation, tliere need be no bar to the careful application of the taxis. But should the strangulation have been allowed to exist f<;r many hours, or even days, and more particularly, sliould the pain which was at first present have ceased altogether, and the patient be passing into a state of collapse, the assistance of one of the senior surgeons had better be summoned at once, lest the house surgeon have the satisfaction of finding, pout mortem^ that he has ruptured the congested or mortified intestine hy his efforts, and returned the fecal contents into tiie perito- neal cavity. The amount of manipulation the hernia may possibly have been submitted to before the patient's admis- sion should also be taken into consideration, for if tlie taxis has been attempted b}' a medical man, recourse had better be had to chloroform at once; but additional caution in manipulating will be necessary, as it is impossible to say what amount of injury the intestine ma\' have already un- dergone. Interference on the part of tiie house surgeon, then, not being contra-indicated, the patient should be placed upr)n a bed or table, with the shoulders well raised by pillows; the thigh of the affected' side is next to be bent upon the abdomen and towards the opposite side, so as to relax as far as possible all the structures in the neighborhood of the groin. With the fingers of both hands the house-surgeon should then manipulate the parts about the neck of the sac, where the strangulation will probably exist, and make firm but gentle efforts to return the contents of the sac bit by bit, and not by attempting to push the wliole mass back by 102 STRANGULATED HERNIA. main force, or by grasping the bulk of the tumor with both palms. A gurgling sound is an indication of success, and should induce the surgeon to continue his manipulations until the whole of the contents is returned; but if, afltr some minutes' trial, there is no symptom of progress, and, more particularly, if so much pain is given as to induce tl:e patient to strain and move himself about, chloi^oform should be at once resorted to. The by no means novel method of assisting the reduction of a hernia l)y holding up the pa- tient's legs, and so making the weight of the intestines drag upon the sac, may be had recourse to if the patient is unconscious. It has the disad vantage of tio^htenino; rather o c o than of relaxing the parts in the groin, but certainly is of service in some cases. Chloroform to be of any use in a case of strangulated hernia must be given until total insensibility and complete relaxation of the muscles have been produced. An assistant taking charge of the inhaler, so as to keep the patient under its continuous influence, the house-surgeon should repeat his efforts at returning the intestine ; but if success do not follow in a few minutes, he should desist, and send for the surgeon under whom the patient is admitted, the patient being allowed to recover from chloroform, and being placed in a warm bed. In old-standing hernia it is frequently impossible to empty the sac completely, owing to the quantity of thickened omentum present. This is of no importance so long as the gut is returned entirel}^ the best criterion of which is, first, the relaxed state of the sac, and, secondly, the relief from pain experienced by the patient upon recover^'- from chloro- form. The house-surgeon should not suffer himself to feel annoyed if the surgeon, upon his arrival, is able to return a hernia without operating. It is remarkable how slight a change in the parts may influence the feasibility of this pro- ceeding ; thus it happened once to the author when a house- surgeon to have sent for the surgeon, after having unsuc- RAPE. 103 cessfully applied the taxis under chloroform to a ease of scrotal hernia, but before his arrival tlie hernia had gone up spontaneously, to the patient's great relief. In any case, as soon as a hernia is returned, a pad and bandage should be carefully applied, so as to prevent its recurrence. Prolapsus Ant. — Children, and occasionally adults, are sometimes brought to the hospital with prolapse of the rectum. In recent cases the part is readily enough returned by the pressure of the fingers, the gut being grasped by the use of a piece of lint, which it will be found advisable to return along with the bowel, and to leave in, as it tends to keep up the prolapse, and will be displaced by the passage of faeces. In old cases, where the mucons membrane has been fretted by the clothes, and ma}', perhaps, have ulcer- ated, the part should be well sponged with cold water before the attempt at reduction is made; and should much ditficulty be experienced, chloroform had better be resorted to at once, so as to relieve the spasmodic contraction of the sphincter. A pad of lint and a T bandage should be ap- plied to prevent the immediate recurrence of the prolapse, and suitable treatm-ent be adopted for its radical cure. Since prolapsus ani is a frequent accompaniment of stone in children, an early opportunity should be taken to ascer- tain the existence of a calculus in the bladder. Rape — Female children are occasionally brought to an hospital b}^ the parents or the police, on the supposition that they have been raped ; and since legal inquiries are likelj' to arise, the house-surgeon must be very circumspect in conducting his investigations. First, he should note the time when the patient is brought to him, and then proceed to examine her. He should notice any external bruises or scratches, and then make a special examination of the genitals. The general appearance of the labia, whether bruised, inflamed, or merely reddened, the condition of the 104 EAPE. h^'men, and the state of the vagina and perinaeiim, shonld be specially investigated, as also whether an}' discharge is presenfor not. Where the alleged assault is recent, the microscopic examination of the vaginal mucus should not be neglected. A small quantity should be removed with a pipette (care being taken to wash it thoroughly first) from within the h3'men, if that membrane is torn, and submitted to the microscope, when spermatozoa ma^'' be discovered, and even in motion. B}^ this means the author was, on one occasion, able to convict a man of rape, the child having been brought to the hospital two hours after the assault. When the investigation is already in the hands of the police, it is no part of the surgeon's duty to put any ques- tions to the child, but when, as often happens, his dictum will determine the parents in their after proceedings, he must necessarily investigate the whole occurrence. Since in b}' far the greater number of cases the suspicions of the parents have lieen unnecessarily aroused, the house-surgeon should be careful to hear the mother's account and that of the patient ."separately, and not in each other's hearing. This is more particularly necessary as respects the child, who may have been frightened or over-persuaded into ac- cusing some innocent person of an assault, while the dis- order she is suffering from, if any, is simply the result of natural causes. In these, as in all other medico-legal cases, the house-surgeon should immediately make a few notes of the principal features of the case, and particularly of the dates, that he may be able to give evidence at any subse- quent trial, if called upon to do so. ALCOHOLIC POISONING. 105 CHAPTER lY. - THE IMMEDIATE TREATMENT OF CASES OF POISONING. Since cases of poisoning not nnfrequently come under the care of the house-surgeon, although, strictl}- speaking, they more properly belong to tlie medical side of the house, the diagnosis and immediate treatment of the more common forms will be described in the following chapter. The after- treatment of poisoned cases will necessarily become the duty of the visiting medical officer, and will therefore require no further mention here. Alcoholic Foisoning. — In the slighter cases, the diagnosis is readily made from the history of the patient, who has probably been "on the drink" all day, and his semi- conscious, drowsy condition, coupled with the strong odor of spirits exhaled by the breath. But in more severe cases, and when the history is wanting, the diagnosis between drunkenness and apoplexy is both difficult and important. Thus, when a person is found lying incapable in the streets, and is brought to an hospital by the police, it is neces- sary to decide at once whether it is a case for the station- house or for the wards. The external appearances of the patient will serve as a guide, in some degree ; for if respectably clothed, with no appearance of disorder of dress, etc., but those dependent upon a fall in the street, the probabilities are that it is not a case of drunkenness. If, in addition, there is no trace of alcohol in the breath, — if the pupils are equally contracted or dilated, and the patient cannot be roused in the slightest degree,— the diagnosis of apoplexy will be confirmed, and the patient should be at once admitted. 9 106 ALCOHOLIC POISONING. Persons are occasionally brought to the hospital from the police cell, where they have been lodged some hours for real or supposed drunkenness, owing to the officers having become alarmed at the supervention of stertorous breathing. The case may have been one of apoplexy from the first, or it may be one of apoplexy following drunkenness, and must be admitted at once, or death may unfortunately occur at the station-house. It sometimes happens that laudanum is taken with or after a quantity of spirits, and in such a case the symptoms of the narcotic will predominate, and the patient must be treated accordingly. (See Opium Poisoning.) A very ex- cessive dose of pure spirit (drunk for a wager, or given to a child) will produce almost immediate death by shock, all the s3'mptoms of which are presented in a marked degree. Treatment. — To empty the stomach is the first indication, and this may be readily accomplished, if the patient is able to swallow, by the administration of an emetic (Zinci Siilph. 5ss. cum Pulv. Ipecac. 9j) in plenty of warm water. When the emetic begins to act, care should be taken to support the patient so that the vomited matters may be at once ejected and not swallowed again, or perhaps find their way into the windpipe. Should the case be more severe, and the patient unable to swallow, recourse must be had to the stomach-pump, which must be introduced through a gag, with the pre- cautions mentioned at p. 135, when warm water may be injected, and the stomach thoroughly washed out. Cold affusion is the most readily applied means of rousing the patient, and for that purpose the water should be poured from a slight elevation upon the head and chest. In ad- dition, flipping the bare skin with a wetted towel is a very effective stimulus, particularly if applied to the soles of the feet and calves of the legs. In cases of very profound coma, mustard poultices to the calves and feet, stimulating enemata, and galvanism, may be employed to rouse the OPIUM POISONING. 107 patient from the effects of the shock, while it may be neces- sary to administer small doses of diffusible stimulants — ammonia or ether — b\" the mouth, to excite the flao-o-ino- vital energies. Opium Poisoning. — Laudanum is the preparation com- monly employed ; and in the majority of cases the diagnosis is at once simplified by the discovery of the bottle which contained the poison hy the patient's side or in his posses- sion, and this may either be labelled, or may contain a minute residue of the tincture, to be readily recognized by its characteristic odor and taste. If seen soon after the administration of a large dose of laudanum, the patient will only be in a drowsy and stupid condition ; but if sufficient time has elapsed for the poison to have produced its full effect (the period varying accord- ing to the dose and the condition of the stomach), there will be profound stupor, from which the patient can be roused only by great efforts, the breathing will be slow and feeble, and the pupils of the eyes very strongly contracted. The distinction between opium poisoning and apoplexy is sometimes required, and the conditions of the pupil and of the respiration are the best diagnostic points. In opium cases, the pupils being equally and strongly contracted, and the respiration quiet and slow; in apoplexy, the pupils being unequally contracted or dilated, and the breathing labored and stertorous. Treatment. — The stomach is to be immediatel}^ emptied by the stomach-pump or an emetic (vide antea)^ and the contents should be examined to confirm or otherwise the diagnosis made. The stomach should then be thoroughly washed out with warm water, until all trace of the laudanum has disappeared. Cold affusion may be used to rouse the patient from his comatose condition, and he should then be made to walk 108 OXALIC ACID POISONING. about supported by two attendants, who should shake him and shout at him so as to prevent his dropping off to sleep. [In hospital practice it will be found a great convenience to send to the nearest police-station for two constables to perform this duty, and the inspector will send rela3^s of men as long as they ma}^ be required.] Care should be taken that the patient has his shoes on during these forced inarches, or his feet will sutfer severely from the rough usage. The house-surgeon may apply an additional stimulus if necessar}^ by flipping the bare skin with a wet towel or a light cane ; but of course this treat- ment must only be very moderately applied. Strong coffee should be given at intervals as soon as the patient can swallow readil}^, and the house-surgeon must pay attention to the state of the pulse, for nothing can be more exhausting than the treatment pursued ; and stimu- lants should therefore be administered in small quantities if the patient's powers appear to be flagging, more particu- larly if the attempted suicide is the result of want. Care must be taken not to prolong the active treatment unnecessarily, for a patient has been known to have died of the exhaustion so produced, and to have shown unmis- takable sisfns after death of the over-zealous treatment to which he had been subjected. If moderately sensible, half an hour's rest and sleep at a time may be allowed until the dangerous symptoms have quite passed off, when the patient will probably require some days' rest before he is conva- lescent. Oxalic Acid. — This is a not unfrequent agent in cases of poisoning, accidental or suicidal, the symptoms being an intensely sour taste in the mouth, followed b}' pain in the throat and stomach of a burning character. Yomiting may or may not be present. Treatment. — Chalk suspended in water should be imme- AGIDS AND ALKALIES. J 09 diately administered, or magnesia, if more readily obtained. Warm water may l)e given to encourage vomiting after the administration of the antidotes, but the stomach-pump should not be employed, on account of the damage the oesophagus and stomach have sustained. Hydrocyanic Acid and the Cyaniden. — Cases of poisoning by tliese agents are so rapidly fatal as ordinarily to be be- yond medical aid. Should a case be seen before death has occurred, the suitable treatment would be cold affusion to rouse the patient, followed by warm frictions to the skin, ammonia to the nose, and an emetic as soon as tlie patient can swallow. Mineral Acid^. — Poisoning b}- the mineral acids is readily recognized by the immediate violence of the symptoms, and the burns and stains upon the lips and clothes. Treatment. — The administration of magnesia or chalk sus- pended in milk or oil. Stomach-pump not to be used, for the reasons given above. Caustic Alkalies. — A solution of caustic potash, or what is termed "soap-lees," are the fluids most commonly taken by accident. A burning pain in the throat and stomach fol- lows immediately upon the dose, and vomiting of grumous matter soon occurs. The reaction with reddened litmus- paper would immediately decide the diagnosis if there were any doubt. Treatment. — Yinegar and water, or ver}^ dilute lemon- juice, together with olive or almond oil. Carbolic Acid. — Since the general introduction of car- bolic acid as a disinfectant, many cases of fatal poisoning have occurred through it being mistaken for other fluids. A large dose of the strong acid is almost immediately fatal. 110 ACIDS AND ALKALIES. but the free administration of olive oil offers the best pros- pect of relief. To guard against accidents of this kind, all strong solu- tions of carbolic acid should be kept in colored fluted bot- tles and be distinctly labelled. TRACHEOTOMY. 3 1 1 CHAPTER y. MINOR OPERATIONS. Laryngotomy. — Since this operation is advisable in the case of any sudden obstruction of tlie larynx, wlien every moment is of the utmost value, its rapid performance is of consequence, and so long as an opening is made in the crico- thyroid space it is a matter of minor importance how the incision is made. The finger carried down the middle line of the neck will readily enough, in men, distinguish the de- pression between the cricoid and thyroid cartilages ; but in women and children, in whom the thyroid cartilage is not prominent, doubt may arise, unless the operator remembers that the hard ring of the cricoid cartilage is always distin- guishable, and that the opening is to be made above this. The part being steadied with the finger, the knife may be plunged in transversely without hesitation, and if a free opening be made, the parts will gape sufficiently to allow an entrance for the air, but if not, they may be easily held apart until a tube can be procured. If necessary, the tube can be inserted readily enough, and it may not be superfluous (judging from what one sees in operations on the dead sub- ject) to remind the young operator that the end of the tube must be directed downwards. The tube is easily maintained in position by a tape round the neck. It is usually recom- mended to make the superficial incision vertical if the opera- tion is undertaken for chronic disease, and there is there- fore no great cause for haste. Tracheotomy. — This is frequently one of the most trying operations the 'house-surgeon will be called upon to per- form, and it is essential for success that he should be thor- 112 TRACHEOTOMY. oughly up in all its steps, and ready for every emergency. In children, the small size of the trachea and the closer proximity of the vessels render the performance of trache- otomy more arduous than in the adult ; and the house-sur- geon should take every opportunity of examining the rela- tive anatom}^, and of performing the operation in the dead-house, both on adults and children. Opinions vary as to the part of the trachea whicli should be opened — above or below the isthmus of the thyroid body. Undoubtedly the operation is easier above the isthmus, if it occupies its ordinary position, and the chances of haemorrhage are less. On the other hand, if the case is one of laryngeal disease, the irritation of the tube may keep up mischief in the larynx, if it is placed too near that organ. In selecting the point for opening the trachea, the surgeon must be guided mainly by the condition of the parts ; if the trachea is superficial and easil}' reached above the isthmus, he had better open it there; if, on the contrary, the isthmus is high and broad, and the trachea exposed below it, he should select the latter situation. For the successful performance of the operation, the po- sition of the patient is of importance. The head should be thrown back so as to stretch the neck and draw up the trachea as much as possible; but as the patient is generally struggling for breath, the recumbent position is almost an impossibilit}^, though of course advisable. A caution is necessary here, and specially with regard to children ; viz., not to let an over-zealous assistant draw the head so far back (at the same time closing the jaws) as to suffocate the patient before the operation is begun. The operator should see that he has everything he may want close at hand, viz., scalpels, forceps, tenaculum, blunt hooks, tracheotom.y tubes of different sizes and lengths, ligatures, sponge, etc. The operator, being on the patient's light hand, and having a trustworthy assistant opposite him, makes an in- TRACHEOTOMY. 113 cision from the cricoid cartilage downwards for a couple of inches if intending to operate above the isthmus, or begin- ning lower down, to the top of the sternum, and even for a little distance on the bone when the neck is sliort and it is intended to operate lower down; in both cases keeping very carefully in the median line. A rapid but careful dissection must then be made between the sterno-hyoid muscles down to the trachea, avoiding both the isthmus of the thyroid gland, which should be pushed with the finger up or down according to the operation intended, and also the veins, superficial or deep, which should be held aside by the assist- ant with a blunt hook or pair of forceps. The trachea being exposed, a tenaculum should be fixed into the upper part of it, by which it may be drawn up and steadied, and the knife, being held with the hack downwards^ should be thrust into the windpipe three or four rings below the tenaculum, and made to cut up to it. In thus entering the knife, the surgeon must be careful not to transfix the trachea, or even wound the oesophagus. The fact that the trachea has been opened will be immediately^ manifested by the rush of air and the expectoration of mucus through the wound, and a tube should be at once inserted, unless the operation has been done for a foreign body which it is hoped may be ejected by a forcible expiration through the wound, which must for this purpose be held open witii hooks. The insertion of the tube is often the most critical part of the operation, but has been much facilitated b}^ the in- vention of collapsing tubes, which when closed resemble a wedge, and can therefore be readilj^ introduced, and ex- panded afterwards by means of the second tube, which fits inside. If the surgeon is not provided with these tubes, he will overcome the difficulty by passing the handle of the scalpel into the upper part of the incision, and then turning it so as to bring it at right angles to the trachea. This has of course the effect of opening the incision, and will allow 10 114 TRACHEOTOMY. an ordinary tnbe to be slipped in with facility below the handle. Some surgeons insert a tenaculum into one side of the trachea, and use it afterwards to make traction upon the incision ; while others prefer to insert the tenaculum at the spot where the tube is to go, and then cut round it, remov- ing completely a portion of one or more rings. The dangers of haemorrhage in the operation of trache- otomy are somewhat exaggerated. So long as the surgeon keeps steadily to the middle line he is not likely to meet with any large vessel in the adult, and in the child the in- nominate vein is seldom in danger if the knife is held as directed in the deep incision. The sources of haemorrhage are the veins, which are generally much congested, and may be found immediately in tlie line of incision ; in which case a steel director may be substituted for the scalpel in the deeper dissection with advantage, and the tracliea thus be exposed. The rule has been laid down, not to open tlie trachea until all bleeding has ceased; but as the haemorrhage depends upon the dyspnoea and consequent congestion, this rule cannot be implicitl}^ obe3'ed, and, provided there is no arterial haemorrhage, the trachea may be safel}' opened. What little blood enters the windpipe is immediately coughed out again and does no harm, and it would take much more blood than is ordinarily shed to choke the lungs as has been suggested. The patient being often moribund before the operation is begun, may apparently die during its performance ; but the tube having been inserted, recourse should be had to the various methods of artiflcial respiration, and even in the most desperate cases the surgeon's efforts may be crowned with success. In cases of croup a quantity of false mem- brane ma}' be found semi-detached in the trachea, and can be extracted with a pair of forceps with the best effect. To secui^e the tracheotomy tube satisfactoril}' is not diffi- cult, provided a sufficientlj^ long and large tube be em- ployed, so as to fit comfortably into the windpipe, and afford TRACHEOTOMY. 115 the patient an abundant supply of air. The outer tube should be provided with a slit (not a hole) on each side of the flattened front portion, and a tape long enough to go twice round the neck having been passed through one of the slits, both the ends are to be carried round the back of the neck, when one of them can be passed through the other slit, and the two tied in a bow at the side and quite out of the way of the tube (Fig. 20). This is a better plan than that of knotting tapes on to the tube, which is apt to create an obstruction at the orifice. Fig. 20. The after-treatment of a case of tracheotomy is of great importance, and consists in keeping the tube clear, prevent- ing the access of cold air, and supporting the patient's strength. For the first few hours a tracheotomy case should occup3'' the sole attention of an experienced nurse, who should sit by the patient's bed and keep the tube constantly clear, either by detaching the mucus with a feather, or by removing tlie inner tube, cleaning, and then replacing it. In a croup case, after a few hours there will be found within 116 TRACHEOTOMY. the inner tube a tenacious sticky material, which materially obstructs it, and cannot be got rid of with a feather. The inner tube must then be removed and immersed in scalding water, which will effectualh'^ soften the mucus, and allow of its being cleared. A good plan is to oil the surfaces of the inner tube, which both facilitates its removal, and tends to prevent the accumulation of mucus. The access of cold air, which would probably excite inflammation of the lungs, is best guarded against by keep- ing flannel wrung out of hot water constantly applied over the tube; and this should be changed by the attendant as often as it gets cold. The amount of support necessary must of course be left to the judgment of the medical attendant. The collapsing tubes spoken of above facilitate the opera- tion, and answer very well for cases where the tube is only retained for a few days ; but if it has to be kept in the trachea for weeks or months, the old-fashioned double tube is preferable, since granulations are apt to grow up between the edges of the divided tube, and thus become a source of constant annoyance. Another and more serious danger arising from the use of rigid tubes for a length of time is the production of ulceration of some part of the trachea, thus opening into the oesophagus, or ulcerating into a large artery. The soft vulcanized india-rubber tubes recom- mended by Mr. Morrant Baker, and made by Maw, obviate this danger, and are very comfortable to wear; and Mr. Durham has also devised a form of tube which meets the evil. Instead of the whole tube being more or less curved, as in the ordinary form, only the extremity of this tube (Fig. 21) is curved, and the length of the straight portion A can be adapted to each case by means of the sliding collar B, which is fixed by turning the screw C. The collar is attached to a small plate D, the extremities of which work in " gimbles " on a neck-plate of the ordinary shape, E, thus securing a certain amount of play. The inner TRACHEOTOMY. 117 tube (Fig. 22) has its extremity jointed like tiie tail of a lobster, in order that it may readily take the necessary curve. This tube is necessarily somewhat expensive, but when Fig. 21. once the parts involved in the operation have resumed their ordinary condition, and the necessary length of tube Fig. 22. Fig. 23. has been ascertained, a simpler and cheaper tube on the Same principle could be readily fitted. 118 PAKACENTESIS. In introducing this or any form of c^'lindrical tube into the trachea, it will be found that a blunt pointed pilot trocar (Fig. 23), made on the same principle as the inner tube (or in tubes of the ordinary curve made simply of lead), will much facilitate the operation. The handle, which in the illustration is cut short, gives great control over the instrument. Paracentesis. — The house-surgeon raaj'- be called upon to perform paracentesis abdominis^ or (more rarel}') thor^acis, in the medical wards. Paracentesis abdominis is best per- formed in the linea alba, and midway between the unj^bilicus and pubes. The operator should first satisfy himself that it is really a case of drops3^ and see that the bladder is empty. The patient then being brought to the edge of the bed, and placed on his side, a piece of Mackintosh cloth should be arranged so as to protect the bed from getting wet, and the necessarj" pails, etc., should be provided to receive the fluid. Making first an incision through the skin with a sharp scalpel, the surgeon thrusts in a trocar and canula, re- ceives the first gush of fluid in a bleeding-basin, and then conducts the stream into a pail, thus avoiding all the splash- ing which otherwise is pretty sure to occur. When all the fluid has been drawn, the wound can be closed with long strips of plaster, or (what is more effectual) a hare-lip pin can be put through tlie edges of the wound, and a twisted suture be applied over it. A flannel roller should next be firmly applied round the abdomen, and the operation is completed. The full-sized trocar usually employed is unnecessarily large, and weakens the abdominal wall by the cicatrix it causes, besides evacuating the fluid so rapidly as to lead to faintness. A trocar of the size used for tapping a hydro- cele is quite large enough, and will evacuate an ascitic abdomen in from half an hour to an hour. The minute trocars introduced by Dr. Southe}^, which take several PAKACENTE8IS. 119 hours to evacuate a large quantity of fluid, have the draw- back that their action is too slow to give marked relief in ascites, and that the fluid is therefore reproduced almost as rapidly as it is evacuated, but they answer admirably for the relief of anasarca. Paracentesis thoracis is usually performed in the space between the sixth and seventh ribs, near their angles, and the object of the surgeon is to enter the trocar at the wpper border of a rib, so as to avoid all possible risk of wounding the intercostal artery. With the view also of making a val- vular opening, the finger should be placed on the skin at the lower margin of the rib. and made to draw it upwards; with a scalpel a cut is then to be made parallel to the rib, and a small trocar entered. When the skin is allowed to resume its proper position the canula will slope downwards, — the best position for evacuating the fluid, — and when withdrawn it will leave a valvular opening in the skin. If it is at hand, the surgeon may use a trocar working iu a canula like a piston, with an india-rubber tube attached to the side, the end of which can be kept under water, or may employ one of the numerous forms of "Aspirator." Should the fluid drawn off prove to be purulent, consti- tuting empyema, it will almost certainly reaccumulate, in which case it will be advisable to make a free opening for its exit. It is to be borne in mind that the pleura reaches the last rib, and that a cautious incision maybe made where a trocar could not be safely thrust, for fear of injuring the diaphragm and liver. Since a dependent opening is most important, the incision should be made not higher than the tenth rib, and well back. The integuments being divided parallel to the ribs, a steel director may be conveniently pushed upwards between the ribs until pus appears along the groove of the instrument, when a blunt-pointed bistoury can be slipped along it and made to enlarge the opening sufficiently to introduce a good-sized drainage-tube. 120 ASPIRATION — VENESECTION. Any immediate washing out of the pleura is to be depre- cated as being not without danger, though later on anti- septic injections may be required. Aspiration. — The pneumatic aspirator of Dieulafoy and its various modifications are now in common use for the diagnosis and evacuation of collections of fluid in various l^arts of the body. The exhausting S3'ringe is a feature common to all the instruments, but the best form is that which admits of a reversal of the current so as to clear the needle of any accidental obstruction during the withdrawal of the fluid. This is of course impossible in the various forms of "bottle aspirator." In using the aspirator it is essential that the needle and tube employed should be per- fectly clean, and this fact is best ascertained by pumping water through the entire apparatus on each occasion of its being einplo3ed. The tap communicating with the hollow needle being then reversed, and a vacuum formed behind it, the needle is to be carefully thrust with a twisting motion into the part to be explored, care being taken to avoid the position of main vessels and nerves. Continuit}'' being then restored by turning the tap, the fluid contained in any cavit}^ which ma}' have been reached will flow into the syringe or reservoir, and if at a greater depth than antici- pated, ma}' be carefull}' sought for with the needle which now forms part of the vacuum. When all the fluid present has been extracted by the pumping action of the syringe, or, in the case of large collections, by simply converting the tube into a siphon, the needle is to be withdrawn, and the minute aperture in the skin covered with a piece of lint dipped in collodion. Venesection. — A tape is to be carried twice round the arm, a few inches above the elbow, and tied in a bow. The veins being thus obstructed and made prominent, the op- erator is to choose the one he intends to open, remembering VE^'ESE€TIOX. llil that while the median-cephalic is the safer, the median- basilic is generally the larger, and therefore yields a better su[)ply of blood, but has the disadvantage of lying directly Fig. 24. over the brachial artery. Standing in front of the patient, and grasping the arm with the left hand, the thumb of which Fig. 25. serves to steady the vein TFig. 24), the surgeon, holding tlie lancet as shown in Fig. 25, with a sweep of the wrist makes an incision (not merely a puncture) into the selected vein, 122 VENESECTION. takinoj especial care not to go through it. An assistant holding the bleeding-basin, the stream ma_y easily be di- rected into it, and not a drop of blood ought to go on the floor or on the dress of the patient. If the blood does not flow readih', the patient may have recourse to the common plan of forcibly grasping a stick and moving the fingers about. When the required amount of blood has been ab- FlG. 26. stracted, the tape is to be untied, and the thumb of the operator placed over the wound. A pad of lint is then to be placed upon the wound, and maintained in position with the thumb, while a bandage is applied. This is done by making a turn round the arm below the joint, then going over the pad to above the joint (Fig. 26), making another turn round the arm at this point, and, lastly, returning across the pad. Or the tape which was bound round the limb may be employed, the middle of it being crossed over the pad obliquel}^, and the two ends carried round the arm in opposite directions, above and below the elbow, until they meet obliquely over the pad. Thej'^ are then to be twisted round one another, and, passing straight round the arm, are to be tied in a bow on the outer side of the limb. INCISION!^. 123 Bleeding from the jugular vein is rarely employed, but is performed in the following way: The left thumb of the operator is to be placed on the vein immediately above the clavicle, so as to obstruct the course of the blood. As soon as the vein is prominent the lancet can be used, takin^^ care that the incision is made parallel to tiie sterno-mastoid mus- cle, and thus somewhat across the vein. When sufficient blood has been drawn, a pad is to be placed on the orifice, and a bandage to be applied over it and under the axilla of the opposite side, but the thumb must not be removed until the whole arrangement is completed, lest air should gain entrance into the vein. Bleeding from the temporal artery is still more rarely performed, and consists in selecting the anterior branch of the temporal arter}', and then making an incision across it, not so deeply, however, as to divide it. In order to arrest the ha3morrhage and prevent the formation of a false aneu- rism, the lancet must be made to divide the artery thor- oughly, and a pad must be firmly bandaged over the wound. Incisions into Inflamed Parts, — Incisions may be neces- sary in carbuncle, erysipelas, etc., and they require care in their performance. An incision into a carbuncle, to do any good, must go right through it to the fascia beneath, and through the whole extent of brawn}^ tissue (though carbuncle may be more satisfactorily treated by subcutaneous section as recommended by Mr French); whether the incision shall be made crucial or not will depend upon the extent of the disease. Incisions in erj-sipelas, etc., should, as a rule, be made in the length of the limb, and not across it, and must divide the whole thickness of the cutis, since otherwise no relief is given to the tension. No fixed rule can be laid down for the length of the incision, but it is better to make two or three small ones rather than one laro;e *' gash " for the whole length of the limb. In the case of all incisions, unless it is intended to ab- 124 ABSCESSES. stract blood from the part, care should be taken to arrest the flow of blood thoroughl}', before an_y warm poultice or fomentation is applied. This is most easily accomplished b}' placing strips of dr}^ lint in the incisions and elevating the limb, or, if necessar}-, by aj^plying in addition a bandage over the lint for an hour or two. The pledgets of lint should not be removed until thej separate spontaneously in the poultice. Absces'ses frequently come under the house-surgeon's sole care, and he must open them on his own responsibility. In making a diagnosis of the presence of matter in a limb, the house-surgeon will do well to bear in mind one constant source of fallac}', viz., the sense of fluctuation imparted to the fingers by the fibres of the superficial muscles. This error is easil}' avoided by remembering (as any one can prove on his own thigh at any time) that although pressure from side to side of a healthy limb will give a Ytry exact imita- tion of fluctuation, yet that if the pressure be made in the length of the limb or muscle, no such sensation will be pro- duced. If deepseated matter be suspected but cannot be satisfactoril}^ made out, the grooved needle, or a fine trocar and canula maj' be used to explore, and a bead of matter being thus evacuated will render the diagnosis certain. If the matter be too thick to flow readily, a small quantity will generally be discovered by blowing through the canula after witlidrawal. The modern "aspirator" will not only facili- tate the diagnosis of matter but will in many cases afford the best treatment of the abscess, which may be tiuis tapped more than once if necessarj^ before being laid open. In opening all abscesses care should be taken to cut parallel to, and not across important structures; thus abscesses in the limbs are opened b}^ a longitudinal incision, and in the breast in a direction radiating from the nipple. Wherever it is possible the opening should be dependent, and in treat- ing deep abscesses among important structures, the house- ABSCESSES. 125 suroeon may do well to avail himself of the method siio^gested b^' Mr. Hilton, viz., to make a small incision in the skin, and then to thrnst a director l)etween the important parts to tiie abscess, which will be shown to have been reached by the escape of a small quantity of pus. A pair of ordinary dress- ing forceps can next be introduced along the director, and be opened so as to widen the aperture and give free exit to the matter. Having made up his mind as to the existence of matter, and having begun to seek it. the house-surgeon should not be dismayed at having to cut occasionally considerably deeper for it than might prima facie have been expected, but should persevere in a careful incision until the abscess is reached. Antiseptic Treatment of Abscesses. — Large abscesses may be satisfactorily opened beneath an antiseptic dressing, ac- cording to Lister's method, as follows: The skin in the neighborhood of the proposed opening is to be cleansed with a strong solution of carbolic acid (l to 20), which is also to be a[)plied to the fingers of the operator and any instrument emplo^'ed. Any hair upon the surface is to be shaved off', and then a solution of carbolic acid (1 to 40) is to be sprayed freel}'' upon it. A dependent incision is now made and the pus evacuated b}^ gentle pressure, after which a drainage- tube of length sufficient to reach the bottom of the cavity is to be inserted and held in position by loops of silk fastened to it. The action of the spra3'-producer is to be carefully maintained until the opening is covered with a piece of anti- septic gauze wetted with tiie solution, and over this a dress- ing large enougli to extend well beyond the wound in every di- rection, consisting of eight folds of gauze, with a piece of thin mackintosh placed between tlie two outermost layers. Over this again a gauze-bandage is to be applied and fastened securely with safetj'-pins. Each subsequent dressing must be conducted with similar precautions, the drainage-tube being removed and cleansed and shortened as may be neces- 126 INTRODUCTION OF EYE-DROPS. sary to keep its month level with the skin. (See also Anti- septic Dressings, p. 155.) Whitlows constantly require incision, and the following may be usefull}^ borne in mind. The sheath of the tendons extends only to the base of the ungual phalanx of each finger, and hence matter in the soft pulp at the extremity, or round the nail, never finds its way up to the palm, and only a very limited incision, therefore, can be required for its evacuation. Matter in other parts of the finger, on tlie contrary, is sometimes within the sheath, and unless it is evacuated by a timely incision, will creep up into the palm, and do irreparable mischief. The proper place for making an incision in these cases is over the head of the metacarpal bone, and the sheath should not be extensively slit up, or the tendons will certainly slough. The incision should be strictly in the middle line of the finger, so as to avoid in- juring the vessels and nerves at the side. In opening abscesses in the palm of the hand, it should be borne in mind that the position of the superficial palmar arch is tolerably well indicated by the middle crease or groove in the skin of the palm, and that the bifurcation of the digital arteries is about midwaj^ between the front line and the roots of the fingers. Introduction of Eye drops. — This little operation is con- stantly required, and demands a little care for its efi'ective performance. It is essential that tl)e fluid should be ap- plied to the whole of the conjunctival surface, and for this purpose, the patient being seated with the head thrown a little back, the operator should gently separate the lids with the forefinger and thumb of the left hand, and apply the drop to the outer angle of the eye, taking care that it passes between the lids, and not outside them. To applj^ the drop, a camel's hair brush, or better, the little spoon contained in every pocket-case, may be employed ; but the neatest and PLUGGI^sG THi!]' NAIIES. 127 most convenient method of introducing e^^e-drops is to keep them in little bottles, the stoppers of which are pierced witli a capillar^' tube, which is covered with a glass cap when not in use. Being kept not more than half full, it is only necessary to grasp the bottle, when the heat of the hand will be sufficient to expel a drop of the contents. The form of the bottle and a convenient mode of holding are shown in Fig. 2T. In using it, the eyelids need not be Fig. 27. widely separated; it is sufficient to introduce the apex of the conical stopper between the lids near the outer canthus, so that the fluid may follow the course of the tears, and sweep across the globe. Plugging the Nares. — The anterior nares may be plugged with strips of lint, and if these are pushed as far backwards towards the pharynx as possible, and the whole cavity of the nose is filled with lint introduced bit by bit, the more complicated operation upon the posterior nares will be but seldom required. For plugging the posterior nares, most hospitals are provided with a " Belloc's sound," 2. e., a piece of watch-spring with a ring at the end, inclosed in a canula; but, if this is not at hand, an ordinar}^ elastic catheter (No. 4 or 5) will answer every purpose. It is advisable that the end should be cut off the catheter and a double thread carried through it (which can be easily accomplished by the aid of a stilette), so that a loop may hang out of the cut extremity. It will facilitate the catching of the thread 128 REMOVAL OF POLYPUS NASI. in the fauces if a knot be tied in the thread about two inches from the loop, which will have the effect both of preventing its receding into tlie catheter, and also of causing it to pro- ject more into the mouth. If Belloc's sound is used, the thread will be passed through the ring simply, or a knot and loop may be formed as above recommended. The sound being passed along the floor of the nose, the loop must be made to project in the fauces, when it is seized with forceps and drawn out of the mouth, the canula being afterwards withdrawn from the nose. A roll of lint (which is better than sponge) being attached, can now be easily drawn up into the posterior nares, guided behind the soft palate by the forefinger. The ends of the thread are thtn to be tied round another roll of lint, close to the nostril, which serves the double purpose of keeping tlie plug firm, and of obstructing the anterior nares. When all danger of hjemorrhage has ceased, the posterior plug may be removed b\^ a stream of water from a syringe, or by gentle pressure with a bougie through the nose. It has been advised by some writers to attach strings to the posterior pad, which the patient is to swallow until they are required for its dis- lodgment ; but if this is done, it is better to bring the strings loosely out of the mouth and secure them in front, though this is rather uncomfortable for the patient. Eemoval of Polypus Nasi. — The presence of an ordinary gelatinous polypus being ascertained by an inspection of tiie obstructed nostril, when a glistening, yellowish body will be perceived, the forefinger of the left hand should be passed behind the soft palate, to ascertain the presence of polypi in the pharynx, and to assist in their removal. A slender pair of polypus forceps being now introduced with the right hand, the polypi can be grasped and rapidl}' twisted out, the left forefinger guiding the instrument to the growths which commonly obstruct the posterior nares. In this way the polypi are thoroughly removed instead of REMOVAL OF TONSIL. 129 being " nibbled at," and the forefinger both keeps the patient steady and prevents the passage of blood Into the throat, but is liable to bites. The polypus-forceps in ordinary use are much too large and clumsy, and the blades are serrated only at the ends instead of in their whole length, as they should be. Puncture of Tonsil.— An inflamed tonsil may be seen partially projecting towards the opposite side, and partly forming a tumor behind the anterior pillar of the soft palate; and it is in the latter situation that a puncture should be made. A sharp-pointed bistoury should be cov- ered with lint to within three-quarters of an inch from the point, with the double view of avoiding injury to the lips and of limiting the depth of the incision. The mouth being open, and the tongue depressed, the point is to be carried straight back, and thrust through the palate into the most prominent part of the tumor. The edge of the bistoury being upwards, the puncture can be readily enlarged to give exit to matter, if it has formed, as it generally does, in the upper part of the gland. The incision in the palate is not of the slightest moment, and heals readily; and further experience only induces me to recommend this method the more strongly, in preference to any attempt to reach the abscess from"^ the side. The haemorrhage, which is some- times sharp for a few minutes, is from the palatine and as- cending pharyngeal arteries, and never from the internal carotid', and will be easily arrested by the use of cold water. (See also p. 44.) Removal of Tonsil— The house-surgeon should be pre- pared to perform this operation if called upon to do so, and will find the hooked forceps and bistoury, or the simple in- strument shown in Fig. 28, as efficient as the complicated '' guillotines," which are always getting out of order, and 11 130 EEMOVAL OF TONSIL. require the attention of the instrument-maker after each time of using. The curved probe-pointed bistoury should have the head covered with a piece of lint, and is to be held in the right hand, while the forceps occupj^ the left. The patient's head being thrown a little back, and the mouth opened, the en- larged tonsil can be grasped ; and if it is on the left side, the surgeon will have no difficulty in passing the bistoury below it, and slicing it off, while standing in front of the patient. Fig. 28. If, however, it is the right tonsil, in order to operate with- out changing hands the surgeon should stand on the patient's rio^ht, and, leaning over him, will be able to use both knife and forceps efficiently. The simple guillotine (Fig. 28) is more convenient for children and unsteady patients, because it thorough!}^ gags the mouth when once fairlj?^ introduced. In order to use it effectively, the operator should be provided with a pair of hooked forceps to draw the tonsil well through the ring of the instrument, or an insufficient portion will be removed. These forceps should be both wider and stronger in the teeth than those usually made, as the tonsil is often very friable, and it is difficult to hold it. The operator should stand in front of the patient, holding the guillotine in the right or left hand, according to the side to be operated on, and if both tonsils are to be removed, should turn the guil- lotine in the mouth, without removing it, so as to prevent closure of the jaws by the patient. SPRAY PRODUCER. 131 The Spray-producer is a very useful little instrument for applying remedies locall}^, both in the throat and nose. Fig. 29 shows one of the forms in common use, consisting of an india-rubber hand-ball and reservoir, by which air is driven Fig. 29. through a double capillary tube communicating with the fluid in the graduated bottle, which is thus projected in the form of spray. The tubes may be of glass, or better, of Fig. .30. vulcanite, and are made by Messrs. Ma3'er and Meltzer, of various shapes, to suit the larynx, nose, etc. Fig. 30 shows a more portable form of spray-producer contrived by Dr. Brakenridge, of Edinburgh, in which the fluid to be em- 132 AMPUTATION OF FINGERS. ployed is carried in a small corked bottle (made in two forms), forming part of the apparatus. This, inclosed in a case, is only four inches long. For the antiseptic spray a steam spraj^-producer may be constantly employed. Local anaesthesia may be produced b}^ freezing the skin with an apparatus similar to the spray-producer, but em- ploying highly rectified ether, as proposed by Dr. Richard- son. The effect of the " ether-spray," when played upon the surface, is to blanch and harden it, and incisions may then be made with very little pain. The drawbacks to the use of this anaesthetic are, that the subcutaneous surfaces are not affected, whilst the skin itself is rendered so hard that it is difficult to operate on it. The pain produced by the freezing and thawing of the part is also considerable, and more than counterbalances the advantages claimed for the method. In using the ether-spray at night the greatest care must be taken to avoid the too close proximity of a naked light, as the vapor given off is highly inflammable. Amputation of Fingers. — In cases of crushed fingers or gunshot injuries, it may be necessary for the house-surgeon to amputate a finger, but he should alwa3's avoid doing so if there is a probability of the member becoming serviceable by care and attention. Amputations at the joints are gen- erally necessary, and are more easily performed than in the length of a phalanx. To Amputate the Third or Second Phalanx. — Grasp the phalanx firmly by means of a piece of lint, and bend it as nearly to a right angle with the next bone as possible. Place the head of a narrow scalpel or bistoury at the side of the joint, exactly midway in the thickness of the next phalanx (Fig. 31), draw the knife horizontally across the joint, which will fly open at once if the lateral ligaments have been thor- oughly divided with the point and head of the knife. Pass the knife through the joint, and cut a flap from the palmar AMPUTATION OF FINGERS. 133 surface of the phalanx. Probably no vessel will require a ligature, and the flap may be retained in its place with a couple of stitches and a strip of lint. It should be remembered that if the first phalanx be left alone it will always be unsightly, owing to its having no ten- don to flex it ; and, therefore, if possible, a part of the second phalanx should be left by making a small dorsal and a larger Fig. 31. palmar flap about the middle of the phalanx, and cutting through it with the bone-forceps. To Amputate the First Phalanx. — In doing this operation, the head of the metacarpal bone may be removed or not, ac- cording to the taste of the operator and occupation of the patient. The oval amputation (Fig. 32) is generally the best, and is performed by placing the point of the bistoury on the metacarpal bone near its middle, cutting along it to the joint and then passing in an oval sweep just below the joint so as to obtain sufficient flap. The flaps are then to be dissected back, without opening the joint, and the head of the metacarpal bone and a portion of the shaft are to be cleared of muscular fibre, when the cutting forceps can be applied to the bone, and the finger at once removed. The 134 AMPUTATION OF TOES. incision will, if properl^^ made, form a single line when the edges are brought together. Tlie position of the incision will var}'^ slightly in the sev- eral fingers ; thus in the forefinger it should be placed as much on the outside of the metacar[)al bone as possible, so that the scar may be hidden, and for the same reason on the inner side of the little finger. In the middle and ring fingers the incision is unavoidably on the back of the hand. Fig. 32. In removing the first phalanx of the thuinb^ the head of the metacarpal bone should be invariably left, since a7ry thumb is better than nothing. With this view the incision should be brought well over the base of the phalanx, and taken almost circularly around it, so as to obtain flap enough to cover the head of the metacarpal bone, which is larger than one would prima facie expect to find it. This method may also be adopted in the fingers when it is desired to leave the heads of the metacarpal bones. (Consult also Fergusson's Fractical Surgery and the au- thor's Operative Surgery.) Amputation of Toes. — This is generally a very simple matter, the crushed portions being removed and the flaps made in any way most convenient; and if there is not suffi- cient skin, the parts will granulate and cicatrize over with- out difficulty. The only caution necessary is, never to THE USE OF THE STOMACH-PUMP. 135 remove any of tlie metatarsal bone, nor in fact to open the metatarso-phalangeal joint, if it can be avoided, since the foot is thereby considerably weakened, and matter is very apt to find its way into the sole of the foot. It is better practice to cut through the first phalanx with the bone for- ceps ; and it must be borne in mind that the metatarso-pha- langeal joint, if it must be opened, will be found to lie mucii higher up than is generally supposed, and that it will be convenient to open the joint from below, the toe being drawn well up. The use of the stomach-pump is most commonly required for the evacuation of poison from the stomach, but may also be needed in order to feed the patient. In either case it mfxy be necessary to open the mouth forcibl}^, and this is most readil}' accomplished by using the screw-gag; for if the extremity can once be insinuated between the teeth, no muscles can resist it. The jaws being separated, the com- mon wooden gag with a hole in the centre can be tied in, and there will be no further obstacle. If the gag can be altogether dispensed" with, as it can in most cases, so much the better. The best form of stomach-pump is that in which the direc- tion of the current is controlled b}' a lever grasped with the left hand, the tap plainly showing in wiiich direction the stream is passing. The instrument is fitted ordinarily with a stomach and a rectum tube, the former havino- the holes at the side, and the latter at the extremity. Haviug oiled the proper tube, the house-surgeon should curve its extrem- it}^ rather abruptly, and introduce it carefully, through the gag, to the back of the throat. In order to do this, the pa- tient's head is generally thrown back ; but when the end of the tube is felt to have reached the back of the pharynx, the head should be bowed forward, or else the vertebrae project and prevent the tube passing down the gullet. A little gentle, steady pressure will make the tube glide down the 136 INTRODUCTION OF RECTUM-TUBE AND BOUGIE. pharynx until it reaches the back of the pharynx, where there is often a slight hitch for a moment; but this is readily overcome, and the tube passes into the oesophagus and stomach. The direction in which the tube should be pushed is upwards rather than downwards, and if a proper curve has been given to the end of the instrument, and it be kept strictly in the median line, there will be no difficulty. With an ordinary -sized tube it is next to an impossibility to pass by mistake into the trachea ; but if the house-surgeon feel anxious about it, he can pass his finger down and make cer- tain that the instrument is not in the glottis, which event w^ould be immediately manifested by the urgent dj'spnoea of the patient. Before attempting to withdraw any fluid from the stomach, some warm water should invariably be intro- duced so as to avoid all risk to the mucous membrane, and then by a series of steady movements the contents may be withdrawn, care being alwaj'S taken not to remove quite as much fluid as was thrown in ; and if necessary the stomach may be washed out in this way several times. A good deal of trouble is sometimes experienced from the eyes of the tube getting choked with undigested vegetables, etc. ; when this occurs, the action of the pump should be reversed im- mediatel}^ so that the fragment ma}^ be driven out ; or if this cannot be done, the tube must be removed, cleaned, and reintroduced. In cases where valuable time is being lost from this cause, it will be better to introduce an emetic through the pump and let it act in the ordinary way, taking care, however, that the patient, if insensible, is not suffo- cated by the vomited matters. In the case of young chil- dren a large elastic catheter forms the best tube, and this can be adapted to the pump by a piece of india-rubber tubing. Introduction of Rectum-tuhe and Bougie. — Ordinary en- emata are generally administered by the nurse ; but in cases of obstruction or stricture of the rectum, the house-surgeon RECTAL ABSCESS. 137 will be called upon to introduce the instrument. The long tube, commonl}^ known as O'Brjan's, is to l^e introduced by the operator while standing behind the patient, wl]o is i>laced on his left side. The house-surgeon's riglit forefinger having been well soaped, is to guide the tube through the anus, and gentle pressure will then be sufficient in most cases to in- sure its passing tlirough the intestine. Sometimes the tube catches in one of the transverse folds of mucous membrane of the rectum, and only bends upon itself; when it must be withdrawn, strengthened, and reintroduced, the operator trj'ing first one side and then the other of the intestine, so as to avoid the folds. In the case of a strictured rectum, it is best, if possible, to pass the forefinger up to the stricture, and thus guide the bougie or tube through the obstruction. When the stricture is high up, this is of course impossible, and careful manipu- lation must be trusted to alone. If doubt is felt as to whether the long tube has passed the obstruction, the injection of warm water should be had re- course to, when, the ear being applied over the colon, the fluid will be distinctly heard passing along the bowel. When it is desired to distend the bowel steadily and slowly to its utmost limit, the siphon arrangement figured at page 40 will be found much more efficient than any form of enema syringe. Rectal Abscess. — An abscess by the side of the rectum should be opened as early as possible in order to prevent the formation of fistula. The oiled forefinger (right or left according to the side to be operated on) having been passed into the bowel, a pointed curved bistoury should be plunged into the ischio-rectal fossa with the back of the knife towards tiie bowel, and a free opening made towards the tuber ischii. If the matter is extremely offensive, showing in all proba- bilit}' a communication with the bowel, it will be well before withdrawing the finger to use a probe, or better, a probe- director, to ascertain the existence of an internal opening. 12 138 CIRCUMCISION. If the probe-point of the director passed into the abscess meets the finger, the fistula is a complete one, and may be at once divided by hooking down the probe through the anus, at the same time pushing the director through the fistula. A little manipulation and stretching of the rectal tissues will then allow the director to be brought out at the anus, and the sharp-pointed bistoury can be run along it with great ease. This is a more certain and easier method of dividing a fistula in ano than with a probe-pointed bistoury introduced through the fistula, and obviates the danger of breaking the knife in the fistula. An inflamed pile at the verge of the anus often requires an early incision to prevent suppuration. It may be con- veniently transfixed with a Syme's abscess-knife in the direction of the anal folds of skin. The little clot of blood almost alwa3's found in these superficial external piles should be gently squeezed out. Circumcision. — This operation is often intrusted to the house surgeon, and may be done in various ways. The fol- lowing is as satisfactory as any : A piece of tape should be tied round the root of the penis, as this restrains all haemor- rhage. Grasping the end of the foreskin evenly with the finger and thumb, or better, with a pair of forceps, the operator then cuts it off obliquely from above downwards so as not to interfere with the frsenum, using either a pair of scissors or a bistoury, according to fancy. The cut skin now retracts, leaving the lining membrane of the prepuce still covering the glans. This membrane is then to be divided along the upper surface, nearly as far as the corona glandis, with the scissors ; and the young operator must be careful that one blade does not slip by mistake into the urethra. The' glans is now exposed, and care should be taken to tear through any adhesions which may have formed between it and the prepuce, particularly near the corona, so TAPPING A HYDROCELE. 139 as to give exit to all the smegma preputii which will proba- bly have collected. The margins of the skin and mucous membrane are now to be stitched together, and this can be readily done with a continuous suture of fine silk, a loose end being left at the point of commencement (conveniently the frsenum) to be tied to the opposite end on the comple- tion of the circular '• hem." In two or three days the con- tinuous suture can be readily withdrawn by simply cutting the knot and pulling the end left long for the purpose. The interrupted suture is difficult to remove, and if employed, very fine silk should be used, and the sutures should be tied so tightly as to cut their way out in a da3'' or two. The employment of wire sutures is to be deprecated, as the sharp ends irritate the tender and swollen tissues. A piece of oiled lint should be twisted round the penis, leaving the urethra uncovered , and this may be conveniently kept on with a narrow strip of plaster, the ends of which being affixed to the abdomen will support the penis. In cases where the prepuce of a child is only contracted and not too long, a cure can be effected by rapidly dilating the orifice with a pair of common dressing or polypus forceps. The prepuce should then be drawn back, and kept so with water dressing for a couple of days, when it may be allowed to resume its usual position. Tapping a Hydrocele. — Before operating, even under or- ders, the house-surgeon should make sure of his diagnosis by examining the scrotum with a candle, so as to observe the translucency of the contained fluid. This may be conveni- entl}' done by using a stethoscope or any other tube to look through, when the red glare will be at once perceived at the end of the tube, and the fallacy sometimes caused by the light showing through the fingers will be avoided. In tapping a hydrocele, it is convenient to sit in front of the standing patient, and having grasped the scrotum with tiie left hand, to ascertain with the right that the testis is 140 INGROWING TOE-NAIL. not accidentally in front of the fluid. The trocar and cannla may then be plunged boldly in with an upward direction, a point in the skin being chosen as free from veins as may be. The fluid being drawn off, a little collodium or a piece of plaster may be put over the puncture. In inject- ing a hydrocele, a S3^ringe holding two drachms of the timc- tura or liquor iodi should be employed, and the scrotum should be well manipulated after the injection, so as to bring the fluid in contact with the whole of the serous surface. Ingrowing Toe-nail. — This painful affection is best treated by the removal of a narrow strip of the nail — never the entire nail — with the scissors. Local or general anaesthesia having been induced (the nitrous-oxide gas being especially useful for this and other short operations), the operator thrusts the narrow blade of a pair of angular surgical scis- sors beneath the nail near the side affected. This is forced completely up to the matrix, and made to divide the nail, when the piece thus cut off is grasped with a pair of torsion forceps as near the root as possible, and twisted out. In lono;-standinoj cases of this affection the nail has become so softened by the constant discharge that it is apt to break away and leave the root of the piece cut off in situ. The success of the operation depends, however, upon the evul- sion of the entire depth of the nail, and an examination of the ragged edge of the piece removed will show how futile any less radical proceeding would be. In the rare cases of both sides of the nail growing in, a slip should be taken from each side, but the central portion should always be left intact. A little cotton-wool introduced by the side of the nail forms the best dressing at the time of the operation, and may be afterwards moistened with a stimulating lotion (sulphate of zinc or copper, two grains to the ounce of water). CUPPING. 141 Seton. — If onl}^ a single or double thread is to be intro- duced, tlie common needle will answer every purpose; but if a larger seton is required, the seton-lancet may be used, or an ordinary bistoury and probe. The skin having been pinched up with the finger and thumb, the bistoury is thrust through the fold, and the probe carrying the seton is passed by its side ; the bistoury having then been removed, the seton can be drawn through and detached from the probe, when the ends should be fastened together to prevent its slipping out unawares. When putting a seton into the temple (in eye affections) with an ordinary needle, the skin should be drawn up by the hairs scattered on it, rather than by pinching, or the temporal artery may be transfixed. Issue. — When an issue is to be made with the potassa fusa, a piece of leather plaster should be laid over the part, a hole having been cut at the point where the issue is to be formed. A small piece of the potash is then to be placed upon the skin, and secured in its position by a piece of strapping over it; and in a few hours, when it has done its work, the strapping is to be removed, and the part carefully cleansed with vinegar and water, to prevent any portion of the caustic from passing beyond the intended boundary. If it is desired to maintain the discharge, a i3ea, or better, a large glass bead, may be fastened on to the ulcerated surface with plaster, and may, in addition, be smeared with savine ointment. Cupping. — This operation requires a good deal of nicety in its performance, and is by no means so easy as it would appear. If the ordinary glass cups are used, it will be necessary to exhaust the air bj' means of the flame of the spirit torch, or, as preferred by some surgeons, by inserting pieces of paper or cotton-wool dipped in spirit, and then setting them on fire in the cup itself. Whichever method 142 CUPPING. is employed, care must be taken not to heat the glass too much, or the patient's skin will be scorched. When the cups are fitted with a little exhausting syringe, the opera- tion, though more tedious, is more easily performed. Whether the cupping is to be "dry" or " wet" the surface of the bod}^ should be sponged with warm water prior to the operation, and the cups be placed in a basin of boiling water before being used. The torch being then held beneath the cup, so that the flame enters it without touching the glass, the air becomes rarefied, and the cup should be immediately applied to the skin, and gently pressed on to it so that the surface may fit closely to its edges. When the skin has risen well within the cup, it may be detached by introducing the nail beneath its edge, and the operation of dry cupping is completed. The scarificator used in wet cupping should be kept scrupulously clean and its blades very sharp, and before commencing the operation they must be graduated to suit the thickness of the patient's skin, which can be best ascertained by pinching up a small piece between the finger and thumb. Care must be taken, in the case of a fat patient, not to set the blades too deeply, or they will cut through the skin and let the little pellets of fat protrude, effectually arresting the flow of blood. In using the scarificator, it must be pressed carefully against the skin, or it may slip and make very irregular incisions, and the freshly exhausted cup must be applied immediately over the cuts. Each time the cup is removed, with its con- tained blood, the surface should be wiped with a warm sponge, that all coagula may be removed from the incisions before it is replaced ; and the cups should be plunged into hot water. A piece of dry lint, with a turn of bandage, will control all further bleeding when a sufiQcient quantity of blood has been abstracted. In cupping on the temple, after the cup is fixed, the lower edge should be a-little elevated so as to take off pressure from the temporal artery beneath, or no blood will be obtained. SUBCUTANEOUS INJECTION. 143 Application of Nitric Acid. — This will be necessary, oc- casionally, to arrest the progress of sloughing in important tissues. In order to render the application effectual, the part must be thoroughly dried; and since the destruction of tissues is necessarily painful, it will be well in severe cases to administer chloroform prior to the operation. The nitric acid should be the strongest fuming acid, and may be most conveniently applied on a piece of firewood, cut to a suitable point, this being preferable to the glass rod or brush. The acid should be applied freely around the margin of the slough, and should involve a line of healthy tissue be^'ond. the disease ; for, unless this is done, the sloughing action will very probably recur. A poultice, and especially the charcoal poultice, when the surface is extensive, forms the best after-treatment. Subcutaneous Injection. — This method of administering sedatives is often of the greatest utilit}*. It consists in in- jecting from three to six drops of a sedative solution into the subcutaneous tissues by means of a small syringe H-ted with a hollow needle. The s_yriuge made with an ordinary piston is preferable to that fitted with a screw, and care must be taken that the needle is both pervious and sharp. The gold needles originally supplied soon become blunted, and those made, as suggested by Dr. Buzzard, with solid steel points and a lateral opening are far better. The solution should be concentrated so that the required dose may be con- tained in not more than five or six drops, and should be of neutral reaction, or it is liable to produce abscess. The solution for h3^podermic injection of the British Pharma- copoeia contains one grain in twelve minims. The skin of the arm (or painful spot if preferred) being pinched up with the finger and thumb, the point of the needle is to be thrust boldl}^ into the subcutaneous tissue parallel to, and not across, the fold, which should be released again before the 144 VACCINATION. fluid is injected. The aperture made is so fine that the fluid cannot escape, and ordinarily it gives no further trouble. Vaccination. — This operation ma}' be performed either by making punctures, or by abrading the skin with scratches. An ordinary lancet is the simplest instrument for the pur- pose, but a lancet with a small hollow in it, or Spratley's vaccinator, may be employed for the punctures, and the little pronged scratching instrument for scoring the skin, if preferred. The position usually chosen for vaccination is as near the insertion of the deltoid as may be, on the left, or both, arms. The punctures (three or four in number) are best miade from above, so that the lymph may gravitate into them, and should not draw more than a trace of blood ; they should not be made so close together as to cause the resulting vesicles to become confluent. The vaccine lymph is best taken from the fully formed vesicle of a healthy child at the time, but may be preserved on ivor}' points, between glasses, or better, in glass tubes. If points are used, the}' should be moistened with the breath before being inserted into the punctures, in which they may be left some minutes. If glasses are used, the lymph must be moistened before it is taken up with the lancet; and if tubes are employed, the extremities are to be broken off and the lympli is to be gently blown on to the lancet. As capillary tubes are now very generally and success- fully employed for the preservation of vaccine lymph, the following directions relating: to them are extracted from Dr. Husband's report to the Privy Council (1860) : '' The tube employed is simple, straight, cylindrical, open at both sides, and of such dimensions as to fulfil the follow- ing conditions, upon which it will be found that its peculiar value, as a means for preserving lymph for future, every-day use, essentially depends. It must be — " 1. In the first place, of such tenuity that it can be sealed instantaneously at tlie flame of a candle. VACCINATION. 145 " 2. In the second place, large enough to contain as much lymph as is sufTicient for one vaccination. " 3. In the third place, long enough to admit of both ends being sealed hermetically without subjecting the charge to the heat of the flame. " 4. And, in the fourth place, of such strength as not to break easily in the mere handling. " Thus the average length is from 2 j to 3 inches, the diameter ^L. of an inch, and the thickness of wall -^^q of an inch. "Havinsf thus described the instrument itself, I come now to the mode of using it. " The vesicles having been opened with a lancet in the usual way, the tube, held in a position more or less inclined to the horizontal, is charged b}' applying one end of it (the straight end, if they be not both straight) to the exuding lymph, which enters immediatel}' by the force of capillary attraction. Allow as much to enter as will occupy from about one-seventh to one-half the length of the tube, accord- ing as its capacity is greater or less. As a general rule each tube should not be charged with more than will suffice for one vaccination. •" It is now to be sealed in one or other of the following ways : '' Either, first, make the lymph gravitate towards the mid- dle by holding the tube vertically and giving it a few slight shocks by striking the wrist on the arm or table ; then seal the end bj^ which the lymph entered by applying it to the surface of the flame of a candle, or an}- similar flame. It melts over and is sealed immediateh^ " Proceed with the other end in the same way, but first plunge it suddenly — say half an inch — into the flame, and as quickly withdraw it till it touches the surface, and hold it there till it, too, melts over. It is necessary to plunge it first into the flame, for this reascm, that if it be once ajDplied to the external surfacerof the flame it melts OA^er, no doubt, 146 VACCINATION. and is sealed ; but before j'ou have time to complete the process, and while the glass is still soft, the contained air expands with the heat, and forms a minute bulb, which either gives way on the instant, rendering it necessary for you to break off the end and commence anew, or, what is still worse, remains entire for the time, only to break after- wards, in consequence of its extreme tenuity of wall, by the lightest touch Mr. Ceely has suggested, that while this precaution is necessarj'^ for the reason stated, it serves also to exi^el a portion of air, and so leaves less air to be sealed up along with the fluid l^^mph. "Or else, secondly, the charge having entered, hold the tube with the finger and thumb, covering the inner extrem- ity of the column of lymph and protecting it from the heat, and draw nearly the whole of the empty portion through the flame, so as to rarefy the contained air, and, in with- drawing it, seal the further extremity. The column now passes quickly along toward the middle of the tube as the contained air cools, and you complete the process by seal- ing, lastly, the orifice by which it entered. "This latter method answers especially well when the tube is below the average size, or has the form in which the opening is so minute that it seals over in the merest frac- tion of a second. " It should be observed, that in no case is a tube to be laid down until the lymph has been made to pass towards the middle of it, for the fluid concretes quickly about the orifice, and 3'ou cannot afterwards detach it without diffi- culty; but if it be at once made to pass away from the orifice by holding the tube verticall}^, you may lay the charge down, and take half a dozen or more in the same way before seal- ing them ; only if you delay the sealing process too long, more than five or ten minutes, perhaps (a delaj^ which need never happen), the lymph within the tube is apt from evapo- ration to become adherent, especially if it be more than VACCINATION. 147 ordinarily viscid, and it cannot afterwards be blown out when you come to use it. "If tlie lymph do not exude freely, the tube may require to be drawn several times more or less obliquely across the surface of the vesicle, or cluster of vesicles, until a sufficient charge has entered ; but generally, if the exudation be copious, and a drop of some size has formed before you begin to take your supply, the orifice of the tube need not — indeed ought not — to touch the surface, but is merely to be dipped into the clear fluid; and one may commonly, in this manner, from one infant's arm, charge five or six tubes in almost as many seconds with perfectly pure and limpid lymph, which shall contain neither epithelial scales nor pus- globules nor blood-disks, and therefore be, so far, in the best possible condition for preservation." 148 THE OPERATING-THEATRE. CHAPTER yi. OPERATING-THEATRE — TREATMENT AFTER OPERATIONS ANTISEPTIC SYSTEM — ANESTHETICS. Operating-theatre. — The position which the house-sur- geon occupies in the operating-theatre varies very consider- ably in different hospitals. In some the colleagues of the operating surgeon alone assist, and the house-surgeon's dut3Ms confined to handing instruments and sponges; in others, the house-surgeon administers chloroform ; while in a comparatively^ small number, the operating surgeon de- pends upon his house-surgeon and dressers for all ordinary assistance, and only asks the aid of one of his colleagues in cases of difficulty. Believing the latter practice to be the best for all parties, including the patient, the author will confine these remarks to that arrangement. The house-surgeon should take care that the patient who is to be operated upon under anaesthetics does not take any solid food for at least four hours before the hour of opera- tion, although in the case of feeble patients the administra- tion of stimulants ma}' be advisable within a much shorter time. The theatre and passages should be thoroughly warmed, and the patient carefully wrapped up while being conveyed to the theatre, lest cold should be taken at this critical moment. All the instruments which can by possibilit}'' be required in the operation should be laid out on a suitable table or tray, and be covered with a cloth ; needles, ready threaded, should be stuck into some convenient cushion, so that they may not get entangled ; and strips of piaster, lint, and band- THE OPERATING-THEATRE. 149 ages should be prepared, suitable for the expected opera- tion. Hot and cold waters are matters of course in an operatino^-theatre, but the house-surgeon should take care to have the means for heating a cautery at hand whenever that instrument may possibly be required. It is well, also, to have a little wine or brandy and some smelling-salts within reach, in case of sudden emergency, as well as an electro-magnetic maciiine, which takes up ver}" little room. The operating-table should have a folded blanket upon it, and a pillow or two. A piece of Mackintosh cloth should be placed over the part of the table at which the ha3mor- rhage will occur, and in addition a piece of " red cloth " over the Mackintosh will be useful in soaking up the blood, while a tray of sawdust should be placed below to prevent drippings upon the floor. Everything should be perfectly- ready before the patient is brought in, so that the inhala- tion of the anaesthetic may be begun at once, if it has not already been administered in an adjoining room. A dresser should stand on each side of the patient while the anaesthetic is administered, to restrain his sometimes violent contor- tions. The best position for the house-surgeon is, as a rule, opposite the operating surgeon, and he should have loosely noosed in bis button-hole a sufficient number of ligatures, not less than sixteen inches in length. One dresser should take charge of the instruments, and should be instructed as to the order in which the}' will l)e wanted ; and others will be required to hold the patient, to sponge^ etc. The sponges should be fine and soft, and scrupulousl}' clean, being soaked in carbolic lotion for some hours before being employed. They must never be used for an}^ other purpose than that they are intended for, and particularly should not be employed to wipe up blood from the floor of the operating-theatre. The sponges should be kept moist, but thoroughly squeezed out, so that they may lie read}^ to absorb the blood directly- the}^ are placed upon a wound. 150 esmarch's bloodless method. Nothing can be more anno3ang to the operator than to have the wound filled with water by a careless assistant. EsmarcWs method of obviating haemorrhage has of late come into general use, and may be advantageously employed in most operations on the limbs. It consists in blanching the limb to be operated on by carefully bandaging it from below upwards with a strong elastic webbing. This should be carried up from the toes or fingers without any " turns," and should be made to cover the limb completely for some distance above the seat of operation. The elastic cord is next made to encircle the limb two or three times close above the bandage, which is then unwound, leaving the sur- face of the limb pale and the bloodvessels empty. It is unnecessary to pull the encircling cord very tight, and there is a danger of damaging the large nerves of the arm if this is done. In the case of collections of pus in a limb or joint it will be unadvisable to apply the elastic bandage very firmly, for fear of bursting the wall of the ab- scess and forcing the matter among the tissues, and the same caution applies to cases of morbid growths of various kinds. Esmarch's bloodless method dispenses with the necessity for an ordinary tourniquet in cases of amputation, but one should alwa3's be at hand for fear of any accidental failure of the elastic cord. The patient being under the influence of ether or chloro- form, the part to be operated on is to be exposed, while the rest of the body and the clothes of the patient should be carefully protected with red cloths. The house surgeon will be ready to sponge, hold back flaps, etc., as directed, and finall}^, if required, to tie the ligatures upon the vessels as the surgeon takes them up. (See p. 53.) It is well worth the house-surgeon's while to practice tjdng ligatures privately, that he ma}' com.mit no blunder in public. Since every drop of blood is of importance, the house-sur- THE OPERATING-THEATRE. 151 eeon and other assistants should be on the alert to arrest at once the stream of blood from a divided vessel b}' placing a finger or sponge upon it, care being of course taken not to obstruct the progress of the operation by such measures. In the case of operations for hare-lip, cancer of the lower lip, etc., the haemorrhage will be more readily controlled by compressing the whole thickness of the lip between the finger and thumb than by any other method. It is always to be borne in mind that the convenience of the students and others in the theatre should be consulted as far as possible, and the assistants should therefore be careful not to stand in the way, and to obscure the view as little as possible with their hands and sponges. The assistant to whom the oflQce of holding a limb about to be removed b}'' amputation is delegated, must be espe- cially careful to have a firm grasp of it by means of a towel or bandage wrapped around the part; and should then draw the limb horizontally away from the body, and never either up or down, while the saw is being applied, since, if he neg- lect this rule, either the saw will become locked or the bone will be splintered. The operation being concluded, the house-surgeon should carefully sponge away all traces of blood, etc., from the pa- tient's body, and as far as possible from the clothes if they are besmeared, and should then see that the patient is care- fully removed to bed. The readiest way to remove a patient is to place on the table beneath him a canvas stretcher, into the sides of which poles can be slipped, with iron cross-bars to keep them apart. The bearers should not keep step in carrying a pa- tient, for if they do he will be swung to and fro at each step. This rule applies also to the conveyance of w^ounded or in- jured persons to an hospital or on the field of battle, when, if there are four bearers, the front and rear men of opposite. sides only should keep step. A stretcher should never be raised to the shoulders of the bearers, unless the patient is 152 patient's bed. effectually secured b}'' straps and the bearers are all of one lieight. Da3dight is of course best for ever^^ operation, but for night-work every operating-theatre should be fitted with gas-lamps having good reflectors. Even with these a bull's- e3'e lantern or candles with reflectors are ex- tremely useful for delicate operations; and fail- ing them recourse may be had to Esmarch's ingenious contrivance of a spoon attached to a candle by means of a bandage, as shown in Fig-, 33. Fig. 33. Patienfs Bed. — While the patient is in the operating-theatre, his bed should be prepared for his reception according to the nature of the case. In any case of severe operation, when the patient will be confined to his bed for some time, a " draw-sheet," i. e., a sheet folded so as to be about a yard wide, should be laid over the ordinary sheet, and across the bed where the pelvis will lie; one end of this being tucked in and the other rolled up on the opposite side of the bed, a fresh portion of it can be drawn underneath the patient when required, with very little trouble. When the operation in- volves the urinar}^ organs, etc., it is well to place a Mackin- tosh cloth beneath the draw-sheet ; and a large sponge should be placed to soak up the urine in cases of lithotomy, etc. In all affections of the genital and urinary organs, undue exposure of the patient's body to cold should be guarded against, lest the tendency to rigors should be ag- gravated by draught. This is easily arranged by folding two blankets and placing them across the trunk and thighs of the patient respective!}', the genitals being left exposed so soon as the sheet and coverlet are withdrawn. A draw- sheet, and in some cases a Mackintosh cloth, should be TREATMENT AFTER OPERATIONS. 153 placed under the part in which the operation has been per- formed, and care should be taken to support stumps with suitable pillows, which should be covered with some water- proof material. The weight of the bedclothes should be kept off the wounded part by a suitable "cradle," a very good substitute for which can on an emergency be impro- vised out of an old hat-box split open and stretched over a patient. Care must be taken, however, that the rest of the patient's body is not chilled b}^ the action of the cradle, which can be obviated by the use of flannel or a hot bottle. Treatment After Operations. — Although the operating surgeon may give some general directions with regard to the after-treatment of operation cases, the supervision of them will fall principally upon the house-surgeon. The pa- tient, particularly if not quite recovered from the effects of the ansesttietic, should not be raised too much into asittinof posture when placed in bed, and this rule must be observed for many hours in cases where much blood has been lost. Sickness is unfortunately a verj^ common sequela of chloro- form, and may produce alarming exhaustion if not checked at an earl}- date. Ice, brandy, and soda water, and small doses of effervescing medicine, are the best remedies ; but if these do not succeed, five minims of dilute hydrocj^anic acid in effervescence, or a drop of creasote in a pill, will often do good, together with counter-irritation to the region of the stomach. In obstinate vomiting, drop doses of ipe- cacuanha wine repeated everj^ half hour will often prove satisfactory when other remedies liave failed. Stimulants may be needed from the first in very bad cases, but it is a great mistake to worr}- the stomach unneces- sarilj^ with them, and so perhaps induce sickness. They should be given in small doses frequently, rather than in larger quantities at longer intervals — thus one or two drachms of brandy every hour give better results than half an ounce every two hours. The pulse will be the great 13 154 DELIRIUM TREMENS. guide in the treatment, and should that begin to lose power, stimulants must be had recourse to without delay, and at the same time care should be taken that the proper heat of the body is maintained. Opium in some form will probably be required after an operation ; and here again better results will be obtained, especially with children, by giving one or more drops of laudanum every ten minutes until the pain is lulled than by one large dose which may induce vomiting. The subcuta- neous method of administering morphia is an extremely convenient mode of giving relief, but the patient must not be allowed to get into the habit of taking that drug unless the peculiar nature of the case requires its administration. Night draughts, to be of service, should be administered not later than 8 p.m., but their general use should be dis- countenanced. A patient who has already taken opium, but cannot get to rest from the pain of an operation, etc., may sometimes be lulled at once by a few whiffs of chloro- form, and may sleep for hours; but the administration of this drug must never be intrusted to a nurse. The chloral hydrate may be advantageousl}^ substituted for opium and its preparations in many cases of simple sleeplessness. The amount of appetite after severe operations varies very considerably with different patients, some being able to resume their ordinary diet with relish on the day after operation, while others require milk diet, beef tea, etc., for da^'S together. It is, of course, impossible to coerce the appetite of a delicate patient, but the sooner he can be in- duced to resume meat and other nourishing food, and dis- pense with " slops," the better. Delirium Tremens. — A patient whose nervous system has been shaken by drink is apt to be sleepless and irri- table, and, after an accident or operation, may pass into the condition known as delirium tremens. Sleeplessness, with a tendency to see spectres about the bed, to pick the ANTISEPTIC SYSTEM. 155 bedclothes or throw them off, to pull off the bandages and splints, and to get out of bed, are the common symptoms, combined with a tremulousness of the hands, from which the disease gets its name. Care must be taken to restrain such a patient from doing himself injury by thoroughly fastening all bandages, and by securing him in bed with a sheet folded across him. An attendant sitting b}- the bed for a few hours will then be al)le to restrain him sufficiently; but in violent cases it may be necessary to secure the arms with a "strait-jacket." The obvious treatment is to induce sleep, and this can be done more safely with hj-drate of chloral than with opium. Twenty grains of chloral with twice the quantity of bromide of potassium should be given at once, and half the quantity may be repeated every four or six hours, until an effect is produced. Nourishment in a liquid form should be given frequentl}', but no stimulants should be given during the attack without the sanction of the surgeon. Antiseptic System. — Several attempts have of late years been made to modify the suppuration of wounds by the application of various chemical agents immediatelj' after an operation. The old-fashioned Friar's Balsam (Tinct. Ben- zoin! Co.) was one of the earliest used applications of the kind, and is, no doubt, of service in contused and lacerated wounds. In cases of compound fracture it may be poured into the wound, and soaked into a piece of lint will form a dry scab over it. A solution of chloride of zinc, from twenty to fort}^ grains to the ounce in strength, or the acidum sulphurosum (B. P.), either pure or diluted, is cer- tainly very Efficient, provided due exit for discharges or drainage be maintained. This necessity for the discharge of the serum which is poured out within a few hours of an operation, was much insisted upon by Professor Syme, and forms one of the most valuable parts of Professor Lister's antiseptic system, 156 ANTISEPTIC SYSTEM. since pent-up fluid is liable to rapid decomposition, and is apt not only to become purulent, but to be the cause of great constitutional disturbance to the patient. Drainage may be provided by leaving a dependent opening through which the ligatures may be drawn or, by the insertion of a drainage-tube or a slip of gutta-percha tissue; and the drainage should be into some absorbent and aseptic ma- terial, such as fine oakum, or jute impregnated with sali- cylic acid, as recommended by Professor Thiersch. Professor Lister, who is a strong upholder of the view that organisms floating in the air are the causes of suppu- FlG. 34. ration, has introduced a system of dressing wounds with carbolic acid, combined with drainage, which requires for its successful application the greatest attention to a number of minute details, and some experience in its employment. In order to render the atmosphere about a wound aseptic, a spray of carbolic acid (1 in 40} w^orked by hand may be employed ; but a more etficient plan is to employ a steam ANTISEPTIC SYSTEM. 157 spray-producer (Fig. 34), with a solution of 1 in 20, wliicli is reduced b}^ the high-pressure steam to half its strength. Tiie care of a steam spra_y-producer should be either undertaken by the house-surgeon himself, or intrusted to a careful dresser, and not to be left to a nurse or porter. If boiling water is put into the boiler (which should be emp- tied after each time of using), and the spirit-lamp is in good order, a steam-spray should be ready for use in ten minutes, during which time all other antiseptic arrangements neces- sary can be made. The "points" through which the steam and carbolic lotion escape should be examined dailj^, and cleaned b}^ unscrewing them and passing a fine wire from within. Picking the points with a pin is the best waj' to spoil them. The lamp should be filled up with spirit after each time of using, and should be kept capped and clean. Every lamp should be fitted with some contrivance for lowering, without extinguishing, the light. The pressure of steam ma}^ be conveniently gauged by opening the safety-valve (which must not be tampered with), and the efficient working of the spray may be appreciated both by the eye and the ear. If steam alone issues, the cloud is blue and transparent, but if the carbolic lotion is being drawn up properlj^, the steam will be white and opaque, and a distinct whistling sound will be produced. The antiseptic gauze which is to form the dressing must be kept in a covered box, lest it should absorb impurities, and is to be in eight la3'ers, and of a size large enough to go well beyond, or, in the case of a limb^ to fold round, the part to be operated on. Between the two outer layers of the dressing should be a piece of waterproof "■ hat-lining," with the waterproof side inwards. Bandages of the gauze should be employed, and be secured witli "safety-pins," and some loose gauze provided to fill up corners, which may be economically made out of unsoiled portions of bandages. A broad elastic webbing bandage maj' be advantageously' used, over all, in cases where the dressings are liable to 158 ANTISEPTIC >SYSTEM. disturbance from the patient's movements, e. g., in the net'k. Tile prepared oil-silk called "protective " is used, after being dipped in a carbolic solution, to protect the edges of a wound or the surface of an ulcer from the direct contact of the dressings. Ligatures of carbolized catgut are emplo^^ed to secure all bleeding vessels, and sutures of silk dipped in a mixture of melted beeswax with a tenth part of carbolic acid, unless metal ones are preferred, which should be dipped in carbolic lotion before use. Tlie skin in the neigh- borhood of a wound which is to be treated antiseptically must be carefully washed with carbolic lotion, 1 to 20, and, when the part has been exposed to unhealthy influences, it is well to wrap it up for some hours pi"ior to an operation in a towel dipped in the same lotion. The fingers — and in some cases the hands — of all assistants should be dipped in this solution before the operation is commenced, and all instruments should be placed in a shallow tray of the same lotion. It is convenient to have two or three pieces of linen well soaked in the lotion at hand as " guards," to be ap- plied during any pause in the operation, or while some alteration in the position of the patient is being made. Drainage-tubes of perforated india-rubber, of various calibres, should be thoroughlj^ soaked in carbolic lotion for at least forty-eight hours before being used, and should have a thread attached to one end to prevent disappearance within the edges of a wound. For the purpose of intro- ducing a drainage-tube into a sinus, a slender pair of dressing-forceps may be conveniently emplo3'ed. In the case of compound fractures, a strong watery solu- tion of carbolic acid (one part of the crystals to twenty of water), or, in the case of recent injuries, a solution of half that strength, is to be injected into the w^ound, and thor- oughly squeezed into its recesses. This may be repeated more than once in the case of complicated wounds (e. g.^ fractures into jaints). All haemorrhage having ceased, the edges of a wound are ANTISEPTIC SYSTEM. 159 to be brought together with sutures, deep wire ones being emplo3'ed to take off tension, if necessary. A suflicieut number of drainage-tubes being then inserted, the projet-t- ing portions are cut off level with the surface, and a layer of " protective " applied, with holes cut to fit over tlie tubes. Over this are to be placed several layers of the gauze, wrung as dry as possible out of 1 in 20 carbolic solution, and fastened on with a gauze bandage. The gauze dressing of eight layers is then to be wrapped round the limb, and to extend to six inches both above and below the wound, and, being folded carefully round, is to be thoroughly bandaged. The antiseptic dressings are to be changed on the next day with the following precautions: A stream of waterj' solution of carbolic acid (I to 40; is thrown beneath the gauze while it is being removed, and is then made to play upon the wound till a piece of calico, soaked with the same lotion, has been placed upon it by an assistant, as a tempo- rary security until the dressing is reapplied. Any exam- ination of the wound that may be desired can be made while the solution is being played over it. The drainage- tube can be removed, cleansed, and shortened, or may be washed out in situ with a syringe. Fresh " protective " and a new gauze dressing should be applied with all the pre- cautions taken before. The intervals between the dressings should be regulated by the amount of the dis^charge, for the more copious it is, the sooner does it exhaust tlie carbolic acid in the gauze. The resin will retain enough carbolic acid for twenty-four hours, however free the discharge may be ; and if the stain on the cloths is slight, the gauze may be safely left for two days, and if there be hardly any, the dressings need not be changed for a week. The following is given by Mr. Lister as an example of a compound dressing, viz., that used after removing tlie mamma: It consists of two pieces of folded gauze and 160 ANTISEPTIC SYSTEM. Mackintosh, — a posterior and an anterior one. Tiie pos- terior portion is about half a yard square, and reaches vertically from above the acromion to a little below the elbow, and transversely from the spine to the arm, which it envelops as it lies beside the chest, thus forming a com- 'plete antiseptic basis for the region of the shoulder, and effectually guarding against what would otherwise be most difficult to avoid, the extension of putrefaction from the bed- ding through the axilla into the outer angle of the wound. The anterior dressing, though not so broad as the posterior one, is of about equal length, so that when applied to the chest it may reach from some inches be3'ond the anterior angle of the wound to the posterior dressing, which it joins below the back of the axilla ; and here it is that it is need- ful to have the Mackintosh well covered in among the folds of the gauze. The infra-axillary region being the part where the chief discharge occurs, it is of the utmost impor- tance that the outer part of the anterior dressing be main- tained well in apposition with the skin ; and this is insured by stuffing a substantial mass of gauze irregularly packed together between the patient's side covered by the dressing and the lower part of the arm. This additional mass of gauze has the further advantages that it serves as a supple- mentar}^ antiseptic material to absorb the discharge, and that it prevents the arm from being closely pressed to the side — a position which, besides being irksome to the patient, would entail the serious evil of interference with free drain- age from the outer angle of the wound. In order to prevent the occurrence of a bedsore over the internal condyle, a wisp of gauze, twisted and rolled together in the form of a ring, is placed beneath the elbow so as to receive the bony prominence in its hollow. The whole dressing is secured in position b}'' suitable turns of a gauze bandage, which is extremely convenient on account of its lightness, and also from the circumstance that the slight adhesiveness of the material with which it is charged checks the tendency of FIRST DRESSING AFTER OPERATION. 161 one turn to slip upon another, so that it is more secure than a common cotton roller, besides the advantage that it in- creases tl>e antiseptic efficacy of the dressing. But, on account of its loose texture, it cannot be properly fixed by ordinary pins, which would be liable to shift their position in it. Those called safety-pins, made on the principle of a brooch, should therefore always be employed ; for there are cases in which the slipping of a single pin might, by allow- ing the dressing to shift its place, endanger the life of a patient. With all imaginable care, antiseptic dressings occasion- ally "break down," and tiiis may be diagnosed by a marked rise in the patient's temperature, and by an offensive odor in the dressings. It is hopeless to attempt to restore a perfectly aseptic condition under these circumstances, but recourse may be had with advantage to oakum, boracic ointment, or boracic lint. Even with a perfectly aseptic condition of wound, a patient's temperature may run up to 103° from absorption of carbolic acid, to which some systems appear specially liable. Evidence of this carbolic acid poisoning is to be looked for in the urine, which will be found to be dark- colored, or even of a greenish-black tint. Under these cir- cumstances tlie carbolic dressings must either be given up, or changed as seldom and as rapidly as possible, in order to avoid the contact of much of the spray- First Dressing after Operaf/o^,— Cases treated on Lister's system require dressing on the next day, or sometimes on the same day, if the dressing becomes soaked through with the serum which is poured out in large quantity under the irritant carbolic acid. Cases treated with chloride of zinc (gr. 20 ad f^j) and a drainage-tube discharging into oakum may very well be left for two days, and if dry dressings are employed, or the surfaces of the wound are allowed to glaze before being brought together, the dressings should not be 14 162 FIEST DRESSING AFTER OPERATION. disturbed till much later, jDrovided there is no great rise of temperature. The practice with regard to first dressings varies in dif- ferent hospitals, some surgeons preferring to superintend the operation themselves, while others are content to inspect the wound after it has been prepared by the house-surgeon. In either case, everything that can be wanted should be at hand, so that the wound ma}^ not be uncovered longer than is absolutel}'' necessary. Then, the patient lying in a com- fortable attitude, and supposing the case to be one of am- putation, the dresser should gently slip his fingers beneath the limb, and raise the stump from the pillow on which it is placed. This is often the most painful moment for the pa- tient, and great gentleness must be practiced, and care taken to avoid shaking tlie stump, which must, however, be grasped tolerably firmly to prevent its being "jerked" by the in- voluntary spasm of tlie muscles. As soon as the stump is raised, the pillow and draw-sheet should be removed in order tliat the^^ may be cleansed or renewed, and the house-sur- geon is then carefull}^ to remove the dressings. If a band- age has been applied, it must be cut with the scissors, and removed in pieces ; and the dressings beneath, which, if originally w^et, will have probably become dry and hard with clotted blood, must then be soaked with warm water, wliich should be allowed to trickle over them from a sponge into a basin beneath. With a pair of forceps the dressings are next to be withdrawn strip by strip, and while removing those in immediate contact with the edoes of the wound care must be taken not to drag it open, which accident is best avoided by lifting the two extremities of the strip of lint at the same time, and so making traction towards, in- stead of awaj'" from, the margins of the incisions. An}^ strips of plaster or sutures whicli may have been ap- plied to the wound are best left untouched at the first dress- ing, and all that need be done is to cleanse the edges of any discharge which ma}^ have accumulated upon them, and to FIRST DRESSIXG AFTER OPERATION. 163 apply fresh clean dressings. These will be water-dressing, or ointment, according to the fanc}' of the surgeon, tiie former being the cleanei- and pleasanter, and the latter hav- ing a lesser tendency to adhere to the edges of the wound. Some surgeons content themselves witii laying a large piece of wet lint over the stump, which can be covered with a piece Fig. 35. of oil-silk and be wetted occasionally by the nurse ; others prefer to apply the dressing in strips, so as to support the stump, and then to put oil-silk and a bandage over it. In order to accomplish this, the strips of wet lint should be tw^o inches wide, and long enough to reach six inches up on both aspects of the limb. With one hand the house-surgeon places a strip beneath the limb and holds it there, while with the other the end is brought up over the face of the stump and is laid upon the front of the limb. The moisture will give the lint sufficient hold to keep its place while an- other strip is applied in the same manner to one side of it, but slightly overlapping, and the third upon the other side 164 SLINGING STUMPS. in the same way. When the stump is sufficiently covered, a long strip of lint carried circularly over the ends of the other piece will keep them in position, as shown in Fig. 35. Great care must be taken not to disturb the ligatures, and particularly the one on the main vessel, which should have been distinguished b}' a knot tied in it. These should be carefully separated from the dressings if they should hap- pen to adhere to them, and may be conveniently wrapped in a piece of lint spread with cerate, which will prevent their again becoming fixed to the surrounding parts. In subsequent dressings the proceedings may be a little varied ; thus, the strips of adhesive plaster will require re- newing, and the same precautions must be taken in remov- ing them as in the case of the strips of lint. Gentle pressure will probably be required to prevent matter from '* pocket- ing" in the flaps, and the sutures ma}'^ be removed as soon as they cease to be required to hold the edges together, or earlier if they begin to ulcerate through the skin, their place being supplied by straps of plaster and judicious bandaging. The ligatures should never be pulled upon unless it is evi- dent, from the lapse of time, that they must have become detached from the vessel and are simpl^^ h^^^g in the wound, and even then great care must be taken of the ligatures upon the main vessel. Slinging Stumps. — The method of slinging so useful in the treatment of fractures, has been adopted with very good effect in St. Bartholomew's Hospital in the case of stumps after amiputation. The plan is shown in Fig. 36, and con- sists in supporting the stump in a small linen hammock, slung from a cradle with india-rubber cord or tubing. The linen has a broad hem at each border, in which is placed a strip of wood, perforated with a hole near each end, and the india-rubber cord is passed from one hole to the other, across the top of the cradle, and through the holes on the opposite side ; and lastlj^, is brought over the cradle to the BED-SORES. 165 starting-point, where it is firmly tied. Or two separate pieces of india-rubber cord may be used, as in the illus- tration (from a sketch by Mr. Eck). The advantages claimed for this proceeding are, that it entirely ol)viates the distressing startings to which stumps are liable, and Fig. 36. that it allows the patient to move more freely than if the stump is laid on a pillow. Another method of suspending a limb is shown in Fig. 37, being that adopted by Esmarch Fig. 37. for the treatment of excision of the wrist, which is, how- ever, applicable to any disease or injury of the upper limb, provided it is firmly attached to a splint. Bed-Sores. — Of all the annoying complications of surgical cases, bed-sores are the worst. The greatest care must be taken to prevent their formation, since, if the skin is once broken, it is a matter of the greatest diflSculty to induce it 166 BED-SOEES. to Ileal again so long as the patient occupies the recumbent position. The slightest tenderness over the sacrum or hips should receive, therefore, immediate attention, and various appli- cations have been suggested for the relief of the complaint. Equal parts of olive oil and brand}', gentl}^ rubbed with the palm of the hand over the tender spot for five minutes twice a da3% will be found efficacious in rendering the skin tough and less sensitive to pressure. Collodion painted over the part is a useful application, and some surgeons prefer to cover the tender spot with amadou-plaster, so as to form a cushion over it. A water-pillow under the pelvis of the patient forms a most valuable addition to either of the above modes of treatment ; and an old or emaciated patient, whom it will be necessary to keep in the recumbent po- sition for any length of time, should be furnished with a water-pillow from the first, so that all risks ma}' be avoided. When the skin has unfortunately given way, the best application will be found to be a linseed-meal poultice, spread to the thickness of at least an inch, so that it may form a sort of cushion as well as a moist application. Mr. Hilton speaks highly also of the application of oiled lint covered with cotton- wool. As soon as the sloughs have come away, stimulating dressings, t^. _g., the Ung. resinde^ may be applied under the poultice, which should be left for the sake of its soilness and w-armth ; and when a healthy granulating surface has been produced, which will seldom be the case until the patient's health is so far amended that he is able to sit up, the lotio rubra, or some other similar stimulant, will be the best treatment. Paralytic cases require not merely a water-pillow, but a water-bed, since they are liable to bed-sores on all parts of the body ; and even with this and all other applications it is impossible in all cases to prevent sores forming. In filling an hidia-rubber water mattress some care is required, or it may be seriously damaged. It should never ADMINISTRATION OF ANiESTIIETICS. 1G7 be lifted when full of water, but, being placed empty on the bedstead, warm water is to be poured in from cans until the mattress is about half full, when some air is to be blown in, so as nearly to fill it. A blanket and sheet being tlien placed on the mattress, the patient's body will be found to float comfortably upon the bed, whereas if filled too full, the patient does not float, or, if insufficiently filled, his weight displaces the water, and he comes in contact with the bedstead. The Administration of AnsesfheticH.—^'mQe the house- surgeon will frequently have to administer anaesthetics, or at least be responsible for their administration by others, it will be well to mention a few points of importance in con- nection with the subject. In the first place, as to the class of patients to whom ether or chloroform should be administered. There seems to be every reason for believing, with the late Dr. Snow, that if a patient be in a state to undergo an operation at all, there need be no bar to the administration of an anaes- thetic on the score of diseased heart, etc., although where that condition is known to exist it will be a reason for the selection of ether in preference to chloroform. Whenever possible, care should be taken that the patient does not eat solid food for four hours prior to the operation, since the neglect of this precaution may entail more serious results than the troublesome vomiting ami nausea, there being good ^rounds for believing that, in the presence of a distended stomach, the heart is more liable to paralysis. At the same time it is a great mistake for a patient to become exhausted from want of food before an operation ; and this is too often the case in hospitals, where the breakfast hour is seven or eight, and the operation may not be performed till two or three o'clock. It is a good practice to give a patient a cnp of beef tea three hours before chloroform is administered. 168 ADMINISTRATION OF ANESTHETICS. and this tends to decrease the liability to sickness, as well as the great danger of fainting. Mr. Clover believes that the presence of alcohol in the stomach, when the breathing has been arrested by chloro- form, adds more to the danger of making the coma per- sistent than it takes from the danger of the heart failing; and he urges that in all cases where stimulants are given before anaesthetics, time should be allowed for their being entirely absorbed from the stomach. Although chloroform ma}^ be satisfactorily administered on a handkerchief, there can be no question that an inhaler renders the operation less dangerous, particularly in the hands of those not much accustomed to the use of the anaesthetic. Dr. Snow's inhaler, and Weiss's or Dr. Sansom's modifi- cation of it, are the best forms for ordinar3' use ; their supe- riority consisting in the fact that they provide, however imperfectly, for a uniform strength of chloroform vapor during^ the progress of an operation, and render it ex- tremely difficult to administer a vapor so highly charged as to endanger the patient's life, by inducing paralysis of the heart. It is needless to describe minutely these instru- ments, the principle of which can be seen at a glance, and may be briefly stated to consist of an arrangement for the maintenance of a tolerably fixed temperature round the blotting-paper from which the chloroform is evaporating, so that the inspired air contains almost always the same amount, or at all events never more than a certain per- centage, of chloroform vapor. The only practical cautions that need be given as to the use of either of these inhalers are, that the administrator should ascertain before using them that all the valves "are clean and dry, and that the bibulous paper in the interior is arranged so as not to pre- vent the free passage of atmospheric air through the instru- ment; also that the water in the external chamber is not hotter than 60° Fahr. The quantity of chloroform which ADMINISTRATION OF CHLOROFORM. 169 should be put into either of these instruments at starting is the same, viz., two drachms ; and the valve should be ar- ranged so that the patient may breathe only a very diluted vapor at the commencement, since the full strength of pure chloroform at first is apt to terrify the patient, as well as to endanger his life. The administrator should allow the patient to breathe this very diluted vapor for a minute, or until all agitation has subsided, and should then gradually close the valve, so that at length the full strength of the chloroform may be inspired. This little manoeuvre occupies about two minutes more, and about a minute's further inspiration of the undiluted chloroform will almost always produce a degree of anaesthesia sufficient for the surgeon's purpose. The whole inhalation, then, should occupy about four minutes, and it is foolish to attempt to induce anaesthesia with greater rapidit}^ The apparatus contrived by Mr. Clover would appear to fulfil perfectly the requirements pointed out by Dr. Snow as essential to absolute safety in the administration of chloro- form, viz., the production of an atmosphere of a constant strength, and never exceeding 4 to 5 per cent, of chloro- form. From a bellows capable of containing 1000 cubic inches, atmospheric air is driven in measured quantities through a vessel supplied with 30 to 35 minims of chloro- form, and surrounded by hot water, into a large bag, where the mixture of chloroform and air is stored up for use. As the quantity of atmospheric air is known, and as the whole of the chloroform is taken up in vapor by the atmospheric air, the mixture in the balloon must be of uniform strength. The balloon is detached from the bellows when filled, and can be connected with a mouthpiece fitted with valves, and resembling that of Snow's inhaler, an ingenious two-way stopcock, contrived by Mr. Clover, effectually preventing any waste of the vapor when not in use. This has been in 170 ADMINISTRATION OF ANESTHETICS. use in many hospitals for some yesirs with the most satis- factory results. The first symptoms produced in all patients are those of confusion of the intellect and thickness of speech. Next the muscular system becomes affected, and it may either be- come slowly and quietly paralyzed, or there may be an in- troductory stage of violent and spasmodic contraction of the voluntary muscles before they become palsied. The final condition is one of complete unconsciousness and mus- cular flaccidit}^, with calm and equable respirations (which become stertorous if the chloroform is pushed), and a com- plete abolition of the sensibility of the surface, which may be convenientl}^ ascertained b}^ touching the conjunctiva without producing an}- closure of the lids. Certain practical differences between different patients are to be noticed, the most important of them being the dis- tinction between those who do, and those who do not, pass through a stage of strong muscular excitement or convul- sions. Setting aside all voluntary struggling from fright, etc., in the cases where there is violent striigi^ling of an in- voluntary kind after consciousness is lost, the right course is to push the chloroform very decidedl}', by closing tlie valve so as to allow the patient to breathe the whole strength of the vapor. Inexperienced bystanders are apt to be ter- rified by the appearance which a patient presents wiien struggling violently, with the features swollen and the eyes suffused, and to fancy that his safety demands an intermis- sion of the inhalation. This congestion, however, is caused entirely b}^ the spasm of various muscles and by the spas- modic catching of the breath, and the right course is to con- tinue the administration until this spasm ceases, which it will soon do, and the patient's countenance will then at once become calm and of a natural color. Care should be taken that the chloroform vapor is not increased during the strug- gling, and if the pulse should become imperceptible, the chloroform must be removed. We can often, however, feel ADMINISTRATION OF CHLOROFORM. 171 the pulse of the temporal arteiy, whilst that of the radial cannot be felt. At all times whilst giving chloroform it is necessary to keep a constant watch upon the pulse, which furnishes one very useful indication of the extent to which the chloroform has taken effect. Hysterical patients, and persons who have been accus- tomed to hard drinking or to a great deal of muscular exer- cise, seem to require more chloroform than others to produce the full anaesthetic effect; otherwise, the action of the drug is very constant, the same dose producing the same amount of insensibility in the majority of persons. The extent to which the inhalation ought to be pushed is materially affected by the character of the surgical operation in hand. There are many operations which do not require absolute quietude on the patient's part, and which do not involve paits of exquisite sensibility, and in these cases it is not desirable to push the inhalation to the point of ex- treme muscular relaxation and well-developed stertorous breathing, but only so far as to abolish sensibility. But in cases where the operation necessitates perfect stillness, and also where the sensibility of the parts involved is high, as, for instance, in operations about the anus and genitals, it is generally necessary to produce complete flaccidity of the muscles and stertorous breathing, and to maintain this con- dition during the greater part, if not the whole, of the oper- ation. From time to time the administrator should test by in- halation the amount of chloroform in the instrument, and replenish it, a drachm at a time, as often as may be neces- sary. With regard to the dangers of chloroform, the most alarm- ing symptoms are those which indicate failure of the heart's action, such as fluttering or intermission of the pulse, or sudden blanching of the face. Since the administrator siiould keep a finger on the pulse, any failure in the heart's action will be immediately recognized, and inhalation should 172 ADMINISTRATION OF ANESTHETICS. be at once suspended until it has recovered itself. So long as the breathing is tranquil and even, but not too slow, the noisj respirations of some patients need excite no alarm, any more than an occasional catching of the breath. It is often found that if the cliin is raised as far as possible from the sternum, the sounds of obstruction cease, and this should always be tried before catching hold of the tongue with ar- tery forceps. It is only when difficulties of respiration are combined with pallor of the face, or a failing pulse, that they become really alarming, and the breathing will then be noticed to take place in gasps. In all cases of apprehended danger the inhalation should be at once suspended, and unless the pulse and breathing recover themselves immediately, artificial respiration should be had recourse to without a moment's delay. There ap- pears to be a disposition in many of these cases for the tongue to drop or be drawn back so as to obstruct the orifice of the larynx ; it should therefore be firmly grasped with the fingers or forceps, and drawn out of the mouth, so that there may be free access of air to the lungs. A current of fresh air should be freel3^ admitted by throw- ing open the windows, and by not allowing bystanders to crowd round the patient, and cold water may be dashed over the chest as an auxiliary measure, to assist in pro- ducing a forcible inspiration. Galvanism may be tried, pro- vided it does not interfere with the artificial respiration, and a batter}^ affording an interrupted current should be employed, of which "Stohrer's" is the best and simplest. The conductor connected with the positive pole, and covered with sponge, should be moistened with salt water and pressed firmly upon the margin of the sterno-mastoid muscle (which should be relaxed) close above the sternum and over the phrenic nerve, where it crosses the scalenus. The other conductor, also moistened, is then placed over the lower part of the sternum, when contraction of the diapliragm should be produced. As soon as this takes place, the upper NITROUS OXIDE GAS. 173 conductor slionld be raised to allow the diaphragm to relax, and in a few seconds reapplied, to renew the contraction, thus imitating natural respiration. Nitrous Oxide Gas. — The use of this ansestlietic has lately been revived after being superseded for five-and-twenty years by ether and chloroform. It is to be obtained in the com- pressed form in iron bottles, from which it is drawn into an india-rubber bag for inspiration ; and it is manufactured b}' many dental practitioners for their own use, and retained in a gas-holder, from which the patient inhales direct. For portability the iron bottles have necessarily the advantage, but one of Clover's bags filled with the gas from the gas- holder is almost equally convenient. The hissing noise of the gas escaping from the bottle may be prevented by a rarefier made for the purpose. The nitrous oxide gas answers admirably for short pain- ful operations, such as the extraction of teeth, evulsion of a toe-nail, etc. ; but in prolonged operations, or when muscu- lar relaxation is required, as in dislocations, chloroform is preferable. In order to produce the full anaesthetic effect without excitement, it is essential that the gas should be pure and given without the admixture of any atmospheric air, and with this object a mask should be used, lined with a water-pad, and fitting thoroughly over both nose and mouth. The gas should not be turned on until every prep- aration is made, and in the case of tooth-drawing the mouth should be gagged with an ebonite gag to which a string is attached. The time of administration averages one minute, and evidence of the full effect of the gas is shown by the blue color of the lips and by the breathing becoming ster- torous. The anaesthesia will last for about another minute, after which, if the operation is prolonged, the administra- tion must be renewed. So far as is at present known, nitrous oxide gas may be safely administered to patients of all ages ; and though it 174 ADMINISTRATION OF ETHER. would be advisable to avoid its use in cases of obstrutrtive cardiac disease, there can be no question that persons with fatty heart, etc., have frequently taken it with impunity. Ether^ the original anaesthetic, has of late been re- introduced into surgical practice in preference to chloro- form, on account of its being safer than the latter, since it does not tend to paralyze the heart's action. It is also less depressing in its effect, and less liable to induce sickness than chloroform, and hence may be advantageousl}^ em- ployed after severe accidents, when the S3"stera has received a considerable shock. Ether may be administered Yui\\ an inhaler, or simply on a napkin folded into a cone, and cov- ered with oil-silk to prevent evaporation. It is apt to cause irritation and cough when first inlialed, and hence it is con- venient to lull the sensibility of the patient at first by either chloroform or nitrous oxide gas before having recourse to the ether. Ether vapor is ver^^ heavy, and therefore the napkin holding it should be held above the nose and mouth, and so arranged that a considerable proportion of the expired air is breathed again. The inhalers of Dr. Morgan, of Dublin, and the smaller ones of Ormsby and Clover, oblige the patient to continue breathino; into an india-rubber bat? until the anaesthesia is produced. Mr. Clover has contrived an arrangement by which the nitrous oxide gas and ether may be given consecutively through the same mouthpiece, thus avoiding the risk of the admission of air, and the excitement due to its admixture with the gas. This arrangement is in constant use at Uni- versity College Hospital, and is found to save time in the operating-theatre very considerably. Tlie patients also very rarel}^ manifest any discomfort in going to sleep. The effect is produced partly by ether, and partly by the withdrawal of oxj'gen. Less ether is required, and the DICHLORIDE OF ETHIDEXE. 175 system is more speerlily relieved of it afterwards. Air is admitted b}^ removing the inhaler during one inspiration in six or eii^ht, as soon as either convulsive twitchingrs, ster- torous breathing, or any pause in the respiration is observed. The strength of the ether vapor, which need not be so strong as to excite the act of swallowing, is regulated b}' a stop- cock, which marks how mucii of the respired air passes through the ether bottle, and how much passes directly into the gas-bag. Dichloride of ethidene is intermediate in its properties between chloroform and ether. Mr. Clover has used it extensively in conjunction with gas, and prefers it to any- thing else; but it is liable to produce s3'ncope if given too strongly, and vomiting also. In cases where its use has not been required for more than ten minutes the recover}' is marked by cheerfulness. 176 gui&rin's cotton- wool dressing. CHAPTER VII. DRESSINGS — POULTICES — STRAPPING. Dry dressings are considered by most surgeons to have a tendenc}^ to induce immediate union of the injured sur- faces, and partly for this reason, but still more for conveni- ence' sake, the first dressings of a wound are frequently dry. No special direction is necessary for the application of this dressing, which should consist of suitable strips of lint ; but in removing the dressing it is necessary to soak it carefully with tepid water, in order not to tear open the fresh adhesions to which it will probabl}^ be more or less attached. Guerin'^s cotton-wool dressing is a dry dressing consisting of a ver3" large quantity of cotton- wool, simply bandaged firmly round a wound to which it has been applied without any particular precautions. It is left thus for weeks at a time by M. Guerin. Such wool is known to be an efficient filter against grerms in other cases. This dressing^ has been applied at Universit}'^ College Hospital with marked success by my colleague, Mr. Arthur Barker, but with the following important modifications. The wool has been baked for some hours at a temperature between 300° and 400° F. The limb has been thoroughl}^ washed with carbolic lotion immediately before the operation, as also all instruments used for the latter, and the hands of the operator and assist- ants. Every antiseptic precaution is taken, in fact, except the spray. The vessels are secured with carbolized catgut, and the wound and end of stump having been wiped over with 10 per cent, carbolic oil, the former is stitched in the usual wa3", a drainage-tube being first inserted. Over the ABSORBENT DRESSING. 177 end of the stump is placed a piece of lint dipped in carbolic oil. The cotton-wool spread evenly on a towel to the depth of about the thickness of the limb, immediately before use, is passed under the stump, and then folded up over the end and along its upper surface so as to completely envelop it. It is now bandaged very firmly and evenly as far up the limb as convenient or possible. It is found that an amputation thus treated may be left untouched for eight or ten days without any marked rise of temperature or offensive odor from the dressing. Should either of these appear, it is taken down and re-dressed, the drainage-tube and stitches having been removed. Water dressing is of almost universal application. It consists of a double fold of lint, of a suitable size, soaked in water or any lotion, over which is to be placed a piece of oil-silk or thin gutta percha, to prevent the evaporation of the moisture. The waterproof covering should be slightly larger than the lint, and may be kept in its place by a strap of plaster or a bandage. This dressing occasionally pro- duces a troublesome crop of pinaples in the vicinity of the sore, and when this happens recourse maj' be had to the dry dressing or the evaporating dressing (q, v.) for a time. Water dressing may be varied in form to suit the exi- gencies of particular cases. Thus, many ulcers will heal best when the lint is cut so as to fit exactly to the shape and size of the sore, and the oil-silk must of course corre- spond. In some wounds, and particularly in stumps after amputation, the water dressing should be applied in the form of long strips, which should encircle and support the flaps, the waterproof being applied over all (p. 163). Absorbent Dressing. — In the case of deep discharging wounds, lint, being composed of cotton, fails to absorb the pus, and in many cases acts as a plug, preventing the exit of the discharge. Fine tow, or, still better, well-picked 15 178 ANTISEPTIC DRESSING. oakum, on the contrary, absorbs freel}^, and will keep a deep wound dry, if placed over it. The slight admixture of tar with the oakum has an antiseptic effect, and proves advan- tageous, while the cost of either tow or oakum is much less than that of lint. Oakum, "marine lint," and " tenax," which are all modifications of the same material, may be advantageously inclosed in a layer of Lister's antiseptic gauze, which prevents their becoming entangled in the wound, while it does not interfere with the absorption of the discharges. Antiseptic dressings are described under the head of "Operations," p. 155, but the following directions by Mr. Lister for the preparation of his antiseptic gauze may be conveniently inserted here : " Invaluable as the gauze is, I greatly regret to find that its use is restricted by the high price at which it is often sold. I will therefore now describe the manner in which it has been prepared for a long time past at the Royal Infirm- ary of Edinburgh, with the effect of reducing by more than half the wholesale price previously paid by the institution. First I may remark that the chief element in the cost is the cotton cloth, the expense of the materials with which it is charged being less than a farthing per square yard of the gauze. It is therefore of great importance to obtain the muslin as cheap as possible from the manufacturer, and a little saving is effected by having it unbleached. The ma- terials used for charging the gauze are : 1 part of crystal- lized carbolic acid, 4 parts of common resin, and 4 parts of solid paraflfin ; the last ingredient being used for the pur- pose of preventing undue adhesiveness. Paraffin has tliis advantage compared with any other substance of similar consistence with which I am acquainted, that it does not blend at all with carbolic acid in the cold, and therefore simpl}^ dilutes the mixture of acid and resin, without inter- fering in the least with the tenacity with which the resin ANTISEPTIC DRESSING. 179 holds the acid. If, for example, we compare it with a sub- stance like spermaceti, we find that a mixture of 1 part of the acid with 5 parts of resin and 5 parts of spermaceti Is really much more pungent to tlie tongue than the 5 parts of resin and 1 of acid alone. For althougli the former mix- ture contains only half the quantity of the acid, 3et the spermaceti, blending with the acid like the resin, but hold- ing it less firmly, takes the acid from the mixture and gives it up to surrounding objects. Such a mixture of resin, spermaceti, and carbolic acid, therefore, though admirable in consistence, would be both less mild and less permanent in action than the resin and acid alone. The addition of paraffin, on the other hand, has no other effect on the mix- ture than to render it somewhat more mild. It seems need- ful to point out this circumstance, because, from want of knowledge of it, modifications of the gauze have been sug- gested in which the paraffin has been replaced bj^ other ma- terials, which cannot fail to be disadvantageous. " In order to charge the gauze, the paraffin and resin are first melted together in a water-bath, after which the acid is added and blended by stirring. The object now is to difl[use this melted mixture equably through the cotton cloth, and for this purpose two things are requisite, viz., that the cotton be at a higher temperature than the melting- point of the mixture, and that it be subjected to moderate pressure after receiving it. The cotton cloth, a 3^ard wide, is cut into six-3'ard lengths, and these, having been folded so as to be half a ysird square, are placed in a dry hot chamber formed of two tin boxes placed one within the other, with an interval to receive water, which is kept boil- ing bj^ fire or gas beneath, the upper edges of the boxes being connected and provided with an exit pipe for the steam. There is also a glass tube arranged as a gauge of the amount of the water, and the^ chamber has a properly fitting lid. The bottom of the chamber is strengthened with an iron plate, to enable it to bear the weight used for 180 ANTISEPTIC DRESSING. compressing the gauze when charged. This is a piece of wood, about two inches thick, nearly fitting the chamber, covered with sheet lead, so as to make it about as heavy as a man can lift by means of two handles in the upper surface. The weight is heated along with the cotton, and is put first into the chamber, so as to leave the cotton loose for the penetration of the heat, which occupies two or three hours. The cotton, when heated, is taken out of the chamber along with the weiglit, and placed in a wooden box, to protect it from the cold. (It would be better to have a second hot chamber for this purpose, since in cold weather the cotton is apt to be too much cooled in spite of the protection of the wooden box.) The heated gauze is then at once charged with the melted mixture of carbolic acid, resin, and paraffin, in quantity equal to the weight of the cotton fabric (or slightly less) ; and, in order to diffuse the liquid as equably, as possible, it is sprinkled over the gauze by means of a S3ainge with a number of minute perforations in its ex- tremit}^, the body of the syringe and the piston-rod having each a wooden handle to protect the hands of the workmen from the heat. The syringe is constructed to hold half the quantit}" of the mixture required for charging one piece of cloth. One folded piece being placed at the bottom of the hot chamber, its upper half is raised and turned aside, and one syringeful is sprinkled over the lower half. The upper half is then put back into position, and another syringeful thrown on. The same process is repeated with all the other pieces of gauze, after which the weight is put into the cham- ber to compress the charged cotton, and the lid applied. An hour or two are then allowed to elapse, to permit the complete diffusion of the liquid, when the material is fit for use. " The apparatus above described can be constructed b}'' a common tinman for £10 ; and it is estimated that the entire cost of the gauze to the Edinburgh Infirmary, including the price of materials and manufacture, is somewhat less than DRAINAGE-TUBES. 181 ^d. per square yard. For hospital purposes this expense is further reduced by the fact that the gauze, after being used for dressing a case, can be entirely cleansed of the sub- stances with which it was charged by washing in boiling water, care being taken to press it well in the hot water with a suitable wooden implement. The cotton clotii is then even better adapted for the purpose than it originall}'' was, having lost the slight rigidity caused by the starch or gum used to stiffen the threads before weaving. Tlius the same piece of cotton may be used over and over again, with saving to the institution of the chief cost of the material, which, as before said, is that of the cotton. Practicall}'^, however, it is only larger dressings which will repa}- the trouble of washing and arranging in proper masses for re- charging." — Lancet^ March 13th, 1875. Boracic Acid Dressing. — The following is extracted from a clinical lecture on antiseptic surgery bj^ Mr. Lister (Lancet, December 20th, 1879), to illustrate his method of skin-grafting beneath a boracic dressing: "The large callous and foul sore, having been dressed for a few days with moist boracic lint covered with gutta-percha tissue, was purified completely by sprinkling the surface lightly with the powder of iodoform, after washing the sur- rounding epidermis with strong water}' solution of carbolic acid. Prepared oiled silk (protective) dipped in boracic lotion was then applied to the sore, and covered with bo- racic lint overlapping well in every direction. A similar dressing of oiled silk and boracic lint was applied every third or fourth day, until the granulations had assumed thoroughly healthy characters ; when skin-grafting was per- formed by shaving a thin slice about a quarter of an inch across, consisting of little more than epidermis, from the inner side of the upper arm, which had been washed with 1 to 40 watery solution of carbolic acid, cutting this into small pieces on the thumb nail, and placing each, with the 182 EVAPORATING DRESSING. raw surface downwards, on the granulations, each graft being covered, as it was deposited, with a little bit of the oiled silk, dipped in boric lotion. A general piece of the oiled silk, rather larger than the sore, was then applied, and over this boric lint, in two layers, secured with a bandage. This dressing was left untouched for a whole week, so as to allow the grafts a long period without mechanical disturbance." Drainage-tubes^ of india-rubber perforated with holes, are useful in many cases, and almost essential in antiseptic dressings to secure the free discharge of secretions. The tubes may var}^ in size in proportion to the quantity of dis- charge anticipated, from the thickness of a crowquill to that of the little finger, and the holes in them should have a diameter about half that of the tube. The outer end of the tube should be on a level with the skin, and it is conve- niently maintained in that position by means of two pieces of silk passed with a needle through two opposite points of the edge of the tube, the ends of each thread being knotted at a distance of one or two inclies from the tube. These knotted threads being placed straight upon the skin, one at each side, the knots excite friction upon the dressing bound down upon them, and prevent the tube from being pushed in, while the dressing itself keeps it from protruding, so that the orifice lies flush with the integument. When the tube is to be placed obliquely, its outer end must be cut ob- liquely in proportion, otherwise it is apt to become partially buried and blocked up. When both ends of a drainage-tube are brought out through the skin they may be conveniently tied loosely to- gether with a piece of ordinary ligature, and the tube can then be temporarily withdrawn from the sinus for cleansing, and be replaced with the greatest facilit3\ Evaporating Dressing. — The advantage of this is the con- stant maintenance of a low temperature in the affected part. IRRIGATION". 183 It is applied in its simplest form by placing a piece of dou- bled lint upon the wound, and letting the patient or nurse keep it constantly wetted with water or an evaporating lo- tion. To be of any service, the surface of lint must be full}'' exposed to the action of the atmosphere, a fact which is very commonly ignored, the part being carefully covered with the bedclothes. Care siiould be taken to protect the bedding and the rest of the patient's body from getting wet- ted, by the judicious npplication of waterproof sheeting. Mr. Jonathan Hutchinson has systematically einploj'ed an evaporating lotion (Liquor plumbi f^ss., Sp. Yini rect. fjjss.. Aquae Oj) to obviate inflammation and suppuration in operation wounds, with good results. All vessels having been tied, the wound is to be carefully closed, except at the dependent part where a drainage tube is inserted, strips of plaster are placed between the stitches, and a compress of lint wetted with the above lotion over the wound, and over this cotton-wool and a bandage are tightl.y applied for from six to twelve hours. After the conclusion of this time the evaporating lotion applied on lint forms the only dressing, and the only care requisite is that the nurse should damp the lint sufficiently often. Irrigation is a more perfect method of lowering the tem- perature of the part, and has a direct tendency to prevent the occurrence of inflammatory action, provided the appli- cation of it be sufficiently prolonged ; for if irrigation be suspended after a short time, the reaction will only be all the greater and the inflammation more severe. Irrigation, then, to be of an}- service, must be continued until all dan- ger of inflammatory reaction is past and the wound has put on a healthy appearance. It may be most simply accom- plished by placing a vessel containing water (iced) slightly above the level of the patient's bed, from which a piece of cotton-wick, or skein of worsted, can conduct the fluid, after the manner of a siphon, to the affected part. This should 184 POULTICES. be covered with a piece of lint, into which the water may soak, and waterproofs should be arranged so as to protect the bed, and also to conduct the water into a suitable recep- tacle below. The siphon may be formed of gutta-percha or tin tubing, if preferred, or the nasal douche shown in Fig. 1, may be employed, with a common hair-pin placed across the tube to regulate the flow ; or a pipe and stop-cock may be fitted to the bottom of a tin can, which is to be suspended directl}^ over the injured limb. The same form of apparatus may be used when it is desir- able to have a stream of tepid or warm water constantly flow- ing over a part, as in crushes, gangrene, etc. Ointments are to be applied on lint, and should be well worked up with the spatula before being spread, in order that their surface may be smooth and even. Some surgeons lay great stress upon the selection of the right side of the lint for the reception of the ointment, and diflfer as to which is* the right side. The soft flocculent side would appear the more reasonable, since, if the other is used, the lint pos- sesses no advantage over ordinary linen. It is claimed for greasy dressings that they are more readily detached from a sore, and thus cause no pain to the patient, nor occasion any haemorrhage. This is no doubt the fact, but water dressings, if properly wetted, are as readily detached, and any one who has contrasted the ap- pearance of sores dressed by the two methods under pre- cisely similar circumstances, will not hesitate to give the preference to the water dressing. POULTICES. Linseed-meal poultice is the one in common use, and the meal should be made from the crushed seeds, without any of the oil having been expressed. The house-surgeon, although not often called upon to do so, should be able to make a poultice, which in no respect POULTICES. 185 resembles the "dab" of half-dry brown material to which patients are in the habit of appl3'ing the term. A piece of linen rag will be required, two inches larger each way than the intended poultice. This being spread upon a board or table, a quantity of meal slightly larger than will be actually required is to be put in a basin which has been scalded out, and boiling water poured into it, a little at a time, until the mixture, which is to be well stirred, is brought to the consistency of thick porridge. It is then to be turned out of the basin upon the cloth, and spread with a large spatula or knife to the thickness suitable for tiie case (from a quarter to three-quarters of an inch). The sides should now be neatly squared off about an inch from the margiu of the rag all round, by cutting off the superfluous matter with the edge of the spatula, and each edge of the rag should then be doubled upon itself, and afterwards folded over upon tlie meal, thus forming a neat margin to the poul- tice, and preventing the escape of the meal or of the dis- charge from beneath it. If the water was boiling, and the preparation has been performed with proper activity, the poultice will be quite as hot as the patient can bear it, but if it has at all cooled, it should be held to the fire for a few moments to restore the temperature. A poultice should not be "clapped on" a tender sur- face, but one end being gently laid on, the rest should be gradually allowed to cover the wound, and similar precau- tions should be observed in removing a poultice. A piece of oil-silk, or, what is cheaper, oiled calico, should be placed outside a poultice, in order to retain the heat, and the whole must be kept in position with straps of plaster or a light bandage. A little olive oil spread upon the surface of the poultice prevents the possibility of its adhering to the part on which it is applied, and it is advisable where the ordinar}'' linseed- meal is used, though not absolutely necessary. Some per- 16 186 BREAD POULTICE. sons recommend that a piece of fine muslin should intervene between the poultice and the sore, but by that arrangement the poultice loses nearly all its power. It may be advisa- ble, in the case of boils, etc., to limit the action of the poul- tice to the exact locality of the disease, and this can be readily done by cutting a suitable hole in a piece of soft linen, which may be placed over the affected part and be- neath the poultice. Bread poultice is seldom used in hospital practice, and is not so efficient or comfortable as the linseed. It is made from the inside of a stale white loaf, well crumbled, upon which boiling water is poured. This is to be covered and allowed to stand for a few minutes, when the water is to be strained off, and the resulting pulp to be spread with the spatula. Ghai'coal poultice is directed by the British Pharmaco- poeia to be made of bread, linseed, and powdered wood charcoal; but the bread is an unnecessar}^ addition. The powdered charcoal had better be animal and not vegetable, which has a much smaller disinfecting power. Yeast poultice (B. P.) is made by adding yeast to a mix- ture of flour and water, and letting it stand before the fire until it rises. It is an uncomfortable application, and pos- sesses no special advantage. Poultices of different characters may be readily prepared by adding suitable drugs to the ordinary linseed poultice ; thus, the tincture of opium, henbane, or hemlock, or the liquor sodse chloratse, may be selected for each variety of case. Oakum poultice is a very useful application for keeping up fomentations around a limb, particularly when there are discharging openings which it is important to keep sweet STRAPPING. 187 without any accumulation of the discharge. It is made simply by taking a sufficient quantity of loosely picked oakum, and wringing it out of hot water with a twisted cloth. It is then conveniently placed in a fold of antiseptic gauze to prevent its adhering to the wounds, and applied as hot as the patient can conveniently bear it. A Mackin- tosh sheet should be folded over it and the limb, in order to keep in the heat and moisture. Strapping. — The common adhesive strapping answers perfectly for all ordinary purposes, but should it be too irritating to the patient's skin, the soap plaster may be sub- stituted for it ; and in cases of disease of joints, etc., it will be well to employ stout twilled calico plaster, which is much stronger than the common strapping. In some cases it may be advisable to substitute the opium or belladonna plaster where an anodyne effect is wished for, or the pitch plaster when counter-irritation is required. Strapping being mainly used to support the tissues, it should always be cut in the length of the piece of calico, so that it may wot give ^ as it infallibly will do, if cut in the opposite direction. When applied to hold the edges of the wound together, the strapping should be long enough to go for some distance on each side, so as to take a firm hold of the tissues ; and in some cases of w^ound it will be well to carry it quite round the limb, as will be shown in strapping an ulcerated leg. The edges of a wound should be held firmly together while the plaster is applied, and, as a rule, the traction of the plaster should be upivards^ i.e.., it should be affixed to the lower edge of a wound first. In removing strips of plaster from a wound, care should be taken not to drag it open ; and to avoid this the strip of plaster should be lifted up at the ends and drawn gradually to the centre, whence it may be gently detached at last. In ordinary wounds, where other dressings are to be ap- plied, not more than one or two straps will be required ; 188 TO STKAP A LIMB. but in exposed situations (as the face), where other dress- ings cannot be conveniently applied, the strapping may be made to cover the wound entirel}^, being cut in small strips, which should partially overlap one another ; and these may he again crossed by others, if necessar3\ Where traction is required, as in plastic operations, it will be found convenient to use two strips of plaster of dif- ferent widths, the narrow one passing through a transverse slit in the broader one, so as to allow of the parts being forcibl}'' drawn together. (Fig. 11.) Ordinary strapping is soon decomposed by the secretions of a wound, and turns black from the lead it contains ; and the part to which it is applied is often discolored in the same way. This may be at once removed by gentle fric- tion with a little olive oil or vinegar, and the subsequent application of soap and water; and in the same way the house-surgeon may clean his sticky fingers more readily than with turpentine, as usually recommended. Plaster is readil}^ warmed by holding it with the plain side against a hot-water tin, with which the operating-theatre, surgery, and each of the wards should be provided ; or, more ef- ficiently, b}^ dipping the straps into the hot water for a minute or two. When treated in this way, the plaster lies much more smoothly, and can be more readily adapted to an irregular surface. A cloth should be used to soak up the superfluous moisture after the plaster is applied, and to press it close to the limb. Before using a sheet of plaster it should be wiped briskly with a dry cloth, to get rid of the dust and particles of plaster which collect on the surface. To Strap a Limb. — The leg is the limb most frequently strapped for the treatment of varicose ulcers, etc., but the arm might, if necessary, be treated in precisely the same way. The straps should be one and a half inch wide, and about twenty inches long, and should be applied from two TO STRAP A LIMB. 189 inches below, to at least the same distance above, tlie ulcer; and where the veins are much enlarged, the strapping may be carried further up the limb with advantage. The heel being raised upon a stool, the surgeon, facing the patient, passes a well-warmed strap under the limb, and applies the middle of it to the back of the leg, then brings the ends over the sides of the limb and crosses them in front, the direction of the ends being upwards, so as to accommodate Fig. 38. the inequalities of the limb, and enable the strapping to lie perfectly smooth, without any snipping. The next strap is put on in the same way, but is made to overlap the first for a third of its width, and so on throughout (Fig. 38). In drawing the ends of the strap forward, care must be taken to exercise sufficient but not too great traction, lest the patient should be unable to bear the pressure, and the whole thing have to be undone. It will be observed in the illus- tration that the ends of the straps are not seen, they having 190 TO STRAP A JOINT. been carried on towards the back of the limb ; and the straps should always be cut sufficiently long to pass, as in this instance, well be3'ond the margin of the ulcer. In removing strapping from a limb or joint, it saves both time and trouble to pass a director beneath it, and lay it Fig. 39. open with a pair of scissors, and so remove the whole at once, instead of pulling off each strap separately. To Strap a Joint. — The ankle or knee most commonly require the application of strapping, either alone or con- joined with other applications. Ankle. — The strapping should be carried from near the roots of the toes to a couple of inches above the ankle- joint, and should be begun under the sole and crossed over TO STRAP A TESTICLE. 191 the instep as far as possible towards the heel. A second set of straps must then be carried up behind the tendo A chillis, so as to emlirace the malleoli and cross on the instep; and thus the whole joint will be covered — the heel being left exposed, which is an advantage rather than other- wise (Fig. 89). In order to make the plaster lie smoothly on the inequalities of the joint, it will be necessar}^ to snip the edges in various places, and smooth each strap with the palm of the hand before applying another. Knee. — Twilled calico plaster, or soap plaster, spread upon wash leather, is the most suitable for strapping the knee or elbow. The straps are to lie applied in precisely the same way as upon the leg, and must be long enough to reach thoroughly round the joint and cross in front (Fig. .39). ScoWs dressing consists in the application of strips of lint spread with mercurial ointment (Ung. Hj^drargyri Co.) in the same way as the straps, which are then to be applied over the lint so as to make pressure on the diseased joint. They should be carried for a short distance below and above the lint, so as to take a firm hold of the limb. To Strap a Testicle. — One or two methods have been de- scribed, but the following will be found simple and efficient. It is essential to shave off all the hair from the pubes and scrotum of the affected side, and the operator, sitting in front of his patient (who should stand with his back against the wall), is then to grasp the enlarged testis with his left hand, and separate it from its fellow, pushing it well down to the bottom of the scrotum. A strip of wash-leather plas- ter is then to be applied immediately above the testicle as tightly as it can be borne, so as to prevent the organ^s slip- ping up again, and this strip should go twice round ; or if the plaster is not at hand, a piece of lint may be put beneath common strapping to protect the skin. Strips of ordinary strapping, half an inch wide, are then to be cut of sufficient length to reach from the ring of wash-leather vertically over 192 TO STRAP A TESTICLE. the testis, and back to the same point on the opposite side, and these should be applied all round so as to envelop the testis completel3\ The simplest way is to appl}^ one or two in front first, and then similar ones at ris^ht anojles, as is shown in the engraving (Fig. 40), and afterwards to fill in the intervals. A long strip of plaster, half an inch wide, is then to be wound horizontally over the other straps, begin- FiG. 40. Fig. 41. ning from as near the bottom of the testicle as convenient, and carrying it up over the original wash-leather ring, so as to envelop the testis and keep all the vertical straps from slipping (Fig. 41). Three or four of these long strips will probabl}^ be required. So long as compression is effected, the regularity of the strapping is a -matter of secondary importance, and the house-surgeon must not be disappointed if he is unable to produce the picturesque appearance which is given in draw- ings not taken from nature. In a day or so the testicle will TO STRAP A BREAST. 103 be fonnd to have shrunk, so that the strapping forms a loose bag around it, and will require a repetition of the ap- plication. To Strap a Breast. — This is one of the most efficient modes of giving support to an inflamed or enlarged breast, and has the advantage over the bandage of not getting Fig. 42. loose. The straps should be from one and a half to two inches wide, and about thirty inches long; and the breast being held up by an assistant, the end of a strap should be firmly attached just above the spine of the scapula of the opposite side, then brought over the clavicle, under the dis- eased breast, across the axilla, and round to the back again (Fig. 42). The first strap should go just below the breast ; the next, slightly overlapping it, sliould go a little higher; and so on towards tiie nipple, until the neeessar}^ support is given; additional straps being brought down from the shoul- der of the affected side if required. If compression is de- sired as well as support, cross straps maj- be brought from 194 STRAPPING IN FRACTURES, ETC. the upper part of the axilla of the affected side above the nipple, and to end below the opposite arm. Strapping in Fractures^ etc. — Besides the above ordinary uses of strapping, it will be found a most useful adjuvant in the treatment of fractures, deformities, etc., both by fixing splints and apparatus more firmly than can be effected by bandages alone, and by giving the power of effecting trac- tion upon a limb without exercising compression, which is often a matter of great importance. BANDAGES. 195 CHAPTER Yin. BANDAGE?. A THOROUGH knowledge of bandaging is essential for a house-surgeon, and can only be attained by constant prac- tice. The material used for bandages varies slightly at different hospitals, but generally consists of coarse unglazed calico, torn in lengths of from seven j^ards upwards, and of several widths to suit different purposes, the most com- monly used being three inches wide. A bandage should be firmly and evenly rolled, for unless this is done it is impos- sible to apply it to a limb properly; and this may be accom- plished either by hand or, better, by one of the little ma- chines invented for the purpose, of which the illustration (Fig. 43) represents one of the neatest (made by Mr. Aitken, of York), which may be readily attached to a table or bench when in use. Bandages are called single-headed or double-headed roll- ers, according as they are rolled in one or two parts, the former being the ordinary method, and always intended in the following pages, unless the contrary is expressly men- tioned. The following will be found to include all the bandages which can be required in the ordinar}'^ practice of surgery; the minute subdivisions and nseless complications of the French school have been pnrposelj^ avoided. If a surgeon is fully acquainted with all here described, he will find no difficult}^ in adapting his bandage to any out-of-the-way case which may occur to him. In applying any bandage, the operator should grasp the roll in one hand, and, taking the loose end in the other, 196 SPIRAL BANDAGE. apply it to the limb so that the outer surface may be against the skin, by which the roller, as it is being carried round, will always lie close to the limb, and the bandaging will be much neater than if applied in the contrary way. The lower limb being the one to which a bandage is most fre- quentl}' applied, will be taken first. Fig, 43. Spiral Bandage. — The nature of the spiral bandage is indicated by its name, and it consists in covering a limb Iw a series of spiral turns, each overlapping the one below for about one-third of its width. In practice, however, owing to the enlargement of the limbs at the upper part, it is im- possible to apply this bandage without making " turns " in it, i. e., folding the bandage upon itself so as better to accom- modate the shape of the limb. To make these " turns " neatly is the difficult}^ which besets the beginner, but if he attends to the following rules a little practice will soon overcome it: 1st. A turn should never be made over a prorai- FIGURE-OF-EIGHT BANDAGE. 197 nence of hone, and, where possible, should be on the out- side of a limb. 2d. However tightly the bandage may have been drawn before, at the moiYient of making the turn it should be held quite looeely, when with one movement of the wrist the required "turn " may be made, and can after- wards be pulled as tight as may be necessary. (It is some- times recommended to lay the forefinger of the opposite hand upon the bandage at the point where the turn is to be made, and to fold it over the finger ; but if the above rule of holding the bandage quite loose is attended to, there is not the least necessity for so doing.) 3d. In making the turn, the hand should be held slightly above the level of the limb, and care be taken not to unroll more bandage than is actually required for its performance. Figure-of-eight Bandage. — The nature of this is also indi- cated by its name, and, being formed without any turns, its application is easier than that of the other variet3^ The spiral is most applicable to the surface of the limb, while the figure-of-eight is peculiarly adapted for the joints. Either may be applied separately, as in the accompanying drawing, where the right leg (Fig. 44) was bandaged with the spiral alone, and the left (Fig. 45) with the figure-of- eight alone. It will be observed, however, that the spiral does not fit well around the ankle, while the fiijure-of-eio-ht would have been very difficult to apply smoothly over the swell of the calf. A combination of the two is the best, as seen in Fig. 46, where the spiral is used in the foot, the figure-of eight round the ankle, and the spiral is begun again (at first plain, and afterwards with " turns ") in the It will be observed (in Figs. 44 and 45) that the appear- ance of the two bandages is almost precisely similar; so that a skilful manipulator would carry his bandage from the toe to the groin, using the figure-of-eight over the ankle 198 TO BANDAGE THE LEG. and knee, and the spiral over the limbs, without in any way interfering with the uniformity of its appearance. In order to render the method of bandaging uniform, it is recommended to bandage from the inside of a limb, and thus bring the turns to its outer side. The operator, in order to do this while in front of his patient, — the proper Fig. 44. Fig. 45. position, — must be able to bandage equally well with both hands (an art easily acquired) ; for he will require to bandage the right leg with the left hand, and vice versa. This method is, of course, not absolutely essential, but en- hances considerably the symmetrical appearance of the bandages. To Bandage the Leg. — To fix the bandage firmly (a most important point) a figure-of-eight turn should be made TO BANDAGE THE ANKLE. 199 around the ankle, the foot being raised to a convenient height upon a stool. If it is desirable to bandage the foot, a few spirals and turns (Fig. 46) may then be made over it, beginning at the roots of the toes; but if not, the bandage should take another figure-of eight turn at once, overlapping the former by about one-third of its width. This will give the bandage sufficient " spring " up the leg, and the spiral Fig. 46. folds msiy be at once begun, the first two or so being plain, the turns then commencinor on the outer side of the leg;. and being continued as high as the bandage goes. In simply bandaging the leg, it is usual to leave the heel ex- posed ; but if for any reason it is desirable to cover it, this can be readily done with a few extra turns alternately underneath and at the back of the heel. To Bandage the Ankle. — The method of applying the figure-of-eight to this joint is sufficiently explained in the above paragraphs (Fig. 46). 200 TO BANDAGE THE KNEE. To Bandage the Knee. — The figure-of-eight is to be used for this, but its application requires some little care, or it will be found to slip. In order to fix the end, supposing the bandage has not been brought up the leg, it should be laid across immediately below the patella (Fig. 47), and the band- age be carried round the limb below the knee, so as to cross Fig. 47 Fig. 48. it. The roller is then carried behind the ham to the inner condyle, and makes a loop embracing the thigh immediately above the joint ; it is then brought behind the ham again to the inner side of the joint, and made to overlap the former loop neatly ; then around the femur again, but lower than before, so as to make the next loop fit in properly, and so on till the appearance of Fig. 48 is produced, where the original loop round the femur is completely hidden b}'^ the folds of the figure-of-eight loops applied over it. TO BANDAGE THE GROIN. 201 To Bandage, the Grcnn : Spica. — This useful bandage is best applied while the patient stands, the surgeon being in front of him. Two turns should be made round the thigh of the aflfected side, from within outwards (Fig. 49), then the bandage is to be carried along^ the lower part of the groin, Fig. 49. and over any pad which it may be desired to hold there; then to pass round the pelvis, and back over the pubes, crossing the former fold at the groin, and thus completing the figure-of-eight. A series of similar turns, each slightly overlapping the other, may then be carried round in the same way, until the part is covered and sufficient compres- sion produced. In the drawing, for the sake of clearness, a space is left between the turns round the thigh and the re- mainder of the bandage; but this is not necessary or advisa- ble in practice. The amount of compression in the groin may be easily regulated by increasing or diminishing the 17 202 TO BANDAGE BOTH GROINS. size of the pad, to which the bandage may be secured by a couple of stitches. To Bandage Both Groins : Double Spica. — Beginning in precisely the same way as in the single spica, the bandage is carried over the right groin, then around the pelvis, and (Fig. 50) brought over the left groin to form a loop on the Fig. 50. left thigh. It is now carried across the abdomen to the right side, and encircles the body at the waist, whence it traverses the abdomen again to the right groin, crossing the com- mencement of the bandage there, and passing round the right thigh. A series of turns of this description will effec- tually cover both groins, as seen in the figure. It must be noticed that the "turns round the pelvis" should be kept strictly below the brim of the pelvis, but that those " round the waist " will be at the^ level of the TO BANDAGE THE BREAST. 203 umbilicus, since the integrity of the bandage depends very much upon this being fully attended to. It wilUbe also observed that, contrary to the French practice, the spicas are begun at the thigh instead of the abdomen, since the limb oifers a much firmer starting-point than the constantly moving abdominal walls. To Bandage the Breast. — A couple of turns are to be taken round the waist, immediately below the breast, in Fig. 51. order to fix the bandage, which is then to be carried under the affected organ, and over the opposite shoulder, then around the waist, so as to fix the former turn ; and next under th^e breast and over the shoulder again, and so on alternately until the breast is sufficiently covered and supported. In the drawing (Fig. 51), th^ bandage is only partially 204 TO BANDAGE BOTH BREASTS. applied, and it will be seen that, at the last, two turns have been suflcessively made under the breast, and this will often be found advisable. The next turn would go round the chest above or below the opposite breast, and so on, as high as might be necessary. To Bandage both Breasts (Fig. 52). — Beginning around the waist as before, the bandage is taken under the left breast and over the right shoulder, and then half round the Fig. 52. waist again to fix the turn ; next across the back to tile left shoulder, across the chest and under the right breast, and round the back to the left side ; the next turn is under the left breast, and half round the chest, and so on alternately, the folds being applied on the left from below upwards, and on the right from above downwards, and crossing alter- nately on the front and back of the chest. The order TO BANDAGE THE FIXGER. 205 would, of conrse, be reversed, if the bandage were applied in the opposite direction round the waist at first, and it is immaterial which method is followed. To Bandage the Fiyiger (Fig. 53). — A bandage, three- quarters of an inch wide, will be most convenient, and a couple of turns (leaving out a loose end) should be made round the wrist ; the bandage is then brought over the back of the hand, and taken in a series of spirals to the tip of the finger, which it surrounds, and is brought back by regular Fig. 53. Spirals in the opposite direction to the root of the finger again ; crossing the former bandage on the back of the hand, it finally surrounds the wrist, and can be finished off by making a knot and bow with the loose end. The penis may be bandaged in similar wa}', but it will be sufficient generally to commence at the root of that organ, without going round the groins. In applying simple dressings to either finger or penis, it will be sufficient to twist a piece of lint round a few times. 206 TO BANDAGE ALL THE FINGERS. after the manner of the above bandage, and finish off by splitting the lint and tying the two ends around the part. To Bandage All the Fingers. — The bandage is carried round the wrist, and then spirally over the little finger as described above ; it then passes round the wrist and down to the ring finger and back to the wrist, and so to each finger and the thumb successively as seen in Fig. 54. This bandage is used when, in cases of fracture of the upper arm, etc., it is thought advisable to bandage the hand to prevent oedema, and is also applicable in cases of wound of the palm. Fig. 54. To Bandage the Thumb : Spica of Thumb, — A bandage, about three-quarters of an inch wide, should be fixed round the wrist by a couple of turns from within outwards, and is then to be brought over the back of the thumb to the lower part of the first phalanx, around which it is to form a loop. Then crossing itself at the phalanx, and passing over the back of the hand, the bandage will arrive at the outer side of the wrist, under which it is to pass, to descend upon the thumb and form another loop, slightly overlapping the former one, and so on until the appearance given in Fig. 55 TO BANDAGE THE ARM. 207 is produced. The bandage is to be finished off by two or three simple turns round the lower end of the forearm. This bandage is very useful in maintaining pressure upon the ball of the thumb in cases of wound, attended with smart haemorrhage. To Bandage the Arm. — The bandage is to be fixed hy a figure-of-eight turn around the metacarpus and wrist, and the bandage may then be commenced as near the fingers as Fig. 55. desirable, by a series of figure-of-eight turns (Fig. 56) pass- ing over the back of the hand, under the wrist, and down again over the root of the thumb, thus crossing on the back of the hand in regular succession. As soon as the bandage is brought fairly above the wrist, a few plain spirals ma}-^ be applied, and the "turns" may then be commenced and car- ried along the outside of the arm. Around the elbow-joint the figure-of-eight turns should be resumed and applied as on the knee, or as figured in the application of a bandage 208 BANDAGE FOE THE AXILLA. after venesection (p. 122), and the "turns" may be again resumed in the upper arm. If it should be desirable to in- clude the fingers at the same time as the arm, this will be best accomplished, first, with a small spiral bandage, as Fig. 56. shown in Fig. 54, and the above can afterwards be applied over it. Bandage for the Axilla. — The bandage is fixed b}^ a couple of turns round the upper arm from within outwards, and is then brought under the axilla and over the pectorals to the top of the shoulder. It next forms a loop around the root of the neck, and, crossing itself, is brought behind the shoul- der to the axilla again. These figure-of-eight turns may be repeated as often as necessar}', but it should be remembered that the one first applied is to be the highest of the set. BAifDAGES FOR THE HEAD. 209 This bandage may, if it is preferred, be carried under the opposite arm instead of round the neck (Fig. 57). It will Via 57. be commenced in precisely the same way, and the crossings will similarly be on the top of the shoulder. Bandages for the Head.— The simplest form of bandage for the head consists of a couple of turns round the forehead and occiput, but this is very apt to slip up unless conjoined with a turn under the chin (Fig. 58). The circular portion is to be fastened with a pin just in front of the ear, and the bandage being folded down over it, can be easily carried under the chin and over the vertex. In applying this last turn or two the roll of the bandage is necessarily reversed, as shown in the illustration. When dressings are to be kept on the top of the head, some of the turns under the jaw should be made first, so that they are kept in place by the circular ones, or, where it is desirable to avoid the unsightly appearance of the band- age under the chin, the circular portion should be applied 18 210 EECURRENT BANDAGE OF THE HEAD. and fastened with a pin at the forehead ; a turn can then be taken over the head and pinned again at the occiput, and so backwards and forwards two or three times. When it is advisable to appl^^ pressure to the side of the head (wound of temporal artery, etc.), the following modifi- cation of the circular bandage will be advantageous: After a couple of simple turns round the forehead and occiput, the bandage is to be made to ascend and descend alternately as Fig. 58. it passes over the point where pressure is to be applied. The arrangement is seen in Fig. 59, and closely resembles the appearance produced by making reversed turns, none of which are, however, made, the bandage being kept flat to the head throughout. Recurrent Bandage. of the Head: Capeline. — This bandage is an exceedingly useful one for keeping dressings upon the head, or for making pressure upon the integument after KECUEEENT BANDAGE OF THE HEAD. 211 extensive scalp wounds. It has the disadvantages of being a little difficult to apply, and of being ratlier hot. A double-headed roller, two inches wide, is required, one head being a third larger than the other. The patient being seated, the operator stands behind him, and taking the small roll in the right, and the other in the left hand, ap- plies the intermediate portion of the bandage upon the Fig. 59. patient's forehead. It is essential that the commencement of this bandage should be as low on the brow as possible ; and the rolls are then brought round the side of the head to as low on the occiput as convenient, for this will vary somewhat vv^ith the shape of the individual's head. The bandage in the operator's left hand is now to cross the other, and to be transferred to the right hand, while the other bandage is to be folded over it, and carried along the middle line of the head with the operator's left hand. 212 EECURRENT BANDAGE OF THE HEAD. The bandage now in the right hand continues its hori- zontal course around the head to the forehead, where it ao-ain crosses the other bandage and passes round to the occiput. The vertical bandage is folded back over the horizontal (which keeps it in position), and passes a little to the left side of the middle line to the occiput. It is then crossed again by the horizontal bandage, and passes forward to the Fig. 60. right side of the middle line, and being again crossed by the horizontal, passes to the occiput on the left, overlapping the former fold in the same direction. This is the point in the application shown in the illustration (Fig. 60), and the bands having just exchanged bandages, are seen passing the one in a horizontal, and the other in a nearly vertical direction. These turns, from before backwards and in the contrary direction, are regularly continued until the whole head is covered, when the horizontal bandage is to make a TO BANDAGE A STUMP. 213 few extra rounds, so as to keep all tight. The result is seen in Fig. 61, where the end of the vertical bandage has been left hanging out to show how it is finalh' secured by the horizontal turns. It will be observed that all tlie folds from forehead to occiput are on the left of the middle line, while those in the contrary direction are on the right. Great Fig. 61. care should be taken to keep the horizontal bandage low down on the brow, and to place the crossings of the band- ages as near to the middle line as practicable. To Bandage a Stump. — The object of this bandage is not only to confine the necessary dressings, but, in addition, to support the flaps, and counteract the tendency of the muscles to drag away from the cut extremity of the bone. In order to accomplish these objects, the bandage should be begun at some distance from the end of the stump, and be carried round it with moderate tightness from above 214 TO BANDAGE A STUMP. downwards, for a few turns; the right hand then holding the roller beneath the limb, the left is to grasp the part, so as to fix the bandage with the tips of the fingers at that point. The roller can now be brought up over the face of the stump, and be fixed in front with the thumb (Fig. 62), to be taken back again a little to one side of the first fold, and again secured with the fingers ; and this can be re- peated until the stump is suflSciently covered, a few circular turns being made at the last to secure the folds in their Fig. 62. proper places ; or, if preferred, a circular turn may be made after each fold across the stump, so as to secure it at once, and set the left hand more at liberty. The T bandage is a useful apparatus for keeping dressings on the perineeum or anus. It is formed of one piece of bandage to go round the waist and fasten b}'^ tying, or with a button, to the centre of which another piece is attached, to pass between the thighs and be fastened to the circular portion in front. This vertical portion may be conveniently SUSPENSOKY BANDAGE. 215 split towards the end, so as to pass on each side of the scrotum, and may be used to keep dressings upon the groins, if the ends are made to diverge well in front. An extemporaneous T bandage may be formed from an ordinary roller by fastening it around the waist with a knot in front, then carrying the end between the thighs, and on one side of the genitals, looping it over the circular bandage behind, and bringing it forward again on the other side of the genitals, to fasten in front. This is the form ordinarily applied after the operation for fistula in ano, etc., but is then generally commenced behind. A very convenient plan in the case of operations about the female genitals is to fasten an ordinary diaper behind by means of a tape round the waist, which, being kept out of the way during the operation, can be drawn down and secured with a pin to the tape in front at its conclusion. Suspensory Bandage. — The ordinary woven suspensory bandaa^e of the instrument-makers is convenient enoug-h when the testicle is not enlarged, but if it is, the scrotum may be more conveniently supported with a handkerchief. This should be folded into a triangle, and the straight side or base being passed beneath the scrotum, its ends are to be attached to a piece of bandage going round the waist. The apex of the triangle is then brought up in front and fastened to the bandage at the required height. Support for the scrotum may be gained b}^ adding to a T bandage a piece of calico, sewn at right angles immedi- ately behind the point to which the bandage is split, to allow of the passage of the penis. This passes beneath the scrotum and supports the testicles, being attached on each side to the waistband. . When the patient is confined to bed, efficient support for the testes can be obtained by placing a small cusliion be- tween the thighs, or by fixing a broad strap of plaster across both thighs, upon which the scrotum may rest. 216 SLINGS. Many-tailed Bandage. — This may be formed in two ways, either by taking a piece of calico or muslin the length of the limb, and wide enough to go at least once and half round it, and then tearing it transversel}^ from each side in strips, two inches wide, to within a couple of inches of the middle ; or, by making a number of strips of equal length of ordinary bandage, and then attaching them along another central piece at right angles with a needle and thread. In either case the central portion is to be applied to the back of the limb, and the transverse pieces folded over it in regular order, beginning from below. In stitching the transverse strips to the central portion, the upper strip should be attached first, and the next made to overlap it slightl}^, and so on to the end, so that when folded over from below upwards, each turn may overlap slightly the one below it, and thus give additional support. This is an advantage which the bandage does not possess when made from a single piece of calico. The many-tailed bandage is applied to limbs which require constant dressing, but which it is desirable should not be moved, as they would of necessity be for the appli- cation of the ordinary roller. JSandker chiefs may be usefully employed in some cases, either as temporary or permanent supports. The use of handkerchiefs in British surgery is not, however, of suf- ficient extent to require a detailed account of the various methods of application, which will be sufficiently appreciated by referring to the descriptions of the corresponding forms of bandages. Slings for the arm or hand may be most conveniently formed of a handkerchief folded into a triangle, or of a tri- angle of any suitable material. A sling for the hand (Fig. 63), where the object is to support and raise the part, is best made by folding the triangle into a broad cravat, SLINGS. 217 which can be then knotted round the neck so as to give tlie required height to the hand. In applying this, the end of Fig. 63. the sling passing in front of the hand should always go over the opposite shoulder, to meet its fellow at the back of the Fig. 64. neck. The reverse method of proceeding does not give nearly so efficient a support to the hand. A sling for the arm (Fig. 64) is best formed by placing 218 TO TIE IN A CATHETER. the base of the triangular handkerchief beneath the wrist, and taking the end of the sling which passes in front over the shoulder of the affected side, to meet its fellow at the back of the neck. The apex of the triangle may either be folded in, or brought round the arm and pinned in front. The arm-sling made of leather or perforated zinc, with a padded strap, is a most comfortable support if properly put on, viz., with the strap going through the axilla of the affected side, across the back, and over the opposite shoulder. It is usually. put on round the neck, where its drag is most irksome. To Tie in a Catheter. — Tarious modes of performing this operation are practiced. In all cases, if a silver catheter is used, the tapes will be made fast to the rings at the end of the instrument; but if an elastic catheter is preferred, the tapes must be fastened securely to it by means of a clove- hitch, the nature of which is described in the chapter on dislocations. First Method. — A piece of narrow tape, about twelve inches long, is passed through both rings of the catheter, and the ends are brought down the opposite sides of the penis. The foreskin is then drawn well forward, and a piece of strapping half an inch wide is carried circularly three or four times round the body of the penis immediately behind the glans, inclosing within it the ends of the tape. This method is very eff'ectual, provided the skin has been drawn well forward, for otherwise the catheter has too much 2^^<^y- The strapping round the penis does not produce chordee, as might have been feared, since the plaster only adheres to the skin without materially compressing the organ itself. This method may be modified by using ligature-thread or silk, instead of tape, knotting the two threads together about two inches down, and tying them behind the corona TO TIE IN A CATHETER. 219 gJandis beneath the foreskin, the knot lying by the side of the fra'ULim. Sf'cond Method. — A tape is passed tlirough the rings as in the former case, but a greater length is necessary. The ends are to be brought on each side of the scrotum and be- tween the thighs to the loins, where thej' are to be knotted together and then fastened round the waist. This method holds a metal instrument very securely in the bladder, since it is impossible it can come out while the tapes are properly tightened ; but it is unsuitable for cases where there is a tendency to chordee, or with a soft instru- ment. Third Method. — A piece of bandage a yard and a half long is split at each end for one-third of its length. Two of the tails are fastened round the waist, and the other two carried along the groins and between the thighs, to be fastened to the waist bandage behind. The tapes or threads attached to the catheter can now be readily fastened to the bandage close to the root of the penis, a hole being cut in the band- age for the purpose if desired. Fourth Method. — For this an ivory or gutta percha ring, large enough to go easily over the penis, is necessary. As this method is a little complicated, it is well to avoid its repetition every time the catheter is changed, by tying sep- arate pieces of tape to the rings of the instrument, so that it can be freed vvithout removing the whole bandage. The tapes are brought down on each side of the penis, and are knotted to the ring around the root of that organ, the length of the tapes being accurately adjusted, so as to hold the catheter in its proper position ; the tapes are then carried round underneath the thighs and encircle them, a knot being formed in the centre of the groin on each side. The ends are next carried round the loins, and, having crossed, are finally tied near the umbilicus (Fig. 65). Care must be taken that the ring is amplj' large enough, and that the por- 220 TO TIE IN A CATHETER. tions of tape on each side of the penis are maintained siiffi- cientlj' short. Fig. 65 Fifth Method. — The following plan has been devised by Sir Henry Thompson, and answers well (Fig. 66). The middle Fig. 66. of a piece of "bobbin thread" (which cuts much less than ordinary ligature) is tied on to an elastic catheter, and the TO TIE IN A CATHETER. 221 double tbroad carried half wa^^ down the side of the penis, where it is knotted (A). The two threads then encircle the oro^an loosely, and are again knotted on the opposite side (B). A bundle of pubic hairs having now been selected, the threads are adjusted to the proper length, and are then tied around the bundle of hairs (C). A similar thread is then tied on the opposite side of the catheter, and the pro- ceeding repeated, each pair of threads encircling the penis, and being tied to the pubic hair on the side opposite to that on which they hold the catheter. Fig. 67. When a metallic instrument is used the ordinary stilette will be sufficient to restrain the flow of urine ; but when an. elastic catheter is preferred, a little wooden spigot must be fitted to it. In cases of injury to the bladder, etc., when it is desirable to carry off the urine as fast as it is secreted, an india-rubber tube may be conveniently fixed to the in- strument, and carried into a suitable urinal under the bed. 222 TO TIE A PATIENT FOR LITHOTOMY. A canula or catheter passed through the rectrnn into the bladder is best maintained in position b^^ four tapes, two passing in front and two beliind, to a circular band round the waist. A catheter, when retained for an}'- time, is apt to become clogged with mucus, etc., and if it is undesirable that it should be removed at the moment, it may be readily cleared by passing a stream of water through it by means of the india-rubber bottle described in the section on " Washing Out the Bladder" (p. 96). Fig. 68. To Tie a Patient for Lithotomy. — This operation is fre- quently bungled in the operating theatre, to the annoyance of both operator and b3^standers. The bandage, usually of flannel or soft, broad, worsted tape, should be about a yard and a half long when doubled, and the assistant who is going to tie should make a noose in it, by placing the centre of the double over his own wrist, tlien taking hold of the bandage lower down, and drawing it through the loop on the back of his hand (Fig. 67). The noose thus formed is RETRACTORS. 223 to be fastened securely round the v^rint of the patient on each side i)y a couple of assistants (Fig. 08;, and when the operating surgeon gives tiie signal (generally after the staff is introduced), another pair of assistants should bend the patient's knees and place his feet in the palms of his own hands. The first pair of assistants are then to bind the hands and feet firmly together by forming a series of figure- of-eight turns round the ankle and wrist with the ends of the bandage, finishing off in front of the ankle-joint with a bow. The patient is then brought to the edge of the table, and an assistant on each side holds the knees steady, and in the positions the operator may indicate. Fig. 69. For all long perineal operations, especially the tedious ones performed on the female, some form of retentive appa- ratus is to be preferred to the tie, which is apt to become loosened and slip. Either laced gaiters may be employed, in which case the lacing goes across the sole and the ring is to the outer side, or a simple padded flat strap may be used ; in either case to be hooked on to a stout wristband (Fig. 69). Retractors are not nearly so often used as in former days, but the house-surgeon should know how to make one if de- sired. In amputations of limbs with a single bone a re- 224 RETRACTORS. tractor of two tails is required, but where there are two bones, one with three tails will be necessary. A retractor is made of a piece of calico of a width suitable to the size of the limb, and about three feet in length. One end should be split and torn up to the centre of the retractor, where a small circle may be cut out with the view of accommodating the bone better. The three-tailed retractor is made in the same wa}^, but is split into three parts, the middle one being intended to pass between the bones. FRACTURES. 225 CHAPTER IX. FRACTURES. The entire subject of fractures is much too wide to be treated of systematically in a handbook like the present, and it is to be supi)Osed that a house-surgeon, besides having a general knowledge of the subject from previous reading, will possess some larger work on surgery, to which he may refer for any minute point of diagnosis. In the following pages, therefore, I shall merely enter into such details of the treatment of the ordinary fractures as may be useful to the house-surgeon, leaving him to refer to the works of Fer- gusson, Ericlisen, and Bryant, or to the elaborate American work by Dr. Hamilton, for further information, and for va- rieties of treatment other than those in common use in English hospitals. Diagnosis. — In the majority of cases there can be no doubt as to the nature of the accident on its first admission. The distortion of the limb, and the inability of the patient to perform the ordinary movements, will sufficiently mark the nature of the case, which will be further confirmed by the sensation of crepitus imparted to the hand placed over the seat of injury, while the limb is gently moved. When it is perfectly obvious that the bone is broken, it is only cru- elty to twist and turn the limb about merel3^ for the sake of producing crepitus, and thereby injury is often done to the soft parts, and the amount of extravasation is in all proba- bility increased. The errors into which the young surgeon may possibly fall are, first, in mistaking a deformity resulting from an old 19 226 SIMPLE FRACTURES. injury for a recent fracture (particularly if the patient should not be able to answer questions from drunkenness, etc.), and, secondly, mistaking the crepitus of a joint for that of a frac- ture. The latter is the more common error, and fortunately does little real harm. To guard against this it will be neces- sary to notice whether the entire bone moves when rotated, or whether (as in fractures) the crepitus is produced In the length of the bone ; careful measurement and comparison with the opposite side will show also that there is not the slightest difference in the length of the limb, and the pa- tient, if urged to do so, will probably be able to exercise an amount of force with it which would be incompatible with the existence of a fracture. Women who have been hard at work all day at the wash-tub, not unfrequently find at night that a swelling has taken place at the lower part of the arm, which they attribute to some blow, and apply at an hospital for relief for a supposed fracture of the radius, which the swelling and obscure crepitation, the result of effusion, cause it to resemble pretty closely ; and in the same way persons with rheumatic joints who may happen to meet with an ac- cident, exhibit an amount of crepitus which might ver}^ pos- sibly mislead the unwary surgeon. The house-surgeon need scarcely be warned not to concentrate his attention entirely upon the injur}" in one limb to the neglect of fractures or other injuries in other parts of the body, but such cases of inattention have actually occurred. Simple Fractures. — In the examination of simple frac- tures the greatest care must be taken not to convert them into compound ones by rough manipulation, which might cause a spiculum of bone to perforate the skin ; and in all cases, therefore, of supposed fracture, the limb should be thoroughly exposed by cutting open the clothes before it is manipulated in any way. The time chosen for " putting up" fractures varies a little in different hospitals, some surgeons applying splints, etc., DISLOCATIONS ACCOMPANYIN'G FRACTURES. 227 immediately, others preferring to wait until all swelling has subsided ; but this only applies to fractures of the lower ex- tremitj', those of the arm being dressed at once and treated for the most part among the out-patients. If a fracture is quite recent, it will be found most convenient to put it up at once, since the subsequent swelling is thereby often en- tirely prevented ; but should some hours have elapsed since the accident, and the limb be already swollen, it is impossi- ble to put it up in its final apparatus, and it may, therefore, be laid on a pillow, or loosely fastened upon a splint until the swelling has subsided. In all cases where the treatment has been immediate, the possible occurrence of subsequent swelling must be borne in mind, and the patient, if allowed to go home, should be strictl\' enjoined to come and show himself within twent\'-four hours, or earlier if the limb be- come painful or numbed. In the hospital a little care will prevent any untoward results from tight bandaging, etc., but it does occasionally happen that a limb will swell imper- ceptibly, or while the patient is asleep, and produce an inju- rious amount of constriction, and the house-surgeon should therefore take a look at all recent fractures the last thing at night. Should the amount of swelling which has already taken place interfere with the diagnosis of the injury, it will be better to use palliative measures, such as cold lotions a,ncl a sling, until the swelling has gone down; and in ob- scure cases it will be only right to take the visiting sur- geon's opinion before commencing a course of treatment. Since in certain cases of obscure injury about the upper ends of the femur and humerus impaction is one of the best forms a fracture can take, it would be a very bad practice to undo the natural cure thus effected by rough manipula- tions, though by so doing the diagnosis might be rendered more complete. Dislocations accompanying fractures of the shafts of bones should be reduced as soon as the limb has been firmly put 228 (COMPOUND FRACTURES. up in splints, so that it may receive no further injury ; but in fractured, of or near the articular extremities with dis- location of the fragment, as in the case of fracture of the upper end of the humerus with dislocation of the head, it will be necessary to manipulate under chloroform the head of the bone into its proper place before the fracture can be properly set. Or, if this is impossible, the shaft must be brought into close relation with the glenoid cavity, so that a false joint may be formed, or the fracture must be allowed to unite without reduction of the dislocation. Occasionally it may be possible to reduce the dislocation after union of the fracture, but in the majority of instances the attempt leads to refraction of the bones. In any case of this complicated injury, it is advisable to explain to the patient and his friends exactly what has oc- curred, lest the non-reduction of the dislocation, which will become obvious enough when the swelling has gone down, should be attributed to carelessness. The administration of chloroform is often of the greatest service in cases of fracture, both by enabling accuracy of diagnosis to be attained, and by assisting in the reduction" of the broken fragments b}'^ completel}^ relaxing the muscu- lar spasm, and thus, in many cases, obviating the necessity for the division of tendons, etc. The advantages of the use of an anaesthetic in case of fracture complicated by dis- location must be still more obvious. Compound fractures should, if possible, be converted into simple cases as soon as possible, by healing the rent in the skin. When the injury to the integuments is recent and slight, a piece of lint covered with blood or collodion, or the compound tincture of benzoin, is the best applica- tion ; but where a crushing force has been applied, and the skin is so damaged that union b}^ first intention is impos- sible, it will only do harm to convert a sore into an abscess by sealing it up, and water-dressing or a poultice will SETTING FRACTURES. 229 therefore be the best treatment, unless resort is had to the antiseptic method described at p. 158. The question of amputation in compound fractures must, of course, be left to tlie visiting surgeon, and the house- surgeon should not hesitate to request his immediate attendance should an}' of the following complications be present: 1st, Great comminution of the bones and destruc- tion of soft tissues. 2d. Two or more compound fractures in the same limb. 3d. Rupture of, or severe injury to, tlie principal vessels and nerves of the limbs. 4th. Compound fracture into a large joint. Setting Fractures. — All fractures, both simple and com- pound, must be set properly, i.e., the broken portions must be brought into their proper relation with the rest of the limb before a cure can l»e effected. As a general rule, it is better not to attempt to set a fracture until everything is read}^ and at hand for its final treatment or "putting up;" but when a piece of bone is seen to have taken up such a position that an}' slight movement of the patient may force it through the skin, it will be better to make traction at once, restore the piece, if possible, to its proper place, and keep up extension while the necessarj' apparatus is being prepared. In thus effecting extension, one assistant should grasp the limb firmly above the injury and another below it, and both should then make steady traction in opposite directions until reduction is effected, of which the house- surgeon will judge partly by the restoration of the sym- metry of the limb, partly by carrying the finger along the most prominent portion of the bone, to ascertain its regu- larity, as well as by comparison with the other limb and careful measurements. In making comparative measurements of limbs, great care must be exercised to take precisely the same fixed points on the two sides ; and an ordinary measuring tape is 230 TEST MEASUREMENTS. the best instrument for the purpose, since the exact measure- ment of each side can be at once read off and recorded. The following are the principal points made use of in measurinor the limbs : In the upper extremity — From the extremity of the acromion process to the ex- ternal condyle of the humerus. From the tip of the coracoid process to the inner con- dyle. From the condjies to the st3'loid processes of the radius and ulna. Fig. 70. A In the lower extremity — From the anterior superior spinous process of the ilium to the lower border of the patella. (The lower border of the patella should always be selected, and the bone be pushed up as far as the ligament will allow it to go, or error may be caused by the contraction of the muscles of the thigh.) From the crest of the ilium to the top of the trochanter. From the patella to the inner or outer malleolus. From the anterior superior iliac spine to the malleoli. A line (AB) drawn from the anterior superior iliac spine to the tuberosity of the ischium (Fig. 70) will, in the healthy APPARATUS FOR FRACTURES. 231 subject, just touch the top of the great trochanter. This is Nehiton's test line for dislocation of the femur upwards or backwards, in either of which accidents the trochanter will reach above the line. Mr. Bryant has recently called atten- tion to the value of the iliofemoral triangle (Fig. 70) in the diagnosis of injuries about the hips, and particidarly of im- pacted fracture of the neck of the femur. The patient beino- recumbent, a vertical line (AC) is allowed to fall from the anterior superior iliac spine, from which the distance (CD) to the top of the trochanter can be measured at a ri^ht angle to it. If the neck of the femur be broken, and the trochanter drawn up, this line will necessarily be shorter than on the sound side. Before applying any apparatus, the limb should be cleansed with soap and water; and in hot weather a little starch-powder dusted over the skin will prevent the itching, which may otherwise become intolerable. Apparatus for Fractures.—Splinta oUvqyj ^yo^^ihle form have been invented for the treatment of fractures, the greater number of which are never used, at least in hospital practice. Both metal and wooden splints are in common use, and the ordinary ones will be indicated in the following pages in describing the treatment of the individual frac° tures. Both kinds must be carefully selected so as to fit the limb accurately, and should be thoroughly padded before being applied. Pads may be made of tow, cotton-wool, or sheep's wool— the advantage of the latter being its greater elasticity. The material chosen should be carefully packed together so as to fit the splint and slightly overlap its edges, and should then be inclosed in a piece of soft cloth or muslin, which may either be made to wrap round tlie splint and pad to- gether, or, inclosing the pad alone, may be afterwards stitched to the splint, according to the fancy of the surgeon. 232 GUTTA-PERCHA SPLINTS. Care must be taken to prevent the stuffing of the pads be- coming lumpy and uncomfortable, and in making large pads, which will be subject to continued pressure for some weeks, it will be advisable to have the thread carried through them at a few points, so as to prevent the shifting of the stuffing. Yery sufficient extempore pads may be made for the use of out-patients by wrapping some tow or wool in a piece of muslin or lint, and then fastening it to the splint with a strap of plaster at each end. Splint-room. — Every hospital is, or should be, provided with a room specially fitted to contain surgical appliances. It should be fitted with cupboards, having shelves long enough to hold full-sized splints, which should be kept sorted and padded ready for use. In order to keep the splints and pads clean, a sheet of unbleached calico should be folded round each division ; otherwise the dust gets in, and, when requiied, the pads have to be re-covered. All splints should be thoroughly washed before being re- padded ; and if employed for gangrenous cases, etc., they should be repainted if made of iron, or scraped if of wood, before being again used. Guttapercha is a most useful material for splints, and for this purpose its thickness will xavy from an eighth to a quarter of an inch, according to the amount of support required. To use this substance effectively, one or two minor precautions are nccessar}' ; the first of which is that a pattern of the splint required sliould be made in brown paper, so that the gutta-percha may be cut an inch or two larger every wa}^, since the gum undergoes contraction upon being immersed in hot water. A basin or pan, suf- ficiently large to take in the piece of gutta-percha without bending, should be provided, and boiling water will l)e necessary for its preparation. It will save scalding the LEATHER SPLI^'TS. 233 fingers, and also maintain the sliape of the splint better, if tiie gutta-i)ercl)a he laid upon a piece of muslin of suitable size, by whicii it can be immersed in tiie water, and held there until perfectly softened. Being then lifted out by means of the muslin, it should be allowed to cool for a mo- ment or two, so as not to scald tlie patient's skin, and must next be applied to the part to which it is intended the splint should be fitted. The wet fingers of the operator^ should then mould it carefull_y to the limb, and afterwards a bandage had better be applied so as to maintain it in position until cooled. In a quarter of an hour the splint may be removed, and any roughness of the edges trimmed off with a sharp knife, when it may be padded with wool or lined with wash-leather plaster, and will be fit for use. In order to obviate the unpleasant confinement of the perspira- tion which the gutta-percha causes, it will be advisable to make a series of holes in the splint, when perfectly cold, with a punch of the diameter of an eighth of an inch or more ; and if the splint is lined with leather, it should also be perforated in the same wa}''. In fitting a gutta-percha splint to a case of fracture, care must be taken to bring the parts into the exact position they are intended to occupy eventually, before the gutta- percha cools, or the mould will be useless; and in some cases, therefore, it will be better to shape the splint upon the corresponding portion of the sound limb, and after- wards make any little alteration which may be necessary for the opposite side. Leather. — Thick sole leather may be used for making splints, being cut to a paper pattern with a sharp knife, and then softened in hot vinegar and water before being moulded to the limb, in the same way as the gutta percha, over which it has the advantage of not interfering with the functions of the skin, but is otherwise not so manageable as the gum. 20 234 LEATHER-FELT SPLINT. Leather is particularly useful in the treatment of chronic joint-disease, particularly of the hip, in children, in whom the application of a well-made leather splint, of the form shown in Fig. 71, allows the use of crutches at an early period. In fitting a leather splint to the hip, or any other joint, it is most important that the leather should be thor- oughly softened before it is applied, so as to adapt itself easily to the irregular surfaces ; and the splint should be made sufficiently large to take a firm hold of the pelvis and thigh respectively. When hardened by drying, in situ, the Fig. 71. splint should be lined with wash-leather, and fitted with straps and buckles, or, in the case of the smaller joints, the edges ma3^ be fitted with eyelet holes, and a lace may be emplo^'ed. Leather-felt Splint. — Mr. Hides, of Mortimer Street, has patented a form of felt combined with wash-leather, which can be rendered suflfilciently stiff to afford support to a limb, by soaking the felt in a solution supplied for the purpose. PORO-PLASTIC SPLINT. 235 A [)iece of the required size is to be laid upon a table, with the leather side downward, and the fluid is to be freely applied to the felt by means of a paint-brush. The splint is to be affixed to the limb by tapes, so as to permit evap- oration, and on drying will become stiffened. This splint ma}^ be usefully employed for the support of limbs, but cannot be satisfactorily^ moulded to the joints. On an eraergenc}^, very serviceable splints for fractures ma}'^ be improvised out of cardboard, a hat-box, or even an old hat itself, softened in hot water. Poro-plasfic Splint. — This material, whicli is supplied in sheets of several qualities by Mr. Cocking, of Plymouth, has the great advantage of onl}^ requiring to be dipped in boil- ing water before being moulded to the limb. It rapidly sets, and in the course of a few hours becomes dr}^ and hard, when it may be removed and lined with wash-leather or linen l:)efore being reapplied to the affected part. When used for the treatment of fractures, a wooden splint may be advan- tageously applied as a temporary support during drying. The poro-plastic material is now supplied by the manufac- turer moulded in all the sizes of ordinary splints, which can be slightly modified by the application of dry heat as re- quired. It has also been extensively used for spinal sup- ports, but for this purpose requires in most cases strength- ening by the addition of light metal bands. Iinmovahle Apparatuses. — Under this head will be de- scribed the mode of applying bandages to which certain adhesive substances are added, with the view of fixing them firmly upon a limb, and incasing it so as to form a most useful method of treatment in almost ever}^ varietj" of frac- ture. The substances in most common use among British sur- geons are : 1st, starch ; 2d, a mixture of chalk and gum ; 3d, plaster of Paris ; 4th, glue ; and 5th, silica. Of these the 236 STARCH BANDAGE. starch is, perhaps, the most extensively employed ; but the plaster of Paris bandage possesses, in my opinion, such de- cided advantages over it, that it will eventuall}' in most cases supersede the starch, as the method of using it be- comes more generally known. Starch Bandage. — The starch is mixed in the ordinary way with warm water, and is to bo of the consistenc}' of that used by laundresses. The limb being held in a suita- ble position by assistants, the old practice is to apply a dry bandage over the whole length of it. The starch is now to be painted with a brush over the bandage, and made to soak into its interstices ; and any inequalities are to be filled in with cotton-wool soaked in the starch. Strips of paste- board, torn of a suitable size and shape, and well soaked in the starch, are then to be laid along the limb in the posi- tions in which support will be principally required ; and lastly, a well starched bandage is to be applied two or three times over all. Owing to the amount of moisture necessarily included in this apparatus, it will take many hours to dr}^, and the limb must tlierefore be carefully maintained in position by means of sand-bags, and, if necessar^^, hy extension with a band- age. When the starched case is dry, it is customary to lay it open with a pair of strong cutting pliers, in order to see that the limb is in proper position, and a fresh-starched bandage is afterwards applied over the case to restore its continuity. If the limb should have been swollen when the bandage was first applied, in three or four days the starched case will be found to be too large, owing to the natural sub- sidence of the swelling ; and it will be necessary to split open the case again, and having pared the edges to the requisite amount, to reapply it with a fresh external bandage. The great diflilculty in using this apparatus will be found to be the dangerous and unl'earable constriction of the limb caused by the shrinking of the first dry bandage. This PLASTER OF PARIS BANDAGE. 2;i7 however, ma}' be advantajjeoiish' dispensed with altogether; or if emi)loyed, care should l)e taken to use a liaudage which has been washed and thoroughly slirunk, and this precau- tion will be as well for all the bandages used with the starch. M. Seutin avoids the use of the first dr}' bandage 1)}' emplo}'- ing cotton-wool smeared with starch, in which the limb is wrapped, and this has the advantage of becoming com- pressed by the contracting bandages outside it, and thus guards the limb from injurious pressure. The house-sur- geon must exercise the most vigilant care, for the first forty- eight hours after ai)})lying the starch-bandage, that no such pressure occur, and must not scruple to cut the whole ap- paratus away, if the extremities of the limbs show the least symptom of it, or if the patient complains of feeling great constriction. Chalk and gurii bandage is applied in exactl}" the same way as the starch bandage. The adhesive mixture is made by adding boiling water to equal parts of gum arable and precipitated chalk ; and this material has the advantages over the starch, both of becoming firm sooner, and of having more strength, so that the addition of strips of pasteboard is rarely necessary. Plaster of Paris Bandage. — The plaster for this purpose should be the fine wliite powder used b}' modellers ; and must not be old, or it will have become deteriorated b}' the absorption of moisture. There are two ways of appl3'ing the bandage. First Method. — Taking a loosely woven bandage (the crinoline muslin recommended by Sayre is admirabl}' suited for the purpose), the dry powder is to be rubbed into its meshes on both sides with the palm of the hand, and the bandage is then to be loosely rolled. These powdered bandages may be kept rolled and always ready, if they are l)reserved in a covered jar so as to exclude the air. When 238 PLASTER OF PARIS BAXDAGE. required, the bandage should be placed on end in a basin of water, deep enough to cover it, for a couple of minutes, that it may become thoroughly wetted, and should then be ap- plied as rapidly as may be upon the fractured limb, which must be carefully held by the assistants. The bandage may be applied directl^^ upon the skin, if the fracture is an old one and has been treated in splints, so that there is no prob- ability of svvelling coming on ; but in recent fractures, for which it is peculiarly adapted, it is necessary to envelop the limb in cotton- wadding, and even in old cases it is better to have a stocking over the limb, whether leg or arm. The best protection for the limb is the glazed wadding, and the limb should be thoroughly enveloped in one thickness of this, the o;lazed side beino- outwards. The advantao^e of this over cotton- wool is that it is not easily wetted and messed by the plaster. A turn or two of the plaster band- age may be taken over the limb to fix the wadding, and the limb is then to be S3'stematicall3^ bandaged, and, as far as possible, "reversed turns" should be avoided, but each fold of the bandage should thoroughly overlap the one below. It will materially strengthen the casing if the operator has a little of the plaster mixed with water to the consistence of cream, b}^ his side, and applies some of it with the palm of the hand between the two layers. If the interior of the bandage should not have been sufficiently wetted, it can be readil}^ dipped into the basin again, and a little of the fluid plaster applied over all will fill up any irregularities. Second Method. — If the powdered bandages are not al- ready prepared, the following will be the readiest way of applying tlie bandage. Some cold water being placed in a basin, the plaster is to be shaken in, and the water well stirred until it becomes of the consistence of cream ; then the bandage being placed in another basin of water, that it may become wetted as it unrolls, the operator is to com- mence rolling it in the basin containing the plaster, which will thus become etfectually applied to its surfaces. The PLASTER OF PARIS BANDAGE. 239 bandage should V)e applied to the limb in the manner de- scribed above, and some of the mixed plaster can be used to fill up the interstices. Tliis method has the advantage over that of rubbirg in the dry plaster, that it remains firm when exposed to continued immersion in warm water. When the surface to be covered with the plaster bandage is ver}' extensive, it ma}^ be advisable to dela}'' the setting of the plaster by the addition of a very small quantity of size to the water; or, if that is not at hand, a little stale beer will answer as well. The addition of salt to the water in- creases the rapidity with which the plaster sets. In whichever way the bandage is applied, the assistant who is holding the limb should maintain his hold for five minutes after the operation is completed, when the plaster will be sufficiently set, and will only require time to dry. As far as possible this rule should be followed of fixing the joint above and below the fracture ; thus, in the case of the thigh, the plaster bandage should be begun below the knee, and be carried in a spica round the pelvis, so as to fix the hip-joint, especial care being taken to thoroughly protect the groin with wadding. The day after the application of the bandage, when it has become dry, the surface should be painted with gum-water, white of egg, or, what is much clieaper, common flour paste, which will prevent the plaster from chipping ; and in chil- dren or imbeciles, when the bandage is likely to be wetted with urine, a coat of spirit-varnish over the exposed surface of the limb will prevent all damage, and materially assist in maintaining cleanliness. The great advantages which the plaster bandage pos- sesses over the starch and enm are. the ease with which it can be applied, and the rapidity with which it sets, thus forming at once a perfect case for the limb, and obviating the necessit}' for the maintenance of extension during the process of drying. The plaster bandage is readily removed, when done with, by simply unwinding it, whereas the oper- 240 PLASTER OF PARIS JACKET. ation of cutting open the starch apparatus is always one of considerable difficulty; or should the plaster be too thick for this to be accomplished, the dilute hydrochloric acid may be rubbed along one side for a few minutes, when the bandage will become soft enough to be cut with scissors. In this wa}^ also valvular openings may be made if required. Sayre''s Plaster of Paris Jacket. — The method of treating both lateral and angular curvature of the spine by exten- sion, and the application of a plaster of Paris jacket, intro- duced by \)i'. Saj're of New York, requires care to secure its efficienc}^ The extension is made either from a tripod contrived for the purpose (Fig. 72), or, more simply, from the top of a doorwa}^, or any suitable beam into which the pulleys can be fixed with a screw. The cross-bar attached to the puller's supports a leather strap fitted to the chin and head, and axillary straps, which may be employed if necessary. For lateral curvature the head strap only should be employed, and the patient should be shown how to suspend herself, with the toes touching the ground, while the bandage is applied. In angular curvature the extension, if any, should be carefully regulated so as to relieve and not cause pain. The following is in Dr. Sayre's own words {British Medical Journal, Sept.'27th, 1879j: '*The first requisite is an elastic woollen shirt, knitted and without seams, similar to a stocking, with tapes at the top to tie over the shoulders, instead of sleeves, as the shirt can then be pulled tightly down, and secured by a safety pin between the limbs ; and thus, by its elasticity, be made to fit accurately all the inequalities of the trunk. Previous to its being tlius secured, a pad of cotton, folded in a napkin, should be placed under the shirt, over the region of the stomach ; and in females it should also cover the maramifi. After the plaster has 'set,' the pad is to be- removed, and thus allovv room for the stomach to expand PLASTER OF PAKIS JACKET. 241 on after meals, and also to prevent any undue pressure the mammary glands. The bandages should be made of coarsel^-.woven muslin, called 'crinoline,' so that the plaster Fig. 72. can be rubbed into its meshes. They should be from three to four inches wide, and about three to four yards long. The gypsum should be pure, and freshly ground, and per- 242 PLASTER OF PARIS JACKET. fectly dry. It should be rubbed into the meshes of the cloth, and then rolled, but not too tightly. As thu^ pre- pared, the bandages can be kept in an air-tight/vessel, read}^ for use at any moment. If the climate be yei'y wet, it is as well to subject them to the heat of an ovei; for a few minutes before using, to evaporate any moisture the plaster ma}' have absorbed. ''When about to apply the dressing, the surgeon takes a single roll of the bandage, and drops it into a vessel of cold water, which should be deep enough to completely immerse it in the vertical position, and as soon as the gas has all escaped it is ready for use. As he removes it from the water, he squeezes out the surplus water, and drops into the basin another roll — end up — and by the time the first one is applied, the next will be ready for use. This is to be continued until as many are applied as each particular case ma3^ require, the jacket being strengthened by slips of tin placed between the la3^ers of bandage. " In cases of spondylitis, the patient is to be carefully extended by the head and axillary straps, until he is per- fectly comfortable, and never beyond that point. "As soon as the patient has been extended until he is perfectly comfortable, apply the wetted roller-bandage smoothl}' over the skin -fitting shirt, not drawing it tightly, but simply unrolling it around the bodj^, while an assistant follows with his hand and fingers, and presses it into all the inequalities and irregularities of the body, thus obtaining an accurate mould of the trunk in the improved^position which extension has given to it ; and, by keeping the patient in this position for a few minutes until the plaster has 'set,' he will then be retained exactly in the same position so long as the plaster remains unbroken. "After the plaster has 'set,' the pad which has been placed over the stomach and mammae is to be removed. Slight pressure should be made over the lower part of the abdomen on the crista ilii before the plaster has hardened, PLASTEE OF PAELS SPLINT. 243 SO as to mould it to the form, and remove the undue pressure on the spinous process and the crest of the ilium. As soon as the plaster has 'set,' the patient ("unless par- al3'zed) can go out of doors and take the ordinary exercise so necessar}^ for liealth, and, if an adult, can resume some active employment by which he can earn his support." When the deformity is in the neck, it may be necessary to affix a "jury-mast" to the back of the jacket in the pro- cess of making it, from which a strap passes beneath the chin to support the head and make slight constant exten- sion upon the cervical vertebrae. "The advantages claimed for this plan of treatment are: " 1, Its applicability in all cases where any mechanical treatment can be applied, and by anj^ surgeon in the country, without the aid of an instrument-maker. " 2. That, being accurately adjusted to all parts of the body when in its improved position, it gives more uniformity of support than can be done b}' any other means, and without making any undue pressure at any prominent point, and thus avoids all dano;er from slouo^hinor and excoriations. " 3. By absolutely immobilizing the spine, and removing undue pressure from the inflamed portion of the vertebrae, it affords greater facilities for anchylosis than can be given by any movable apparatus. " 4. The patients thus treated are capable of daily exer- cise in the open air, so necessary for health, and also of earning their support b}^ manual labor. "5. By applying this treatment in the early stages of the disease before deformity has occurred, the patients will be cured (when curable) without any deformity." Plaster of Paris Splint. — The following is another mode of using the plaster so as to form a regular splint for the limb, which can be removed and reapplied at pleasure. The description is that given by Dr. Little, of New York: " The limb is first shaved or slightly oiled ; a piece of old 244 PLASTER OF PARIS SPLINT. coarse washed muslin is next selected, of such a size that when f(>lded about four thicknesses it is wide enough to envelop more than half of the circumference of the limb, and lono- enouo-h to extend from a little below tlie under surface of the knee to about five inclies below the heel. The solu- tion of plaster is then to be prepared. Equal parts of water and plaster are the best proportions, and the plaster is sprinkled in the water and oradually mixed with it. The cloth, having been unfolded, is immersed in the solution and w^ell saturated ; it is then to be quickly folded as before arranoed, and laid on a flat surface, such as a board or a table, and smoothed once or twice with the hand, in order to remove any irregularities of the surface, and, with the help of an assistant, applied to the posterior surface of the limb. The portion extending below the heel is turned up on the sole of the foot, and the sides folded over the dorsum, and a fold made at the ankle on either side. A bandage is to be applied })retty firmly over all, and the limb is then to be held in a jjroper position (extension being made if neces- sary by the siiri;eon), until the plaster becomes hard. The time required in preparing the cloth, mixing the plaster, and applying the casing to the limb, need not take more than fifteen minutes. After the plaster is firm, and tlie V)andage removed, we sliall have a solid plaster of Paris case partially enveloping the limb, leaving a portion of its anterior surface exposed to view. If au}^ swelling occurs, evaporating lotions can be applied to the exposed surface, and we can always easily determine the relation of the frac- tured ends. If necessar}^, an anterior splint, made of the same material, can be applied, and then both be bound to- gether with adhesive plaster, and, if desirable, a roller bandage over all. If the anterior splint is not used, two or three strips of adhesive plaster, one inch wide, or bands of any kind, may be applied around the casing, and will serve to keep it firml^^ adjusted to the limb. Thus applied, we have a most beautiful splint, partialty enveloping the limb, GI.UE BANDAGE. 245 making equal pressure, light, and allowing the yjatient to change his position in bed, or to sit up in a cliair, or go about on crutches ; and a splint which can be easily made in any place where plaster is to be had." Glue Bandage. — Mr, C. De Morgan adopted the use of tliis bandage in the Middlesex Hospital, and thus described it: "The best French glue should be used. It should be broken up and soaked in a little cold water for some hours, and then melted in the usual way in a glue-pot, as little water being used as possible. It is not necessary to soak tlie glue in cold watei', but if this is not done it will re- quire the longer heating. When it is to be used, about a fiftli part of its l)ulk of alcohol must be added ; methylated spirit answers quite well. At first this converts a great part of the melted glue into a whitish coagulum, but by a little stirring it all liquefies, and is then fit for use. The alcohol is added to induce the rapid dr3'ing of the glue, which would otherwise remain soft for many hours, but, when mixed with the spirit, begins to get firm on the sur- face very soon after it is applied, and in a short time be- comes tolerably firm throughout. It should .be applied with a^ moderate-sized flat hogs'-bristle brush. Supposing that a simple fracture of the leg is to be treated, these are the steps to be taken : "■The foot sliould be neatly and firmly bandaged from the toes to the ankle. Two or three streaks of glue alono- the sides and front will secure the bandage, so that it need not be again disturbed. The leg from the ankle to the knee should then be covered with a very thin layer of cotton- wool, — not the medicated wool, as it is called, but such as is procured in sheets for lining dresses. Of this a Wer, not more than the eighth of an inch in thickness, can be easily stripped oflT, and smoothly applied to the leg. A cotton bandage should then be rolled very smoothl}' and with tolerable firmness up the leg from the ankle to the knee. 246 GLUE BANDAGE. and well painted over with the glue. Another bandage should then be placed over the first, and the gluing process repeated. A third may then be applied and glued, and then a bandage should be put on over all, and the leg placed in position, and retained, if necessary, by sand-bags or junks. Of course, if the surgeon please, he may apply strips of bandage, or of any linen or cotton material he may find at band, instead of repeating the rolling process. The glue should be laid on freely, and brushed a little into the bandage. In some cases two la3^ers of the glued bandage will be found sufficient. In others it may be desirable to give greater support; but this can always be done as an after-process. The leg should be left at rest for from twelve to twenty-four hours. The glued bandage must then be cut through its whole length. This ma}^ be done with the ordi- nary scissors used for the starched bandage, or a director may be insinuated beneath the bandage and cut upon with a sharp knife. If too long a time elapses before the bandage is cut through, it becomes so hard that great difficulty may be found in cutting it at all. When the bandage is thus slit up, so great is its elasticity that it may have its edges separated sufficiently to allow it to be easily slipped off the leg ; and when left to itself it will resume its original shape, and this elasticity it will retain for as long as it is used. A strip not more than a quarter of an inch wide, and runuing the whole length of the bandage, should now be cut off from one edge, and holes punched out parallel to the edges on either side, and about half an inch from them ; into these ' eyelets ' are to be inserted, such as are commonly used in laced bandages or boots. '' The punching and insertion of the eyelets are rapidly done with the common instruments used for the purpose, which, with the eyelets, can be had at any tool-maker's. " The bandage is now complete. If it is thought desira- ble to strengthen it generallj^ or in any particular part, PARAFFIN BANDAGE. 247 this ma}' be done by gluing on fresh strips of linen. Its appearance may be improved V)y gluing on an edging of tape round the top and bottom, and along the sides of the slit. It is reapplied to the leg, and laced up as firndy as ma}^ be thought necessary. The lace, if it is not furnished with a tag, is best introduced on an e3^ed probe, and it should always be passed from without inwards. If the tag is introduced from within it alwa3''s gets entangled in the cotton-wool, and the process of lacing is extremely trouble- some. " Thus a case is formed which is completely moulded to the form of the limb, is very elastic, very firm, and very dural)le, and which can be accommodated with perfect ease to all the varjing states of swelling of the limb. " In situations where the roller cannot be conveniently carried round the part, the splint can be just as well formed by laying strips of linen in any direction and gluing them. The cotton-wool of course adheres to the first layer of the bandage, and comes off when it is removed. It is applied in the first instance, in great measure to keep the glue from contact with the skin." Paraffin Bandage. — Mr. Lawson Tait having noticed in some cases, especially compound fractures and others in- volving discharges from wounds, that both plaster of Paris and dextrin or starch bandages have the disadvantaffe of becoming offensive by absorbing the discharges, in order to obviate this, has proposed to use the ordinar}^ paraffin of commerce applied with a flannel bandage of loose texture. The method which he has found most convenient is to have as much paraffin as is thought necessary melted and placed in a ciliina bowl, which is to be immersed in hot water, to keep the paraflfin in a liquid state. The bandage is to be passed through the melted substance as it is being applied ; and as the paraffin melts at from 105^ to 120'^ F., accord- 248 SILICA BANDAGE. ing to its quality, no fear need be entertained as to scalding the patient. After allowing five or ten minutes for the set- ting of the bandage, two or three coats of the liquid paraf- fin should be brushed over it so as to get a thickness of a fourth or three-eighths of an inch, and if necessarj^ another saturated bandage placed over all. The advantages claimed for this method are its cheap- ness, — as paraffin sells at from fourteenpence to eighteen- pence per pound, — its extreme lightness, its cleanliness, its neat appearance, and that it perfectly resists moisture. It is very firm, and, if cracked, can be mended with a hot wire. Silica Bandage. — Mr. Wagstafle has used at St. Thomas's Hospital a bandage stiffened with silicate of soda alone, or in combination with lime in the form of common "whiten- ing." The silicates of potash and soda, dissolved in an excess of caustic alkali, are now prepared in large quantitj^ in the manufacture of soap, and can be easil}' obtained at a very moderate cost. Messrs. Hopkins & Williams, of 16 Cross Street, Hatton Garden, have supplied it in large quantities at 4d. a pound, and in small quantities at 6d. a pound, and it can be obtained, though inferior in character, at 2d. and 3d., — so that it is not an expensive material. The limb is to be left exposed to the air for about half an hour, but there is no fear of any of the silicate coming off after the first few minutes, and after half an hour or less (varying with the temperature) the bandage is firm enough to prevent movement. Moreover, the bandage continues to harden for about two or three da3's, at the end of which time it should be quite firm ; but it is usuallj^ firm enough in a few hours to insure immobility of a limb. The solubility of the silicate in water is an advantage, for it renders the removal of the bandage easy. SAND-BAGS. 249 Sand-hags are very useful adjuncts in the treatment of fractures, being laid on each side of the limb, with or with- out the addition of splints. Care should be taken that the material of which the bag is made is sufficiently fine to pre- vent the sand from getting out into the bed, and the sand itself should be the finest sea-sand, and thoroughly dried. 21 250 SPECIAL FEACTUEES. CHAPTER X. SPECIAL FRACTURES. Fractures of the skull are accompanied generallj'- by the symptoms of either concussion or compression of the brain. When, therefore, the injurj^ to the bone is only slight, con- sisting merely of a simple depression or crack of the cal- varia with more or less concussion, the house-surgeon may content himself with shaving the head and applying cold to it, conjoined with rest and darkness, unless more urgent symptoms should supervene, when the advice of the senior officer should at once be obtained. When, however, the injury is complicated by a wound of the scalp, rendering the fracture compound, or if it is com- minuted and S3'mptoms of compression are present, no time should be lost in summoning the surgeon of the da}^ ; since any operative interference, to be of service, must be early, and even should no operation be requisite, it is but right that, in cases which are always more or less ambiguous, the greatest experience should be brought to bear upon them. The house-surgeon must be careful not to mistake a bruise of the scalp (the margins of which are often so sharply de- fined as to resemble the edge of bone) for a fracture of the skull with depression. With a little care, it can be satis- factorily made out that the depression is imaginary, and the fluctuation of the blood in the centre of the tumor will assist in the diagnosis. These cases must never be punctured, and only require time for the due absorption of the effused blood. Fractures of the base of the skull may give rise to no FKACTURED PELVIS. 251 special symptoms at first, and be only detected by the flow of clear fluid from the ear after the patient is placed in bed. Perfect rest in a recumbent position is the best method of treatment, followed by the exhibition of mercury should acute head-symptoms supervene. Fractures of the spine are generally complicated with serious damage to the spinal cord, producing paralysis of the parts below the seat of injur}', or, if very high up, causing immediate death by cutting off the nervous supplj-- to the diaphragm. Since time is the only possible means of cure for these cases, tlie house-surgeon's care must be directed to the prevention of bedsores and disease of the bladder, by placing the patient upon a water-bed from the first, and by drawing off the urine at frequent intervals, and washing out the bladder at least once a da}' (vide p. 96). Fractured pelvis, resulting from a severe crushing force or a fall from a great height, is but too often complicated with rupture of some of the abdominal viscera, and es- pecially the bladder. The house-surgeon's first care must therefore be to introduce a catheter, and draw off an}' urine which the bladder may contain, the condition of which, bloody or otherwise, will help to the conclusion as to whether that viscus is injured or not. Bloody urine, though alarming, is by no means a certain sign of rupture of the bladder, since it may simply be caused by a bruise of the kidneys, bladder, or urethra (vide p. 43 for diagnosis). The most certain sign of rupture of the bladder is when 7io urine can be drawn off by the catheter, while it is shown by the history of the case that the bladder must have contained a considerable quantity at the time of the accident. If, as generally happens, the urine has passed into the peritoneum, probably nothing can save the patient ; but if, fortunately, the rupture may have taken place in front of the membrane, it is just possible that timely incisions may do good, and 252 rRACTUKED NASAL BONES. the visiting surgeon should therefore be summoned to see the case. Rupture of the urethra is occasionally caused by fracture of the pubic portion of the pelvis, and will possibly impede the passage of the catheter into the bladder, or subse- quently give rise to extravasation of urine (q. v.). Treatment. — A])solute rest being necessar}^, it is advisable to put the patient upon a fracture-bed, so as to avoid all disturbance when the bowels are relieved, etc. A broad strip of leather plaster may be fastened round the pelvis to keep the fractured portions in position, and, where the injury has comminuted the anterior part of the bone, the finger should be introduced into the rectum (or vagina) to restore the fragments as nearly as possible to their proper position. Occasionally the whole acetabulum of one side is detached by a double fracture, and consequentl}^ is pushed up by the contraction of the muscles of the thigh ; and it will then be- come necessary to make extension by means of a long splint, which will take its point of counter-extension from the oppo- site thigh, by means of a fillet, similar to that recommended by Sir W. Fergusson for the treatment after excision of the head of the femur ; or by a weight attached to the foot, with a counter-extending perineal band in the opposite groin. Fractured nasal bones should be restored at once to their proper position by means of a director introduced into the nostril, and will generally keep in place without an}^ plugging of the nostrils, provided the patient exercises ordinary care. These fractures are not unfrequently accom- panied b}' emphysema of the tissues about the root of the nose and eyelids, which may possibly be mistaken for com- mencing erysipelas. The best treatment is to paint the part with collodion, which, if repeated a few times, will exercise pressure sufficient to prevent further escape of air into the tissues. FRACTURED LOWER JAW. 253 In every case of injury to the nose, it is well to examine the condition of the septum, since it may be displaced con- siderably with or without fracture. If displaced, it should be at once carefully restored, under chloroform, by means of a strong director or other suitable instrument introduced into the nostril, and it ma}' be necessary to plug one nostril for a time to keep the septum in its place. Great care should be taken to injure the mucous membrane as little as possible. Fig. 73. Fractured lower jaw^ in hospital practice, is generally the result of a blow with the fist, and seldom of a fall, though the patient may assign the latter as the cause of the acci- dent. Care should be taken to examine all the teeth, to see that a tooth has not dropped into the fissure between the broken portions, as^ometimes happens, particularly in the molar regions. If the fracture is near the S3'mphysis, it is advisable to pass a piece of stout silk round the adjacent teeth so as to .254 FRACTURED RIBS. bind the fracture together, but this cannot be accomplished far back in the mouth. The wedges of cork, etc., which are recommended, are, as far as my experience goes, unneces- sary and useless, since they cannot long be kept in position, and then roll about the mouth, to the patient's great annoy- ance. It has been recommended to mould pasteboard or gutta-percha to the jaw externall}^, so as to form a splint for it, but in the majority of cases the following bandage alone will be found to form a quite sufficient and satisfactory treatment. A bandage, three inches wide and a yard long, should have a slit four inches long cut in the centre of it, parallel to and an inch from the edge, and the ends of the bandage should be split to within a couple of inches of the former slit, thus forming a four-tailed bandage with a hole in the middle. The central slit can now be adapted to the chin, the narrow portion going in front of the lower lip, and the broader beneath the jaw; and the two tails corresponding to the upper part of the bandage are then to be tied round the nape of the neck, while the others are crossed over them, and carried over the top of the head, as shown in the illus- tration (Fig. 73). In bad cases of double fracture, a metal "plate" lined with gutta-percha, and fitted by a dentist upon the teeth, is the most satisfactory mode of treatment.* Fractured 7'ibs are often very difficult of accurate diagno- sis, especially if the patient is fat; and in cases of doubtful injury to the thorax, it is as well, therefore, to apply a broad flannel bandage at once, which generally gives great relief. When a fracture can be clearly made out, the application of a broad piece of plaster, or better, of straps overlapping * The various forms of apparatus for the treatment of fractured jaw will be found at length in the author's work on Injuries and Diseases oi the Jaws, 1872. FRACTUEED CLAVICLE. 255 one another slightly, from tiie spine to the sternum of the affected side, will be the best treatment, since the move- ments of the sound side are thereby less interfered with than when the bandage is used. Cases of injury to the thorax, by crushes, etc., with or without fractured ribs, are materially relieved from the con- sequent dyspnoea by small doses of tartar emetic given for a day or two after the accident. Fig. 74. Fractured Clavicle. — More forms of apparatus have been contrived for the treatment of this fracture' than for any other, but the following are the methods most in use in hos- pital practice. A pad being placed in the axilla of the affected side, a figure-of-eight bandage is taken round the shoulders and behind the back; wool being carefully adapted to prevent rubbing of the axillae. This may be conveniently effected by folding some split cotton-wadding around a piece of bandage, and stitching it along the front and back. The shoulders being thus drawn back, the arm is fastened to the side by a few turns of bandage, being at the same time 256 FRACTURED CLAVICLE. pushed outwards by the axillary pad, while the forearm is carried in an ordinary sling. The disadvantage of this arrangement is the uncomfort- able drag of the bandage behind the shoulders, which is very irksome to the patient unless he continues in the horizontal position. In the second method, a firm pad, three inches thick at the upper part, but diminishing to an inch at the lower end^ which should be half-way down the humerus, is to be fast- FlG. 75. ened into the axilla of the affected side by means of a piece of bandage stitched to it and tied over the opposite shoulder. A bandage being taken twice round the middle of the hu- merus, so as to get a firm hold, is then to pass behind the body, and a few times round the chest, inclosing the hu- merus and binding it firmly to the side and in a vertical direction (Fig. 75). (The bandage is directed to be taken across the back first, to counteract the tendency there is to cross the humerus over the ciiest.) The forearm, being now laid across the chest with the hand towards the opposite shoulder, is to be inclosed in a regular series of turns round the body, a few of which should be made to pass under the FRACTUEED HUMERUS. 257 elbow and over the opposite shoulder, so as to keep the arm from dropping down. To keep the apparatus firm, the bandages should be care- fully stitched both along the front and back of the axillary pad and around the elbow; or if the surgeon choose lie may add plaster of Paris or starch to the above arrangement, and so thoroughly fix the parts. Fio. 76. Fig. 77. A very efHcient plan of treating fractured clavicle is with two broad straps of stout twilled calico plaster, as recom- mended by Dr. SaA're. The first strap is looped round the arm just below the axillary border, with the adhesive side outward, and pinned or stitched, with the loop sufficiently open to avoid strangu- lation. The arm is then drawn downward and backward until the clavicular portion of the pectoralis major is put sufficiently on the stretch to overcome the sterno-cleido- mastoid, and thus draw the sternal fragment of the clavicle down to its place. The strap is then warmed, and being carried round the body is fixed to it, and for better security 22 258 FRACTURED HUMERUS. is pinned or stitched to itself behind (Fig. 76). The second strap having a longitudinal slip for the elbow, is to be thor- oughly warmed and fixed npon the shoulder of the sound side and carried across the back to the elbow of the affected side, which is to be fitted into the slit. The elbow is now Fig. 78. to be pressed a little forward so as to bring the arm verti- cally^ to the side, when the strap is to be carried across the front of the chest to the shoulder, and there stitched, thus inclosing and fixing the forearm and hand (Figs. 77 and 78). The effect of this is to convert the humerus into a lever, of which the first strap is the fulcrum, and thus to maintain the broken clavicle in position. A third strap may be ad- vantageously put round the chest, arm, and hand, to keep the limb fixed. Ellis's apparatus for fractured clavicle is a simple and efiicient contrivance, which meets all the requirements given above, and is shown in Fig. 79. Its great advantage is the very serviceable crutch-pad, which is efficiently supported FEACTURED HUMERUS. 259 by the strap passing over the shoulder, and should be pro- tected by a fold of flannel from the perspiration of the axilla. The strap passing round tlie body incloses the upper arm, and keeps it perpendicular and fixed to the padded support of the crutch, and thus the arm is prevented from being crossed over the crutch. The hand should be sup^wrted by a s-imple sling. Fig. 79. Fractured Humerus. — If the fracture is near the upper extremity'' of the bone, it may be conveniently treated with, a rectangular iron splint, to which a crutch is fitted, with a screw so as to permit of extension being made in the axilla (Fig. 80). In using this it will be necessary to bandage the forearm and lower part of the humerus carefully to the splint before the screw is turned, and care must be taken not to press the crutch so forcibly into the axilla as to pro- duce oedema of the limb. This splint is sometimes fitted with a cap to pass over the shoulder and along the outside of the humerus, which may be used or not, at the fancy of the surgeon. Another method is to place only a pad in the axilla, and then to mould a firm gutta-percha splint to the shoulder and outside of the arm as far as the elbow. A bandage is then to be carefully applied over the splint and around the thorax, 260 FEACTURED HUMERUS. the walls of which, together with the pad, prevent disloca- tion inwards. The hand and forearm should be bandao^ed. Fig. 80. and the hand carried in a sling, which should not extend beyond the wrist, so as to allow the weight of the arm and Fig. 81. elbow to draw upon the fracture. Plaster of Paris or starch may be advantageously used to keep the parts firmly in i)0- sition (Pig. 81). FRACTUKED HUMERUS. 261 Fractures of tlie shaft of the humerus may be conve- niently treated with three straight splints, which can be easily cut to the length required for each case. The forearm being flexed, one splint is placed on the inside of the arm, reaching from the axilla to the inner condyle ; and care must be taken that the pad a little overlaps the splint at the up- per part, or it may excoriate the armpit. A second longer splint is placed on the outside of the arm, reaching from the Fig. 82. acromion to the external condyle ; and a third (or fourth if necessary) may be placed in front or behind, between the other two. These may be bandaged to the arm ; or, as shown in the illustration (Fig. 82), a couple of linen straps and buckles may be used. The forearm may be placed in a sling (Fig. 63), taking care that the elbow is not pushed up ; or the whole arm and forearm may be covered with a band- age passing round the thorax. A rectangular splint on the inside alone, or on both sides of the arm, and reaching to the wrist, may be used, care 262 FRACTURED HUMERUS. being taken to pad thickly near the condyles ; or, what is better, to have a hole cut in the splint to fit the projecting bone. The straight splints, figured above, may be conjoined with the rectangular inside splint, or the plaster of Paris bandage alone may be employed. Fractures at the lower end of the humerus are best treated with an inside rectangular splint; and when the injury in- volves the elbow-joint, care should be taken that it is not injuriously compressed by the bandages. In fact, it is Fig. 83. jBASE 4- i.M. THICK better to avoid taking the bandage over the joint at all, so as to allow of the application of fomentations or evap- orating lotions, if necessar^^ Complicated injuries of the humerus or elbow-joint may be satisfactorily treated, so long as the patient is in bed, with Stromeyer's cushion (Fig. 83). The measurements here given are those for an ordinary man, but can be easily modified to suit each case. The cushion should be made of folded blanket, or some firm material, and, when there is an open wound, be protected with waterproof. The cushion is fastened with one tape round the neck, and one round the body; and, when the patient is recum- bent, the arm lies upon it without any other support FRACTURES OF FOREARM. 263 (Fig. 84). When, liowever, the patient is able to sit up, it will be necessary to pin a broad bandage round the arm and body. Fig. 84, Fractures, of Forearm. — The treatment will be the same, whether the shaft of one or both bones of the forearm is Fig. 85. fractured. Two light wooden splints are ordinarily used ; but surgeons differ as to their length, some carrying the 264 FRACTURES OF FOREARM. splints to the tips of the fingers, while others make them reach only to the wrist. It will, however, be found most satisfactory to have the splints long enough to reach to the metacarpal bones, so as to prevent motion in the wrist-joint, but not to interfere with the movements of the fino-ers (Fig. 85). Care should be taken, in selecting the splints, to have them verj^ little wider than the limb itself, — only enough, in fact, to take off the pressure of the bandage, since otherwise the limb will roll about between the splints, and a very indifferent cure will be effected. The splint for the front of the arm must be a little shorter than the other, to allow of the elbow being easily flexed ; and in padding the splints, care should be taken to make the stuffing rather thicker in the centre than at the sides. Although the position which the arm will ultimately assume will be between pronation and supination, in setting the fracture and in first applying the splints the limb should be supinated, by which step the bones will be brought par- allel to one another. Having satisfied himself that the broken bones are in proper apposition, the house-surgeon should then gently lift the limb on to the back splint, and lay the front one upon it ; next, grasping the two ends of both splints firml}^, he should bring the arm into a position midway between pronation and supination, and hold the splints while an assistant passes a strap of adhesive plaster around each end of them, so as to fix them securely (Fig. 85). By thus avoiding all muscular action on the part of the patient, the chances of displacement are greatly diminished, and the bones will probably be in much better position than if the splints are put on after the rotation has been made. A bandage can afterwards be applied over the splints, and the arm suspended in an ordinary sling. A single splint is sometimes made use of; and in that case the hand is generally pronated, and the splint is carved to fit the wrist and metacarpal bones. COLLES S FKACTURE. 265 CoUes''s Fracture. — For the treatment of this fracture of the lower end of the radius, it is necessary that the hand shouhi be adducted ; and for this purpose such a splint as is shown in the illustration (Fig. 8(i), ora more perfectly pistol-shaped one, as preferred by some surgeons, may be employed. The practice varies as to which side of the limb the splint should be applied to; most surgeons, however, preferring the palmar aspect. In applying the splint, the Fig. 86. limb should be firml}- grasped, and the hand adducted until the bones come into proper position, when the splint may be applied to the palmar surface, and held there, while a strap of plaster is applied around tiie hand, and another round the upper part of the forearm, to keep the limb in the necessarily strained position. A bandage should after- wards be applied over the hand and at the upper part of the forearm, but not over the seat of fracture, as it would tend to displace the broken ends.* Gordon's splints for Colles's fracture are much used in Dublin, and have the advantage of leaving the fingers free, and thus avoiding sul)sequent stiffness. The palmar splint * Vide illustration with pistol-splint applied to the dorsal surface, in Erichsen's Science and Art of Surgery. 266 FRACTURED METACARPAL BONES. (Fig. 87) is hollowed out to receive the forearm, which is placed in the prone position, and with the hand hanging over the end. A convex ridge is placed on the radial side of the splint, which keeps the fragments in position ; and Fig. 87. this is aided by the hollow upper splint (Fig. 88), which is broader at the lower than at the upper end, and has an overhanging lip on the radial side. Simple pads are adapted to each splint; and the fracture having been re- FlG. duced, they are applied to the limb, and fixed with straps and buckles, as shown in Fig. 89. Fractured Metacarpal Bones. — If one of the central meta,- carpal bones is broken (generally in fighting), it will be most efficiently treated by placing a stout ball of tow in the palm, and then flexing the fingers forcibly upon it until the frac- ture is reduced, when the hand must be retained in position by bandaging the fingers firmly down to the wrist, the meta- carpal bones being left uncovered. If one of the lateral bones or that of the thumb is broken, a palmar splint, of either wood or gutta-percha, and thickly padded, may be employed ; and it may be necessary to flex the fingers over FEACTURED THIGH. 20 7 the top of the splint, before the broken bone can be properly adjusted. Fractured phalanges are readily treated with a splint of wood or gutta-percha, and a bandage similar to that figured for the finger (p. 205). It will be found convenient to pad the splint by wrapping it up in a suitable piece of lint, two or three times folded ; and it will be best to make it lono- enough to reach well into the palm of the hand. Fig Fractured Thigh.— The long splint, with a perineal band, is one of the commonest modes of treating fracture of any part of the femur. In applying it, care must be taken to select a splint long enough to reach from the lower part of the axilla to a few inches beyond the heel, and that in chil- dren the splint is not wider than the thickness of the limb, or it will be impossible to prevent the thigh from rolling beneath the bandage. A useful addition to the long splint is a small wooden cross-bar fastened below the splint and a few inches from its lower end. This both obviates injurious pressure upon the patient's heel and prevents the rolling of the limb to one side, and is therefore a great assistance, especially in cases of hip disease. In some hospitals, De- sault's splint, with a foot-piece, is preferred to the plain lath commonly known as Listen's splint. The perineal band is a most important part of the appa- 268 THE LONG SPLINT. ratus, and is best made of a piece of soft cotton bandage stitched so as to form a long narrow bag, and tlien stuffed withL cotton-wool. This should be long enough to reach from the middle of the groin to the corresponding point be- hind, and to each end of it should be attached stout tapes, which w^ill work much more easily through the holes in the top of the splint than any bandage. It has been recom- mended to cover the perineal band with oil-silk ; but it will be found that the perspiration, to say nothing of the urine in the case of children, will soon cause the oil-silk to fray out and excoriate the groin. If it is desired to use some waterproof material, the thin india-rubber cloth will be found to be the best. To Apply the Long Splint. — The splint having been care- fullj'' padded, and the perineal band prepared, the house- surgeon should envelop the ankle in cotton-wool, and then make two or three fiorure-of-eight turns with the bandao:e around it, so as to get a firm hold on the foot. Then placing the splint by the side of the limb, the bandage is to be car- ried around its lower end, and, through the notches cut for the purpose, so as to fix the foot; great care being taken to insert cotton-wool wherever there is any pressure, and to avoid crushing the smaller toes against the splint. The bandage is then carried regularl}^ up the leg ; and it will be found that the figure-of eight method can be advantageously used all the wa}', without an}' " reversed turns," the cross- ings of the bandage being made along the line of the splint. The knee having been included in the bandage (unless the fracture is very low down), the perineal band should be ad- justed ; and one assistant should then make extension on the foot, while another tightens the perineal band, until the house-surgeon is satisfied, by manipulation and measure- ment, that the fracture is properly set, and that the limb corresponds with its fellow in length. The tapes of the perineal band should then be carefulh' tied, and a broad FEACTURED THIGH. 269 roller must be carried round the thorax to confine the upper end of the splint ; but the bandage on the thigh need not be carried an}^ higher, since the seat of fracture is best left ex- posed (Fig. 90). When the fracture is high up in the shaft, some surgeons prefer to add a small straight splint to the above, placing it over the fracture, and securing it with a couple of straps and buckles ; others again emplo}^, in all cases, three splints to surround the thigh, in addition to the one on the outer side. Fig. 90. A sand-bag laid along each side of the limb will help ma- terially in keeping the limb quiet ; and, in children or unruly patients, it will be well to fasten a broad bandage or sheet over the thighs and trunk, so as to prevent attempts at sit- ting up, etc. In very young children, it will very much re- lieve the irksomeness of the confinement, if a hole is cut in the bandage or sheeting, through which the ^ound leg can be kicked about as much as may be desired without detri- ment to the fractured limb, which may, for additional secu- rity, be fastened by a bandage to the bottom of the bed. The constant wetting of the bandages with urine is a great drawback in the treatment of children, and may be best combate 1 by smearing the upper part of the thigh band- age with plaster of Paris and afterwards varnishing it, and by changing the perineal band occasionally, unless made of india-rubber cloth. Hamilton's plan of applying a long splint to each thigh, the two splints being fitted into a cross-bar at the feet, is exceedingly useful in children, who can then be lifted with the greatest ease, and turned from side to side for washing, 270 EXTENSIOU^ BY STRAPS OF PLASTER. etc. (Fig. 91). It is not iiecessaiy to apply a perineal band on the sound side, and the bandage round the trunk may be advantageously replaced by a broad belt of plaster. Plaster of Paris or starch may be advantageously used from the first, without splints, and no special directions need be given for their application ; or they may be added to the long splint, so as to prevent all possibility of movement. Fig. 91, The double-incliyied plane, if used, may be formed of an ordinary Maclntyre iron splint, screwed to the proper angle; or, what is preferable, a wooden stand, made to fit the bed, on which a double incline can be at once made to any height, may be employed. Most forms of fracture bed allow of this position being assumed, and in cases of severe compound injury, or fracture of both limbs, recourse may be had to that method of treatment at once. Extension by Straps of Plaster. — The practice of making extension by means of straps of adhesive plaster having come into vogue in America, it has been adopted by many surgeons in this country, and has the advantage of obvi- ating injurious pressure about the ankle. A strip of plaster, two inches wide, is cut long; enouo^h to reach from immedi- ately above the knee to the. sole, and up again on the oppo- EXTENSION OF FEACTURED THIGH. 271 site side of the limb, leaving a loop, eight or ten inches long, below the foot. This is carefull}' applied to the limb. A bandage is carried over it, so as to prevent Siuy possi- FlG. 92, bility of its slipping, and a piece of wood or gutta-percha msiy be placed in the loop and across the sole of the foot, to prevent its being pressed upon b^' the plaster. Fig. 93. The loop at the middle of the plaster, which, it will be observed, exercises traction without compressing the ankle, may be secured in one of the notches of the ordinary long- splint ; or extension may be produced without a splint, by 272 ELASTIC EXTENSION OF FRACTURED THIGH. Fig. 94. attaching a weight to hang over the end of the bed, as shown in Fig. 92, and fixing the patient by means of a perineal band attached to the head of the bed ; or, if pre- ferred, the foot of the bed may be raised so as to prevent the patient slipping down. By employing a pulley for the rope to work over, this contrivance is rendered more perfect. Fig. 93 shows a double pulley fitted to the bed, and carry- ing a flat-linked chain, which is in use in University College Hospital, and by w^iich the line of traction can be readily adapted to suit each case. An American mode of making extension is by using a long splint with a perineal band, and a cross-bar going below the sole of the foot. The limb is not bandaged to the splint; but extension is produced by a loop of plaster, which is acted on by a tour- niquet, or some similar contrivance, attached to the cross-bar, and thus any degree of ex- tension can be made. An improvement on this method, by which elastic tension of the limb is constantly maintained, was introduced in University College Hospital by Mr. Buckston Browne, a late house-surgeon, and is shown in Figs. 94 and 95. The foot-piece (G) is a piece of stout wood, four inches by two and a half, notched to receive a stout india-rubber ring (F), known in the trade as a " horse's cutting-ring " (from its use as a guard for the fetlock). The foot- piece and the ring are secured to the limb by means of an or- dinar}' stirrup of stout strapping, two inches wide, extending above the knee, so as to relieve the joint from strain. A long splint is prepared, ELASTIC EXTENSION OF FRACTURED THIGH. 273 Fig. 95. reaching from the axilla to about eight inches beyond the foot, to the lower four inches of which is screwed a piece of one-inch plank (A) about eight inches long. This piece of wood throws the direction of the trac- tion into a line with the axis of the limb. The limb is then bandaged in the usual way to the long splint, the bandaging being begun above the ankle. When the bandage has been carried above the knee, the leg and splint are grasped together by the surgeon, and extension is made while the perineal band is tightened. A hip spica and a body roller complete the bandaging, but it is well to secure the body roller to the splint by a row of tinned tacks. (In the figure the ban- daging is left imperfect to show the perineal band.) Then on the plank (A) is screwed the bracket (B), through which slides the stem (D) of the hook (E), Along the stem and below the bracket runs the screw-nut (C). The hook is now fixed to the ring, and the stem being passed through the brack- et, extension can be made by screw- ing up the nut. The bracket and stem are similar to those sold by ironmongers for securing the cords of window-blinds, except that in place of the hook there is a little grooved wheel. This wheel is easily changed for a hook ; or the whole apparatus, ring and hook, can be obtained from Messrs. Mayer & Meltzer, of Great Portland Street. 23 274 ELASTIC EXTENSION OF FEACTURED THIGH. Fig. 96. Another method, also introducing the use of an india- rabber band to keep up constant extension in cases of frac- tured thigh,, was introduced by Mr. De Morgan into the Middlesex HospitaL A long splint is fitted, about six inches from its lower end, with a cross-bar, which passes beneath the foot, and has three small pulleys fixed in it, — one in the foot-piece, and one at each end of the splint. A loop of plaster being arranged as above directed, a cord is attached to it, and passed over the pulleys in the foot-piece and lower end of the splint, and up the out- side of the splint, where it is attached to an india-rubber " accumulator," or door-spring. The other end of the india-rubber is attached to another cord, which is carried over the upper pulle}^, and attached to a well-pad- ded perineal band, as shown in Fig. 96. If the length of the ropes is properlj^ adjusted, the spring is kept in constant action, and extension is maintained. In order to facilitate this, Mr. De Morgan emplo3'S a piece of hard wood, four inches long, an inch broad, and half an inch thick, in which are three holes, to one of which the india-rubber is attached, whilst the end of the upper cord passes through and is firmly held by the other two. By this the cord can be easily tightened after the man- ner of the ropes of a tent. Thomases Splints.— Fov the treatment of disease of the hip and knee joints, Thomas's splints are very useful, if applied properly. The hip splint (Fig. 97) consists of a piece of flat malleable iron, from three-quarters to one and a quarter inch iu width, and from three-sixteenths to one- THOMAS S SPLINTS. 275 Fig. 97. quarter of an inch thick, long enough to extend from the lower angle of the scapula, perpendicularly over the buttock and back of the thigh to the middle of the leg. Metal hoops attached to this encircle the thorax, the upper part of the thigh, and the middle of the leg, which they are to fit accurately- The splint is lined with a layer of felt, and covered with " basil leath- er," and attached to the bodv by straps over the shoulders and round the waist, and a bandage round the thigh. In cases of early hip disea.se there is no difficulty in fitting the splint to the patient, who should stand with the foot raised on a block so as to bring the pelvis straight. In more advanced cases, where the thigh is flexed, it will be found suf- ficient to lay the patient in tlie splint, so that he may be absolutely on his back, when in recent cases the weight of the linib will gradually stretch the muscles and ligaments, and in a few days bring it down into the splint. Or, in old cases, the iron bar must be bent up to tit the back of the flexed limb, and then gradually straight- ened, with the limb in it, by means of a suitable "wrench." One great advantage of this splint is, tliat it permits of the patient getting about upon cratches, while wearing a pat- ten on the sound side so as to raise the foot of the diseased side completely oflf the ground (Fig. 97). A caution is necessary, that a child's patten requires to be higher than an adult's, or it will be found to put the diseased limb to the ground. The knee splint (Fig. 98) consists of an ovoid iron ring, 276 Thomas's spliists. three-eighths of an inch thick, varying in size according to the age of the patient, which is covered with felt and V^asil leather. From this two iron rods pass down the sides of the thigh, the inner one forming an angle of 55° with the ring, and are inserted into a patten carried some inches below the foot. Across the two iron rods is stretched an apron of basil leather to support the limb, and in the leather are two slits for the insertion of the bandage. A patten is Fig. 98. Fig. 99. to be worn under the shoe of the sound limb, so as to bring it to the same length as the splint, which, when properly fitted with a strap over the shoulder (Fig. 99), transmits all shocks directly to the pelvis, leaving the knee at rest. The foot-piece shown in Fig. 99 is added for cases of disease of the ankle and foot, and slides up and down be- tween C and D, where the rods must be strictly parallel. FRACrrURED PATELLA. 27" Fractured Patella. — In treating tliis fracture, unless a plaster of Paris bandage is promptly api)lied, it is important not to put on any apparatus too soon. The knee-joint must have been injured to a certain extent, and will require rest, cold lotions, etc., for some days, before the swelling suij- sides. The portions of bone sliould be approximated as closel3^ as possible, by relaxing all the muscles of the limb, by making the patient sit up in bed, and by raising tiie whole limb to a convenient height on pillows or a leg rest. When all inflammator}' action in the joint is past, if the patient is kept in bed, a simple splint at the back of the knee, with two straps of plaster to hold the fragments to- Fia. 100. iiiiiia!!iiiiiii»g!ssiiiiiiiBi!iHi'gii'p gether, will answer very well ; or Wood's splint may be employed, which is merely a back splint with hooks put into it, to give fixed points for the bandage to act from, and so to drag the parts together. A broader splint than the common ones will be the best for this purpose, since thus all pressure on the vsides of the knee-joint will be avoided ; and it is well to bandage the thigh carefully, from above downwards, so as to counteract the action of the extensor muscles (Fig. 100). Elastic traction without pressure upon the nutrient vessels of the bone has been applied by Mr. Manning, a late house-surgeon of University College Hospital, as fol- lows ; A many-tailed bandage is formed by stitching seven 278 FltACTUEED PATELLA. or eight broad straps of plaster to a piece of stout bandage. This latter is brought to the back of the thigh, around which the slips of plaster are firmly fixed, and is then car- ried through a slit in a straight wooden splint, upon which the limb is laid. The foot and leg are next carefully ban- daged to the splint, so as to keep the lower fragment in place, and elastic traction is maintained upon the upper fragment b}^ attaching an elastic band to the end of the bandage, and fixing it to the heel of the splint. Traction upon the fragments, by means of plaster and a weight, may be eraploj^ed, as described by Mr. Callender. The limb being secured to a back splint, crescentic pieces of plaster are fitted above and below the patella, and for some distance on the limb, and are secured by bandages carried round the splint. A cord is then attached to a loop in one horn of the lower crescent, and being passed through a loop in the corresponding horn of the upper crescent, is brought down to meet its fellow of the opposite side in a double pulley projecting from the foot-piece, so that the weight attached to the cords ma}^ hang be^'ond the bed. The traction would necessarily draw the two fragments together. The same result would be gained by emplo3'ing the pulley attached to the bed (Fig. 93) without the use of a splint. Mr. Teale, of Leeds, finds that equall^^ good results are obtained with sand-bags onlj' as with complicated appara- tus, and recommends that the patient should be simply con- fined to bed for six or eight weeks, and when allowed to get up should be fitted with a soft leather splint, which will limit but not arrest the movements of the joint. Plaster of Paris and starch are particularly applicable to the treatment of this fracture when all active mischief has disappeared, and either of them may be applied alone, or in conjunction with a light wooden splint at the back of the knee. This latter method has the great advantage of ena- bling cases to be treated as out-patients much earlier than FRACTURED TIBIA. 279 would Otherwise be possiljle. The joint must be kept fixed for many weeks, for if flexion be permitted, the tissue uniting the fragments will become stretched and will permanently weaken the limb. Fractured tibia ma}^ be treated, from the fii'st, most satis- factorily, with the plaster of Paris, the starch, or the silicate bandao:e. Maclntyre^s iron splint is a good but rather cumbersome method of treatment, and, unless care be taken to have the Fig. 101, splint no broader than the limb, it is apt to shift to one side as the patient moves in bed. The splint should be slightly flexed at the knee (by means of the screw beneath) ; and the foot-piece made of a suitable length, and placed at rather more than a right angle to the leg-piece. It is usual to fasten a piece of bandage to the splint which is intended to go beneath the heel; but this will generally be unnecessar\^, if the foot is properly secured to the foot-piece, and it is rather apt to rub the patient's skin (Fig. 101). A turn or two of bandage having; been made around the ankle in order to fix the roller, and the foot having then been secured to the splint, some cotton-wool should be inserted between the malleoli and the side of the splint, to prevent any rubbing at those points; and the fracture being in proper position — the best criterion of which is that the great toe is in a line with the inner border of the patella — 280 FRACTURED TIBIA. the bandage can be carried round tbe splint and as far up the leg as may be deemed necessary. Another roller around the thigh and upper part of the splint will complete the ar- rangement, which can be rendered infinitely more com- fortable to the patient by slinging the whole limb either to an ordinar}^ cradle or in a Salter's swing, which allows of more extended movement on the patient's part, and gives Fig. 102. great facilities for dressing compound fractures, etc. (Fig. 102). A practical point of importance is, that whenever a frac- tured tibia shows a tendency to "ride," the cure is to be found in thoroughl}^ raising the foot. However firmly a limb may be fixed to a splint, it "gives" a little to the weight of the limb, and suspension b}' the foot will generally get over the difficulty. In setting; a fractured tibia, care should be taken that the foot is exactlj^ at right angles to the leg, and that the inner FRACTURED TIBIA. 281 border of the great toe is in a line with the inner border of the patella. In many hospitals three splints are employed for all frac- tures of tiie tibia, the back one being a straight splint reach- ing to the ham, with a foot-piece at right angles, and the side-splints having foot-pieces also to pass on each side of the limb. In applying it the foot is secured to the foot- piece in the ordinary way with a bandage, which is only car- ried up to the ankle, and another is used to confine the limb Fig. 103. to the splint above, being applied immediately below the knee. A broad piece of gutta-percha enveloping the limb and the margins of the splint may be substituted for the upper bandage. The side- splints are best attached by linen straps and buckles, so that they can be readily taken off, if necessary (as in dressing a compound fracture), and the whole limb can be swung in the manner recommended above. The whole arrangement is shown in the accompanying illus- tration (Fig. 103), from a sketch of an actual patient. Hester^s ajDimratus^ which is very effective, and in con- stant use at the Westminster Hospital, combines the advan- tages of the above arrangement together with those of the swing, as the splint is suspended from rollers and a cradle, wdiich allow of tiie free movements of the patient. In 24 282 SIDE-SPLINTS. making use of it, the knee is first firmly fixed, a pad being placed below the tuberosity of the tibia, and another below the head of the fibula; and the foot being well strapped to the footboard. Extension is then made by means of a screw underneath, and thus shortening is effectuall}^ pre- vented ; whilst the side-splints, when screwed on, keep the limb perfectly steady. Fig. 104. Side-splints^ commonl}^ known as Cline's (Fig. 104), may be used alone for fractures of the tibia, and the limb may be kept straight and in a swing, or be semiflexed and laid upon its outer side. The latter method is the ordinary treatment for simple fractures of the tibia in some hospitals, and the flexed position is found to relax the muscles very efficiently, and to permit of proper coaptation of the broken ends more readil}' than any other plan of treatment. A bandage is not necessarj^ in this method, the splints being sufficiently secured with straps and buckles, and the limb being laid upon a pillow with the knee bent. Side-splints are sometimes made with the toe-piece on one side cut off, but there seems to be no rule as to which side of the foot the truncated splint should properly go upon ; FRACTURED FIBULA. 283 and it will generally be found more convenient to have the two. splints of the same shape. There is sometimes a diffi- culty in reducing a fractured tibia, owing to the contraction of the muscles of the calf, and this may be obviated by flex- ing the knee-joint, as in the case of dislocation of the ankle {q. v.). Fractured Fibula.— If the fracture is at the upper part, where the displacement will be slight, the plaster of Paris or starch bandage will answer every purpose, or the limb may be put up in side- splints with the leg extended. When the fibula is broken towards the lower end (Pott's fracture), with or without dislocation of the foot and frac- ture of the inner malleolus, Dupuytren's short splint may be used; and in applying it two or three cautions are neces- sary. In the first place, it is to be applied on the tibial side, so as to draw the foot in that direction, with the view of throwing the broken ends of the fibula outwards. Sec- ondly, the efficacy of the splint depends, in a great degree, upon the pad, which is to be made very thick opposite the point of injury, but thin in the other parts ; only sufficient, in fact, to protect the limb from pressure. The foot is now to be bandaged firmly to the lower end of the splint, the notches in which will allow of considerable traction being used ; and the bandage is to embrace the malleolus, but not to go more than an inch above it. The thick pad being now carefully inserted between the limb and the splint, im- mediately opposite the point of injury, another roller is to bind the top of the splint firmly to the tibia, immediately below the knee, but is on no account to be prolonged to the point of fracture. Some surgeons prefer to apply the upper bandage first, as giving more purchase in bringing the foot straight. The drawback to this method is the uncomfortable strain kept up upon the foot; and Pott's fracture may be equally well treated with side-splints, or even a back-splint. 284 AFTER-TEEATMENT OF FRACTURES. Fractures of the foot are generally the results of a severe crush, and need no special mention here. The os calcis is occasionally broken across by falls upon the heel, and the treatment is the same as that for ruptured tendo Achillis (p. 68). After-treatment of Fractures. — The treatment of cases of fracture, after they leave the wards, devolves generally upon the house-surgeon, who should see that the retentive apparatus is worn long enough to perfect the union of the fracture, but not so long as to interfere with the use of the limb. A weakly united or ununited fracture should be brought under the notice of the surgeon at once, and so, also, an}^ case in which great loss of power in the limb exists. The stiffness of the joints above and below the fracture, due to the wearing of splints and bandages for some weeks, is to be treated by frictions with oil and passive movements S3^stematically carried out by the patient or his friends. When, however, a joint is firmly locked by adhesions within or without the articulation, the patient should be put under chloroform, and forcible flexion and extension be made. If this is not done, the patient may probably drift into the hands of a " bone-setter," who will certainly tell him that some bone is "out," and by forcible manipulation will produce a cracking, taken by the ignorant to show a reduction of a neglected injury. DISLOCATIONS. 285 CHAPTER XI. DISLOCATIONS. The dislocations which ordinaril}- come under the house- surgeon's care are those of the upper extremit}-, those of the lower being of very much less frequent occurrence, and for that reason, as well as for their greater severity, being usually referred to the visiting surgeon. The existence of a dislocation will be evidenced by the deformity produced in the joint, the ordinary shape of which will be materialh' altered, while tlie extremity of the dis- placed bone will form an unusual projection in the neighbor- hood of the articulation. The limb will have assumed an unusual position, in which it will be fixed, unless the dis- location should happen to be complicated with a fracture of the shaft of the bone, in which case there will be an ab- normal amount of motion in the lower part of the limb, while the upper part will remain fixed and distorted. In recent dislocations there will be no sensation of crepitus ; but in old cases there may be a spurious form of it present, resulting from effusion in the neighborhood of the joint. Dislocations ma^^ be simple or com-pound, and may be con- joined with fractures either of the articulation or of the shaft. Compound dislocations, being accidents of great severity, in which the question of immediate operative interference will be involved, should be referred without delay to the visiting surgeon. In cases of dislocation with fracture of the shaft of a bone, the fracture should be set and put up firmly in splints, etc., and the dislocation imme- diately reduced ; but dislocations with fractures of the articulation must frequentl}' be left in their abnormal po- sitions. ( Vide page 227.) 286 THE CLOVE-HITCH. Simple dislocations can be reduced, for the most part, by manipulation or by extension, without the administration of chloroform, thougli that agent must always be resorted to at once if any difficulty should be encountered from mus- cular resistance. If the pulleys are obliged to be resorted to, care should be taken to have a good fixed j^oint to which they may be attached, and to protect the limb from injury during their action. Fig. 105. The clove-hitch is the knot ordinarily employed to obtain a firm hold of the limb, and maj' be made of stout bandage, or, what is better, a stout skein of worsted, which not only takes a better grasp of tlie limb, but is less likely to inflict damage upon it than a bandage or rope. To make a clove- hitch the operator grasps the worsted with his left hand, and forms a simple loop in it with his right, as shown in Fig. 105, where a cord is employed for the sake of greater distinctness. Holding the first loop with the left thumb, he then makes another similar loop, and grasps it with his right hand ; and finally, by passing the one last made beneath the first, completes the clove-hitch (Fig. 106). The hitch is easily slipped over the limb to tlie required point, which DISLOCATED JAW. 287 should be protected by a few turns of a wet bandage around it, and the hook of the pulle3's can then be attached to the other end of the worsted loop. There is some difference of opinion as to the point on which traction should be made, most surgeons preferring the extremity of the dislocated bone, while a few attach the pulleys to the extremity of the limb in order to gain addi- tional leverage. It will be found, however, in most cases, Fig. 106. best to apply the clove-hitch on the end of the dislocated bone itself, since by that means all possibility of injuring the intervening joints is avoided. Dislocated jaw (indicated by the widely gaping mouth if the dislocation is double, or by the chin being thrown to the opposite side if one condyle is displaced) is readily reduced by passing the thumbs, protected by a towel, along the mo- lar teeth to the angle of the jaw, and then forcibly depress- ing that portion of the bone; when the jaw will be imme- diately drawn into its proper position by the contraction of the muscles of mastication. Dislocation of the acromial end of the clavicle is not very 288 DIAGNOSIS OF INJURIES ABOUT THE SHOULDER. uncommon, and is readily enough reduced by drawing the patient's shoulders back, while the thumb is pushed against the bone so as to thrust it into its proper position. The difficulty always is to retain the bone in its proper place, and this may be attempted by placing a pad over the point, and bandaging firmly through the axilla and round the chest, but generally proves futile. Dislocation of the humerus^ as ordinarily met with, i. e., into the axilla or beneath the coracoid process, can be re- duced most readily with the knee. The patient being seated, the house-surgeon standing by the side and placing one foot upon the chair, brings his knee into the axilla, and bends the arm forcibly over it. Should this fail to effect reduction, or if the dislocation is on the dorsum scapulae, recourse should be had to the use of the foot, by which method great force can be exerted. The patient being laid on a flat couch or table, the house-surgeon takes off his hoot^ and having laid a folded towel next the skin, places his heel (right or left according to the side dislocated) in the axilla; then having grasped the arm with his hands, makes forcible but steady traction until the bone flies into its place. Should a fair trial of this method fail in reducing the dislocation, chloroform should be administered and the pulle3'S had re- course to, the scapula being fixed by a jack-towel passed through the axilla and fastened to some convenient point, and the pulleys being attached to the lower end of the hu- merus by a clove-hitch over a bandage. After reduction, the arm should be bandaged to the side for a few da3's, or the accident will very probably recur. Diagnosis of Injuries about the Shoulder. — Injuries iiv the neighborhood of the shoulder-joint are often of a com- plex character and doubtful nature, so that their correct diagnosis will tax the powers of the house-surgeon to the utmost, more particularly if, as frequentl}' happens, swelling DIAGNOSIS OF INJURIES ABOUT THE SHOULDER. 289 has come on before he sees the case. A large proportion of the cases which come before the house-surgeon are simply examples of bruise from falls or blows upon the shoulder, and are best treated by resting the arm in a sling, and the use of an evaporating lotion in the early, and a liniment in the later stages. These cases, however, are often trouble- some from their tediousness, the patient being unable for a long time to raise his arm thoroughly, owing to partial pa- ralysis of the deltoid muscle, the result of the blow. Under these circumstances, the deltoid wastes and the shoulder becomes flattened, the appearances resembling in some de- gree, and upon superficial observation, those of a disloca- tion. Stimulating liniments and galvanism may do good, but the best plan is to make the patient exercise the arm, either by pulling upon a rope with a weight attached to it, passed over a pulle}' above his head ; or, more simpl}', by working at the handle of a common pump in company with another person. The effect of either plan is to assist the weakened muscle in raising the arm, and so to exercise it until it fully recovers itself. In examining cases of injur}' of the shoulder-joint, it is particularly important to observe the amount of power over the limb possessed by the patient, since in both fracture and dislocation voluntary movement is lost to a great degree ; whilst in simple bruising the patient can cross the arm over the chest or back, although it may give him pain, and al- though he may be unable to raise the arm to the head. In the following table the symptoms of the three forms of injury about the shoulder which ma}' be most readily con- founded are given,* and will serve as guides in the diagnosis of these accidents. It m ist be borne in mind, however, that the first and second are much more likely to be met with than the third. * Tabulated from IJarailton on Fractures and Dislocations. 290 INJURIES OF SHOULDER. SiGKS OF A Dislocation. ( Cause, generally a fall upon the elbow or hand.) 1. Preternatural immobil- ity. 2. Abseace of crepitus. 3. When the bone is brought to its place, it ■will remain without the employment of force. 4. Inability to place the hand upon the opposite shoulder (or to hare it placed there by an assist- ant), while the elbow touches the breast. 5. Depression under the acromion process ; al- ways greatest under- neath the outer extrem- ity, but more or less in front or behind, accord- ing to the dislocation. 6. Round, smooth head of the bone felt in its new situation, and moving with the shaft. Absence of the head from the socket. Signs of a Fracture through the sur- GiCAt Neck. (Catise, direct blows.) 1. Preternatural mobility often but not constantly present. 2. Crepitus produced easily when there is no impac- tion, or when the dis- placement is not com- plete, and viee versa. 3. When onee the frag- ments have been dis- placed, it is exceedingly difficult ever afterward to maintain them in place. 4. If the fragments remain in place, the hand can be easily placed upon the opposite shoulder. When they completely overlap it is difiScult. 5. A slight depression not immediately beneath the acromion, but an inch or more below. * 6. Head of the bone in the socket, and moving with the shaft when impacted, but not otherwise. The irregular upper end of the lower fragment often to be felt pressing up- wards to the eoracoid process. Signs of a Fracture OF THE Neck of the Scapula. {Cause, generally a direct blow.) 1. Preternatural mobility. 2. Crepitus, generally de- tected by placing the finger on the eoracoid process, and the opposite hand upon the back of the scapula, while the head of the humerus is pushed outwards and ro- tated. 3. When reduced, it will not remain in place. 4. The hand may gener- ally, but with difiiculty, be placed upon the oppo- site shoulder. 5. Depression under the acromion process, but not so marked as in dis^ location. 6. Head of the bone may be felt in the axilla, but less distinctly than in dislocation. Head of bone moves with the shaft. Head of the bone not to be felt under the acromion process, al- though it has not left its socket. DISLOCATION OF THE ELBOW. 291 Signs of a Dislocation. {Cause, generally a fall vpon the elbow or hand.) 7. Elbow carried outwards as a rule, and not easily pressed to the side of the body. 8. Arm shortened in the dislocation forwards, and slightly lengthened when in the axilla. Signs of a Fracture through thk sur- GICAL Neck. ( Cause, direct hloivs.) 7. Elbow hanging against the side when the frag- ments are not displaced, but away from the side when displacement ex- ists. 8. Length of arm un- changed unless the frag- ments are impacted or overlap. If the frag- ments are completely displaced, the arm is shortened. Signs of a Fracture OF the NIXK OF THE Scapula. {Cause, generally a direct blow.) 7. Elbow carried a little outwards, but not so much as in dislocation. Easily brought against the side of the body. 8. Arm lengthened. 9. The coracoid process carried a little towards the sternum and down- wards. 10. Pressing upon the co- racoid process it is found to be movable, and to obey the motions of the arm. Dislocation at the EWoiu. — Notwithstanding all the minute directions laid down for the diagnosis and treatment of in- juries about the elbow-joint, the house-surgeon will find that he can efficiently treat the great majority of cases by flexing the forearm forcibly upon the upper arm. This can be most conveniently done by placing the knee in the bend of the elbow, the foot being on a chair, and bending the arm around it until the dislocation is reduced, when the forearm can be full}^ flexed upon the humerus. Should the use of the knee not give sufficient power for the purpose, the foot of the operator may be employed, the patient being seated on the ground, and the operator on a chair in front of him. It is possible that fracture of the humerus immediately above the condyles may be confounded with dislocation ; but the diagnosis will be readily made in a recent example, by noticing that, in the case of a fracture, the cond3'les move with the radius and ulna, their relative distances being undisturbed, and that the distortion is immediately repro- duced, after apparent reduction, w^hen the traction ceases. Should the rapid swelling which usually attends injuries 292 INJURIES OF ARM IN YOUNG CHILDREN. about the elbow render the diagnosis of a doubtful char- acter, it will be better to refer it to the higher authorities, rather tlian do damage iguorantly to a very important articu- lation. Dislocation at the wrist is of rare occurrence, and can be readily reduced by flexion and extension. It is liable to be confounded in young persons with a more common acci- dent, viz., separation of the epiph3'sis of the radius, the diagnosis depending upon the fact that in the latter case the styloid process can be felt to move with the carpus. Injury of the Arm Common in Young Children. — Mr. Duncan McNab, of Epping, was good enough, in 1862, to call my attention to a peculiar injiny occurring among young children, and caused apparently by their being dragged forcibly by the hand. The s3'^mptoms are pain and inability to supinate the hand, which is strongly pronated, the arm is semiflexed, and the deformit}^ suddenly disap- pears with a snap, upon the hand being steadily supinated by the surgeon, or frequently while he is simply examining the case. Mr. MclS'ab regards the injury as a dislocation of the lower end of the radius from the ulna. M. Go3a'and described the same injurj^ to the Surgical Society of Paris in 1861, and maintained that it consisted in a displacement of the interarticiilar fibro-cartilage of the wrist, in front of the carpal extremity of the ulna. Other French surgeons, however, have believed that the dislo- cation is at the upper extremity of the radius, and in this Dr. Hedges, of Boston, agrees. I have met with several cases since m}^ attention was called to the subject, and in some of these the injur}^, so far as cou-ld be judged, was at the wrist, while in others it was near the elbow. The treatment is to grasp and supinate the hand steadilj'', when the parts will resume their natural position. DISLOCATION OF THE PHALANGES. 293 Dislocations of the phalanges may be reduced by flexion and pressure with the fingers in a suitable direction, and it will be generally necessary to employ the clove-hitch, made of a piece of tape, to get a sufficient grasp on the bone, or forceps fitted with leather finger-holders, as shown in Fig. 107. Fig. 107. The subcutanous division of the lateral liagments is but rarely required, and, if undertaken, the operator should do as little damage to the articulation as possible. A simple contrivance (Fig. 108), invented by R. J. Levis, an American surgeon, will give a firmer hold upon a dis- FiG. 108. located phalanx than the clove-hitch. It consists of a thin strip of hard wood about ten inches in length, and one inch or rather more in width. One end is perforated with six or eight holes, and the opposite end is cut away so as to form a projecting handle with a shoulder on each side of it. A 294 DISLOCATIONS OF THE FEMUR. piece of strong tape a j^ard long is passed through the holes nearest the end of the splint, leaving a loop on one side, and a similar piece through another pair of holes. With these the dislocated finger or thumb can be firmly attached to the splint by drawing the tapes tight, and twisting them in opposite directions around the handle, to which they should be securely fastened (Fig. 108). The recently popu- larized toy, " the Siamese link," is a revival of a puzzle made by the American Indians, and emploj^ed man}'' years back by American surgeons in reducing dislocated fingers. The tube is admirably adapted for this purpose, as it takes an exceedingly firm hold upon the finger without exercising injurious pressure upon it. Dislocation of the Femur. — The diagnosis and treatment of these dislocations is entered into so fuUj^ in all the ordi- nary works on surgery, that it will be suflScient to indicate here simply the direction in which force should be exerted, in order to reduce the bone, in the forms the house-surgeon is likely to meet with, viz., in dislocation on the dorsum ilii or into the sciatic notch. In either case the operator may place his foot in the groin and draw the limb downwards and inwards, rotating outwards slightl}^ towards the last, the patient being on his back if the dislocation is upwards- on to the dorsum ilii, or on his sound side if the dislocation is backwards into the sciatic notch. If the pullej^s are used, the pelvis must be fixed by a jack-towel passed through the groin, and the extending force applied in the direction indi- cated above. As soon as reduction is eflfected, the patient's thighs should be fastened together, and kept so for some days, to prevent any movement in the joint. Dislocation of the knee is sufficiently obvious, and is readily reduced ; but its after consequences may be serious from injury to the joint or to tlie popliteal vessels. When DISLOCATIONS OF THE ANKLE-JOINT. 295 reduction is effected, the limb should be placed immediately upon a back splint, to insure perfect rest, and everj' means should be taken to prevent inflammatory action in the joint. Attention should be paid to the existence of pulsation in the arteries of the leg and foot, and to any symptoms of in- jury in the popliteal region, since, if rupture of the vessels has taken place, amputation will probably be requisite. Compound dislocations of the knee-joint will very probably require immediate operative interference, either amputation or resection of the articular surfaces being necessary in se- vere cases. Dislocations at the ankle-joint^ with or without fracture of the malleoli, can usuallj^ be readily reduced if the leg is Fig. 109. flexed upon the thigh so as to relax the muscles of the calf, the contraction of which forms the chief obstacle to their reduction. This may be easily accomplished by making an assistant clasp the lower part of the thigh firmly, and hold the limb perpendicularly to the recumbent body, when the operator can readily flex the leg to a right angle with the thigh, and will be able to exercise the necessary traction (Fig. 109). The counter-extending baud should be applied 296 TREATMENT AFTER EXCISION OF JOINTS. in the same manner if the pulleys are employed. When re- duction has been effected, the limb should be immediately put up with side-splints having foot-pieces, so as to prevent all motion in the part. Compound dislocation at the ankle is an accident always involving the question of primary amputation. If it is de- termined to save the limb, it may be put in a Maclntyre splint; or supposing, as is frequently the case, the injury to the skin to be on the tibial side, the knee may be flexed and the limb laid upon its outer side, and fastened to an appropriate splint. TREATMENT AFTER EXCISION OF JOINTS. Since cases of excision of joints are always of great in- terest, the surgeon will naturally give special directions for the treatment of each case according to the particular Aiews he may entertain ; and the following are therefore only general hints upon the subject, which may perhaps be of service to the house-surgeon. In the cases of excision where a movable joint is hoped for, it is of course of no mo- ment that the parts should be kept at perfect rest; but where the firm anchylosis of the articulation is hoped for, as in the knee, it is of the utmost importance that every precaution should be taken to enable the patient to keep perfectl}^ still. With this view it will be advisable in some cases to place the patient, from the first, on a water-cushion, in order to prevent the constant movement of the body, which is other- wise unavoidable. Since in these cases also it is unadvisa- ble to disturb the bandages, etc., for some weeks after the operation, considerable difficulty will be experienced in keep- ing all the dressings thoroughly clean, particularly in hot weather. Carbolic acid will be found useful in preventing flies from infesting a part: but, with all one's care, it is im- possible in all cases to prevent maggots forming beneath bandages which are undisturbed for man}^ days in the heat of summer. These animals, though ver}'^ disgusting, do EXCISION OF ELBOW. 297 little harm so long as they do not attack the wound itself, the patient merely complaining of the tickling they produce when crawling on the skin. The patient may be conve- niently shielded from flies with a curtain of gauze ; but the papier rnoure is rather a nuisance than otherwise near a patient's bed ; since, although very destructive to them, it certainly seems to attract the flies in no small degree. Shoulder. — A pillow covered with waterproof material, for the arm to lie on, is all that will be required at first (Fig. 83). Subsequentl}', when the patient is able to sit up, the arm must be well supported in a sling. Fig. 110. Elbow. — Surgeons differ very much as to the position in which they place the limb after the operation of excision of the elbow, the rectangular, semiflexed, and straight posi- tions being employed in different hospitals. A more or less rectangular splint for the fore and upper arm will be neces- sary for the two former positions, and a straight inside splint, or none at all, is employed for the latter. At Bar- tholomew's Hospital, a sling from the top of the bed has been adapted to cases of excision of the elbow with ad- vantage. Mr. F, Mason has contrived a very good splint for cases 25 298 EXCISION OF HIP. of excision of the elbow, which has the great advantage of permitting the movements of pronation and supination during the process of healing. It is shown in Fig. 110, and being firmly applied to the inner side of either arm, the necessary separation between the cut ends of the bones can be maintained, and the forearm can be flexed and rotated by relaxing the fl}' -screws. The wrist may be conveniently treated upon a well- padded splint, on which the hand and forearm may be laid in the prone position.* Hip. — This excision can be treated with a long splint, interrupted opposite the joint, and bracketed with a light bar of iron. The splint should reach from the foot to the axilla, and be firmly fastened to the trunk, extension being made by means of a rack-and-pinion movement in the splint itself, or by extension from a fillet on the opposite thigh. The distorted position of the limb renders it sometimes diflScult to apply any splint properly; and these cases may be most conveniently treated by making extension with a weight over the end of the bed. The weigrht is to be fast- ened to the limb by means of a strip of plaster carried up each side as far as the knee, leaving a loop beneath the foot, to which a cord carrying a weight can be affixed (p. 271). This can either hang over the end of the bed, or be carried over an}'^ simple form of pulley. If the foot of the bed be raised upon a couple of blocks of wood, the patient will be effectually prevented from being drawn down by the weight ; or, if there is much distortion of the spine, this can at the same time be to a great degree remedied b^y using a counter- extending perineal band passed through the opposite groin, and fastened to the head of the bed, as seen in Fig. Ill, * For further information as to the after-treatment of this rare ex- cision, the house-surgeon may advantageously consult Mr. Lister's elaborate paper in Lancet, 1st April, 1865. EXCISION OF HIP. 299 where the weight is attached by means of a padded socket, and the pulley is shown affixed to the foot of the bed.* By the addition of another pulley, as in Fig. 93, the Fig. 111. tendency of this contrivance to draw the limb up from the bed can be readily overcome. Fig. 112. Fig. 112 shows an arrangement contrived for a case of excision of the head of the femur, where the patient M'as at * From a paper on Hip Disease, by Mr. W. Adams. Lancet, Dec. 4th, 1869. 300 EXCISION OF KNEE. death's door from the irritation caused by his lying on the wound, which had been carried far back on the buttock, but who made a perfect recovery as soon as he was placed in the " hammock s win or." The contrivance was used in the treatment of several cases subsequently, and has met with some favor among German surgeons, who have also employed the swing in cases of bedsore with advantage ; but where the wound is made well at the side of the limb, it is not essential. Knee. — A simple straight splint, reaching from the foot to the back of the thigh, with a foot-piece, is all that is Fig. 113. necessary for the treatment of this excision, and may be of either iron or wood. A side-splint with a perineal band has been added to this by some surgeons, with the view of stead3ing the limb to a greater degree, but it is not at all essential. The splint should be carefall}^ padded through- out, and near the joint the pads should be covered with some waterproof material, to prevent the discharges from soaking into pads, which it will be impossible to change for some weeks. The practice of swinging the limb in a Salter's cradle has its advantages and disadvantages, the former being the ease it affords the patient in moving in bed without disturbing the joint, and the latter the tendency there is to produce rotation of the limb and eversion of the knee. In order to counteract the tendency to eversion, Mr. W. P. Swain has had a trus's- spring fitted to a bar on EXCISION OF KNEE. 301 the inner side of the splint, which arches over the joint, and makes effectual pressure on its outer side. In the later stages, a well-fitted gutta-percha splint, lined with wash- leather, is the best application. Dr. Heron Watson, of Edinburgh, has successfully em- ployed a wooden back-splint, with a stout wire carried down the front of the leg and arched over the knee, and furnished with hooks for suspension to a cradle. The limb is placed on the splint, and the wire being adjusted, the whole is envel- oped in plaster of Paris at the time of the operation, the wound only being left uncovered (Fig. 115). This insures fixity of the lx)nes, and has yielded good results. Dr. Eben Watson, of Glasgow, has employed the splint shown in Fig. 114 combined with antiseptic dressings, and thus describes his method {^Britiah Medical Journal^ Dec. 13th, 1879): "a B is a firm band of iron, on which are fixed d d, etc., bands of flexible tin, about three inches apart, and in length about two-thirds the circumference of the limb at each place, A F is another band of white iron joined to the one formerly described at a, and twisted so as to av'oid the hip and come up at the side of the body as far as the waist, round which the flexible band g h passes about half-way, and B c is a foot-piece at the other end. When the splint is applied, it is well padded with cotton sheathed in gutta- percha tissue. The foot of the patient is bandaged to the foot-piece, and the flexible bands d d d, etc., and G h are made to fit firmly to the limb and to the waist of the patient by means of broad tapes secured by buckles. "When I perform excision of the knee-joint, I have the splint prepared as above, and exactl}^ made or altered to fit my patient ; and, the operation having been finished, of course, under carbolic spray, I carefully bring the cut ends of the bones into apposition, and lay the naked limb in the padded splint. The spray is maintained during the entire dressing, so that there need be no hurry in this important 302 EXCISION OF KNEE. part of the proceeding. The lateral bands d d, etc., are now pressed up to the sides of the limb, which is protected from their pressure by the interposition of cushions of cotton sheathed in gutta-percha tissue. These cushions Fig. 114. should be made of such a length that they shall not en- croach upon the wound, but leave it and the skin in the neighborhood bare for three or four inches. This part is to be sponged clean with carbolic solution, and then dressed EXCISION OF KNEE. r>f\o in the usual manner with protective and gauze. The large dressing with the waterproof jaconet is then made to sur- round the whole limb, and the splint as well, for several inches above and below the part operated on. It is sus- tained by a bandage ; and the foot, if not previously ban- daged, is now fastened to the foot-piece The patient may then be removed to bed, and, on his recovering from the chloroform, the waistband may be secured by its tape. "One great advantage of this splint is that no part of it is removed when the dressings are changed, for it ought to be so arranged that the operation-wound comes between two of the lateral bands, and indeed this space is generally made Fig. 115. wider than the others, to permit free access to the w'ound without displacement of the splint. The second and all future dressings are performed under the carbolic spra}^, as follows : First, the bandage securing the external layers of gauze is removed, and then the}' are themselves laid open, and the loose gauze and protective are also with- drawn. The splint is then raised at the foot bj^ an assist- ant, and all the dressings are taken from beneath it. The iron band of the splint and the vicinity of the wound may now be cleaned by sponging with carbolic solution, or by 83'ringing the same solution upon them. The large or ex- 304 EXCISION OF ANKLE. ternal dressings are then placed on the bed beneath the middle of the splint, which is lowered on them. The wound is next pa,cked as before with protective and loose gauze, the external dressing is brought round the whole, and ties of bandage are slid in beneath it to hold it close ; or the splint ma}'^ again be raised at the foot, and a bandage ap- plied. " During all these procedures, there is no movement of the limb permitted, except en masse^ in and with the splint, and therefore no pain is caused to the patient. Indeed, after one or two dressings have been performed, the natural nervousness of the patient is entirely dissipated, and, instead of dreading a new dressing, he looks forward to it as a refreshment. I need hardly add, to those acquainted with practical surgery, that, during the long period of heal- ing in these cases, parts of the apparatus, especially the cushions, require to be shifted or exchanged for fresh ones. !Now this may easil}^ be done with my splint, for all that is required is to press down one or more of the lateral bands, and then the cushion may be dealt with without an}^ great or painful interference with the limb itself." Ankle. — A simple back-splint and foot-piece is all that will be required after this excision, and will leave the wound , at the sides of the limb perfectly free for the exit of the discharge. A method of suspension similar to that em- ployed by Dr. Watson for the knee is shown in Fig. 115, and has been found serviceable both after injury and re- section of the ankle-joint. ON CASE-TAKING. 305 CHAPTEU XII. ON CASE-TAKING. The careful and systematic reporting of cases is a most important part of a student's duty, and the practice thus acquired will be found of the greatest service to the surgeon in after-life. Moreover, in the present day, it is to the house-surgeons and ward-clerks of the various hospitals that we look for the reports of cases of interest which have occurred in their several institutions, and the publication of which is of the greatest moment for the advancement of medical science. In the following chapter an attempt will be made to suggest the general mode of reporting a surgical case, and to draw attention to the principal points which should he recorded, and the order in which it will be ad- visable to take them. It must be understood that the sub- sequent observations are only intended to apply to surgical cases ; medical cases, being of a more occult and compli- cated character, require a more extended method of pro- ceeding, and a different order in the record of particulars.* The great point in recording surgical cases is to give all the facts bearing upon the injury or disease under consid- eration, but to omit all others which, however interesting in themselves, have no relation to the particular case. Different reporters will bestow a greater or lesser degree of polish upon a case according to their command of language and powers of composition ; but if the above cardinal rule be attended to, every scientific requirement will be com- plied with, and the anno3'ance of having an imperfect or over-written case will be avoided. * See also the Introduction to the author's Student's Guide to Sur- gical Diagnosis. 26 306 ON CASE-TAKING. The following particulars must invariably be noted : 1. Christian and surname. 2. Age, condition (single or married), and occupation. 3. Late residence of patient (in case of inquiry after the patient has gone home). 4. Date of admission (day of month and year; or hour, if a case of accident or urgency). 5. Ward, and No. of bed. 6. Name of surgeon under whose care the patient is ad- mitted. 7. The most palpable outward symptom of the disorder for which the patient was admitted should then be noted in the plainest terras — thus, "broken leg," "tumor of the ^high," "severe burn," etc. In order to arrive at a clear understanding of the nature of the case, whether it be one of disease or accident, it will now be necessar}^ to inquire into (8) the history of the case so far as the patient can give it. This will be extracted with ease from some patients, whilst others will wander into all kinds of irrelevant details, and can only be kept to the point by the most rigid cross-examination. It is in collect- ing these details that the case-taker's intelligence will be chieflj^ exercised; but if he will bear in mind the rule stated above, his duty will be much facilitated. Thus, in cases of accident, the nature of the accident and its immediate re- sults to the patient should be briefly described (e. g., a cab horse knocked the patient down, and the fore-wheel went over the right leg) ; also any medical attendance which the patient may have received before admission should be noted. It is to be borne in mind that all dates of cases should be recorded as da3^s of the month, and not of the week, or the report will be unintelligible in a short time. This naturally leads up to (9) the patten fs condition on admission, which must be ascertained from the officer who ON CA>SE-TAKING. 307 saw the case at first ; and the physical condition of the pa- tient should always be recorded— thus, faint from loss of blood, insensible, sober, drunk, etc. These last particulars (9) will only be necessary in cases of accident, since in chronic cases the condition of the pa- tient when seen by the case-taker will vary but little from that on admission. 10. The patients premous history must next be ascer- tained, so far as it bears upon the probable result of the case or the treatment. Tlius, it will be important to record whether the patient is habitually sober or given to drink ; whether a woman is some months advanced in pregnancy; or whether the thigh of the opposite side was fractured some years ago and has been shortened since that date. Again, in cases of disease, e. gr., tumor, the family history will have a direct bearing upon the question of malignancy, and so also the previous existence of other tumors, the amount of pain experienced, etc. It will be well to ascertain whether the patient has resided habitually in town or country, and whether he has been engaged at any time in occupations of an injurious tendency. It will be advisable also in many cases, and particularly in the case of children, to obtain fur- ther information from the parents or friends when they come to visit at the hospital. 11. Description of Case. — This gives a wide field for the case-taker's ability to show itself, for nothing is more diffi- :eult than to give a good verbal description of morbid ap- pearances. In the simpler cases a few lines will suffice, thus : " There is a simple transverse fracture through the right humerus immediately below the insertion of the deltoid, with a small effusion of blood into the surrounding tissues, and a bruise 308 ON CASE-TAKING. on the outer side of the arm over the seat of fracture. No other injury." More complicated cases of disease or injury will require more elaboration, and the reporter should endeavor to elu- cidate all those points which will assist the surgeon in mak- ing his diagnosis. Thus, in the case of a tumor of the breast: " In the lower part of the left breast, a tumor of the size of a large orange is developed. The surface of it is smooth, and the skin can be made to glide over it, the nipjjle being quite normal. The tumor is freely movable on the subjacent tissues, and its boundaries can be distinctly made out. At one point in the lower part of the tumor an obscure sense of fluctuation is perceived. There is a little pain present occasionalh" in the tumor, but it is only of a dull aching character. There is no enlargement of the axillary or cervical glands, nor any other tumor in any part of the body." In all cases of surgical disease, the condition of the tho- racic, abdominal, and genito-urinary organs should be inves- tigated, and the fact that they have been examined and found normal or otherwise should invariably be noted. The general appearance of the patient (full-bodied, cachectic, etc.) should be noted, and whether he presents any indica- tion of a scrofulous or tubercular diathesis. If the case-taker can give a little drawing of the appear- ances of the disease, though only a pen-and-ink sketch, it will add much to the value of the report. 12. Diagnosis and Bemarks of Surgeon. — These must be carefully reported, and the best way is to enter them roughly in a notebook at the time, and w^rite them out carefully afterwards. A few lines will generally suffice, provided the case has been properly taken beforehand, but some surgeons have a weakness for dictating the whole case over again in their own words. ON CASE-TAKING. 309 13. Treatmeiit. — The treatment, both local and general, must be careful!}' noted ; and in the case of fractures, etc., the apparatus used should be distinctly named (long splint, Maclntyre, etc.), or, if of unusual form, it should be fully described, and its inventor's name mentioned. The diet ordered must be recorded, and all prescriptions carefully copied, with the several ingredients under one another, and not in one line. When the form of book will allow of it, it is well to enter the prescriptions in the margin. 14. Progress. — In acute or urgent cases, the daily or even hourl}' condition of the patient should be reported ; but in chronic cases, a report twice or three times a week is ample. In all acute cases, particularly when any operation has been performed, a tabular record of the pulse, respiration, and temperature should be kept for the inspection of the visiting surgeon. These should be recorded twice a day at the same hour, morning and evening, and will be found of great service in guiding the treatment. Clinical thermome- ters are now in common use, and can be procured of various makers. The " register" thermometer, i. e., a thermometer in w^hich a small portion of mercury, separated by a bubble of air, serves as an index, is much more convenient than the common form of instrument, as it can be removed from the patient and carried to the light for inspection. In using the register thermometer it is necessary that the register should be set, and this is readil}^ accomplished b}' holding the instrument firml}- between the finger and thumb of one hand, and giving it a slight jerk by striking one arm against the other. The detached portion of mercury is thus shaken down to the column in the instrument, and will indicate any rise in its level. The thermometer is most conveniently placed in the mouth of the patient, and should be left in situ for five min- utes in order to get the correct temperature. The normal temperature of the human body is 98.4'^ F., and any great 310 ON CASE-TAKING. rise above this is indicative of severe constitutional disturb- ance. The occurrence of a rigor, as in pysBraia, is usually preceded by a sudden and extreme rise in temperature. The records of temperature may be kept either in columns or in a tabular form, by which latter the variations are more readily appreciated, and of which the accompanying is a convenient specimen (see page 311). It is most important to record any new sj^mptom at the time of its occurrence, since thereby the absurdity of noting the cessation of a symptom which has never been mentioned before is avoided. Also, precise terms should be used, and such vague statements as " Is better to-day" be avoided. Any remarks which the surgeon may make during the progress of the case should be recorded, and particularly any reasons he may assign for change of treatment, or for proposing operative interference. 15. Operation. — The steps of an operation should be most carefully described ; thus, the fact of anesthetics being administered or otherwise ; the incision made (length and direction), and the instrument it was made with ; the use of saw, bone-forceps, or other instrument ; the amount of haemorrhage (arterial or venous), and the method emploj'cd to arrest it ; any unexpected occurrences during the opera- tion ; the dressings applied ; and the condition of the patient when removed to bed. An}^ remarks upon the case which the surgeon ma}^ make in the operating-theatre should be taken note of, but it will not be necessary, of course, to re- capitulate the history of the case, of which he will probably give a sketch to the spectators. In the case of tumors, limbs removed for disease, etc., a minute account of tlie appearances of the diseased portions, as seen after removal, should be appended. ' The history of the case must, of course, be resumed after an operation, and especial care taken to notice the state of the pulse and I'espiration ; whether sickness is present or ON CASE-TAKING. is •aivos SjXiaHiiaaHVj « 312 ON CASE-TAKING. not; the administration of stimulants or anod^-nes, etc. The condition of the wound must be minutely described, whether there is oozing of blood, and if so, to what extent; whether suppuration is set up or the parts heal by first intention, and the nature of the dressings which are ap- plied. Daily reports are essential for at least the first week or ten da3^s after a severe operation ; subsequently, longer intervals are allowable, but all important epochs should be recorded, e. gr., the first dressing, the coming away of the ligature from a main artery, the removal of stitches, the first time the patient leaves his bed, and the date of the final closing of the wound. 16. Result. — This must invariably be recorded. If favor- able, mention should be made of the general condition of the patient at the time of his discharge, and more particu- larly of the results of the treatment to which he has been subjected. The date both of month and 5^ear must be care- full}^ recorded, and also whether the patient is discharged to a convalescent institution, or to his own home. In the case of death, the date and hour of death must be recorded, and also, if possible, the mode of death. The record of the post-mortem examination should be appended to the case, and the condition not only of the part aflfected, but of all the organs of the body, should be investigated, since the information thus collected may have an unex- pected importance at some future time. When a case is concluded, the name of the disease and the result should be placed at the top of it, for the sake of easy reference, and the clerk should sign his name at the end. In long cases which are carried on to a page at a little distance, double references should be given, — "Con- tinued at p. — ," and " Continued from p. — ." A case-book should be provided with a double index ; in one, the names should be in the first column, in alphabeti- cal order, for reference while the patient is in the house ; ON CASE-TAKING. 313 but the second index should consist of several parallel columns, in which the following should he entered: 1. Dis- ease (referred to each organ, — thus, Urethra, stricture of; Breast, scirrhus of, etc.) 2. Name. 3. Age. 4. Date of admission. 5. Date of discharge, or death. 6. Operation. 7. Result. The number of the page being placed before or after the other particulars, as most convenient. TABLE FOR REPORTING A SURGICAL CASE. 1. Name. 2. Age and Condition, and Occupation. 3. Address. 4. Date of admission (day of month and year). 5. Ward and Bed. 6. Surgeon. 7. Injury or Disease. 8. History of Case from Patient. [9. Condition on Admission.] 10. Patient's previous Histor}'-. 11. Description of Case. 12. Diagnosis and Remarks of Surgeon. 13. Treatment. 14. Progress. [15. Operation.] 16. Result. 314 POST-MOKTEM EXAMINATION. CHAPTER XII I. POST-MORTEM EXAMINATION. The neat and satisfactory performance of a post-mortem examination should alwaj^s be aimed at in hospital prac- tice ; while in private it is of still greater importance to avoid offending the feelings of relatives by unnecessary noise, or wanton soiling of the clothes, furniture, etc. The body being stripped and laid upon a table or the lid of the coffin, the house-surgeon should take notice of any external appearances which may be worthy of remark ; and in cases of medico-legal investigation these should be at once noted with pen and ink. In the case of surgical operations, also, the appearance of the wound should be investigated before anj^ further steps are taken. If the head is to be examined, it should be taken first, since the appearance of the brain will be materially modi- fied by the cutting of the large vessels of the heart, etc. Examination of the Head. — The head being raised to a con- venient height upon a block or tripod-stand, the hair should be parted across the top of the skull from ear to ear. An in- cision down to the bone is then to be carried in the same di- rection across the top of the head, and never across the fore- head. The scalp, being thoroughly divided, can be drawn forward over the brow, and backwards over the occiput, being freed from the skull, where necessary, with the knife. A line is now to be marked with the knife all around the skull, necessarily cutting through the temporal muscle on each side ; and the mistake is often made of carrying this line much too low, thus materially embarrassing the after- EXAMINATION OF THE HEAD. olO Steps. It should pass about an inch and a half above the orbit in front, and half an inch above the occipital pro- tuberance behind, while at the sides the line between these two points should be kept as high in the temporal fossae as the shape of the head will allow. In order to saw through the calvaria easily, the head must be held quite steady, and the saw must be sharp and used lightly. The best way is to stand on the left side of the corpse, to grasp the head firmly with the left hand, and place the heel of the saw on the frontal bone. A few firm but light backward and forward movements will soon cut through the outer table of the skull, and the cut can then be readily prolonged backwards. The head must be moved as may be most convenient; and, when approaching the occiput, the operator will either have to stoop considerably to use the saw effectually, or must raise the back of the head to a suitable level. Having finished the left side of the head, the operator may either lean over, if he is tall enough, and continue the sawing on the right side, or, what is much easier, he may come round to the right side, and putting the heel of the saw in the extremity of the former cut, can carry it back to meet the one of the opposite side at the occiput. There are three points where the saw re- quires to be thoroughly applied, viz., at the occiput and at the anterior extremities of the temporal ridges on the frontal bone; but care should be taken not to carry the instrument so deeply as to wound the dura moter or brain. In the hospital dead-house, where noise is of no conse- quence, it is unnecessary to saw through more than the outer plate of the skull, and the inner may be more expe- ditiously divided with the chisel and mallet : but in private houses the saw must be carried through the entire thick- ness of the skull, which must be merely '' prized " open ■with the chisel, to which a handle should be fitted at right angles with the shaft, so as to give a leverage to the oper- ator's hand. When the calvaria is very firmly attached to 316 POST-MOETEM EXAMINATION. the dura mater, it may be either dragged off forcibly with the hook provided for the purpose, or a steel sound or staff (of which there is usually one in a post-mortem room) may be introduced between the two, and be made to tear throush the adhesions. When the adhesions are especially firm, the shortest way of overcoming the difficulty is to divide the dura mater all round in the line of the incision, and remove skull-cap and dura mater together. In cases where any injury to the skull is suspected during life, and generally in cases the subject of medico-legal investigation, great care should be taken to divide the calvaria altogether with the saw, lest a difficulty should arise in determining whether a fracture of the skull is not the result of the violent efforts to remove the skull-cap. (A good plan in such cases, sug- gested by Mr. Hutchinson, is to cut off the upper convolu- tions of the brain and their membranes with the skull-cap, and to remove them subsequently for its examination.) The superficial parts of the membranes having been exam- ined, they should next be opened in the following way: The knife is carried round the cut edge of the skull, and made to divide the dura mater, which can then be lifted up on each side, so as to expose Va^ falx ; this, being detached with the knife from its attachment to the ethmoid bone, can be drawn backwards, and the upper surface of the brain will be fully exposed. (If it will be necessary to examine the sinuses of the skull, the superior longitudinal should, be laid open before the falx is detached.) To Remove the Brain. — Lift up the anterior lobes with the left hand, turning up with them the first pair of nerves. Next divide the optic nerves (second), which will be seen close to the clinoid processes, and immediately behind them the internal carotid arteries, with the infundibulum in the middle line. The third pair will next be seen, and then the tentorium cerehelli^ which is to be divided on each side by carrying the knife along the posterior margin of the TO REMOVE THE TEMPORAL BONES. 317 petrous bone; this cut will divide the fourth nerves, and the fifth will be at once exposed, wlien the sixth, seventh, eighth, and ninth nerves will follow in their natural se- quence. Lastly, the knife is passed tli rough the foramen magnum to divide the medulla oblongata and vertebral arteries, and the brain can then be lifted out. The brain having been weighed, the base and the arteries should be first investigated ; and it may then be carefully sliced from above downwards, in order to examine the several parts of the organ. The sinuses of the base of the skull ma}'- now be readily examined, by carrying the knife along their several situa- tions. To Open ilie Orbit. — This is best done from above, after the removal of the brain. The saw should be carried through the remainder of the frontal bone, at the inner and outer angles of the orbit, and these cuts can then be pro- longed backward through the roof of the cavity with the chisel. The triangular piece of bone thus marked out can then be tilted forward, and the contents of the orbit will be exposed. If it is merely required to examine the ej'eball, this can be more readily removed from the front, in the same way as during life, with a pair of scissors. To Remove the Temporal Bones. — This may be required in cases of deafness, or occasionally in fractures. The brain having been removed, the knife should be carried clown outside the bone, so as to separate the auricles with the skin, which should be drawn down. The saw is then to be carried behind the mastoid process to the jugular fora- men, and through the squamous portion up to the basilar process ; a little force with the chisel, and a division of any soft parts with the knife, will tlien lift the bone from its place. The knife is next to be carried beneath the bone, to free it from its attachments to the lower jaw and pharynx, 318 POST-MORTEM EXAMIJS^ATION. care being taken, however, to leave the Eustachian tube attached to the under surface. To Eemove the Spinal Cord. — The body being turned on its face over a block, so that the dorsal region maj^ be well elevated and curved, an incision is to be carried from the occiput to the lower part of the lumbar region. All the muscular tissue is to be turned aside as far as possible with the skin, so that the vertebral arches may be fully exposed. With the saw a cut is then to be made on each side of the dorsal region, close to the articular processes, but sloping inwards towards the vertebral canal, and with the chisel these three or four arches can then be removed. A strong spine-chisel or rachet is next to be used, and the hook being inserted in the canal, it can be hammered through the arches for the whole length of the spine, and with a pair of bone- forceps they can readily be removed in a few minutes; the dura mater will then be exposed, and must be divided to expose the cord. To remove the cord, the knife must be carried outside the dura mater, to cut through the nerves on each side, and the cauda equina below, when the cord can be readily lifted out, and sliced in various parts as may be necessary. Chest and Abdomen. — These cavities are generally laid open together by an incision from the root of the neck to the pubes. This cut, begun over the lower part of the tra- chea, should be carried along the centre of the sternum and down the bone, then only through the skin to the umbilicus, in a semicircle around that point, and so on to the pubes. Keturning to the lower extremity of the sternum, the oper- ator should then carefully deepen the incision, so as to open the cavity of the peritoneum for an inch or two ; this being done, the first and second fingers of the left hand can be in- troduced, and will serve to hold up the abdominal wall, while the knife is passed between them, with its back to the THORAX. 319 intestines, and made to cut through the whole thickness of the muscles at once down to the pubes. The skin and pec- toral muscles are then to be dissected off the sternum and cartilages of the ribs, which should be full}' exposed. Thorax. — The knife is now to be carried through the sterno-clavicular articulation on each side, which will be readily accomplished by placing the point close to the inner end of the clavicle and cutting downwards and outwards. The cartilages of all the ribs are next to be divided, and it must be borne in mind that the cartilage of tlie first rib will be found a little farther from the middle line than either the sterno-clavicular articulation or the cartilage of the second rib. All the cartilages should be divided as near their re- spective ribs as practicable, and should be cut evenly on the two sides. In old subjects the cartilages of the ribs, and particularly the first one, are more or less calcified, and will require the application of the bone-forceps. The lower part of the sternum is now to be lifted up, and the attach- ment of tlie diaphragm divided; after which, by the division of a little cellular tissue, the sternum will be quite freed, and may be lifted oflT. If, as is generally' the case, the pleu- rae are very adherent to the sternum, they will be removed in part with that bone, and the lungs will be fully exposed. These are to be drawn forward and examined superficially, notice being taken of the amount of fluid in the pleural sacs. The pericardium is next opened by a vertical incision, and the heart exposed. (Any fluid in the pericardium, if its measurement is required, should be withdrawn with a syringe.) The heart and lungs are best removed together, by cut- tins: throuofh the trachea, drawinsj it down with the left hand while dissecting it away from the oesophagus, then cutting across the great vessels at the root of the neck, and so dragging the whole contents of the cavity out together. The heart will be found to be attached to the diaphragm by 320 POST-MORTEM EXAMINATION. the remains of the pericardiiira and by the vena cava, but these can be readily divided, and the organs removed for further examination. The lungs are to be carefully sliced from above down- wards, and the bronchi can be readily laid open, if neces- sary, by carrying a pair of scissors along the back of the trachea, and so into the bifurcation. The heart may be either examined as it is, or separated by dividing the pulmonary vessels and the arch of the aorta, when the interior can be readily exposed. The cavities are best laid open in their natural order, /. e., fol- lowing the course of the blood. The right auricle is opened by an incision from one vena cava to the other, and a second at right angles to it into the auricular appendage. To open the right ventricle^ pass the forefinger through the auriculo- ventricular opening into the cavity, then push the knife through the anterior wall, well to the right of the sep- tum, and, guided b}^ the finger, transfix the ventricle, and cut downwards so as to make a sort of triangular flap. The finger, introduced into this opening, will then guide the knife towards the auriculo-ventricular aperture; and the tri- cuspid valve should first be examined from below, and then the auriculo-ventricular ring being cut through, it will be fully exposed. The finger will next guide the knife into the pulmonary artery, which is to be laid open, care being taken to pass the knife between the semilunar valves. The clots generally found in the right side of the heart should be re- moved, and the cavities washed out, so that the,y may be thoroughly examined before the left side is opened. The left auricle will be exposed by a vertical cut through ABDOMEN. 321 the posterior wall, passing between the pulmonary veins of the two sides. The left ventricle should be transfixed with the knife to the left of the septum, and opened in the same way as the right ; and the mitral valve, having been examined from below, will be fully exposed by dividing the auriculo-ven- tricular ring. The finger should be passed into the aorta, to direct the knife between the valves, and the vessel may then be laid open, the knife necessarily passing through and destroying the pulmonary artery and valves. The dissection of thoracic tumors, aneurisms, etc., will vary according to circumstances ; but it will be alwaj's found much more satisfactory to dissect the tumor in sitii^ than to remove it en masse and attempt to examine it after- wards. To Examine the Larynx. — An incision is to be made from the chin to the sternum, and the skin carefully dis- sected back for some distance. The knife is then to be pushed through the floor of the mouth, and made to detach it on each side from the jaw. The tongue can next be drawn down through the aperture thus made, and the knife made to divide the pillars of the fauces, and go well back to the vertebrae, so as to divide the pharynx. The tongue, larynx, and pharynx can thus be drawn down together, and either separated from the lungs or removed with them. The cavity of the larynx is best exposed from behind. Abdomen. — The contents of this cavity having been fully exposed (page 318), they should be first examined in situ, and then removed. Stomach is removed, with its contents, by tying the oesophagus, and dividing it above the ligature, then placing 27 322 POST-MORTEM EXAMINATION. two ligatures at the pylorus, two inches apart, and dividing between them. The contents should be carefully set aside in any case of medico-legal inquiry, and the viscus laid open by carrying a pair of scissors along the lesser curvature. Intestines^ large and small, are to be removed together, by placing a couple of ligatures at the commencement of the jejunum and of the rectum^ and dividing the intestine at these points. The large intestine should be separated from its attachments in its whole length, and turned over to the right side ; then turning the small intestines in the same direction, and grasping the mesentery with the left hand, one sweep of the knife will free them from their attachment. The small intestines will be most readily pre- pared for examination by cutting off the mesentery with a pair of scissors, and they must alwa3^s be opened on the side to which the mesentery was attached. Pancreas^ duodenum, and spleen will be fully exposed by the above proceeding, and can be examined in situ^ or readily removed, if desirable. Liver is most easily removed by taking with it a piece of diaphragm, — that is, if the thorax has been opened ; if not, the ligaments must be divided, and the organ dissected away from the diaphragm. The vena cava will, of course, require to be divided both at the diaphragm and also below the liver; and any dissection within the abdomen should be finished before this is done, or it will be spoiled by the blood which pours out. Kidneys can be extracted without interfering with the intestines by turning them over to the opposite side, dividing the peritoneum in the lumbar region, and drawing forward the gland. The vessels and ureter must be divided to allow of its removal, and its interior is to be exposed by an incision along tlie convex border. TO REMOVE THE URETHRA AND BLADDER, 323 Bladder and rectum^ uterus and ovaries, can be removed by dividing all the structures lying upon the floor of the pelvis close to the levator ani, and drawing them out of the cavit}', severing at the same time the connections at the sides. If it is desirable, however, to remove the bladder with the urethra, the following dissection must be made. To Remove the Urethra and Bladder. — The most satis- factory way is to remove also a portion of the pubes. The abdomen having been opened by the usual incision, it should be prolonged on to the upper surface of the penis for a short distance, and the skin be separated from the body of that organ as far as the glans, where the penis may be divided, unless it is desired to remove the whole of the ortyan, in which case the foreskin must be cut, and reflected from it. An incision carried round the root of the penis, and through the scrotum to the anus, will allow the skin with the testes to be reflected from off the front of the pubes. The saw should make a vertical cut through the bone, about an inch on each side of the symphysis ; and the bladder having been separated from its attachments in the pelvis and to the rectum, a few touches of the knife will isolate the part, so that the bladder, urethra, and penis can be re- moved in one piece. The symphysis may be afterwards divided, and the urethra and bladder be laid open from above, or otherwise, as may be most convenient. No special directions can be given for the post-mortem examination of injuries, tumors, etc. ; a knowledge of anat- omy, and of the use of the scalpel, being all that is required for their due performance. In all cases of post-mortem examination, care should be taken to restore the exterior of the corpse to its ordinary appearance. Thus, the head should be weighted to corre- spond to what it was before the brain was removed; the 324 POST-MORTEM EXAMINATION. scalp should be carefully sewn up, and the hair arranged so as to hide the incision. In order to keep the calvaria in its proper position, and thus prevent a deformity of the fore- head, brass pins, half an inch in length, and sharpened at both ends, may be advantageously employed. If one of these be inserted into the diploe at each temple and at the occiput, the calvaria can be pressed down upon tliem, and fixed in its proper position with a few gentle blows of the hammer. Another mode of accomplishing the same thing is to drill a hole in'each temporal fossa with a gimlet, and correspond- ing holes in the calvaria, and to twist pieces of copper bell- wire firmly between them with a pair of pliers. The twisted ends are covered in b}' the temporal muscles, and make no projection on the surface. The sternum should be replaced, and the abdomen and thorax sewn up from below, the thread being always entered on the under surface of the skin and at regular intervals, and a long strip of plaster may be laid over all. If the rectum or vagina have been divided, their orifices should be sewn up, or fluid will pour out when the body is removed ; and where the front of the pubes has been taken away, a piece of wood should be inserted between the innominate bones, so as to keep them steady. When the glans penis has been left, it will be sufficient to distend the skin behind it with cotton-wool ; but where it has been removed, a piece of liver cut to an appropriate shape, and secured in the foreskin with a stitch, makes a ver}^ passable substitute. ' The neck should be stuffed v\ith tow or cotton-wool when the larynx has been removed ; and where the eyeball has been extracted, a very good substitute can be made of a knuckle of small intestine, tied with a piece of thread, and inserted between the lids. After any post-mortem or dissecting work, the house- surgeon should be most careful to cleanse his hands, and, POST-MORTEM EXAMINATION. 325 if possible, change his clothes, before entering the wards or touching a patient. The hands should invariably be washed in cold water, and well brushed with a hard nail brusli. If then immersed for a minute or two in some of Condj's fluid, or in a very weak solution of chloride of zinc or carbolic acid, and then washed again, or if carbolic acid soap be employed, all smell will be effectually removed, and the possibilit}' of any infection being tranf^mitted to the patients considerably lessened. Eau de Cologne sprinkled on the hands, and allowed to evaporate, is the most efiicient agent for removing any slight remaining scent from them, after having been thus thoroughly washed. The practice of oiling the hands before commencing operations certainly diminishes the amount of absorption of offensive matter, but renders the holding of instruments difficult, and hence increases the liability to accidental cuts or scratches. In case an}' injury is received in making a post-mortem examination, it is a safe precaution to wash the hands at once, to suck the wound, and apply a piece of plaster until the operation is completed, when water-dressing is the best application. Any tenderness or redness of the lymphatics of the arm is best treated by the prompt application of the glycerinum belladonnie. It is not generally from evident cuts that the occasional danger arises, but from unseen scratches in a person out of health, which are inoculated with the poison of some specially diseased body. The record of the post-mortem appearances should be made at the time, and with the parts in view; for unless this plan is adopted, some important point is almost certain to be omitted. The easiest way is for the operator to dictate to a bystander, who can roughly report the particulars, which should be carefully written out immediately after- wards. 326 TABJLE OF AVERAGE WEIGHTS, ETC. TABLE OF AVERAGE WEIGHTS OF THE ORGANS OF THE BODY. Tabulated from QuAiN and Shabpey's "Anatomy." Brain, .... Cerebrum, . Cerebellum, Pons and medulla oblongata. Spinal Cord, . Heart, .... Lungs, .... Thyroid, Liver, .... Pancreas, Spleen, .... Kidney, .... Suprarenal capsule, Prostate, Testis, .... Uterus (virgin), . . , ^ Ovary, Male. Female. 492^ oz. Avoir. 44 oz. Avoir. 43 oz. 15 dr. 38 oz. 12 dr. 5 oz, 4 dr. 4 oz. 12J dr. 15f dr. 1 oz. I dr. 1 oz. 4 dr. 1 oz. 4 dr. 11 oz. 9oz. f right, 24 oz. \ left, 21 oz. right, 17 oz. left, 15 oz. 1 oz. 2oz. 53 oz. 45 oz. 3oz. 3oz. 6oz. 5 oz. 5^ oz. 5 oz. 1 dr.— 2 dr. 1 dr.— 2 dr. 6 dr. 1 oz. 7 dr.— 12 dr. 1 dr.— IJ dr. FOEMULJE. The following formula have been selected from the phar- macopoeias of those metropolitan hospitals which have issued a new edition of their special formulae since the publication of the last edition of this book : 1. CoNFECTio CuBEB^ Co. (St. Mary's). R. Pulv. Cubebae, giv; Balsami CopaibEe, f ^ij ; Theriacae, f ^ij. Dose. — f^ij. % CoNFECTio Senit^ cum Sitlphure (St. Mary's). R. Confect. Sennae, f 3vj ; Sulphuris, 3j. Dose. — f^j ad f^ij. 3. Enema Olei Bicini (Westminster), R. Olei Eicini, f^ij ; Saponis mollis, ^j ; Aquae calidae, f.^xx. Misce. 4. FoMENTUM Pap AVERTS (Westminster). R. Papaveris Capsularum, ^j ; Aquae, f^xx. Boil for a quarter of an hour, and strain. 5. Gargarisma Acidi Tannici (Consumption). R. Acidi Tannici, ^j ; Glycerini, f ^ij ; Aquam ad f ^^v. Misce. 6. Gargarisma Alumlnis (University). R. Aluminis, 5j ; Mellis, f^iv; Aquam ad f ^iv. Misce. 328 FORMULA. 7. Gargaeisma Boracis (Westminster). R. Boracis, 3j; Theriacse, f 3^ I Aquam ad f,^v. Misce. 8. Gaugakisma Hydrarg. Perchlor. (St. Mary's). R. Corrosivi Snblimati, gr. iij ; Glycerini, f ^j ; Acidi Hydrochlorici, '"Xxij ; Aquam ad f 5xij. Misce. 9. Gargarisma Potass^ Chloratis Acid a (Consump- tion). R. Potassse Chloratis, gr. 1 ; Acidi Hydrochlor. dil., ttjjI ; Syrupi Khoeados, f .^ij ; Aquam ad f^v. Misce. 10. Gargarisma Sod^ Chlorate (St. Bartholomew's). R. Liquoris Sodse Chloratas, f^iv; Aquse, f^viij. Misce. 11. Gltcerinum Belladoi^nje (University). R. Extracti Belladonna, ^viij ; Aquse, f ^ij ; Glycerin um ad f ,^ij. 12. GuTT^ Atropi^ Stjlphatis (Ophthalmic). R. Atropife Sulphatis, gr. j ; Aquse destillatse, f ^j. Misce. 13. GUTT^ Opii (Ophthalmic). R. Vini Opii, f ,:^ij ; Aquam ad f ^j. 14. GuTT^ ZiKCi Sulphatis et Alumikis (Ophthalmic). R. Zinci Sulphatis, gr. j ; Aluminis, gr. iij ; Aquse, f ,^j. Misce. FORMULAE. 329 15. Hatjstus Aromaticus (Middlesex). R. Pulv. Cretse Aromatici, gr. xxx; Mucilaginis, f^} ; Aquam Carui ad f Jj. 16. Haustus Carmin-atiyus (Westminster). li. Ehoei, gr. v; Zingiberis, gr, v ; Sodse Bicarbonatis, gr. x ; Sp. Ammonise Aromatici, ^xx ; Aquam Cinnamomi ad f^j. 17. Haustus Diaphoreticus (Westminster). R. Antimonii Tartarati, gr. -^^ ; Liq. Ammonise Acetatis, f ^ij ; Aquam ad f ^j. 18. Haustus Diureticus (Westminster). K • Potassse Acetatis, gr. xx ; Sp. iEtheris Nitrosi, f ^ss. ; Decoctum Scoparii ad i^j. 19. Haustus Efferyescens (Westminster). R. Sodae Bicarbonatis, gr. xx ; Aquae, f §j ; R. Acidi Tartaric!, gr. xviij ; Aquae, f ^j. Misce. 20. Haustus Emeticus (St. Bartholomew's). R. Vini Ipecacuanhae, f^iv; Oxymellis Scillae, f ^iv ; Aquam ad f Jiss. 21. Haustus Imperialis (University). R. Potassae Tartratis Acidi, 3j ; Sacchari, giv; Aquae bullientis f ,^xx. Misce. 22. LiKCTUS Communis (Charing Cross). R. Extract! Opii liquidi, ^iij ; Acidi Sulphuric! diluti, tt)Jv ; Syrupi Scillae, 'i^xv ; Theriacae, f ^ss. ; Aquam ad f^j. 28 330 FORMULA. 23. LiNCTUs SciLL^ Co. (University). R. Oxymellis Scillse, TT^xxiv ; Tincturee Camphorse Co., ^xij ; Vini Ipecacuanlise, Tr^vj ; Mucilaginem Acacise, ad f^j. 24. LoTio AciDi KiTRici (University). R. Acidi Mtrici diluti, ^xv; Tinct. Opii, ■"Kxv ; Aquse, f^j. Misce. 25. LoTio Ammonia Chloridi (Eyaporans) (St. George's). R. Ammonise Chloridi, gr. xxx; Aceti destillati, f 3j ; Spiritus Rectificati, f ^j ; Aquam ad f ^j. Misce. 26. LoTio Calamine (University). R. Calaminge levigatse, gr. xl ; Zinci Oxidi, gr. xx ; Glycerini, ^xx ; Aquam ad f ^j. 27. LoTio Calcis SuLPHUKATiE (University). R. Slaked lime, ^iv; Sulphnris, ^iv ; Aquse, f^xxxv. Boil and evaporate to one pint (for scabies). 28. LoTio HYDRAP.a. Perchlor. Htdrocyanica (St. Bar- tholomew's). R . Hydrargyri Perchloridi, gr. J ; Glycerini, f^ij; Acidi Hydrocyanici, 1^)2 viij ; Aquam ad f ^j. 29. LoTio Rubra (Middlesex). R. Zinci Sulpliatis, gr. x ; Spiritus Rorismarini ; Tincturse Lavandulae Compositse, aa f 3ijss. ; Aquae, f ,f x. Misce. FOEMUriiE 331 30. Lotto Kubra (St. George's). R. Cupri Sulphatis, ^ss.; Camphorse, gr. viij ; Armenian Bole, .^ss. ; Aquse ferventis, f^viij. Misce. 31. LoTio SoD^ Hyposulphitis (Charing Cross). E:- Sodse Hyposulphitis, ^vj ; Glycerini, f.^iv; Aquse, ad f,f x. Misce. (For parasitical skin affections.) 32. Mist. Acacia Opiata (Consumptidn). R. Tinct. Camph. Co., f 5ss. ; (Sp. Chloroformi, ^^y • Mucilaginis Acacise, f ^ij ; Aquam ad f ^j. (For coughs.) 33. MiSTURA AciDA Aromatica (King's). B. Acidi Hydrochlor. dil., ^xv; Sp. Armoraciffi Co., ^x ; Tinct. Zingiberis, ^ri^v; Infusum Calumbse ad f^j. (Aromatic tonic.) 34. MiSTUKA Acidi Gallici (Consumption). R. Acidi Gallici, gr. x; Tinct. Camphorse Co., tt^xx ; Acidi Sulphurici dil., n^^xv ; Aquam ad f^j. (To check sweating.) 35. MiSTURA Acidi Phosphorici (University). R. Acidi Phosphorici dil., ^xv; Sp, Chloroformi, '^:s: ; Infusum Gentianse Co. ad f ^j. (Nervine tonic.) 332 FORMULA. 36. MiSTURA JEtheris Composita (St. George's). R. ^theris Sulph., f ^j ; Sp. Ammoniee Aromatici, f ^ss. ; Syrnpi, f ^ss. ; Aqua Pimentse, f ^iij ; Aquam ad f ,^j. (Stimulant.) 37. MiSTURA Alba (King's). R. Magnesiee Cai-b., gr. x; Magnesise Sulph., 5j ; Aquam Meiithse Pip., f ^j. (Saline purgative.) 38. MiSTURA Ammoki^ Acetatis (University), R. Liq. Ammonise Acetatis, f ^ij ; Potassse Nitratis, gr. x ; Aquam Camphorse ad f ^j. (Anti-febrile.) 39. MiSTURA Aromatica (St. Mary's). R. Sodse Bicarbonatis, gr. x ; Ammonise Carbonatis, gr. iv; Tinct. Cardamomi Co., f 5ss. ; Infusum Caryophylli ad f^j. (Warm stomachic.) 40. MiSTURA Aromatica Infantum (Middlesex). R. Confectionis Aromaticse, ^ij ; Magnesise Carbonatis, gr. viij ; Tincturse Ehei, ii^xl ; Aquse Menthse Pip., f ^j. Misce. (Carminative and purgative.) Dos6. — f .5j to f ^ij. 41. MiSTURA Carminatiya (St, Thomas's), R. Magnesise Carbonatis, gr. xx; Pulveris Bhei, gr. x ; Tinct. Camphorse Co., ti;52xxx ; Sp. AmmoniEe Aromat., t^J^xxx ; Aquam Anethi ad f.^jss, (Soothing antispasmodic.) FORMULAE. HVj/} 42. MiSTURA CoLCHici APERiENS (University). R. Tinct. Colchici, "^xv; Magnesia Carbon atis, gr. vj ; Magnesise Sulphatis, ^ss. ; Aquam Menthse Piperitaj ad f^j. (Purgative in gout.) 43. MiSTURA Copaiba (University). . ijc. Copaibse, ttJ^xxx; Liquoris Potassae, ^rj^xij ; Aquam Cinnaraorai ad f ^j. • (Stimulant to urinary organs.) 44. MiSTURA Cret^ Aromatic^ Anodyita (London Oph- tlialmic) . R. Pulv. Cinnamomi Co., gr. x; Pulv. Acacise, gr. x; Cretse prejDaratse, gr. x ; Tinctures Opii, ^v ; Aquam ad f ^j. (Astringent.) 45. MiSTURA Diaphoretic A (London). R. Vini Ipecacuanlije, tt)^xv; Sp. iEtlieris JSTitrosi, f^ss. ; Mist. Salinse ad f Jj. 46. MiSTURA DiURETiCA (St. Mary's). R . Potassse Acetatis, gr. xx ; SpiritHs JEtheris Nitrosi, f 3ss. ; Spiritus Juniperi, f ^ss. ; Mucilaginis, f^ss. ; Decoctum Scopari ad f ^j. 47. MiSTURA Effervescens (King's). R. Sodas Bicarbonatis, gr. xx ; Aquse, f,^j. Misce. Capiat dum efFervescendum cum sequente. R. Acidi Taxtarici, gr, xviij ; Aquse, f^ss. (Cooling saline.) 334 FOEMUL^. 48. MiSTURA Feriii Aperiens (University). R • Magnesise Sulphatis, ^ss. ; Ferri Sulph., gr. ii ; Acidi Sulpliurici dil., "^x ; Aquam Menthse Pip. ad f ^j. (Tonic aperient.) 49. MiSTURA IPECACTJATsrH^ Co. (Consumption). R. Vini Ipecacuanhfe, '^x; Tinct. Campliorse Co., f ^ss. ; - Aquam Anethi ad f ^j. (Sedative and expectorant.) 50. MiSTURA Ipecacuanha In^fantum (Middlesex). R. Vini IpecacuanhfB, ^xl; Mucilaginis, f ^iij ; Syrupi, f .5iss. ; Aquam ad f^ij- (Expectorant.) Dose. — f ^j to f ^ij. 51. MiSTURA Olei Morrhua (Consumption). R. Olei Morrhuse, f ^vj ; Liq. Potassse, gr. xl ; Liq. Ammonise fort., ^r^^ij ; 01. Cassise, ^y, Syrupi, f.5ij. Misce. 52. MiSTURA Rhei cum Magnesia (University). R. Rhei Pulveris, gr. vijss. ; Magnesise Garb., gr. xv ; Tinct. Zingiberis, f^ss.; Aquam MentLse Pip. ad f ^j. (Mild purgative.) Dose. — f 3j to f ^ij for children 53. MiSTURA Salina Aperiens (University). R . Magnesise Sulphatis, 3j ; Magnesise Carbonatis, gr. ix ; Aquam Menthse Piperitae ad f ^j. 54. MiSTURA SciLiiA Co. (St. Mary's). R. Oxymellis Scillse, f ^ss. ; Tinct. Camphorse Co., ti^xv ; Sp. ^theris Nitrosi, ^ri^xv ; Aquam Camphorse ad f ^j. (Expectorant.) FORMULA. 335 55. MiSTURA Taraxaci Acid a (University). R. Succi Taraxaci, f.5j ; Acidi Nitro-hydrochlor. dil,, HKx; Tinct. Columbse, WRxxiv; Infnsum Columbse ad f §j. (Cholagogue tonic.) 56. MiSTURA ToLUTAi!?'! (Consumption). R. Tincturte Tolutani, ti^x; Tinct. Camphorse Co., f3ss. ; Mucilaginis, f ^ss. ; Aquam Anisi ad f ,5j. (Soothing expectorant.) 57. Pasta Caustica (Middlesex). R . Zinci Cliloridi, ^j ; Flour, 5iij ; Liq. Opii Sedativi, f ^j. (To be mixed into a paste.) 58. SupposiTORiUM Belladonna (University). R. Ext. Belladonnse, gr. i; Olei Theobromse, gr. xv. 59. SUPPOSITORIUM Morphia (University). R , Morphiae Hydrochlor., gr. J ad gr. j ; 01. Theobromge, gr. xv. 60. SupposiTORiUM Oph (Middlesex). R. Pulv, Opii, gr. j; Olei Tlieobromse, gr. xv. 61. Unguentum Acidi Boracici (University). R. Boracic Acid, 2 parts; White Wax, 1 part ; Paraffin, 2 parts ; Almond Oil, 4 parts ; Prepared Lard, 3 parts. • (Dissolve and mix.) 336 DIET TABLES. ST. BARTHOLOMEW'S HOSPITAL. FULL DIET. 2 pints of tea. 14 oz. bread. Yi lb. meat, cooked. 3^ lb. potatoes. 2 pints beer (men). 1 " " (women). 1 oz. butter. HALF DIET. 2 pints of tea. 12 oz. bread. J^ lb. meat, cooked. 3^ lb. potatoes. 1 pint beer, p^ oz. butter. BKOTH DIET. 2 pints of tea. 12 oz. bread. V/2, pint broth. 6 oz. potatoes (mashed). ^ oz. butter. Gruel. MILK DIET. 2 pints of tea. 12 oz. bread. V/^ pint milk, or 1 pint milk with arrowroot, rice, or sago. ^ oz. butter. Gruel. GUY'S HOSPITAL. FULL DIET. 14 OZ. bi'ead. 1 OZ. butter. 1 pint porter. 6 oz. meat, cooked, with potatoes. ^ pint broth, occa- sionally. y^ lb. rice i^tidding, three limes a week. MIDDLE DIET. 12 oz. bread. 1 oz. butter. y^, pint porter. 1^ lb. meat, cooked. 34 pint broth, oc- casionally. 3^ lb. rice pudding, thrice weekly. LOW DIET. 10 oz. bread. i^ oz. butter. 3^ pint beef tea. MILK DIET. 12 OZ. bread. 1 oz. butter. 2 pints milk. 34 pint beef tea. ST. MilRY'S HOSPITAL. FULL DIET. ORDINARY DIET. 2 pints tea, with sugar. 3^ pint milk, 15 oz. bread. 6 oz. meat, cooked. 3^ lb. potatoes. ^ oz. butter. 2 pints tea, with sugar. 34 pint milk. 12 oz. bread. 4 oz. meat, cooked. ^^ lb. potatoes. ^ oz. butter. HALF DIET. 2 pints tea. 1 pint milk. 12 oz. bread. 2 oz. meat, cooked. 3^ lb. potatoes, % oz. butter. UNIVERSITY COLLEGE HOSPITAL. FULL DIET. 12 OZ. bread. 8 OZ. potatoes. 6 oz. meat, cooked. %pint soup, aliernate days. 4 oz. rice pudding. 1 pint milk. 1 pint beer. MIDDLE DIET. 12 oz, bread. 8 oz. potatoes, 4 oz. meat, or 8 oz. fish. 1 pint milk. 1 pint sijtip or beef tea, or 4 oz. rice pudding. 34 pint beer. SPOOif DIET. 2 pints milk, 1 pint beef tea. 12 oz. bread. 2 oz. arrowroot, and 1 oz. sugar made into jelly. Tea and sugar morning and evening with all diets. INDEX. Abdomen, post-mortem examination of, ai9 stabs in, 35 tapping, 118 Abscess, opening, 124 antiseptic treatment of, 125 rectal, 137 Absorbent dressing, 177 Accidents, immediate attention to, 23 haemorrhage from, 30 machinery, 68 Acids, poisoning by, 109 carbolic, 109 oxalic, 108 Prussic, 109 Acupressure, 56 Administration of chloroform, 167 nitrous oxide, 173 Air-passages, foreign bodies in, 84 Alcohol, poisoning by, 105 Alkalies, ditto, 109 Amputation, fingers, 132 toes, 134 Anaesthesia, 167 local, 132 Aneurism, false, 38 Ankle, sprained, 67 strapping for, 190 bandage for, 199 dislocation at, 295 excision of, 304 Antiseptic system, 155 Antiseptic gauze, 157, 178 dressings. 178, 181 Anus, prolapse of, 103 Appliances for arresting hsemorrbage 49 Arch, palmar, wound of, 38 Arm, bandage for, 207 dislocations of, 288 fractures of, 259 Arteries, wounds of, 36 Artificial respiration, 76 Asphyxia, 76 Aspiration, 120 Bandage roller, 195 Bandages, 195 ankle, 199 arm, 207 axilla, 208 breast, 203 breasts, both, 204 capeline, 210 figure-of-eight, 197 finger. 205 for all fingers, 206 four-tailed, 254 glue, 245 groin, 201 groins, both, 202 hand, 207 head, 209 knee, 200 leg, 198 lithotomy, 222 many-tailed, 216 paraffin, 247 penis, 265 plaster of Paris, 237 silica, 248 spica, 201 spiral, 196 starch, 236 stump, 213 suspensory, 215 T, 214 thumb, 206 tight, in fracture, 219, 237 venesection, 122 Bed, patient's, 152 Bed-sores, 165 I Bites of rabid animals, 75 1 of snakes, 76 I Bladder, haemorrhage from, 43 diagnosis of, 43 paralysis of, 92 rupture of, 251 washing out, 96 Bleeding, 120 from jugular vein, 123 from temporal artery, 123 Bloody tumor of scalp, 65, 250 urine, 43 Boracic acid dressing, 181 338 INDEX. Bougie for rectum, 136 Bowel, wounds of, 35 Brain, compression of, 79 concussion of, 79 Bread-poultice, 186 Breast, bandage for, 203 for both, 204 opening abscess in, 125 strapping, 193 Bruises, 65 Bryant's diagnostic line, 230 Burns, 69 cicatrices from, 72 Calcaneum, fractures of, 284 Calculus causing retention, 93 Carbolic acid, 155 poisoning by, 109 Carron oil, 71 Case-taking, 305 Catheter, introduction of, 88 female, 93 tying in, 218 Catgut ligature, 56 Catheter, washing out, 98 Charcoal poultice, 186 Chest, injuries to, 254 post-mortem examination of, 319 stabs of, 35 * tapping the, 119 Chloride of zinc, 155 Chloroform, administration of, 168 death from, 171 Circumcision, 138 Clavicle, dislocation of, 287 fractures of, 255 Cline's splints, 282 Clove-hitch, 286 Colles's fracture, 265 Collodion, 31 Compress, graduated, 37 Compression of brain, 79 Concussion of brain, 79 diagnosis of, 81 Contused wounds, 60 Contusions, 66 Cornea, wound of, 62 Cotton-wool dressing, 176 foreign bodies in, 82 Crepitus in fracture, 226 Cupping, 141 Cut throat, 33 Delirium tremens, 154 Diagnosis of concussion and compres- sion, 81 dislocation of shoulder and frac- tures, 288 Diagnosis of hernia, heematooele, and orchitis, 100 Dichloride of ethidene, 175 Diet, 21 after operations, 153 tables, 336 Dislocatiors, 285 with fractures, 227, 285 ankle, 295 clavicle, 288 elbow, 291 femur, 294 fingers, 293 humerus, 288 jaw, 287 knee, 294 shoulder, 288 wrist, 292. Drainage-tubes, 158, 182 Dressings, 176 absorbent, 177 antiseptic, 155, 178 boraeic acid, 181 cotton-wool, 176 dry, 176 evaporating, 182 first after operations, 161 Scott's, 191 water, 177 Drowning, 76 Ear, bleeding from, 32 foreign bodies in, 83 serous discharge from, 251 Elastic extension, 272, 274 Elbow, dislocation of, 291 excision of, 297 Emphysema, 35, 252 Epistaxis, 39 Erysipelas, incisions in. 123 Estnarch's bloodless method, 51, 150 Ether, 174 Evaporating dressings, 182 Excision of ankle, 304 elbow-joint, 297 hipjoint, 298 knee-joint, 300 shoulder-joint, 297 Extension by a weight. 272, 298 by elastic band, 273, 274 Extravasation of urine, 94 Bye, bandage for, 63 foreign bodies in, 82 lime in, 83 wounds of, 62 Eye-drops, introduction of, 126 Face, wounds of, 31 INDEX. 339 Femur, dislocations of, 294 excision of j-iead of, 298 fractures of, 267 Fibula, fractures of, 283 Fingers, amputation of, 132 dislocation of, 293 fractures of, 26f5 Forceps, artery, 52 angular, 83 dislocation, 293 Forearm, fractured, 263 Foreign bodies in air-passnges, 84 ear, 83 eye, 82 larynx, 84 nose, 83 oesophagus, 85 rectum, 87 trachea, 85 urethra, 86 vagina, 87 Fractures, 225 after-treatment of, 284 amputations in, 229 chalk and gum for, 237 compound, 228 crepitus in, 226 diagnosis of, 227 elastic extension in, 272, 274 extension by plaster in, 270 glue bandage for, 245 gutta-percha for, 232 impacted. 227 leather for, 233 measurements in, 230 pads for, 231 paraflSn bandage, 247 plaster of Paris bandage, 237 plaster of Paris splint, 243 poro-plastic splint, 235 setting, 229 signs of, 225 silica bandage, 248 simple, 226 splints for, 231 starch bandages in, 236 with dislocation, 227, 285 speciul, 250 clavicle, 255 Ellis's apparatus for, 258 Sayre's plaster for, 257 Colles's, 265 femur, 267 fibula, 283 fingers, 267 foot, 284 forearm, 263 humerus, 259 Fractures, jaw, 253 metacarpus, 266 nasal bones, 252 patella, 277 pelvis, 251 Pott's, 283 radius, 263, 265 ribs, 254 scapula, neck of, 290 skull, 250 skull, base of, 250 spine, 251 thigh, 267 tibia, 279 ulna, 262 Frasnum, ruptured, 34 Gauze, antiseptic, 157, 178 Glottis, foreign bodies in, 84 scalds of, 72 Glue bandage, 245 Gordon's splints, 266 Gunpowder injuries, 273 Gunshot wounds, 74 Gutta-percha, 232 Hjematuria, diagnosis of, 43 Haemorrhage, 28 arrest of, 50 after-treatment of, 28 after extraction of teeth, 44 after incisions into inflamed parts, 46 after surgical operations, 44 after lithotomy, 48 appliances for arrest of, 50 bitten tongue, 32 constitutional treatment of, 29 cut lip, 31 cut throat, 33 epistaxis, 39 false aneurism, 38 from accidents, 30 from bladder, 43 from disease, 39 from ear, 32 from leech-bites, 45 from nose, 32 from rectum, 42 from tonsils, 44 intermediary, 45 pressure with fingers in, 50 pressure graduated in, 37 ruptured freenum, 34 scalp wounds, 30 secondary, 47 stabs, 36 teeth knocked out, 33 340 INDEX. HseuLorrhage, treatment of, 28 ulceration and sloughing, 44 varicose veins, 43 wounds of arteries, 36 wounds of face, 31 wound of palmar arch, 38 wound of veins, 39 Hsemorrhagic diathesis, 44 Hair-pin in urethra, 87 Hand, bandage for, 207 Handkerchiefs, 216 Hanging, 76 Head, bandage for, 209 post-mortem examination of, 314 Heart, post-mortem examination of, 320 Hernia, strangulated, 99 diagnosis of, 100 Hip, dislocation at, 294 excision of, 298 Horse hair probang, 86 Howard's artificial respiration, 77 Humerus, dislocations of, 288 fractures of, 259 Hydrocele, tapping, 139 Hydrocyanic acid, 109 Hypodermic injection, 143 Incised wounds, 59 Incisions into inflamed parts, 123 Ingrowing toe-nail, 140 Inhaler, 169 Injection for bladder, 97 Intermediary haemorrhage, 45 Intestine, wounded, 36 Iris, prolapse of, 62 Irrigation, 183 Issue, 141 Jaw, lower, fracture of, 253 dislocation of, 287 Joints, excision of, 297 wounds of, 64 Jugular vein, bleeding from, 123 Kidneys, haemorrhage from, 43 Knee-joint, dislocation of, 294 bandage for, 200 excision of, 299 strapping for, 191 Knot, clove-hitch, 286 granny, 53 reef, 52 reef, method of tying, 53 Lacerated wounds, 60 Laryngotomy, 111 Larynx, foreign bodies in, 84 Leather splints, 233 Leather-felt splints, 234 Leech-bites, 45 Leg, bandage for, 1^8 strapping for, 188 Levis's reduction instrument, 293 Ligature, 52 mode of tying, 53 Lime in eye, 83 Linseed-meal poultice, 184 Lip, cut, 31 Lithotomy, haemorrhage after, 49 tampon, 50 tie, 222 Local anaesthesia, 132 Lung, wound of, 35 Machinery accidents, 68 Mad animals, bites of, 75 Marshall Hall's method, 76 Mason's splint for excised elbow, 297 Metacarpus, fracture of, 266 Mineral acids, poisoning by, 109 Minor operations. Ill Muscles, rupture of, 67 Nasal bones, fractured, 252 douche, 42 Nelaton's diagnostic line, 231 Nitric acid, application of, 143 Nitrous oxide gas, 173 Nose, foreign bodies in, 83 haemorrhage from, 32, 39 Nostrils, plugging, 127 Oakum, employment of, 178 poultice, 186 (Edema glottidis, 72 (Esophagus, bodies in, 85 Ointments, 184 Operating theatre, 148 Operations, minor, 111 treatment after, 153 first dressing after, 161 Opium, poisoning by, 107 Oxalic acid, poisoning by, 108 Palmar arch, wound of, 38 Paracentesis abdominis, 118 thoracis, 119 Parafl&n bandage, 247 Paraphimosis, 98 Patella, fracture of, 277 Pelvis, fracture of, 251 Penis, bandage for, 205 thread round, 99 Perchloride of iron in haemorrhage, 39 Pharynx, foreign bodies in, 85 INDEX. 341 Piles, hseniorrhage from, 42 inflnraed, 138 Pilot trociir for tracheotomy, 117 Piaster, 59 Plaster of Paris bandage, 237 jacket, 240 splint, 243 Plugging nostrils, 127 Poisoned wounds, 75, 325 Poisoning, treatment of, 105 Polypus nasi, removal of, 128 Poro-plastic splint, 235 Post-mortem examination, 314 Pott's fracture, 283 Poultices, 184 Pressure in haemorrhage, 50 graduated, 37 Probang, 86 Prolapsus ani, 103 Prostate, enlarged, with retention, 92 Puncture of tonsil. 129 Punctured wounds, 35 Radius, fracture of, 263 Colles's fracture of, 265 Rape, 100 Reaction after haemorrhage, 29 Rectum, abscess by, 137 foreign bodies in, 87 hsemorrhiige from, 42 prolapse of, 103 tube, passage of, 136 Reduction of dislocations, 286 of fractures, 229 of hernia, 104 Reporting cases, 305 Resection. Sep- Excision Respiration, artificial, 76 Retention of urine, 88 Retractors, 233 Ribs, fracture of, 254 Rupture of bladder, 251 of muscles, 67 of tendo Achillis, 68 of frsenum, 34 Sand-bags, 249 Sayre'& plaster of Paris jacket, 240 plaster for clavicle, 257 Scalds, 69 of glottis, 72 Scalp, bloody tumor of, 65, 250 wounds of, 30 Scapula, fracture of neck, 290 Sclerotic, wound of, 63 Scott's dressing, 191 Secondary haemorrhage, 4 7 Serpents, bites of, 75 Seton. 141 Shot, injuries by, 74 Shoulder, diagnosis of injuries of, 288 dislocation of, 288 excision of, 298 fractures near, 259 Silica bandage, 248 Siphon-tube, 40 Skin grafting, 18! Skull, fractures of, 250 fractures of base of, 250 Slings, 216 Slinging stumps, 164 Sloughing, causing haemorrhage, 44 application of nitric acid to, 143 Snakebites, 75 Solution for hypodermic injections, 143 Spine, fractures of, 251 Splint room, 232 Splints, 231 gutta-percha, 232 leather, 233 leather-felt, 234 plaster of Paris, 244 poro-plastic, 235 Sponges, 149 Sprains, 67 Spray-producer, 31, 156 Stabs, 35 Starched- bandages, 236 Stings, 75 Stomach-pump, 135 Strains, 67 Strangulated hernia, 99 Strapping, 187 ankle, 190 breast, 193 in fractures, 194 knee, 191 leg, 188 testicle, 191 Stricture of urethra, spasmodic, 88 permanent, 90 Stromeyer's cushion, 263 Stumps, bandage for, 213 dressing of, 163 haemorrhage from, 46 slinging, 164 Stypticsr39 Subcutaneous injection, 143 Sulphurous acid, 155 Suspended animation, 76 Suspensory bandage, 215 Sylvester's artificial respiration, 76 Syncope from chloroform, 172 from haemorrhage, 29 29 342 INDEX. T bandage, 214 Table for reporting cases, 313 Table of weights of organs, 326 Tapping abdomen, 118 abscesses, 124 chest, 119 hydrocele, 139 Taxis in hernia, 102 Teeth, knocked out, 33 heemorrbage after extraction of, 44 Temperature, 309 Temporal artery, bleeding from, 123 Tendo Acbillis, rupture of, 68 Testicle, strapping, 191 Thermometer, 309 Thigh, fractures of, 267 Thomas's splints, 274 Thread round penis, 99 Throat, cut, 33 stabs in, 35 Thumb, amputation of, 134 gunshot, wound of, 74 Tibia, fractures of, 279 Tie for catheter, 218 lithotomy, 222 Toe-nail, in-growing, 140 Toes, amputation of, 134 Tongue, bitten. 32 Tonsils, hgemorrhage from, 44 incision of, 129 removal of, 129 Torsion of arteries, 58 Tourniquets. 50 Tow, use of, 177 Trachea, foreign bodies in, 85 Trachea, wounds of, 35 Tracheotomy, 1 11 tubes, 116 to secure, 114 Tubes for vaccine matter, 144 in chemise, 48 Ulcers, strapping of, 188 Ulna, dislocation of, 291 fractures of, 263 Urethra, calculus in, 93 foreign bodies in, 86 hair-pin in. 87 organic stricture of, 90 Urethra, rupture of, 252 spasmodic stricture of, 88 Urine, blood in, 43 extravasation of, 94 retention of, 88 from atony of bladder, 92 from calculus, 93 from enlarged prostate, 92 from organic stricture, 90 from spasmodic stricture, 88 in female, 93 Vaccination, 144 Vaccine lymph, preservation of, 145 Vagina, foreign bodies in, 87 Varicose veins, rupture of, 43 Veins, wounds of, 39 Venesection, 120 bandage for, 122 Venous haemorrhage, 39 Viscera, abdominal injuries of, 35, 251 Washing out bladder, 96 catheters, 98 Water-dressing, 177 Water-bed, filling a, 166 Weight, extension by, 272, 298 Whitlow, incision of, 126 Wounds, 59 contused and lacerated, 60 gunshot, 74 of abdomen, 36 of arteries, 36 of chest, 35 of cornea, 62 of face, 31 of joints, 64 of palmar arch, 38 of scalp, 30 of throat, 33, 35 of tongue, 32 of veins, 39 over shin, 63 poisoned, 75, 325 punctured, 35 Wrist, dislocations at, 292 Yeast poultice, 186 vy,..-,-.->^ ^t^ - J-"^-- >y ■•'■A' 2% > ^■i::'<.^-> ^j.- VL ■«1 pi ;t-S ,^. 1*. ^-.^-M COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) RD 111 H35 1880 C.1 A manual of minor surgery an bandaging / 2002201550 .- . 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