P.O i^ Columbia (Hnttiersfttj) mttjeCttpofBrmgurk College of ^fjpsiiciang anh burgeons Hitirarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/surgeonshandbookOOesma Inscribed to Her Majesty the Empress of Germany and Queen of Prussia AUGUSTA, the noble patroness of military surgery, the all -admired leader in the conflict of philanthropy against the horrors of war with the deepest veneration by the Author, PEEFAOE TO THE FIRST EDITION, Un the occasion of the Exposition at Vienna, Her Majesty the Empress of Germany, in order to forward the interests of liumanity under the symbol of the Red Cross, in time of peace as well as in war, condescended to offer two large prizes, one of which was to be awarded to the best handbook of military surgery. According to the requirements, upon the exact fulfilment of which the award of the prize was made to depend, this handbook must „so completely represent the modern views of military surgery by an exact but brief description of the different dressings, and the various methods of applying them, as well as of the surgical operations which are performed in the field, that it would become the indispensable companion and practical assistant of every mili- tary surgeon". The first prize was awarded to the author of this essay by the appointed jury, consisting of three members — Professor B. von Langenbeck of Berlin, Professor Billroth of Vienna, and Professor Socin of Bale. The author confined himself strictly to the requirements of the prize, and was influenced by the thought that a handbook of this kind should principally serve as an aid to the memory. This object can be better accomplished by pictures than by an abun- dance of words, for in the field there is not time to do much reading. A glance at a picture which plainly represents a dres- sing, an operation, or an anatomical preparation, will most quickly recall what had been previously learnt, but had escaped the memory in the pressure of military emergencies. The book, therefore, contains many pictures, but as little text as possible, - yi — While the surgeon, in time of peace, consults his anatomical handbooks and atlases before an important operation, to refresh his knowledge of the parts involved, in war-time he must generally relinquish this assistance with regret. Accordingly, the more important anatomical relations for all the major operations are illustrated by distinct drawings, partly taken from works with good copper plates, but for the most part prepared expressly for this essay. In addition to this chief purpose, the author has kept in mind the following : 1. The book should be suitable for use in the instruction of those who are studying to become military surgeons, and also of the orderlies and nurses, for in war the surgeons are often so situated that they must educate their assistants themselves. The use of the illustrations will facilitate this task. For the same reason, particular attention has been given to the j)reparation of improvised dressings. 2. The book should be the guide of the organ of the sanitary aid societies in the preparation and preservation of dres- sing materials, apparatus, and instruments, as they are especially used in war. It would answer as an illustrated catalogue for the depots of the sanitary aid societies, and a reference to the pict- ures would spare the surgeon many words, when he desired mate- rials for dressings from the depots. 3. The book should be useful to the surgeon who has to organize a hospital in any small place, in the preparation of apparatus for the treatment of the wounded — making his wishes clear to the artisans (carpenters, tinsmiths, etc.) by means of the illustrations. PREFACE TO THE THIRD EDITION. Ihe first and the second (unaltered) edition of this work had already been exhausted, when, in 1881, the publisher unfor- tunately became bankrupt. As I could not, for evident reasons, agree to the suggestion of the creditors' administrators of the estate, that the new edition should be published by their establishment, the book has not appeared until now, when, several difficulties having been over- come, it is issued in a very different form. It is unnecessary to state that I have taken pains to make use of the extraordinary advances which surgery, and especially its technique, has made in recent years. An index, which is as complete as possible, will greatly facilitate the search for names, articles, and illustrations. I have moreover, omitted all the colored plates, which made the work unnecessarily expensive, and were besides not executed to my taste. I have had woodcuts made instead, in which the colors are replaced by various methods of shading, and I hope that the object will be just as well attained by them. In the illustrations of the different operations for ajDplying ligatures to the arteries, the surrounding parts have been omitted, because they required so much space. A human figure with very strongly marked muscular outlines, has been inserted in place of them, and the position of the various incisions for the application of ligatures has been indicated upon it by numbers. In the sketches of the operations themselves, the arteries are indicated by parallel strokes of shading, and the veins by cross-barred strokes, while the nerves are left white, so that these — VIII — three structures can be distinguished from one another at the first glance. The ligature of arteries in their course above the wound, in cases of recent injury to the artery, will scarcely be of imiDortance any longer, because in most cases the injured artery will now be sought in the wound. I could not, however, make up my mind to omit the description of these operations, as they are indispensable for practice upon the cadaver, and because this handbook is much used by physicians and students as a guide in rehearsing operations. I have also added some anatomical repre- sentations of the relations of the arteries, in order to recall to memory their entire course. The transverse sections of the limbs, which are intended to serve as guides in amputations, are also no longer shown in colors, but in woodcuts, in which the cut ends of the arteries are drawn circular, those of the veins elliptical, and the sections of the muscles have their names inscribed upon them. The methods of the antiseptic treatment of wounds now in use are fully described in the part treating of surgical dressings; but secondary antisepsis is not discussed until the treatment of septic wounds is dealt with in the part devoted to operative surgery, because the latter really forms one of the most import- ant parts of operative technique at the present time. Some chapters of the operative part (for example, trans- fusion) have been considerably simplified and abbreviated, while others (the treatment of injuries of the intestine, for instance) had to be described at greater length. The indications for the various operations are also every- where considered, even if they had to be briefly dismissed. I had at first intended to omit everything that was anti- quated, and no longer employed in my practice, especially among the surgical dressings. But as the book is very often used by beginners in medical studies as well as by passed military surgeons, I have again al- lowed some dressings and dressing -materials to be represented which generally serve only for practice, or possess some value in the history of the development of surgical technique. KIEL, May 1885. ESMARCH. TRANSLATOR'S NOTE. -Si#i^- 1^ Ihe anatomical nomenclature employed by the translator has been that of Gray's Anatomy. Wherever it has been im- practicable to alter the names of parts in the wood - cuts , a key is given below with the English synonyms. TABLE OF CONTENTS, PART I. o^ GENERAL RULES FOR THE TREATMENT OP WOUNDS AND INJURIES. page. The object of the treatment of wounds 1 Cleanliness (asepsis) 2 Cleanliness of tlie surgeon and liis assistants 2 Cleansing tlie instruments 3 Purifying the air (spray) 5 Cleansing the patients 6 Cleansing the wound 8 The irrigator 10 Pus-basins 10 Arrest of hemorrhage 12 Catgut 15 Czerny's silk 16 Uniting the edges of the wound • 16 Suture 17 Drainage and deep sutures 18 Drainage 19 Deep sutures 20 Dressings 25 Materials for dressings 26 Impermeable materials 28 The position of the patient 29 Antiseptics 30 Sterilization 30 Carbolic acid 33 Bichloride of mercury 34 Chloride of zinc 35 Iodoform 35 Boric acid 36 Acetate of alumina 37 Salicylic acid 37 Permanganate of potash 37 Thymol 38 Naphthaline 38 Peroxide of hydrogen 38 Absolute alcohol 38 — XII — page. Antiseptic powder dressings 39 Iodoform powder 39 Rene-wal of the dressing 40 The open treatment of -wounds 41 Treatment of inflammation 41 Cold applications 42- Massage 48 Bandages • • 48 The application of bandages 48 Dressings for the head 53 Dressings for the upper extremity 55 Dressings for the trunk 57 Dressings for the lower extremity 58 Handkerchief dressings 58 Splint dressings "• • 70 1. Wooden splints 70 2. Pasteboard splints 75 3. Metal splints 78 4. Glass splints . . • 80 Immovable dressings 81 1. Starch dressings 81 2. Water-glass dressings " 82 3. Gutta-percha dressings 82 4. Plaster of Paris dressings 83 5. Re-enforcement of the plaster dressing 87 6. Fenestrated plaster dressings 91 7. Interrupted plaster dressings 92 8. Plaster splint dressings 96 Miscellaneous apparatus 106 Apparatus for moving the injured . 114 Extension dressings 117 Emergency dressings 124 Emergency splints 125 The soldier's dressing-package 136 Antisepsis in war 138 -©5<@@^^- TABLE OF CONTENTS, PART II. o^c OPERATIVE SURGERY. page. Chloroform anaesthesia 144 Treatment of septic wounds (secondary antisepsis) 150 Treatment of complicated injuries of the bones and joints .... 155 Indications for amputation 157 Fixation dressings in compound fractures and injuries of joints . . 168 The removal of foreign bodies from wounds 159 Suture of tendons 166 Suture of nerves 166 Treatment of injuries of blood-vessels (control of hemorrhage) . . 166 Direct compression of the wound 167 Styptics ' 167 The actual cautery ~ 168 Compression of the main artery 168 The bloodless method - 175 The permanent arrest of hemorrhage 187 Direct ligature 187 Ligature of the artery in its continuity above the wound (indirect ligature of Hunter) 191 Directions for the ligature of the individual arteries 196 Ligature of the left common carotid at the level of the crico-thyroid ligament 196 Ligature of the left common carotid between the two heads of the sterno-mastoid 197 Ligature of the lingual artery 197 Ligature of the left subclavian in the supra-clavicular fossa .... 198 Ligature of the left subclavian in the infra-clavicular fossa .... 199 Ligature of the right axillary artery 200 Ligature of the right brachial in the middle of the arm 201 Ligature of the right brachial in the flexure of the elbow (arteria anconea) 202 Ligature of the right radial in the upper third of the forearm . . 202 Ligature of the right ulnar artery in the upper third of the forearm 203 Ligature of the right radial above the wrist 203 Ligature of the right ulnar artery above the wrist 203 Ligature of the abdominal aorta below the origin of the renal ar- teries (Maas) . 204 - XIV - page. Ligature of the left common iliac 204 Ligature of the right external iliac artery 205 Ligature of the right femoral below Poupart's ligament 206 Ligatui'e of the right femoral below the origin of the profunda (at the lower angle of Scarpa's triangle) 207 Ligature of the right femoral in the middle of the thigh (behind the sartorius) 207 Ligature of the right popliteal artery 208 Ligature of the left anterior tibial artery above the middle of the leg ... 208 Ligature of the right posterior tibial artery above the middle of the leg 209 Ligature of the left anterior tibial artery in the lower third of the leg 210 Ligature of the right posterior tibial behind the internal malleolus 210 Bleeding (venesection, phlebotomy) 211 Transfusion 213 The removal of limbs (amputations and disarticulations) 216 General rules for amiDutations 216 Preparation 216 Division of the soft parts . 217 Circular method of Celsus 217 Method by circular skin-flap (Petit) 218 Method by flaps of skin with circular division of mus- cles (Lowdham, 1679) 220 Method by muscular flaps 223 Sawing the bone 224 Closure of the wound 227 General rules for disarticulations 229 Amputations and disarticulations of the upper extremity 229 Disarticulation of the third phalanx of the finger 229 Disarticulation of the second phalanx of the finger 230 Disarticulation of the finger at the metacarpo-phalangeal ar- ticulation 231 Oval Method 231 Method by flaps 232 Disarticulation of the thumb at the carpal joint 233 Oval method 233 Method by a lateral flap according to v. AValther . . 233 Disarticulation of the metacarpal bones of the fingers with preservation of the thumb 234 Disarticulation at the wrist 235 Circular method 235 Method by flaps 236 Method by a lateral flap (Walther, 1810) 236 Amputation of the forearm 238 Disarticulation at the elbow 241 Circular method 241 Method by flaps 242 Amputation of the arm . 243 Disarticulation of the arm at the shoulder 246 - XV - page. Method by flaps 246 Circular method 250 Amputations and disarticulations of the lower extremity 250 Disarticulation of the toes 250 Disarticulation of all the toes in the metatarso-phalangeal articulation 250 Amputation of all the metatarsal bones 251 Disarticulation of the great toe with its metatarsal bone . . 252 Disarticulation of the fifth toe with its metatarsal bone . . 253 Disarticulation at the tarso-metatarsal articulation, according to Lisfranc 253 Disarticulation through the tarsus, according to Chopart . . 256 Subastragaloid disarticulation of the foot, according to Malgaigne 258 Disarticulation of the foot according to Syme 260 Disarticulation of the foot according to Pirogoff 263 Giinther's modification of Pirogoff's method 264 Le Fort's modification of Pirogofi''s method 266 Amputation of the leg 268 Disarticulation of the leg at the knee by the circular method 271 Disarticulation of the leg at the knee by antero-posterior flaps 272 Amputation of the thigh 275 Disarticulation of the thigh 278 "With a large anterior and a small posterior flap, ac- cording to Manec (method by transfixion) .... 278 Circular method, Vetch 280 Reamputation 283 The indications for operative measures after injuries of the large joints 284 Injuries of the wrist 284 Injuries of the elbow 285 Injm-ies of the shoulder 285 Injuries of the ankle 286 Injuries of the knee-joint 287 Injuries of the hip-joint 287 Resection of the joints 288 General directions for resections 288 Resection of the inferior articular ends of the radius and ulna . . 292 Complete resection of the wrist 297 Resection of the elbow, according to Listen 300 Subperiosteal resection of the elbow, according to von Langenbeck 302 Resection of the elbow, accoi'ding to HUter 304 Resection of the shoulder . 305 Subperiosteal or subcapsular resection of the shoulder 308 Resection of the articular surfaces of the scapula 310 Resection of the ankle-joint 310 Osteoplastij3 resection of the tarsus (Mikulicz-Wladimiroff) 315 Resection of the knee-joint 317 Subperiosteal or sub-capsular resection of the knee-joint 322 Drainage of the knee-joint 324 Resection of the hip-joint 324 Subperiosteal resection of the hip-joint 326 Resection of the head of the femur 329 _ XVI - page. Trephining .• 331 Tracheotomy 336 Operations upon the chest 340 Paracentesis of the thorax 340 Resection of the ribs 342 Intestinal suture 343 Resection of the intestine with circular suture (Neuber's method) . 346 Gunshots wounds of the rectum 348 External urethrotomy and cystotomy 349 Hypodermatic injections 351 Operations by artificial light , , , , . 352 -^^^3^^^- PART I. RULES FOR DRESSING WOUNDS. GENERAL RULES FOR THE TREATMENT OF WOUNDS AND INJURIES. THE OBJECT OF THE TREATMENT OF WOUNDS. The object of the treatment of wounds is the exckisiou of all injurious influences which can interfere with healing. These injurious influences are : 1. Every contamination of the wound, for the agents of de- composition may thus gain admittance to the wound , and thej' are the cause of decomposition of the discharges of the wound , of in- flammation, sujDpuration , wound fever , and all the accompanying com- plications of wounds. This is to he avoided by extreme cleanliness (asej^sis) , the exclusion of the agents of decomjjosition (antisepsis), and their destruction (disinfection) if they have already contaminated the wound. 2. The collection and retention of blood and lymph (wound- discharge) in the wound, for these fluids separate the surfaces, and are themselves particularly liable to decomposition. This can be prevented by careful arrest of hemorrhage , by providing free escape for the discharges of the wound , by avoiding cavities in the wound, and by compression, exercised by a good ab- sorbent dressing — making the wound as dry as- possible. 3. Gaping of the wound, because it hindei'S union by adhesion - — by first intention. This is avoided by timely and exnct union of the edges and surfaces of the wound (suture of the wound). 4. Every disturbance of the wound (Ijy movement, toucliing, inechauical injury, unnecessary examination, squeezing), for this inter* I — 2 — feres witli the healing jDrocess , and may cause hemorrhage and in- flammation with their consequences. This is avoided by abundant covering of the wound (protective dressing) , careful securing of the dressing , and by changing the latter as seldom as possible (permanent dressing); and also by placing the injured part completely at rest (by bandages , cloths , splints , firm dressings , proper position , cradles , etc.) , absolute rest in bed if the injury is severe, undisturbed quiet of the wound, avoidance of unneces- sary examination, probing and squeezing. ^) 5. Every hinderance to the return- circulation of blood and lymph (congestion), for this may cause dischai'ge to be effused into the wound from capillaries and lymphatics. This may be prevented by elevation of the injured part, and by the avoidance of every constriction (strangulation), and the remo- val of constricting clothing or dressings. 6. The entrance and settlement of the agents of decom- position during the healing of the Avound (septic infection). • This can be avoided by antiseptic dressings and by changing the dressing as seldom as possible (permanent dressing). 7. Inflammation of the injured j)arts, with its consequences. This is to be combatted by abstraction of heat, rest, elevation, elastic pressure; and, in inflammation of a joint, by separating the joint-surfaces by extension (antiphlogosis). CLEANLINESS (ASEPSIS). Since the agents of decomposition (micro-organisms of putrefac- tion) are to be found everywhere, in the air as well as in the water,, and attach themselves to every object, they must be removed, destroyed^ or rendered harmless, before and during every operation, and before and during every dressing of a wound. This is accomplished by scrupulous cleansing and disinfection of the wound and its surroundings, as well as of everything which can come in contact with the wound — air, hands, instruments, dressings. CLEANLINESS OP THE SURGEON AND HIS ASSISTANTS. Before touching any wound, before every opei'ation, and before- every dressing of a wound , the hands and forearms of the surgeon, ') Absolute rest is the ideal treatment of wounds (Optimum remedium quies est — Celsus. To be let alone — Lister.) Altliough the ideal has not yet been quite attained by Lister's metliod (Cheyne, Antiseptic Surgery, p. 597), because the drainage-tubes and sutures iiave necessitated frequent change of the dressing, we nevertheless owe the immeasurable improvements in the. modern treatment of wounds to the great surgeon, Joseph Lister, alone. — 3 — and of all his assistants (assisting sur- geons, orderlies, nurses, students), must be very carefully cleansed with soap, brush, and nail-cleaner, and then washed in 1 to 20 carbolic acid solution , or 1 to 1000 bichloride of mercury solu- tion. This cleansing must be repeated whenever, during the operation, the surgeon comes in contact with anything unclean — pus, feces, urine, etc. ■^). Infectious material is apt to cling to dark woolen clothing , therefore it is advisable that not only the surgeon, but all his assistants should wear freshly washed white linen coats while they are at work in the hospital. Sleeves and aprons of rubber cloth are also very useful, and these are to be thoroughly washed and dis- infected with carbolic acid solution be- fore every operation. Fig. 1, for example, shows the dress which my assistants and myself wear at operations in the surgical clinic. To protect the feet from wetting by the very free use of water and anti- septic solutions, we wear Russian rub- ber boots over our shoes. Fiff. 1 Operating-dress. CLEANING THE INSTRUMENTS. Every instrument which is used in operations or in dressing wounds must be cleaned and disinfected with the greatest care. When- ever they are used, they must be afterwards washed by an orderly or assistant trained in the antiseptic method, with hot water, soap, and a ^) I take this opportunity to emphasize the duty of every physician to attend to his teeth and mouth, and to keep them clean. I have only too often seen physicians greatly annoy their patients by the pestileiit odor which came from their mouths, and some have lost patients from this cause. It is well enough known what masses of l)acteria and vibriones may exist in the saliva of a neglected mouth. I need not argue further that no spray can be of any use, while such vapors pour upon the wound from the mouth of the operator. brush, then dipped m a 3 '^'^^ carbolic solution, and dried with a cleau linen cloth. They should be kept in a place where they will be safely protected from handling by meddling j^ersons , and from contact with the atmosphere. Before an operation, all the instruments are to be laid in a clean flat glass or china dish (Fig. 2) filled with 3 '^j^ car- Fis. 2. Glass tray for instruments, bolic solution. But the knives must not be left in the solution too long, for the edge will soon be attacked by the carbolic acid. It is therefore better to lay them in a smaller dish fUled with alcohol. The instruments should be made as plain as may be. and, in particular. Avith as few grooves and fissures as possible, for dirt is apt Fio-. 3. Aseptic knife, to lodge in them. The knives, etc. made of one piece of steel (aseptic) are preferable to those furnished with wooden or ivory handles (Fig. 3). PURIFYING THE AIR (SPRAY). As the atmosphere always contains the agents of decomposition, and especially in old, badly yentilated. and over - crowded hospitals, Lister considered it necessary to disinfect the air durins' operations, and whenever a dressing was renewed. This is accomplished by a spray of some disinfecting fluid (a 3 ^Iq carbolic solution , hydrogen j^eroxide , etc.) , produced by an Fig-. 4. Carbolic atomizer. atomizer (Richardson's sjjray-producer , Fig. 4). and directed upon the wound and the hands of the operator. If for any cause, the spray had to be discontinued for some time, Lister endeavored to protect the wound from contact with the atmosphere during this interval , by covering it with a compress of gauze wet with carbolic solution (the „ guard"). But long exjierience of practical surgeons has shown that perfect results can be obtained in operations without the use of the carbolic spray, so this inconvenient accessory may be dispensed with in military surgical practice. ^) ') In my clinic, the carVjolic spray has not been used duriug an opera- tion for a lono- time. I now use our very complete apparatus , operated by a compressing air-pump (see Neuber. Anleituug zur Technik der antiseptischen Wundbehaudlung, p. 9), only tor disinfecting the atmosphere of the operating room before operations. — 6 — CLEANSING THE PATIENTS. Before every operation, and before every dressing of a fresh wound, the entire body of the patient should, if possible, be thoroughly washed in a bath-tub with soap and a brush. Fiff. 5. Quincke's bath-tub. The bath. - tubs invented by Quincke , with a very oblique side for the back (Fig. 5) , are exceptionally well fitted for use in war, Fiff. 6. Arm bath-tub of sheet-zinc, because they require less water than the ordinary form, and the patient reclines very comfortably in them. Fis. 7. Leg bath-tub of sheet-zinc. — 7 — For cleansing injured extremities , arm- and leg - baths of sheet zinc , having a cover with an opening at one end (Figs. 6 and 7), are employed. There are knobs on both sides , to which strips of bandage can be attached, upon which the injured limb may be suspended. Large bath-tubs can be made after the same pattern , suitable for the treatment of burns, wounds of the back, bed-sores, etc. Immediately before the operation, the entire field of operation, the entire neighboi'hood of the wound, is again thoroughly cleansed and disinfected. In the first place, since the agents of decomposition cling especi- ally to the hair, all hair near the wound must be shaved off — and on the scalp for a distance of at least 1^/'., inches from the edges of the wound. Then the neighborhood of the Avound is rubbed with a piece of cotton dipped in ether or spirits of turpentine, in order to dissolve and remove the oily matter of the skin. . Next follows a thorough washing with soap and a brush ; and , finally, the disinfection with car- bolic , or bichloride solution. The Avhole field of oj^eration may be p)ainted, in addition, with a solution of iodoform in ether — 1 to 7. Before operations on the hand or foot, the thick upper laj'ers of epidermis should be removed , as far as possible , by stiff brushes and files, after having been softened by soap-baths, and especial care must be taken to remove the dirt under the nails acd between the toes. Before operations about and within the mouth, the teeth must be very carefully cleansed with a tooth-brush and soap, tartar and decayed teeth removed , and the mouth repeatedly washed out with acetate of alumina. Before operations in the neighborhood of the anus and genitals, the intestine must be thoroughly emptied several days beforehand . if possible, by laxatives, enemata, and irrigation. If there are crusts, scabs, ulcers, or septic granulations in the wound, or in the field of operation, they must first be thoroughly scraped away with the sharp spoon, and their site then disinfected with an 8 '^Iq solution of chloride of zinc. If these proceedings are painful , they are not to be undei'taken until chloroform-anaesthesia has been begun. The operating-table , upon which the patient lies during the application of a dressing, or during the opex'ation , must be perfectly clean , and should therefore be scrupulously cleansed from blood , pus, etc., and disinfected after every operation. Hubber cloths are very viseful to spread over the cushions of the operating-table, having been always thoroughly washed, and disuifected with carbolic solution, before they are used. It is best to have the patient laid upon the operating - table naked, and then wrajDped in a large rubber cloth, which has an opening at the proper place through which the part to be operated upon can be exposed, Fiff. 8. ■^•1",' I ' 4,lllili y.i* i; 1 :W^ isirJvCjS^^iiiii^ '.^^ IM 11 Protecting cloth.. (The use of the protecting cloth for operations upon the lower extremity will serve for an example, as in Fig. 8.) CLEASING THE WOUND. Fig. 9. For wiping away blood during an ope- ration, sponges and wipers, dipped in 3 ^j^ carbolic solution, or in 1 to 5000 bichloride solution, are employed. "Wipers (German, Tupfer; artificial sponges) are loose balls of absorbent cotton, wood - fibre , jute , or some similar substance, wrapjied in asej)tic gauze (Fig. 9). As the cotton collects into a firm mass when the fluid is squeezed out, and no longer readily absorbs, it is advisable to put a layer of sterilized cocoa-nut fibre between the inner and outer layers of cotton (Sampson Gamgee), which will, by its elasticity, prevent this masT "^iper. sing of the cotton. Recently I have had wipers made of wood-fibre, wrapped in gauze , and then sterilized , and I find that they are far more useful than the cotton wipers. — 9 — The wipers are to l)e destroyed after having been used once ^). Sponges should never be employed for Aviping away the blood during an operation unless all the dirt contained in them has been removed with the greatest care, or rendered harmless. To clean bath - sponges thoroughly , they must first be beaten between cloths, while dry, with a wooden mallet, until all the sand has been removed. They are then repeatedly washed in lukewarm clean water which has been boiled — hot water makes them shrink. They are next soaked in a cold solution of permanganate of potash , 1 to 1000, for 24 hours, and the solution must be renewed in 12 hours. After they have been again washed out in boiled lukewarm water, they are put into a 1 ^/^^ solution of hyposulphite of soda, to which is added one fifth as much of an 8 *^/„ solution of concentrated hydro- chloric acid in water. They are well stirred about in this with a wooden stick , until they have lost their brown color. If they are left too long in this solution, they become soft, and tear easi]3^ They are next washed in clear water until they are entirely odorless. For 25 large sjDonges , about 5000 grams (175 fl. oz.) of the hypo - sulphite of soda solution, and 1000 grams (35 fi. oz.) of the hydro-chloric acid solution will be required. In order to destroy the dry spores (which are by no means rendered harmless by the manipulations just described), after they have begun to grow, the sponges are laid in lukewarm water and kept for 3 to 5 days in a warm place (95" to 100" F.). The water being changed daily. The same object can be attained by sterilization , if a sterilizing-oven is available. Not until then are the sponges put in 1 to 20 carbolic acid, or 1 to 1000 bichloride solution, and this must be renewed in two days. They remain in this until they are needed. The solution must be renewed every fortnight, and the sj)onges must have been in the solu- tion for at least one week before they are used for an operation. During the operation, the sponges must be washed out in clean water, when they are bloody, before they are put back in the carbolic or bichloride solution; they are then handed to the operator from the solution, after having been squeezed out dry. Sponges which have been used in aseptic operations must be repeatedly washed with soap and washing soda to free them from clotted blood and fat, and then kept in 1 to 20 carbolic solution for a week before they are used for another operation. Sponges which have been used in infectious, decomposing, or gangrenous wounds should be burned at once. ') In time of war, the preparation of wipers, under strict medical super- vision, would be a thankworthy employment lor the ladies — instead of the pre- viously customary preparation of lint. — 10 — To clean the neigliborliood of wounds, and to wipe away pus on the renewal of a dressing, sjDonges should never be employed — only ,. wipers". THE IRRIGATOR. For cleansing and disinfecting wounds and their surroundings by irrigation, the irrigator, or wound- douelie (Fig. 10) is employed — a vessel of tin or glass (Fig. 1 2) , to the lower outlet of which is fastened a rubber tube with a nozzle, by which a stream of disinfecting fluid can be conducted to the wound ^). The strength of the stream is regulated by the j)i'6ssure of two of the fingers which hold the tube , and by elevation or depression of the vessel. The nozzle is to be put into the vessel when the irrigator is not in use (Fig. 11), and the nozzle should be of pewter or glass, and heavy enough to keep the end of the tube in the vessel. A stopcock is unnecessary. It is dangerous to irrigate the crevices of the wound under strong pressure, for by so doing the fluid may be driven into the cel- lular tissue. For the same reason, the use of a syringe for washing out wouncls is to be condemned, for with this instrument the pressure of the stream can not be controlled -). According to Thiersch, an irrigator can be improvised by knocking out the bottom of a wine - bottle , sticking a rubber tube through a hole in the cork, and hanging up the inverted bottle by a string (Fig. 13). PUS - BASIN'S. Variously shaped pus -basins of sheet -metal, hard rubber, or glass, serve to receive the water and pus — their edges fitting closely to the diff'erent surfaces of the body (Figs. 14 and 15). '■) Sterilized water, or boro-salicylic acid solution (I to 6 to 500) is em- ployed for irrigation during the operation ; at the end of it, before tlie sutures are inserted, bichloride solution, 1 to oOOU. ^) I invented the wound -douche in 1858, to take the place of the dan- gerous wound -syringe which had been in common use up to that time (see Deutsche Klinik, 185>', No. 2.5). — 11 Fiff. 10. Fiff. 11. '^^ Improvised irrigator. Glass irrigator. — 12 — In changing the ]3ns- basins, the emj^ty basin is to be jolaced Tinder the full one, so as not to conceal the latter from sight, and not to spill its contents. Fiff, Kidney-shaped pus-basin of hard rubber, sheet-metal, or glass. Fiff. 1.0. Pus-basin of sheet-metal or glass, for use in cleansing an entire extremity. The contents of the full basin must be poured at once into a slop -jar. ARREST OP HEMORRHAGE. Before the wound is closed and dressed, the hemorrhage must be scrupulously arrested. This is best done by seizing all the wounded vessels — arteries and veins, with clamp-forceps, and by tying them firmly and securely with antiseptic catgut (Lister's catgut). The reef- or square -knot is to be used in tying ligatiires (see Fig. 24) ; not the granny-knot (see rig. 25), for tlie latter is apt to slip. The ends of the threads are cut off about iiich from the knot. In operations performed with artificial ischaemia (Esmarch's bloodless method) such as amputations , resections , etc. , it is not easy to find all the wounded vessels, as they do not bleed. In such cases , diagrams of sections of the limbs , in which the exact position of the most important arteries, veins, and nerves is indi- 13 cated, will be found useful aids to the memory for consultation before tlie operation. Great readiness in finding even the smaller vessels can be attained by practice. The muscular branches of medium size are usually the most difficult to find, because they retract into the bellies of the muscles , and these arte- ries are the most frequent source of secondary hemorrhage. These branches can generally be found in the middle of the transverse section of the belly of the muscle , where the coarser layers Fig. 17. Fi?. 16. Ligature of a vessel, lorceps hanging. Fio-. 18. Amputation-stump with artery-clamps. — 14 — Fis. 19. of cellular tissue between tte muscular fibres meet together, forming a star-shaped figure. In amputations , after the bone lias been sawed off, as many- wounded vessels are to be seized with clamp - forceps , or Spencer Wells's artery clamps (Figs. 16 and 17) as the supply of these in- struments will admit , and they are allowed to hang while the vessels are ligated — beginning Avith the uppermost (Fig. 18). The rest of the vessels are then to be sought out and seized with the forceps thus set free. If a bleeding vessel cannot be well isolated and drawn forward as is necessary for ligature, it may be secured by suture. A strongly- curved needle is made to carry a. suture through the tissues which sur- round the bleeding point, and the thread is then tied so as to include- a small portion of these tissues , to- gether with the bleeding vessel (Fig. 19). If antiseptic ligatures are not at hand , the arteries can also be closed by torsion. The vessel to be, secured is seized with a clamp-for- ceps, drawn out a little , and twisted on its axis six or eight times , ac- cording to its size, the central end of the exposed piece being held by the fingers , or , preferably , by- another pair of forceps (Amussat's forceps) (Fig. 20). Artery occluded by suture. Yis. 20. Torsion of an artery. By this procedure, the internal coat of the artery is torn across, and rolled up within itself, so that it securely closes the vessel. like a valve. — 15 — In prolonged and difficult operations in regions of the body in which the bloodless method cannot be employed, it is well to isolate all vessels — arteries and veins , as soon as they are recognized , by j^ushing a probe or forceps under them, so that they can be secured by two clamp - forceps. The vessel is then to be cut between the for- cej^s. and each end tied separately. CATGUT. Antiseptic catgut (Lister's catgut), which is used for the liga- ture of vessels, and the suture of wounds, has the j^ropeity of dissolving in the wound, and of becoming completely absorbed, after it has fulfilled its purpose. The simplest and most efficient method of making catgut anti- septic, is the following: The ordinary commercial catgut (No. 1 to 3) is vigorously cleaned with a brush in soft soap and water, and, after washing in pure water . is wound on glass spools and laid in bichloride solution, 1 to 1000, for 12 hours: then in an alcoholic 1 to 200 solution of bichloride for 12 hours; and it is then preserved dry in tightly closed glass vessels. Glass catgut - box. .Tu^t before It is used, it is laid in a vessel filled witli an alco- holic, 1 to 2li00 solution of bichloride — for example in the glass catgut -t exes (Fig. L^l), suggested by Hagedorn , in which stands — 16 — another smaller box contaiuing three glass spools upon which, is wound catgut of three different sizes. A ball and socket valve prevents the ends of the thread from slipping back into the inner box ■'■). The catgut first proposed by Lister, prepared with carbolized oil , is not reliably antiseptic , and hence is probably not in use any- where at present. On the other hand, the chromic acid catgut, afterwards sug- gested by Lister, is very hard, and resists absorption for a longer time than the sublimate catgut , hence it is to be preferred for certain operations — in ligature of the pedicle in ovariotomy, for example. To prepare the catgut in this way, it is put in 10 "/(i carbolized glycerine for 48 hours , and then in a -"^/^ "'/^ aqueous chromic acid solution for 5 hours. The juniper - catgut of Kocher is also very hard, and reliably antiseptic. The catgut is put in oil of juniper for 24 hours, and then kept in alcohol. CZERNY'S SILK. In some operations it is advisable to employ an antiseptic mate- rial for ligature which will not be absorbed, but encapsuled. E,aw Chinese silk is suitable for this purpose, made antisejDtic according to Czerny's directions — boiled for 10 minutes in carbolic acid solution, 1 to 20, and preserved for use in a 2 ^|^y solution. Unfortunately, it cannot be entirely relied upon to Ijemain encapsuled permanently. The ligatures are not infrequently thrown out by suppuration after a longer or shorter interval. UNITING THE EDGES OF THE WOUND. The practice of uniting the edges of the wound with sticking- plaster , which was formerly common , should be rejected , because it hermetically closes the wound, irritates and inflames the skin, and contradicts the princij)les which lie at the foundation of antisepsis. A surgeon who brings together a fresh wound with sticking- plaster , without observing antiseptic precautions , is in danger of legal prosecution (v. Nussbaum). Very small and superficial wounds can be closed with English sticking-plaster, or with strips of gauze and collodion, after they have been disinfected with an antiseptic solution. •') These boxescaii be obtained from v. Ponctt, Ulashiittenwerke, BerUn. — 17 Superficial wounds of the skin, which are un- Fig. 22. suitable for suture because , for instance , the edges are contused , can be drawn together by strips of starched gauze bandage , wet with cai"bolic acid solu- tion , in such a way as not to cause retention of the discharge of the wound. In some cases (for example, in wounds of the scalp) it is advisable to use a bandage which has been rolled at both ends (double - headed roller bandage — Fig. 22), and thus to press the edges of the wound together from both sides. But the best method for fresh, clean (aseptic) Double-headed Avouuds, is to unite the edges by suture. SUTURE. Sutures are inserted with straight or variously curved needles, and only with material for sutures which is completely aseptic — - •catgut, Czerny's silk, silver wire, iron wire, horse -hair, silkworm- gut, etc. The interrupted suture (Fig. 23) is the form most frequently used, and is decidedly the best when it is important to secure very ac- curate adaptation of the edges of the wound, as in plastic opei'ations. ;f' It is necessary to tie the suture in a reliable double knot , so that it will not slip. Accordingly the square-, or reef-knot (Fig. 24) is employed, in which both ends of the thread pass in the same direc- Interrupted suture. Fio-. 24 Square - knot. Granny-knot. tion througli each loop ; while in the granny-knot (Fig. 25), which is apt to slip, the ends of the thread pays tlirough the loops in opposite directions. Q — 18 — If there is much tension of the edges of the wound, it is well to give the threads a double turn in the first knot (the surgeon's- knot, Fig. 26), and then to finish the knot like the square-knot. Fiff. 27 Fig. 26. Continuous suture. Fiff 28 Surgeon's knot. Glover's suture. The continuous or glover's suture (Fig. 27), which can be- applied much more quickly than the interrupted suture, has recently come into common use again. A modification of this suture which is very frequently useful, is shown in Fig. 28 , in which the needle is passed under the loop of the previous stitch every time before the thread is drawn tight. In wounds with such great loss of substance that it is not pos- sible to bring the edges together with sutures (skin and scalj] wounds), primary union may nevertheless be obtained by immediate transplanta- tion of large pieces of skin from the arm of the patient, or from the freshly amputated limb of another, or from the body of one who, has just died. In transplantation, flaps of skin, two inches square and larger,, are cut , and all the subcutaneous adipose tissue is carefully removed, by scissors curved on the flat, so that the j)iece of skin looks like white glove -leather on both sides. The wound is then covered with one or more such pieces , which are secured to its edges by catgut sutures, and an antiseptic dressing applied over them. In this way I have at once completely covered the large Avound on the forehead left after a rhinoplastic operation with two large flaps, from the arm, and secured union by first intention. DRAINAGE AND DEEP SUTURES. Before the wound is closed, care is to be taken that no fluids, can remain in the bottom of the wound. To conduct these from the wound, we employ drainage. — 19 — DRAINAGE. When much suppuration is to be feared — in septic wounds, abscesses , resection of the hip , etc. , it is advisable to place rubber tubes, perforated on their sides by holes (Fig. 29), in the dependent parts of the wound, in order to drain the cavities which exist in it — as first recommended by Chassaignac. Fig. 29. Kubber drainage-tube. Lister uses a peculiar dressing-forceps with long slender arms (Fig. 30) for introducing drainage-tubes into deep wounds. Fiff. 30. Lister's drainage-tube forceps. It is not a bad idea to sprinkle the drainage-tubes with jodo- form before inserting them (Konig). In fresh and clean (aseptic) wounds, the use of rubber drainage- tubes is disadvantageous , because they irritate the wound , acting as foreign bodies ; because they jiermit the entrance of the agents of de- composition into its interior ; and because they always necessitate an early renewal of the dressing, and thus cause a disturbance of the wound. To avoid the last-mentioned draw back, the use of softened (decalcified) bone-tubes (Neuber, Fig. 31) is to be preferred, for they dissolve in the wound and are absoi-bed, like catgut, as soon as they have fulfilled their pui'pose. These tubes are turned out of tlie bones of cattle , put in a 83 *^/() solution of hydrochloric acid for about 12 hours, to decalcify them, and preserved in an alcoholic solution of bichloride of mercury, 1 to 5000. 2* 20 In case of need , bundles of catgut strands (Cliiene) , or of dis- infected horse -hair, or braids of glass-wool (Schede) can be employed for drainage. Fis-. 31. / Bone drainage-tube. In most fresh and aseptic operation - Abounds , however, drainage is ' unnecessary, if care is taken: 1. That no closed cavities remain in the bottom of the wound, in which blood or serum can collect; 2. That the Avound in the skin is not entirely and hermetically closed — so that any discharge which may form within the wound can easily make its way to the surface. 3. That the wound is covered with a dressing which will exert equable pressure uj)on every part of it, which will readily absorb the escaping discharge , and which will favor the drying up of the latter by evaporation. DEEP SUTURES. Cavities ia the deeper jjarts of the wound are best avoided by deep sutures which press the deeper parts of the surfaces of the Avound together ; they are the following : The fold-suture (Fig. 32), which is most useful for uniting very thin and loose edges of skin — for example , in the eyelids , as it raises the skin in a fold so that broader surfaces are brought into contact. Fig. 32. V Fig. 33. t \ Fold-suture. Mattress - suture. The mattress - suture (Fig. 33) is the same, except that the needle is carried much deeper, in order to j^ress together the surfaces at the bottom of the wound. 21 — The twisted or hare-lip suture (Fig. 34) is made with pins (entomological , or Carlsbad pins) , the points of which have been ham- mered and ground flat. The pins are inserted through the skin at a little distance from the wound , and cotton threads which have been soaked in bichloride solution, are twisted around them in alternate Fig-. 34. Twisted suture. circular and figure-of-eight turns , so as to press the edges of the Avound together. The ends of the pins are then cut off with wire-cut- ting pliers. Some fine interrupted sutures can be inserted in the inter- vals between the pins , to gain more accurate adaptation of the edges of the wound. The pins can be with- drawn with a forceps, by twisting move- ments, on the second day, but the Imnches of threads, which are usually adherent to the skin by crusts of blood , are to be left some days longer. This suture is particularly well adapted to unite the widely gaping wounds of the skin which occur in j)lastic operations on the face. The quill suture (Fig. 35) presses the deeper parts of the wound together by cylindrical rods (quills , pieces of a catheter) , drawn to- gether by silver wire or Czerny's 8ilk. Quill suture. — 22 — The lead plate suture (Lister) (Fig. 36) is made with silver wire, passing through lead plates with a hole in the center, and twisted around their uj)-turned edges, in figure-of-eight turns. Fio-. 36. Lister's leadplate suture. Yis. 37. Fig. 38. Combined sutures. Bead suture. The bead suture (Thiersch) (Fig. 37) is made by passing the silver wire through the lead plates, and then through glass beads, and securing it by twisting it around a small piece of wood — such as a match. — 23 — The superficial and deep interrupted suture can be combined, if there is tension, when it is important to relieve the suj^ei-ficial sutures of pressure until the first adhesion has occurred in the wound — relaxing sutures (Fig. 38). In the same way , the continous suture may be combined with the mattress suture, and so on. But when it is important to press together the deeper parts of the wound so that every cavity will be surely obliterated, it is best to employ the sunken , or buried catgut suture (Fig, 40) — that is, the deeper parts of the surfaces of the wound are sewed together by continuous or interrupted sutures of catgut, before the ordinary super- ficial sutures are inserted, the threads are cut off close to the knots, and the sutures left to be absorbed like the ligatures applied to ves- sels -^). The action of the lead-plate and deep sutures upon the deeper parts , is shown in the schematic sections of amputation stumps , in Figs. 39 and 40. Fiff. 40. Lead-plate suture, schematic. Buried sutures, schematic. But as it is never possible to be entirely certain that there will be no discharge anywhere in the bottom of the wound when these deep sutures are employed, the wound in the skin is left open a little at its most dependent part (according to the law of gravity), or small openings in the skin (buttonholes) are made with the knife at suitable places , parallel with the direction of the wound in the skin , so that the tension of the superficial sutures will cause them to remain open (Fig. 41). It is well to cut away (with scissors curved on the flat) some of the fat from the inner part of these openings in the skin , so that *) The surgeons of the large Hopital Saint- Andre in Bordeaux, have obtained brilliant results in major operations (amputations, etc.), since 1869, by the combination of deep compressing sutures (quill, lead-plate sutures) with incomplete superficial sutures , even without following the antiseptic method. (Azam, „Reunion primitive et pansement des grandes plaies." Bordeaux, 1879.). — 24 — it cannot block up the holes from within. The edges may also be everted a little by a catgut suture. The small openings rapidly heal up after they have served their jDurpose. Finally the wound must be fully covered with a dressing, which will be sufficiently soft and elastic to equably press together the whole region of the wound. In this way the oozing of blood, and the discharge of lymph can be prevented, or lessened. The dressing must also readily and quickly absorb the discharge which takes place (crumpled gauze , sponges , cushions of peat , moss , sawdust , etc.) and favor the drying up of the discharges, by evaporation of their watery constituents. Hence air- and water-proof materials (protective silk,, mackintosh, varnished paper) are not to be employed. The elastic bandages which are applied over the dressing to increase the com- pression at first, must be removed after some hours. Fiff. 41. Button-holes. Final irrigation. Before the dressing is applied, the closed wound must be once more irrigated with antiseptic fluid until the latter returns clear from all the openings (Fig. 41). The wound is then to be firmly squeezed together with a large sponge or wiper, until all the fluids which have l^een left in it are — 25 — pressed out, and this pressure must be maintained until the sjoonge is replaced by the first j)art of the dressing (cushions, or crumpled gauze) which must also be very firmly applied. DRESSINGS. The dressing of a wound has the following objects to accomplish: 1. It should protect the wound from all external injurious in- fluences , and from the entrance of the agents of decomposition in particular. It must therefore fully cover the whole region of the wound , fit closely on every side , especially shutting it at the edges (occlusive dressing, protective dressing). 2. It should readily absorb the discharges of the wound — blood, serum, pus; and readily allow them to dry (dry dressing, dry treatment). 3. It should prevent the decomposition of the discharges (anti- septic dressing, Lister). There are a great number of materials which more or less com- pletely fulfill these purposes , and a still larger number of (antiseptic) substances which have the property of preventing or stopping decom- position in the discharge of wounds. MATERIALS FOR DRESSINGS. The materials to be employed for dressings: 1. Must be perfectly clean — aseptic; 2. Must be soft and elastic, so as to fit closely to the surface of the body under moderate pressure ; 3. Must readily absorb every sort of fluid — possess great ab- sorbent powers ; 4. Must not be air-tight, so that the absorbed fluids may evapo- rate quickly, and be readily oxidized by the oxygen of the atmosphere. 5. Must contain substances which will render the agents of de- composition harmless — antiseptics. In military practice the most suitaljle materials for dressings are the following : 1. Gauze (Mull, surgical gauze), a loose cotton cloth, made absorbent by having its oily matters removed by boiling in soda, is employed : a. in several layers, as a Lister occlusive dressing ; b. in pieces very loosely folded together, as Volkmann's crum- pled gauze; — 26 — c. made into bags of different sizes — sewed with aseptic cot- ton thread , which are filled with other dressing - materials (peat , moss, sawdust, wood-wool, etc.) and serve as cushion-, or padded-dressings; d. cut into bandages, 2 to 5 inches in width, which serve to secure the occlusive dressings, after being dipped in antiseptic fluid — carbolic or bichloride solutions. For this last purpose, the starched gauze (crinoline) is particu- larly well -fitted, because the turns of the bandage when applied wet, stick together, and prevent the dressing from slipping. 2. Cotton. a. Cotton, made absorbent by removal of its fatty impurities (Bruns), quickly absorbs water, and is therefore especially fitted for cleaning soiled parts of the body, when used as balls or wipers, and used only once ; also for the padding of particular parts (the axilla) ; but it is not at all suitable for laying directly upon the wound, as the surface in contact with the discharge packs together into a" hard impenetrable layer. b. The ordinary cotton, not absorbent, is used for padding splints; and especially in the form of cotton batting bandages, 4 to 6 inches wide, for stuffing and closing the edges of the dressing, for it is well known that cotton is the best filter for straining out the infectious materials floating in the atmosphere. 3. Peat, coarsely powdered in the form of peat-dust (Neuber). The light brown variety („Moostorf") absorbs very well (nine times its weight of water), if it is slightly moistened beforehand ; the black peat is less absorbent, but has antiseptic properties because it contains humic acid. It is, moreover, much cheaper in regions where there are peat bogs. 4. Peat-moss (sphagnum), which can be obtained cheap in any forest or marsh region, can be easily made aseptic by drying and sterilization, is very compressible, absorbs very well, and is cleaner than peat. 5. Wood-sawdust, wood-wool, and wood-fibre, are good dres- sing-materials, because they are all very compressible, absorb well and quickly, are easily rendered aseptic by sterilization, or by pouring boihng water over them, and are not expensive. Sawdust (Porter) can be obtained everywhere, and is already at hand in large quantity when wooden barracks are built. Poplar sawdust is the most absorbent. Pinewood sawdust has also antiseptic properties. Wood-wool and wood-fibre are prepared in various manufactories at a low cost. The latter is particularly suitable for filling wipers, to be used in operations instead of sponges, as well as for padding splints. 6. Forest-wool, oakum, and jute, are inferior to the others, for they are not so soft and absorbent, but in case of need they are always useful as dressings. Fiff. 42. f — 27 — The last mentioned materials (Nos. 3 to 6) are all best used for dressings in the form of cushions , or stuflFed bags — a bag of gauze being partially filled with the material — so that it can easily be shaken about in it (cushion dressings). For use in different parts of the body , various shapes and sizes of cushions are used — in some of them, slits must be made in certain places , to allow them to fit more closely to the desired part -"). | Fig. 42 shows a gauze cush- l ion of this sort, suitable for an | amputation of the thigh. | Since it is inconvenient to | have a very great variety of sizes |_; and shapes, only the dimensions of pS the most useful will be given here. ti>^ The cushion for the largest r dressings (chest, abdomen, thigh, V groin) should be 28 inches long, I 20 inches broad, and from ^/^ to p 1^/^ inches thick, and should have fc a slit 4 to 8 inches deep, its edges R being sewed up before the cushion is filled, situated in the middle of^^^^^^fisi the long or the short side — ac- cording to the wound or operation. For smaller dressings, cushions 2, 4, 8, to 16 inches square ai-e employed. Cushions 20 inches long, and 6 inches broad are suitable for padding splints. Before applying these cushions, the contents are to be arranged by shaking so that they will fit all the depressions in the neighbor- hood exerting equable pressure upon the entire wound, and so that the greatest quantity will lie at the most dependent part — for example, at the back, in dressing wounds of the chest and axillary Cushion for dressing. By folding over the corners, as in dressing amputation stumps, the surgeon should attempt to completely occlude the wound. A gauze bandage wet with carbolic acid or bichloride solution, is. then applied so as to bind the cushion firmly and smoothly to the surface of the part. *) In time of war the preparation of these bags and filled cushions under medical supervision, would form a thankworthy task for patriotic women. — 28 — The edges of the dressing are then covered with cotton - batting bandages, so that the entrance of air to the wound will be prevented; and , finally , additional turns of gauze bandage are carried near the edge of the cotton , but so as not to touch the skin anywhere , the cotton projecting from under them upon every side (see Pig. 43). All cavities and depressions (the axilla, for instance) are care- fully filled with salicylated cotton, or crumpled gauze, before the turns of bandage are carried over them. When an operation has been performed by Esmarch's bloodless method, an elastic bandage of thin rubber is applied in addition over the entire dressing , to increase the pressure during the first two or three hours ; and in operations in the neighborhood of the anus a bandage of this kind is applied at the edges of the dressing, to pre- vent the entrance of the contents of the bowel. IMPERMEABLE MATERIALS. ImjDermeable materials are now seldom used in dressing wounds since it has been recognized that they do more harm than good — by preventing the evaporation of the discharges of the wound. Under this head are to be classed : — Lister's oiled silk protective , which is laid directly over the wound, to shield it from the irritating qualities of the carbolic acid, etc. If the material of the dressing possesses sufficient absorbent power , it is unnecessary — as is also the glass - wool recommended by Schede. Should it be desired to use anything of this sort, the far cheaper varnislieci - paper ^) is to be preferred. This may also replace the expensive mackintosh, which was laid between the seventh and eighth layers of gauze in the original Lister dressing, in order to prevent any discharge which might penetrate the dressing from directly reaching the surface. This varnished -paper is also excellent to cover and retain the moisture of wet applications (Preissnitz's compresses, cataplasms): and parchment paper , oil - silk , and rubber-tissue can also be employed for this jDurpose. Heavy waterproof materials, such as cotton cloth filled with oil-varnish, or rubber-cloth (for example, Billroth's batiste, oiled cloth, etc.) are used to protect the bed -linen when renewing dressings, in per- manent irrigation, etc. ^) Tissue-paper is painted with a large brush with linseed varnish, to which 3 •'/o siccative („drier") or varnish-extract has been added. The sheets are then hung up on strings in an airy room for 48 hours, until they are perfectly dry. To make the paper antiseptic, 1% of thymol is added to the varnish. 29 Pure sheet rubber, made of raw brown rubber, is excellent for covering the operation -table, and protecting the rest of the patient's body in operations , and when the dressings are renewed (see Fig. 8) ; and for making the aprons and sleeves for the surgeon and his assis- tants {see Fig. 1). From the same material are cut the rubber bandages , 2 to 3 in- ches wide, which are used: 1. For bandaging the limbs in emjiloying Esmarch's bloodless method. 2. For applying outside of the entire dressing of the wound after operations performed upon the extremities with this method, in order to increase the compression for the first two hours . until the danger of secondary oozing of blood has passed. Fig-. 43. 'i> Elastic bandage with Lister dressing. 3. For applying along the edges of the dressing, in order to prevent the entrance of air {hy the respiratory movements of the chest or abdomen , for instance) , or of the contents of the bowel when the dressing lies near the anus (Fig. 43, after lister). THE POSITION OF THE PATIEWT. The position of the patient is of great importance in applj'iug or changing the dressings. He must be so placed that the part to which the dressing is to be _. applied is accessible on every side , and the body must be maintained in a natural position during the entire .^^g dressing of the wound. ^^ To suppoi't the body, the ojierating table will an- vswer in part, but the pad- ded pelvic support descri- bed by Yolkmann (Fig. 44), Pelvic support (Volkmann). Fig. 45. — 30 — which should have a height of 8 inches for adults, will also be necessary, and in some cases two of these will be needed. The assistants or orderlies hold the body in the chosen position with their hands. In making some dressings, mi heel-rest (Fig. 45) will also be found useful. The figures 46 to 50 show: (See pag. 31 and 32.) 1. The position of the patient in applying dressings to the upper part of the body (Fig. 46). 2. The position in applying dressings in the neighborhood of the pelvis, anteriorly (Fig. 47). 3. The position in applying dressings in the neighborhood of the pelvis, posteriorly (Fig. 48). 4. The position in applying dressings to the abdomen (Fig. 49). 5. The position in applying dressings to the lower extremity (Fig. 50). Heel-rest (Esmarch). ANTISEPTICS. STEEILIZATION. The surest way of rendering the materials to be employed for dressings aseptic , to destroy the agents of putrefaction which are in them, is sterilization by dry heat and steam. The air in a sterilizing oven of good size is slowly heated to a temperature of 90 " C. (194*^ F.), while the material lies sjDread out in it on wire-grating. After the dry heat has acted upon it for a quarter of an hour, hot steam is allowed to enter the oven until the temperature reaches 100^ C. (212** F.). This temperature is maintained for half an hour, then the steam is allowed to escape, and is rej^laced by dry hot air, which is allowed to cool off gradually after half an hour, the moisture being thus made to evaporate from the material. Materials made asep- tic in this way, must be at once wrapped in parchment or varnished- paper , and kept in boxes of sheet-metal or glass until they are used^ or until they are impregnated with antiseptics. — 31 — Fiff. 46. Water can be sufficiently sterilized for use in operations , to cleanse the wound, by long-continued boiling. But as plain water irritates the tissues, making them swell up, it is necessary, to make it resemble blood -serum by adding ordinary table -salt in the proportion of 6 to 1000. Sea -water, drawn up from some distance below the surface of the sea, can also be employed for this purpose, after it has been Fis. 47. — 32 — Fi^. 48. Fig:. 49. Fiff. 50 boiled and has liad its proportion of salt reduced to that giveu above, by the addition of boiling fresh water. — 33 — Among the large number of substances which prevent putre- faction, now used in the antisejjtic treatment of wounds, the most im- portant for military surgical practice are the following: 1. CAHBOLIC ACID (Lister). This is a very powerful antiseptic. A watery solution of 1 to 1000 will hiMer the development of bacteria by continuous action, although the action of the concentrated solution (1 to 20) for 24 hours is necessary to entirely prevent their growth. According to Koch , solutions in oil and alcohol have no anti- septic action. Carbolic acid is, however , poisonous — and not by internal use alone. It is also quickly absorbed by wounds , and even by the skin, especially in children; and in weak, thin blooded adults, as well, and in those who suffer from disease of the kidneys , it not infrequently causes severe symptoms of poisoning — both acute (collapse) and chronic (disturbances of digestion , vomiting , marasmus.) It is also irritating to the skin, especially when employed in a moist form, and causes erythema and eczema, often with febrile symptoms; and strong solutions irritate the surfaces of wounds and cause an increase of the discharge — and even suppuration (antiseptic suppuration — Lister). Recently, therefore, it has been used much less than formerly, when by Lister's recommendation it dominated the entire antiseptic method. It is used : a. In weak carbolic solution (3 ^^|^^) to disinfect the hands, the instruments, the skin in the neighborhood of the wound, the wound itself, the sponges , and the atmosphere (cai-bolic - spray). b. In strong solution (1 to 20) to disinfect septic wounds. c. For the impregnation of the materials used for dressings — especially gauze (Lister gauze, carbolized gauze). Since carbolic acid is very volatile, and the quantity of it in the impregnated materials diminishes very rapidly by evaporation, it is advisable to prepare the latter only just before they are to be used. In time of war , the best method for its preparation is that of Bruns : — To 400 grams of powdered colopliony is added in succession 100 grams each of alcohol and carbolic acid, and 80 grams of castor oil — or 100 grams of melted stearine. The mixture is stirred until it is reduced to a smooth brittle mass about the consistency of an extract , and is immediately placed in an air-tight vessel for preser- vation. When desired for use , the mixture is dissolved in 2 liters of alcohol, with constant stirring. To impregnate the gauze, the mixture is poured out over 1 kilogram gauze, which is spread out roughly 3 — 34 — in a flat pan , and readily absorbs it. In order to secure an even distribution , the gauze must be wrung out two or three time& from one end to the otlier (3 to 5 minutes are to be spent in doing this) or passed through a wringing machine. The material is then hung up to di'y — but for as short -a time as possible , until the alcohol has for the most part evaporated — about five minutes out-of- doors in the summer , and from ten to fifteen minutes in a moderately heated room in winter. The gauze is then to be kept in closed boxes of sheet - metal. 2. BICHLORIDE OF MERCUEY (Koch). This is the strongest of all the disinfecting substances in use. According to Koch, a solution of 1 to 20,000 in water will kill the- spores of the anthrax-bacillus, and a solution of even 1 to 300,000 in water will prevent their development. The bichloride is odorless , but very poisonous , if used in strong solution , or in a weak solution for a long time. In addition to great irritation of the skin (eczema, chajDping) it may cause symptoms of systemic poisoning (stomatitis , salivation , severe diarrhoea with tenesmus , ulcerative inflammation of the rectum and colon, nephritis, etc.) so that the greatest prudence is necessary in using the stronger solutions. As the bichloride is at once decomposed by contact with metal,, it cannot be used for the disinfection of instruments , nor kejDt in metal vessels. The irrigators for use with bichloride solutions must therefore be made of glass, and the basins of glass, china or paper. It is employed : a. In Aveak aqueous solution, 1 to 5000, to disinfect the hands and the neighborhood of the wound, to wet the wipers and sponges, and to irrigate the wound before applying the sutures. b. In strong aqueous solution, 1 to 1000, for thorough irri- gation of septic wounds, and for this purpose it is far more reliable and less dangerous than the 1 to 20 carbolic solution. c. In alcoholic solution, 1 to 1000, to preserve catgut, silk,. sjDonges and drainage tubes. d. To impregnate gauze and other materials for dressings. A solu- tion of 1 jDart bichloride, and 100 parts table-salt, in 40 parts gly- cerine and 1000 i^arts water, is jDoured over the materials, the super- fluous fluid squeezed out with the hands or a wringing machine, and the material dried by moderate heat. As aqueous solutions, and the materials impregnated with them,, sometimes irritate the skin, and as the bichloride after some time eva- porates from them (Lazarski) , Lister has proposed to mix the bichloride with the serum of the blood of horses (I to 100) and to impregnate — 35 — the gauze with this (bichloride-serum gauze). In this way it is deprived of its irritating properties , but not of its antiseptic power. 3. CHLOEIDE OF ZINC (Lister). This is a tolerably strong antiseptic , does not attack uninjured epidermis , but is caustic to other tissues. It is odorless , not poiso- nous, and not expensive. It is used: a. In strong (8 ^j^^) aqueous solution (Lister) for the thorough disinfection of septic tissues , when suj)puration with decomposition is present , etc. b. In concentrated solution (with water in equal parts) with which cotton tampons are wet, as an a excellent caustic in hospital-gangrene (Konig). c. In weak solution (1 to 2000) for antiseptic compresses, and for impregnating materials for antiseptic dressings (jute gauze). d. In chloride of zinc pads (Bardeleben) which form a very cheap antiseptic dressing. 100 grams chloride of zinc is dissolved in 1^/^ liters hot water, and 1000 grams jute is worked in it until all the solution has been absorbed. The jute is then spread out and dried in the air or in an oven. 4. IODOFORM (v. Mosetig). Iodoform is not a very strong antiseptic , as it does not jorotect against erysipelas , but its action is lasting , for it is but slightly soluble, and not very volatile. It does not irritate the wound, in fact it diminishes pain, and the quantity of the discharge; the disagreeable odor of iodoform can be improved by the addition of tonka-bean. On the other hand, the use of the drug is not without danger; there are persons, especially old peoj)le , and those afflicted with dis- ease of the kidneys or of the heart, in whom the severest symptoms of poisoning (disturbances of digestion, vomiting, brain - symptoms , mania , melancholia) , often with fatal results , apear after the use of small quantities. On this account very large amounts should not be employed. Iodoform is used : a. As a powder for sprinkling over fresh wounds , in which union by first intention can not be expected — gunshot wounds, for example; and also wounds in the neighborhood of the various natural openings of the body (mouth, anus, vagina) where infection can not be avoided. b. In solution in ether (1 to 7), for washing parts where an operation is to be performed — leaving a finely divided yellow de- posit upon the skin, when the ether has evaporated. 3* — 36 — c. In iodoform gauze, to place over fresh sutured wounds in a single layer under the other dressings ; and to tampon wounds of the mucous cavities (month, nose, pharynx, rectum, vagina, bladder, urethra) which are to be kept ojDen, and in which complete antisepsis is impossible. Iodoform gauze is made by sprinkling 100 grams (3 oz) of iodoform over 10 meters {11 yards) of gauze in a clean basin, and rubbing up the latter with clean hands until it is of a uniform yellow color. For use in mucous cavities, the sticky iodoform gauze of Billroth is best, because it adheres closely to the surfaces of the wound and will prevent decomposition for weeks. It is prepared by drawing 6 meters of gauze through a solution of 100 grams of colophony in 50 grams of glycerine and 1200 g'rams of alcohol (95 **/(,), and rubbing 230 grams of iodoform into it, after it has dried. Iodoform gauze, suitable for any purjaose can be prepared very rapidly by pouring iodoform ether (1 to 7) upon gauze, and rubbing it until the ether has evaporated. This method is of course more ex- pensive than those previously described. 5. BOEIC ACID (Lister). Boric acid is a moderately strong antiseptic , which irritates the tissues very little, if at all, and it has, moreover, no poisonous properties. ■^) It is employed: a. In aqueous solution (35 **/„) instead of carbolic acid, for operations upon the abdominal cavity, the rectum, etc 5 and also, for the same purpose , with the addition of salicylic acid as suggested by Thiersch (2 parts salicylic acid, 12 boric acid, 1000 water). b. As borated lint (Lister) , very useful for covering small wounds, especially in the face, made by dipping lint in a solution of 1 part boric acid in 3 of boiling water; borated cotton and borated gauze are prepared in the same way. c. Boric acid ointment (Lister) for covering sutured wounds to which a large antiseptic dressing can not be ap^jlied — in plastic oj)erations on the face, for example; and for covering granulating wounds. Lister's boric ointment is prepared of: — Acidi borici pulv., cerae albae, aa. 5 grams, ol. amygd. dulc, paraffini, aa. 10 grams. Simjiler and more durable, and therefore bettei', is a mixture of 20 parts boric acid with 100 parts vaseline or glycerine ointment. , ') But it is said that it is not altogether safe to use large quantities with children. — (Rupprecht.) — 37 — 6. ACETATE OF ALUMINA (Burow). Acetate of alumina is a very jjowerful antiseptic, for a solution of 25 parts to 1000 will not only prevent the develoj)ment of bacteria, but will destroy their power of reproduction after it has acted for 24 hours (Pinner). It quickly corrects the foul odor in the discharge of wounds, and in the secretions of the skin ; it is not poisonous , and not expensive, but it can only be employed in a fluid form, because the acetic acid evaporates in drying, leaving only the inert hydrate of alumina. As it attacks the instruments , and makes the hands rough, it is not suitable for use in operations , although it diminishes the hemori'hage by its strong astringent action on the capillaries, and it is therefore not a bad idea to wet the wipers with it. It is emjDloyed in an aqueous solution , 1 to 5 ''/^ , in which gauze compresses are dipped for use as moist applications ; and also in purifying baths for supjDurating , gangrenous, or foul wounds and ulcers, and for eczema and foul - smelling secretions of the skin (axilla , anus, scrotum) ; and it is the best of all antiseptics for permanent irrigation of gangrenous abscesses , decomposition , and gangrene of the tissues. A 1 ^|^^ solution is made by mixing 24 grams of alum , and 38 grams of sugar of lead, with 1 Liter of water, allowing it to stand for 24 hours and then filtering. 7. SALICYLIC ACID (Thiersch). Salicylic acid is a strong antiseptic, ii'ritates the wound but little, and is not poisonous. But it is apt to separate from the dressing- materials in the form of dust, which causes coughing and sneezing. It is also not cheap. It is used in salicylic solution (1 part to 300 water) for ii'ri- gating wounds; and, with boric acid, for antiseptic irrigation; and it acts very well in cases of eczema due to carbolic acid or bichloride of mercury, when used as an emulsion (1 part to 5 of water) or as sali- cylic acid ointment (10 "/^^ Avith vaseline, or glycerine ointment). In the form of salicylated cotton (3 "/^ and 10 ^Jq), freshly made, it was formerly much employed; but it is not to be recommended for use in the field, for the salicylic acid falls out of the cotton while it is being transj)orted. 8. PERMANGANATE OF POTASH. Permanganate of potash is very soluble, not expensive, not poi- sonous, and it is quite a strong antiseptic, for it kills spores even in a 5 "/j, solution, and entirely corrects the foul odor of decomposing wounds after irrigation for a shoi't time. But its action is of short duration, for it is at once decomposed by the dischai'ge of wounds, and — 38 — forms a slimy brown deposit with it, which soon begins to emit a foul odor. It is used in aqueous solution (1 to 1000, up to 100), the co- lor of red wine and darker, according to the amount of decomposition to be corrected (Condy's fluid). 9. THYMOL (Eanke). Thymol is a good antiseptic, for it prevents the development of bacteria even in a 1 to 2000 solution. It has an agreeable odor, irri- tates the skin but little , diminishes the discharge of wounds , and is only sHghtly poisonous ; but it is verj^ expensive. It is employed in aqueous solution , 1 to 1000 , with the addi- tion of 10 parts alcohol, and 20 glycerine; and in thymol-gauze, made by impregnating 1000 parts gauze with 500 parts spermaceti, 50 parts resin, and 16 parts thymol. In the treatment of burns, the addition of 1*^1 ^ thymol to the liniment which is used everj^where for burns (equal parts linseed oil and limewater) renders it analgesic and antiseptic. A 1 to 1000 solu- tion is also to be warmly recommended as a mouth-wash. 10. NAPHTHALINE (E. Fischer). Naphthaline is a very good antiseptic , which does not irritate the wound, is not poisonous, and is very cheap, but it has a very un- pleasant, j)enetrating odor. When sprinkled over open wounds in the form of powder, it disinfects them quickly and durably. Gauze , with naphthaline rubbed into it, makes a very useful material for antiseptic dressings. 11. PEROXIDE OF HYDROGEN (Trommsdorff). Peroxide of hydrogen is a very strong and not poisonous anti- septic, which acts very powerfully in a 3 ^'/^ aqueous solution, used as a spray , in disinfecting foul wounds , as well as sick - rooms , but it is unfortunately too exj)ensive. ]2. ABSOLUTE ALCOHOL. Absolute alcohol is a moderately strong antisej)tic, which is very useful for the disinfection of instruments , especially knives , the edges of the latter not being liable to be attacked by it. — 39 ANTISEPTIC POWDER DRESSINGS. Antiseptic powder di-essings, that is, the sprinkling of antiseptic substances in the form of powder, are suitable for : a. Such wounds as may be expected to heal under the scab (jDenetration-fractures, simple gunshot wounds, superficial burns). b. Fresh contused and lacerated wounds of considerable size (caused by the explosion of bombs , or by machines) which are not united by suture, and therefore can not heal by first intention, as well as large and deejD burns — in order to prevent decomposition. c. Suppurating wounds , in order to diminish the discharge , and j)roduce healthy, quickly-cicatrizing granulations. d. Septic, gangrenous wounds, to correct the sejjsis. These powders, however, must not be strewn in fresh wounds which are to be closed by suture , because they may act as foreign bodies, and prevent union by adhesion. Only those antiseptic substances are suitable for use in this way which do not irritate the wound — that is , do not increase the dis- charge, but rather diminish it. This purpose is best fulifilled by lODOFOEM POWDEE (v. Mosetig) because its antiseptic action is not only tolerably strong , but it is lasting. It is , therefore highly to be recommended for sprinkling in small gunshot wounds Avhich it is not desirable to disinfect thoroughly. In very large wounds (from exploding bombs , etc.) care is necessary, because symptoms of poisoning are sometimes observed. In such cases the mixture of some indifferent substance (chalk, talc, sawdust, peat) with the iodoform is advisable , if iodoform gauze or other material is not at hand for an antiseptic dressing. The following substances can also be used for powder dressings, — the carbolic powder of Bruns , carbolized lime (Port) , naphthaline (Fischer) , oxide of zinc (Socin , Petersen) ; especially the last , for it is harmless , odorless , and cheap , and has some antiseptic power , while subnitrate of bismuth (Kocher) is sometimes poisoilous ; but both form concrements when strewed in wounds containing cavities. Salicylic acid is not to be recommended for sprinkling on wounds as a powder, for it irritates the wound too much, and causes pain. It is also poisonous in large quantities , and affords no protection against erysipelas (Kiister). — 40 — RENEWAL OP THE DRESSING. Tlie dressing of a clean wound should , if possible , remain un- touched until the wound heals , or at any rate be changed as seldom as possible. In order not to miss the proper time for the renewal of the dressing, it should be frequently examined, esjoecially its most depen- dent part; the temperature also must be constantly watched by the- aid of the thermometer, and the patient's general condition observed. If the discharge penetrates the dressing and reaches its external surface , decomposition is at once set up in it by the contact of the atmosphere, and rapidly spreads through the layers of the dressing to tlie wound. To avoid this , the superficial layers of the dressing at the spot where the discharge has made its appearance must be at once disin- fected by washing with bichloride solution, and then covered with an antiseptic cushion extending far beyond the affected place. If the spot made by the discharge is larger than the palm of the hand, it is better to remove the external layers of the dressing, the large external cushion, and after abundant irrigation of the inter- nal layers below it with bichloride solution, to apply a fresh large cushion. A renewal of the dressing will be necessary: 1. If great pain is felt in the wound. 2. If fever appears, with such general disturbance that sepsis of the wound is probable (septic fever); but if the general condition con- tinues good, in spite of a rise of temperature, the skin and tongue remaining moist (aseptic fever), it is to be concluded that there is no sepsis of the wound. 3. If a foul odor arises from the dressing. 4. If rubber drainage tubes have been placed in the wound, it will be necessary to change the dressing in a few days (four or five), in order to remove the drainage tubes at the proper time. If they are allowed to remain longer then necessary, they increase the discharge. The change of the dressing must be made as rapidly as possible, so it is necessary to have everything which can by any chance be needed for it ready beforehand. Before removing the dressing, the patient is placed in such a position that the fresh dressing can be readily applied, and the bed is to be protected from dirt and moicture by covering it with a rubber cloth. A large, powerful pair of shears is exceedingly useful for rap- idly cutting the bandages (see Fig. 163, j)laster of Paris shears). If the wound is found to be antiseptic, it is entirely unnecessary to irrigate it. The neighboring parts are merely to be cleansed with wipers or bunches of cotton which have been dipped in bichloride solution, and a fresh dressing is to be quickly a^^plied. — 41 — If rubbei' drainage tubes were inserted, tliey are to be withdrawn, and only to be replaced (after having been cleansed), when some dis- charge from the deeper parts of the wound apjDears upon pressure. If the wound has healed, except some superficial granulations, some borated lint, or a piece of gauze spread with borated vaseline, is laid upon it. If there is eczema in the neighborhood of the wound, the in- flamed part is to be thickly covered with salicylic glycerine ointment, or salicylic vaseline. If no primary union has taken place, another antiseptic dressing is to be applied and renewed more frequently. But if the wound has become septic, if inflammation, sujDpuration, lymphangitis, abscesses, or erysipelas has appeared, all the stitches must be removed at once, and the wound freely opened, and thoroughly disinfected and drained, as will be fully described farther on (see secondary antisepsis, in Part II., Operative Surgery). THE OPEN" TREATMENT OF WOUNDS. The open treatment, leaving the wound without any dressing (Bartscher, Burow), attained far better results than any treatment which had previously been tried, for in the older methods all sorts of injurious influences had been ^brought to bear on the wounds. Among these injurious influences were, in particular, frequent renewal of the dressings, retention of the discharges, and the use of lint, old linen, sticking plaster, and other dressing which contained the agents of decomposition. The method has also undoubtedly rendered service by drawing the attention of surgeons to these injurious influences. But as this method foregoes primary union, allows the agents of infection which exist in the air to have free access to the surfaces of the wound, and permits the discharge to decomj)Ose, it should be employed only when there is some reason why the rational antiseptic treatment of wounds, previously described, can not be carried out. It is still less suitable for military practice, because the air of rooms which contain many wounded persons is usually full of the agents of infection. TREATMENT OF INFLAMMATION (Antiphlogosis). Rest, elevation, and cold applications are the principal means of treating inflammation of tliost; tissues which are not in contact with the atmo8]i)here. Antisepsis, in the widest sense of the word, combats inflammation in wounds of any kind. — 4:2 — A large part of the following chapter deals with rest for injured and inflamed parts. • ' Elevation of the part assists the return circulation of venous blood and of lymph, diminishes the arterial blood supply, and thus acts against congestion (hyperaemia) , and quickens the absorption of extravasations and exudations. The following methods can be employed to elevate the hand; a. My adjustable in- °' ' ' clined plane, which stands . upon a table near the bed i (see Fig. 55); or on the bed, upon a board, arran- ged to conduct the water used for irrigation into some vessel (see Fig. 57). b. For vertical sus- pension of the hand and forearm, the entire arm is to be secured to a splint, such as is used in resection of the elbow, or to Volk- mann's suspension - splint (Fig. 51), by a bandage applied with spiral turns which do not overlap (see Fig. 60) not with circular turns, and the splint sup- ported in an elevated position by a string attached to its lower end (Fig. 52). To elevate the lower extremity one of the various forms of apparatus used for this purpose can be employed (Petit's fracture-box, the double inclined plane, etc.), or the limb, enclosed in an immovable dressing, is suspended by strings and pieces of wood so that the foot is higher than the rest of the body (Fig. 53). For similar reasons, the prone position is to be chosen in in- juries of the back, and elevation of the head and neck practiced in injuries of these regions. Volkraann's suspension-splint. COLD APPLICATIONS. Cold applications are made , or heat abstracted in various ways, when it is desired to reduce the temperature of any part of the body. 1. By cold compresses ; these require very frequent renewal, if they are really to abstract heat continuously, and thus the injured — 43 — Fig-. 52. Suspension of a fenestrated plaster splint for open treatment after resection of ttie ankle. 44 — part is liable to be disturbed. If tbey are allowed to remain long enough to grow warm, they act as excitants (Preissnitz's compresses). 2. By dry cold, best applied by means of ice in rubber bags (ice-bags). The ' ice - bags must be securely closed by tying the closed mouth of the bag tightly around a wooden cylinder or large cork (champagne cork) with a narrow bandage (Fig. 54). If the cold is too intense , a few layers of linen or gauze are to be placed between the ice - bag and the body. Pig -bladders are apt to allow the water to penetrate them, and soon decay. To avoid the first, they should be rubbed with lard, inside and out, before being used. The decay can be prevented by washing them in antiseptic solutions every time before filling. Ice-bags of parchment paper do not remain water-tight long, and as they sometimes tear, the patient may be sud- denly flooded with the water. Glass bottles and tin boxes fill- ed with ice or cold water, abstract heat more eft'ectively than rubber bags, but thev do not fit so well to the body. Ice-bag. But cold bottles can very easily be made useful in practice among the poor, and in case of need in war. A very great reduction of the temperature in inflammation situated in the extremities can be attained by the cold-coil (Fig. 55). I gave this name to a long rubber tube which is wound in spiral turns around the inflamed part, and one end of which, provided with a perforated pewter nozzle, is dropped into a vessel full of ice- water, while the other end hangs in an empty vessel. By applying suction to the latter end, a stream of ice -water can be set in motion, and this can be regulated by compression exercised on the lower end by a string tied a round it. "When the upper vessel is empty it can be refilled by pouring the water back again into it from the other. ^) I have also endeavored to make use of the same method for reducing the temperature of the entire body in the febrile diseases (typhus, scarlet fever, etc.), by having a long rubber tube sewed upon ^) Verhandhnigen dor Deutschen Gesellschaft fiir Chirurgie. Vierter Con- gress, 1875, p. 97. — 45 a sheet so that it covered one side of it, in close -lying parallel coils. If this cold sheet is spread over the naked body and a stream of Leiter's cold-coil for the head. ice -water allowed to run through the tube, the temperature can' be greatly reduced in a short time, without the necessity of wetting the patient or of removing him from bed. — 46 Leiter has employed a thin flexible lead tube for the same pur- pose, and this abstracts heat even more rapidly and energetically; for,, as is well known, metal is a much better conductor of heat than rubber (Fig. 56). 3. By letting cold water drop upon the part (irrigation) (Figs. 57, and 58). Cold water is made to drop from an irrigator hung above the bed upon the injured part, covered with a linen cloth in which the Irrigation. fkiBllili water distributes itself. The rapidity of the dropping can be regulated by sticking straw into the opening in the metal nozzle of the irrigator. Instead of the irrigator, a rubber tube can be used, provided with a stop-cock at one end, and with a pewter nozzle at the other, which can be dropped into a vessel of water. The tube acts as a siphon, and must be set in action by apjDlying suction to one end. Small siphons of glass, or metal tubing, can also be used for this purpose (Fig. 58). The amount of heat abstracted by irrigation is very great, on account of the evaporation of the water. The water, therefore, need not be of a very low temperature. The overflowing water must be collected by an inclined plane (Fig. 57), or by a waterproof cloth, and directed into a vessel below. — 47 4. By immersion in cold water. For this purpose arm- and leg-baths {Figs. 6, and 7) are employed, the injured limb resting upon strips of bandage which are secured to the knobs on the side of the bath-tubs. This is an excellent method of reducing the temperature in fresh injuries of the hand and foot. It is not necessary to employ a very low temperature in these continuous baths , as their action is very Yis. 58. Irrigation powerful. "Water at 68 *^ to 72 ^ F. has a very well-marked cooling effect when the bath is continued for some time. The regulation of the temperature, by the addition of cold water, can as a rule be left to the patient. In the treatment of chronic inflammatory processes ; exudations of blood and serum; thickening of the cellular tissue, adhesions of the tendons and muscles, and stiffness of the joints, such as occur after injuries of any kind, or resections, and with long-continued fixed dressings, — 48 — MASSAGE can be employed -n-itli the greatest advantage. By kneading, pressing, and beating with the oiled fingers , the extravasations and exudations must first be broken down, the adhesions loosened, and the lymphatics cleared; then by rubbing and stroking in a direction away from the extremities, the materials thus set free are moved on towards the heart. By the application of rubber bandages , by passive and active motion (therapeutic gymnastics) , by the galvanic current , and by exci- tant compresses (Preissnitz), absorj)tion can he still further promoted. BANDAGES. Bandages and cloths are employed in applying and securing dressings and splints, and for covering, supporting, and immobilizing injured parts. They are made of; a. Linen — best of old ,. soft linen which has been frequently washed ; torn , or cut along a thread. Bandages of new linen do not lie smoothly, being too stiff. b. Flannel, torn; soft and elastic, and therefore fitting nicely, especially suitable for putting under starch and plaster of Paris bandages. c. Shirting, (muslin) torn: 'cheaper than linen, and suitable for starched bandages. d. Cambric, cut; very soft, aud fit as closely to the body as flannel bandages, but cheaper than the latter; very durable, and easily washed. They are particularly good for securing splints and heavy dressings. e. Gauze (muU), cut: lie smoothly, if they are applied Avet; and if. they are starched (crinoline) the turns adhere to eachother when dry, so that the dressing can not change its position. They are most fre- quently used in applying antiseptic dressings, and in making plaster bandages. f. Cotton-batting, cut; are very soft and elastic, and are there- fore very suitable for applying under stiff bandages , as well as to fill in the edges of the antiseptic dressings. THE APPLICATION OF BANDAGES, BANDAGING. Bandaging must be done with great exactness and care, for an improperly applied baudage is liable to become displaced, and may do great injury by strangulation. 49 A strangulating baudage causes at first venous congestion; the parts below the point of constrictiou swell , with great pain , and become blue and cold (Fig. 59); and if the strangulation is not soon Fis. 59. Strangulation by a tight bandage. removed, gangrene follows, or an incurable degeneration of the muscles which have been thus shut off from the circulation for some time (ischaemic paralysis and contracture of the muscles — Volkmann). Fig. (iO. Fig-. 61. Continuous bandage. Circular and spira) bandage. 50 — If bandages are applied dry and made wet afterwards (by cold compresses, for instance), tbey shrink very much, and cause strangulation. In bandaging, the following methods are to be distinguished r 1. The circular, which surrounds the part at one level (Fig. 60,. the lower part of the figure). Fi?. 62. Fiff. 63. 2. The spiral (dolobra repens). a steep spiral, in which the turns do not overlap (Fig. 60, the upper part of the figure). 3. The continuous (dolobra ascendens), a moderately inclined ascending spiral, the successive turns of which partly overlap (Fig. 61). The descending spiral (dolobra descendens) is seldom used be- cause it leads to venous congestion. 4. The reversed (dolobra reversa) (Figs. 62 to 64) must be employed whenever the circumference of the limb increases or diminishes, in order to prevent separation of the turns of the bandage (Fig. 65). In making the reverse , the thumb of the left hand must be pressed 51 — upon the lower edge of the bandage, so that the upper edge is relieved of tension, and can he easily turned over. Fig. 64. Ym. 65. .5. The spica, or figure-of-eight, is used whenever the bandage passes over a joint to another part of the body (Pig. 66). 6. The double-headed bandage, which is rolled at both ends, is used by preference on the head , and 1 on amputation stumps; it can also be em- Fig. 66. rr"" Figure-of-eight bandage. ployed to draw together the edges of wounds, and of ulcers of the leg (see Fig. 22, p. 17). ,5. The many - tailed bandage (Scultetus) made of many short strips, overlapping half of their width , is sometimes used in dressing compound fractures, and in making plaster of Paris dressings (Fig. 67). 8. The T- bandage, a strip of Gaping bandage. bandage, to the middle of which an- other strip is fastened at right angles to the first, serves for some dressings of the pelvis and head (Fig. 68). 4* ^ 52 Fiff. 67. Many-tailed bandage of Seultetus. Fio-. 6S; T - bandages. — 53 — To secure the end of the bandage, a pin, or better, a safety- pin, is employed (see Fig. 90). If none is at hand, or economy in pins is desirable , the end of the bandage (esjoecially if it is a gauze bandage) is torn in two, and one half is carried backwards and then tied in front with the other half. as is shown in Figure 69. Fis-. 69. DRESSINGS FOR THE HEAD. Fis. 70. ] . The double-lieaded roller (fascia unieus) (Fig. 70). The middle of the bandage is applied opposite the injured sj^ot, .and the heads of the roller are brought around oyer it, then back to the Fig. 71. starting point, and these turns are repeated several times , alternately covering eachother behind and in front. 2. The sagittal bandage (fas- cia sagittalis) (Fig. 71), a T-bandage which is particulai'ly well suited for bringing together transverse wounds of the scalp. ^ "^ 3. The knotted bandage (fas- sagitaii bandage, cia nodosa) (Fig. 72), a double- headed bandage, the turns of which are crossed at right angles over tlie wound with considerable force, as in tying ujd a bundle, is espec- ially useful in case of need in wounds which bleed profusely, and upon which it is necessary to exert great compression. A tightly drawn cravat, or a piece of rubber tubing can be used for the same purjiose. 4. The halter-bandage (capistrum) (Fig. 73). The first turn begins upon the top of the head, surrounds the face, passing undei- the cliin, and returns to the top of the head. The second turn runs from this point around the back part of the head, then from tlie nape of the neck forwards, and around the anterior surface of the chin, returns to the nape of the neck, and passes back again to the tojD of the head. After both of these turns have been repeated two or three times, the third part surrounds the forehead and the back of the head by a cir- cular turn. Double-headed roller. — 54 — NB. This bandage, as well as the following, is especially to be recommended for practice, because the different turns can be used in various dressings. They are both most easily applied by using wet gauze bandages. 5. The recurrent bandage of the head (mitra Hippocratis) (Fig. 74), a double-headed bandage, of which one head, by circular Fig. 72. Fiff. 73. iV. 74. Knotted bandage. Halter bandage. The cap of Hippocrates. turns around the forehead and occiput, secures the turns of the other head of the roller, which jDass alternately over the right and left pari- etal bones, overlapping for half of their width. 6. The various turns of the halter bandage serve for injuries of the temple and cheek (Fig, 73). Fisf. 7.5. Fig. 76. Fig. 77. Four-tailed bandage of the jaw. Nose bandage. Eye bandage. 7. The eye bandage (monoculus) is used for injuries of the eye (Fig. 75). 8. The nose bandage is employed in injuries of the nose, and is made of a broad strip of bandage folded together (Fig. 76). 9. In injuries of the lower jaw, the fourtailed bandage of the jaw (funda maxillae) (Fig. 77) is used — a bandage 5 feet long, 2-^/2 inches wide, split at both ends, leaving a piece in the middle 2^/2 inches wide not split, and making four ends of equal length. The middle piece, having had a small slit made in it, is laid over the middle of the chin, the upper ends are led backwards over the occiput, and thence — 55 — to the forehead, and the lower ends are led upwards over the temples and down on the opposite sides. DRESSINGS OF THE UPPER EXTREMITY. 1. In bandaging the entire upper extremity, bandages are first applied to each finger, and the whole hand bandaged with narrow ban- dages (glove bandage, cMrotheka) (Fig. 78, a and b). Next follows the bandage of the forearm, with a reversed continuous bandage (Fig. 78, c); then the elbow, with a figure- of-eight (testudo) (d) ; the arm proper , with a simple spiral (e) ; and the shoulder, with the sjoica of the shoulder (f). 2. Dressings for injuries of the hand and fingers. General rules : — no stran- gulation ; unbutton the shirt ; cut open the sleeves of the shirt and under-vest up to the shoulder; bandaging of the hand must not be begun by circular turns around the wrist ; the hand must not be allowed to hang down. Fresh simple wounds are to be brought together with English sticking-plaster, wet gauze band- ages , or strips of dry gauze painted with collodion or traumati- cine, or fine sutures — the epider- mis sutures of Bonders. Hemor- 'rhage is usually to be controlled by pressure — bandaging. 3. Contused and lacerated wounds of the fingers are treated by narrow gauze bandages which have been moistened with weak cai'bolic, or salicylic solution, and are from Bandage of the hand and arm. time to time moistened again by dipping them into the same, or by irrigation : still better is a complete antiseptic dressing. 4. Fractures of the fingers are treated by a plaster-splint (bandaging with narrow flannel bandages — chirotheka, and over that — 56 Fiff. 79. nari'ow plaster of Paris bandages) ; or by simple splints (nairow thin wooden splints wrapped in cotton batting), secured by wet gauze band- ages , and paste spread over them, or by dry gauze bandages, painted with collodion or traumaticine. 5. Fracture of a single metacarpal bone is treated by band- aging the hand with flannel bandages upon a ball fa large bunch ot cotton) placed in the palm — ball-bandage. When there is great shortening, extension will be found useful — two strips of adhesive plaster being secured to both sides of the finger by a spiral adhe- sive plaster strip , and extension made by a rubber ring attached to a splint bound to the hand. 6. After disarticulation of one finger, a com- pressive bandage can be formed by a narrow figure- of-eight bandage (Fig. 79). b. In fracture of the clavicle , displacement of the ends can be corrected , although not perma- nently, by Desault's dressing for fracture of the cla- vicle. This dressing has, indeed, gone out of fashion but it is excellent for joractice, for some of the turns are employed in nearly all dressings about the- shoulder. Figure-of-8 in dis- The first part (Fig. 80) secures a wedge — sha- -artieulation of a ^ , . • ,i -n ±1 1 • i, i j • i finger. ped cushian m the axilla, the arm bemg held ni ab- duction, by turns encircling the chest. Fio-. Fig. 81. First part. Second part. Desault's dressing for fracture of the clavicle. 57 The arm having been lowered and pressed against the cushion, is fixed to the chest and at the same time drawn backwards by the second part {Fig. 81). The third part (Fig. 82) supports the arm like a sling. To prevent the bandage from slipping, paste may be spread over it, or it may be sewed together in numerous places with needle and thread. The dressing of Velpeau (Fig. 83) which secures the hand of the injured side upon the sound shoulder, and the elbow in front of the Fiff. 82. Fiix. 83. Desault's dressing. Third part. Velpeau's dressing for fracture of the clavicle. ensiform appendix of the sternum, is useful both iu fracture of the clavicle, and in chronic inflammation of the shoulder-johit. DRESSINGS OF THE TRUNK. 1. Bandage for the chest (Fig. 84). 2. Figure-of-eight for the Ijack (Fig. 85) 58 Fio-. 84. Eig. 85. DRESSINGS FOR THE LOWER EXTREMITY. Bandaging the entire lower extremity (Fig. 86) is begun by bandaging the foot with a narrow bandage in figure-of-eight turns (stirrup bandage, staj^es). The leg is next bandaged with a broader continuous reversed bandage, the knee by a figure-of-eight (testudo), the thigh by a continuous reversed bandage, and the hip by a figure-of-eight (spica of the hip), which is finished by a few circular turns around the pelvis. Many of the bandages which have been figured are obsolete, and are little used, if at all, in practical work. But they are all very useful for practice, and although it is easier to apply a wet gauze bandage than one of stiff linen, still a complete mastery of the art of bandaging is necessary for making proper antiseptic dressings. Fig. 87 shows, by way of example, how a well-applied antiseptic cushion - dressing appears after an important operation in the region of the neck. HANDKERCHIEF DRESSINGS. Almost every dressing can be secured by linen or cotton cloths, triangular (neckerchief) , or square (handkerchief) in shape , and some- times better than by bandages ; their application requires little or no 59 — Fiff. 86. Fiff. 87. J practice, and the danger of strangulation is far less than in bandage-dressings. These dressings are therefore particularly suitable for temporary or emergency dressings , and especially for „ first aid" on the field of battle. They are also useful in the later stages of the treatment of wounds, for covering stumps, etc. The handkerchief dressings were most warmly recommended as much as fifty years ago, by Grerdy and Mayor, of Lausanne. But as they had passed al- most entirely into oblivion, the author exerted Bandage of the lower hiii^gelf to secure their admittance again into field extremity. . ^ ^ . • , -, 7i , • i practice, by having printed upon the triangular cloths representations showing the application of the handkerchief to injuries of the various part of the body. ^) As is to be seen in these pictures, the cloths can be employed for various purposes in different sizes and shapes — sometimes as handkerchief-bandages, folded together from the point to the bottom into long cravats; sometimes open, as a triangle, with varjdng use of the different angles, by turning in, folding over, tying, or pinning together. For military use, the handkerchief should be large enough to form a sling for a large man , that is , the base of the right-angled triangle must be at least 1 ^/^ yards long, and the material out of which these handkerchiefs are cut must be at least 1 yard wide. If smaller ^) Esmarch, Der erste Verband auf dem Schlacbtfelde. Kiel, 1869. — 60 Fisf. Square-knot. Fig-. 89. Granny-knot. cloths are needed, the large hand- kerchief can be cut in two from the apex to the hase with scissors. For tying the ends together, only the square-knot should be employed (Fig. 88), as it holds much better than the granny-knot (Fig. 89) : or the ends may be pinned together. The safety- pin (babies' pin, fibula) is best suited for this purpose (Fig. 90). These handkerchiefs are brought into use in the difiFerent regions of the body as follows : For injuries of the head are employed : Fisr. 90. Safety-pin. a. The triangular bonnet (capitium parvum triangulare) (Figs. 91 and 92). The middle of the triangular cloth is laid upon the top of the head so that the lower edge lies squarely across the forehead, and the corners hano- down over the neck. The two ends are then Fio-. 91. Triangular bonnet, anteriorly. Triangular bonnet, posteriorly. passed backwards above the ears, crossed behind over the occiput, brought forwards again and tied across the forehead. The corner which hangs down behind is then drawn down tight , turned up over the occiput, and secured on top of the head with a safety-j)in. 61 b. The four -tailed bandage for the head (Figs. 93, and 94), a rectangular cloth, 24 inches long, 8 inches wide, split at both ends like a split con^press. To secure a dressing on the top of the head with this cloth, the two posterior ends are to be tied under the chin, Fiff. 93. Fiff. 94. Four-tailed bandage for the vertex. Four-tailed bandage for the occiput. the two anterior ends under the occiput (Fig. 93). On the other hand, to secure a dressing upon the occiput, the anterior ends are tied under the chin, and the posterior across the forehead. c. The large square head-eloth (capitium magnum quadrangulare) (Figs. 95, and 96) covers the entire region of the ears, nape of the Fiff. 96. The large square head-cloth. neck, and throat, as well as the head, and is therefore a very convenient dressing in cold or ])ad weather. A cloth 40 inches square (a napkin), is folded so that the long edge of the upper part lies about 4 inches behind the long edge of the under part. In this way an elongated rectangle is formed whicli is laid on the head ol" the patient, so that the middle of the cloth lies over the sagittal sutuie, the free edge of the lowei* pnrt hangs down as far as the end ol" ilic nose, tJie edge of the up})er part hangs down to tlie eyebrows, and the short sides of the rectangle fall over both shoulders. The two outer corners of the four which hang in I'ront over the chest are iir.st tied tonetlier under tlie chin; then the edge of tlic under — 62 — layer, which hangs in front of the eyes, is turned up over the forehead, and its corners are pulled backwards above the ears and tied together at the nape of the neck. For injuries of the eyes, the eye bandage (Fig. 97) made of a folded handkerchief is employed. For injuries of the lower jaw, the four-tailed-bandage of the jaw (funda maxillae) is used, which is made of two small folded hand- Fig-. 97. Fis". 98. Eye bandage. Pour-tailed bandage of the jaw. kerchiefs, the middle of one being laid upon the anterior surface of the chin, and its ends tied together at the nape of the neck; the other being led from the under surface of the chin over the top of the head (Fig. 98). In gunshot wounds of the bones of the jaw, the mouth must be carefully washed out with an irrigator. The displaced fragments are best held in place by hard-rubber splints, which must be made by a skilful dentist. In injuries of the neck, the following methods are in use for securing dressings: 1. The simple neck -cloth (Fig. 99), made of a triangular cloth folded like a cravat. Fiff. 99. Fiff. 100. Neck-cloth with paste-board splint. 2. For transverse wounds of the neck the head can be inclined towards the injured side by a piece of stiff pasteboard laid in the cloth (Fig. 100). 63 — a. Figure-of-eight for the hand (Fig. 101). b. Covering for the entire hand (Fig. 102, the left hand). c. Handkerchief dressing for the elbow (Fig. 102, the right elbow). Fi?. 102. Fis. 101. Figure-of-eigh.t for the hand. Handkerchief dressings for the shoulder, hand, and elbow; and small sling. d. Handkerchief dressing for the shovilder (Fig. 102, the left Bhoulder, front view, and Fig. 103, the right shoulder, rear view). e. Handkerchief dressing for amputated arm (Fig. 103, the left arm). f. Handkerchief dressing for disarticulation of the arm (Fig. 104). g. Slings , for supporting the arm (mitella) : 1. small sling (mitella parva) (Fig. 102, the left arm). 2. triangular sling (mitella triangularis): X. the first, ordinary, form (Fig.. 105) in whicli both the ends are carried over both shoulders around the neck. Fio-. 104. Fio-. \(o. y. The second form (Fig. lOR), in wliicli thn ends are carried only over the sound shoulder, so that the shoulder of the injured side may be relieved of pressure. 65 z. The third form (Fig. 107). in which the ends are canned over the shoulder of the injured side, so that the uninjured arm may be left free -^ for carrying weapons , etc. 3. Large square sling (mitella quadrangularis) (Fig. 108), which is made by a large napkin. Fig. 106. Fiff. 107. NB. The corners are best secured by pins, because the knots are apt to make disagreeable pressure, es[)ecially in tlie nape of the neck. For l)etter fixation of the arm (after reduction of a dislocation of the shoulder, for instance) a broad cravat is applied over tlie sling, to pi*ess the arm against the chest (Fig. 10^)). 5 — 66 - Fiff. 110. Szymanowsky's handkerchief-dressing for fracture of the clavicle, a. anterior view. b. posterior view. Fio-. 111. Fiff. 112. Handkerchief-dressings for the chest. — 67 -- Fig. 113 Fiff. 114. Handkerchief-dressings for the foot, knee, and pelvis. Handkerchief-dressings for the pelvis. Fio-. 120. Fiff. 119. Roser's handkerchief - dressing for the groin. Handkerchief;- dressing for the pelvis. — 69 Fi^. 121. Unna's suspensory. Fio. 122. Major's handkerchief dressing for fracture of the patella. 70 — SPLINT - DRESSINGS. Splints, fastened to the limbs by bandages or cloths, are used for the fixation of fractured bones. They are made of a great variety of materials. The most frequently used are the following: 1. WOODEN SPLINTS. Ordinary small pieces of thin board, of various lengths and widths, flat or concave (Fig. 123). Kr. 123. Provisional splints for fracture of the leg. A splint - dressing , formed by four padded splints (Fig. 124) secured with handkerchiefs is used for simple fractures of the middle of Fig. 124. ^li® arm. The entire extremity must be care- fully bandaged, from the ti]DS of the fingers up, and supported by a sling. The bandage should not be carried up too high on the inner side, as it is liable to exert too much pressure in the axilla. Gooch's coaptation splints are made of thin (-"^/g inch) pine wood, which is divi- ded into strips -^j^ inch wide by shallow cuts, not quite penetrating the wood, and glued to leather or linen. They are flexible transversely, unyielding lengthways (Fig. 125). Schnyder's cloth splints consist of splints of flexible walnut veneering 1 to l-^j^ inch wide, and ^/g inch thick, lying close together, and sewed between two layers of linen or cotton cloth (Fig. 126). The author's splint material (Fig. 127) consists of wooden shavings, 1^/^ inch wide, SpUnt-dre^ssing^orJracture ,, -^^^j^ ^^^-^^^ ^^.j^i^l^ ^^e laid parallel to 71 each other, ^/. inch apart, between two layers of unbleached muslin, and pasted to it with water-glass, or paste. This material is easily, Fiff. 125. Gooch's coaptation splints. Fiff. 126. Z^ 1 ^^ Schnyder's cloth splints for the lower extremity. Fiff. 127. -jxaexstM' P -'i-'!'-"-^^' Esmarch's splint material. quickly, and cheaply made; it can be cut with the regulation military scissors; and when rolled up it can be easily carried to the field of battle in considerable quantities. — 72 English modeled splints (of Bell, Pott, and Cline), carved from. %YOod, exactly iu tlie form of the limbs, with strips of leather fastened to the outside, under which straps with buckles can be drawn through (Fig. 128, and 129). Flo-. 128 A pair of Bell's splints for the leg. FiMi^^ j~j:ii4si-rt**s .* .Jlililiii w c ! !:-;*ji * nil ]i'^- — 140 — 1. It is a pressing demand of humanity that the protection and advantages of the antiseptic treatment of wounds should be enjoyed by all the wounded, even in war. 2. To answer this demand, it is necessary that: — a. All military surgeons should be perfectly familiar with the antiseptic treatment, and experienced in applying it. b. The sanitary corps of lower rank (hospital orderlies , litter- bearers) should be taught the fundamental principles of antisepsis , and educated in rendering assistance in carrying out its measures. c. Not only the field hospitals, and the sanitary corps , but also the medicine wagons of the regiments, the dressing knapsacks, and the pockets of the hospital orderlies must be "sufficiently supplied with antiseptic dressing materials. d. Every soldier should carry in war a package of materials for dressings, with which an antiseptic protective dressing can be provis- ionally applied in case of need. 3. All the materials for dressings should be packed as closely as possible, so as not to occupy too much space, and should be already divided for dressings of different sizes, so that they can be applied without loss of time. If the requisite material has to be taken from larger packages at the time when it is needed , waste is almost unavoidable , and infection of the whole by dirty hands, dust, etc., is greatly to be feared. 4. As the bichloride of mercury has proved itself, up to the present, the most efficient of all disinfecting substances, it would be the best to employ for impregnating the materials for dressings. 5. As the material for the dressings, surgical gauze (unbleached gauze) best answers all the requirements; and it is to be used both in the form of compresses to cover the wounds, and in the form of ban- dages to secure the dressings. 6. Therefore, gauze impregnated with 1 to 1000 bichloride so- lution (bichloride gauze) is proposed as the single dressing material. The volume can be considerably reduced by compression. 7. From this bichloride gauze, pieces of one size can be cut which can be employed as compresses for all sorts of wounds. Should, for example, a size of 20 inches square be chosen, one such piece, folded so as to make four thicknesses, could be used as the first covering for a simple gunshot wound, while ten such pieces laid upon each other without folding would serve as the dressing for a large wound — after amputations, resections, etc., for instance. 8. From the same material, bandages of a fixed width and length could be made, which could be used for all sorts of wounds. Should for example, a size 4 inches wide and 5 yards long be chosen as a standard bandage, it could be employed for securing — 141 — gauze compresses upon wounds of every size. If a narrower bandage were needed, the rolled up bandage could easily be divided into two parts with a sharp knife. 9. In case of need, a compress of any desired thickness can be made of this bandage by folding it back and forth upon itself. 10. A carbolic acid solution for disinfecting the hands and instruments cannot very well be dispensed with. Materials should therefore be at hand, both in the field hospitals, and in the chief dressing station, from which large quantities of this solution can be quickly prepared. For the field hospital, large quantities of crystallized carbolic acid must be carried, together with instruments for measuring it. For the chief dressing station, and the sanitary corps, it would be advisable to carry carbolic acid in solution, in small glass vessels of such a size that the contents of one of them poured into a vessel of known capacity (irrigator, basin, jar) would make a solution of a certain strength, for the inferior members of the sanitary corps are far too apt to make mistakes in the preparation of solutions. The carbolic spray can be dispensed with in practice in the field; and also protective silk and mackintosh. In case of need, the latter can be replaced by varnished tissue paper, 11. In order to be able to prepare fresh, antiseptic materials quickly, if the supply of materials for dressings which has been carried should fail, sufficient bichloride (dissolved in 2-*^/^ parts glycerine) should also be taken, and the sanitary corjDS should be instructed how to transform a great variety of stuffs (gauze, cotton, jute, peat, moss, lint, sawdust, wood-wool) into materials for antiseptic dressings. 12. Powdered iodoform, in sprinkling boxes, can scarcely be dispensed with for some kinds of wounds , but in general its antisej^tic powers do not compare with those of the bichloride. 13. Bichloride catgut of various thicknesses, and drainage tubes of various diameters, must be at hand in sufficient quantity. 14. Sponges should not be used at all at the dressing station, because it is impossible to protect them from infection. In their place, wipers are to be employed, made of antiseptic material (balls of bichloride wood-fibre tied up in gauze) moistened with bichloride solution before use. They should be destroyed after having been used once. 15. The surgical instruments should have as few grooves and depressions about them as possible, because the agents of decomposition ■are liable to become so fixed in them that they can not be removed by ordinary means of cleansing. 16. By the use of these materials , not only in the field hospi- tals, but also at the chief dressing stations, all wounds can be dressed strictly antiseptically , and operations may even be performed in an antiseptic manner. — 142 — 1 7. AVlien strict antisepsis cannot be carried out, as, for instance, in the regimental dressing stations, the first principle of every wound treatment should govern what is iindertaken — ,,at least do no haiTm". 18. Therefore avoid any examination of wounds with fingers or instruments which are not surgically clean (aseptic), for the agents of decomposition invariably adhere to fingers and instruments which have not been cleansed, and they are wiped ofi" and left in the wound during the examination, and cause inflammation, sujjpuratiou, and wound decom- position. The only exception to be made to this rule is when life is threatened by hemorrhage, for then quick treatment is most important. 19. Extraction of bullets without antiseptic precautions is by no means to be allowed. A projectile in the body does but little harm in itself. Bullets often become encapsuled in the bod}^ without giving rise to any subsequent trouble. Experience teaches that even very severe internal injuries (of bones, joints, tendons, nerves, lungs, heart, brain, etc.) which have been produced by bullets in their course , may heal without fever and with- out complications, if no agents of decomposition have entered the wound. 20. Wherever strict antisepsis cannot be carried out (for instance, at the regimental dressing station) the surgeon should abstain from any operative measures. His only duties at that point are: 1 . To apply temporary dressings — that is , to cover fresh wounds with abundant antiseptic material , to protect them from the entrance of the agents of decomposition. 2. To immobilize the injured parts (fixation by cloth, splints, etc.) 3. To send the wounded as quickly as possible where the wounds can be treated with strict antisepsis. 21. If on the arrival of a wounded man at the field hospital with a temporary dressing, no symptoms appear wliich render an inter- nal examination of the wound necessary (fever, pain, hemorrhage, pene- tration of the dressing by the discharge of the wound), the wound should' be left untouched, and the first occlusive dressing should not even "be removed , for many gunshot wounds may heal under the scab, without suppuration , without fever , and without other complications. 22. But if symptoms appear which render an examination of the wound necessary, the dressing must be at once removed and an ener- getic antiseptic treatment of the wound undertaken. In addition to the major operations which may apj)ear necessary, am^iutations , resec- tions, etc., this requires in the first place, free opening, drainage, and thorough disinfection with efficient antiseptic substances (such as chlo- ride of zinc, bichloi'ide of mercury, iodoform, etc.) ; and in the second place, the aiDplication of an autisej^tic dressing. — 143 — 23. The litter bearers should place the wouBded on the litters with great care , and cari-y them to the dressing station as quickly as possible, if the latter is near by. 24. Only in case no surgical aid is near , or no more material for dressings is to be had, should the dressing package which the soldiers carry be used, by the wounded themselves , or by the litter bearers. This is most likely to occur in the cavalry division. In addition to the antiseptic material for dressings (two bichloride gauze compresses, and a bichloride gauze bandage) these packages must also contain a three-cornered cloth, with which the protective dressing can be covered, fixation of the injured limb made, and an improvised splint secured. PART 11. OPERATIVE SURGERY. CHLOROFORM ANAESTHESIA. 1. lu every major operation, and for every prolonged painful examination, the patient should be rendered anaesthetic by inhalation of chloroform (Simpson, 1847). 2. Under some circumstances, however, this -wonderful drug may be dangerous to life, therefore certain prudential rules are to be ob- served in its administration. 3. The patient to be chloroformed should fast, taking no nour- ishment for three or four hours beforehand. During the operation he should lie upon his back, or on one side, not on his abdomen, because the last position interferes with the respiration. He should not sit up, because fainting is more likely to occur in a sitting posture ; most of the fatal cases have occurred during small operations when the patient was allowed to sit up. 4. Shortly before beginning the administration of the chloroform, a subcutaneous injection of morphine (gr. -"^/g to Y^) i^ given, which quiets the patient and hastens the anaesthesia. It also considerably lessens the pain in the wound after recovery from the anaesthetic — . combined morphine-chloroform anaesthesia. 5. All constricting clothing is to be removed, so that the neck and chest are free and the abdomen is easily accessible. 6. During the administration of the chloroform, pulse and res- piration must be kept under observation. If enough assistants are present, the respiration can be watched by the person administering the chloroform, and the pulse watched by the two assistants who hold the arms. 7. The chloroform vapor must be abundantly diluted with atmospheric air when inhaled. It is dangerous to press a thick cloth or sponge upon Avhich chloroform has been poured, close to the mouth — 145 and nose. It is far better to employ a "wire frame (wire-mask} covered with a piece of loosely woven woolen cloth upon which the chloroform is poured one drop at a time — as, for examj)le, in the Skinner chloroform inhaler, simplified by the author, with its accompanying clrop-bottle (Fig. 290). This apparatus can be easily carried in the Fiff. 290. Esmarch's cMoroform inhaler. pocket, packed in a leather case with a tongue forceps. Sufficient atmospheric air will be drawn through the cloth with every respiration. •Care must be taken not to pour the chloroform on so freely as to make it drop from the inner side of the cloth; and also not to allow it to flow over the sides upon the skin, and especially into the eyes, as it may excite violent inflammation. The mask should not be closely applied at once, but should be gradually lowered over the mouth, 8. Chloroform generally causes an excitement like that of alcoholic intoxication at first — the stage of excitement, to which succeeds, after a longer or shorter time, the stage of toleration. Movement gradually ceases, and sensibility is extinguished, together with conscious- ness, the cornea and the mucous membrane of the nose becoming insen- sible last. By touching these parts it can be ascertained wdien the anaesthesia is deep and complete, for then no reflex movements will be caused by the irritation. 9. Chloroform , however , paralyzes the vaso-motor centers in the medulla oblongata , and the motor ganglia contained in the heart , and so weakens both respiration and heart action. The respiration accord- ingly becomes more rapid, and shallower; and the pulse smaller, and feebler. The blood consequently grows darker and more venous, because it contains more carbonic acid. The arterial pressure is lowered, the temperature of the body falls , and the chemical changes are retarded. 10 — 146 — 10. If tKere is anything in addition which interferes with res-: piration and with heart action , the condition becomes dangerous, and demands quick and skilful assistance. 11. A sudden cessation of the movements of the heart and respiration may appear even in the first stage , in consequence of the inhalation of concentrated chloroform vapor. This is jDrobably to be considered as an inhibitory reflex from the pneumogastric nerve, caused by irritation of the terminations of the trigeminus in the mucous membrane of the mouth and nose. After several stertorous respirations, with violent convulsive mus- cular movements, the respiration entirely ceases ; the abdominal wall is retracted and as hard as a board; the pulse becomes slow, then imper- ceptible; the face turns dark-red; the jaws are locked; the tongue is drawn convulsively backwards, and closes the glottis by its j^ressure (convulsive asphyxia). 12. In the stage of deepest toleration the entrance of air into the trachea is not infrequently impeded by the tongue, which falls back- wards against the posterior wall of the pharjTix , on account of the relaxation of the muscles , and mechanically obstructs the glottis. In old people, moreover, the closed relaxed lips may act as valves in in- spiration, falling against the toothless jaws, and the relaxed nostrils- may be drawn against the septum and thus prevent the entrance of air. In either case the respiration becomes difficult and snoring, the face turns blue, the blood very dark, and the pulse irregular and weak (paralytic asphyxia). This accident is the more dangerous as the symptoms do not, begin with such violence, but the blood, already very venous, becomes in a short time quite overloaded with carbonic acid. 13. The most dangerous accident is sudden paralysis of the- heart (syncopej, and this may occur in any stage of chloroform anaes- thesia, and quickly cause death. In this case the pulse quickly becomes imperceptible, and while the respiration may continue for some time, although superficially and irregularly , the face becomes as white as death, the pupils dilated and immovable, and the jaw falls. The hemor- rhage from the operation wound ceases. Collapse of this kind may occur at the very beginning of the anaesthesia under the influence of fear, in weakly individuals with a tendency to fainting , but it takes place by preference in acute anaemia (after severe injuries with great loss of blood) and in chronic anaemia , and especially in muscular degeneration of the heart (fatty heart, atheroma of the arteries, alco- holic dyscrasia) which disposes to early exhaustion of its powers. In such persons , therefore , particular care is necessary, and the heart should always be examined before chloroform is administered. Unfortunately in many cases, fatty degeneration of the heart cannot be recognized with certainty. — 147 14. As soon as symptoms of this kind appear during chloroform anaesthesia, the inhaler must be immediately removed and an attempt made to restore the halting respiration and heart action. 15. In asphyxia, open the mouth at once, and press- the lower jaw forwards with both hands by placing the forefingers behind the ascending ramus, so that the lower teeth project in front of the upper (partial dislocation) (Fig. 291). By this movement the hj^oid bone Fig. 291. Raising the jaw in the paralytic asphyxia of chloroform anaesthesia. the root of the tongue, and the epiglottis are drawn forwards,'' and the entrance to the larynx is thus freed from obstruction. If this can not be accomplished because of convulsive contraction of the muscles, separate the teeth with a dilator, seize the end of the tongue with the fingers, or with a tongue forcejos (Fig. 292), and draw it out of the mouth as far as possible. Fig. 292. Drawing out the tongue in convulsive asphyxia. 10^ — 148 — 16. If ill spite of this, the respiration remains difficult and rat- tling, the cause may be the presence of mucus or blood in the chink of the glottis. Remove this by a sponge , carried down to the larynx on a dressing forceps. 17. If respiration ceases entirely, artifloial respiration must be instituted at once — and preferably by Sylvester's Method. "While the tongue remains drawn forward , or is secured to the chin by a rubber ring, stand behind the patient's head as he lies on his back, seize both arms below the elbows and draw them above his head. Hold them stretched upwards in this way for two seconds, then bring them down again and press the elbows gently but firmly against the sides of the chest, the left nearer the middle line, opjDOsite the region of the heart. Repeat this up-and-down movement of the arms about fifteen times in the minute, quietly and correctly, until spontaneous respiratory movements begin again (Figs. 293, and 294). 18. By stimulating the skin in certain ways, reflex respiratory movements can be started or assisted. The most efficient means for applying this stimulation are : — striking the chest and abdomen with a wet towel , sprinkling the epigastrium with cold water, rubbing ice or snow on the nape of the neck, injecting cold water into the nose, introducing a ]3iece of ice into the rectum , and irritating the nasal mucous membrane with the electric current. 19. If syncope occurs, artificial respiration is to be instituted immediately. It is then important to place the head, low and to elevate the body, and this is most easily accomplished by raising the end of the table upon which the feet of the patient rest (Figs. 293, and 294). (Nelaton's method by inversion.) In this way the flow of the stagnant blood away from the right side of the heart and towards the brain is accelerated. For the same reason, the left elbow is to be firmly pressed against the heart every time the chest is compressed. If the movements of respiration and of the heart do not at once reappear, the effort to restore them should not be discontinued too soon. Cases are known in which, even after three or four hours of continued artificial respiration, the suspended animation was successfully recalled. ^ 20. In such cases an attempt may also be made to set the inspi- ratory muscles in motion again by stimulation with electricity, ^^ by firmly pressing both electrodes of an induction apparatus in the depression above the clavicle, behind the external edge of both sterno- mastoid muscles, so that the two phrenic nerves and the other nerves of inspiration contained in the brachial plexus shall be affected by the current. ^) Electro-puncture of the heart, recommended by Steiner, is certainly not to be advised, and it could scarcely effect more than direct compression of the heart in artificial respiration. But in desperate cases it would be well to make a trial of the subcutaneous injection of strychnine (grain '/so to Vio) (Liebreich) Artificial respiration'by Silvester's method. — 150 — 21. Should vomiting take place during anaesthesia, turn the head away from the injured side at once , so that the vomited materials shall not find their way into the air-passages, or the wound. I 22. When great exhaustion and heart — weakness are present, give the patient a glass of strong wine shortly before the anaesthesia is begun. 23. If there is great excitement in the first stage, too much force must not be employed to restrain the patient. It is preferable to inject some morphine subcutaneously. TREATMENT OF SEPTIC WOUNDS. SECOND AEY ANTISEPSIS. Every wound which has not been made by aseptic instruments and with antiseptic precautions, is to be considered septic — suspected of infection, and to be treated accordingly — that is, disinfected. Simple gunshot wounds which j)ass entirely through any part of the body can generally be considered aseptic, because all the agents of infection which may have been adherent to the ball are destroyed or made harmless by the heat acquired by the ball in its flight. Experience also teaches that many such gunshot wounds heal under the scab without inflammation or suiDpuration , when simply oc- cluded antiseptically, if septic material has not been introduced into the track of the wound by examination with fingers or instruments which are not clean. For the same reason, biillets which have remained in the body heal in without exciting inflammation or suppuration, even if they have injured bones, joints, or other important organs in their course. But if the ball has carried with it into the wound, pieces of clothing, or anything else to which the agents of infection are attached, these will in most cases cause inflammation and suppuration sooner or later. Since this can not be ascertained from the outward aj)pearance of the wound, it is advisable to consider every gunshot wound aseptic in the first place unless it is complicated with severe hemorrhage, considerable extravasation of blood, great comminution of the bones, and injiu-y to the joints — and accordingly, to refrain from any exami- nation of the wound, and merely to apply an antiseptic occlusive dressing. Simple antiseptic occlusion consists in carefully cleansing and disinfecting the neighborhood of the wound, then laying upon the wound an antiseptic dressing (bichloride gauze, peat-bag,, iodoform powder, etc.) and securing as good fixation to the injured part as possible (hand- kerchief dressings, splints, plaster of Paris dressings, position apparatus). — 151 Fiff. 295. If a plaster of Paris dressing is applied for an uncomplicated gunshot fracture, an antiseptic wiper must be laid upon the wound, in order that an opening may be cut at the right place. Wounds with such extensive loss of skin that they can not be closed by suture or by plastic operation (injuries from fragments of a bomb , large shot , machinery) should be covered with antiseptic dressing material (bichloride gauze, iodoform gauze, bichloride peat-bags) under which aseptic suppuration and granulation can take place. Every fresh wound which has been evidently infected, and every wound which was at first considered aseptic, but in which symptoms of sepsis (abundant dischai'ge , pain, swelling of the neighborhood of the wound, inflammation, suppuration, wound-fever) have appeared, must be immediately subjected to a thorough disinfection (secondary antisepsis), and this must be energetic in proportion as the septic symptoms are threatening. The same princi23les ajDply here as in primary antiseptic treat- ment of wounds , and since the necessary proceedings are for the most part very painful , it is ad- visable to put the patient on the operating - table and to administer chloroform — so as not to be pre- vented by his complaints and rest- lessness from carrying out the dis- infection with proper energy. As in all operations, begin with a careful cleansing and dis- infection of the entire neighborhood of the wound; cut off the arterial blood-supply, if the wound is situ- ated upon an extremity, with the elastic band , after perpendicular elevation of the limb ; enlarge the wound by freely incising the skin and by tearing open the deeper soft parts with the fingers, the dressing -forceps, or the dilating forceps (Fig. 295); and hold the wound open with retractors (Figs. 296 to 299) so that its interior is completely exposed to the eye. All blood-clots (and granu- lations) are next scraped out with the fingers, with wipers and spong- es , and with the sharp spoon Hoser's dilating forceps. — 152 Fig. 296. Fia-. 297. Fm. 298. von Langenbeek's blunt retractors. Fig. 299. Volkmann's retractor. Improvised retractor. (Fig. 300); all shreds of tissue and layers of cellular tissue infiltrated with blood or pus, and all portions of muscle which have been contused, are Fig-. 300. Sharp spoon. removed by forceps , scissors or knife ; every foreign body (bullets, fragments of clothing, loose splinters of bone, earth, dirt) are removed; the finger is forced into every pocket and sinus of the wound, and incisions are made through the fascia and skin at the end of the latter (button-holes) so that drainage tubes can be inserted into them. Then follows a thorough washing out and irrigation of the cav- ity of the wound with antiseptic solutions, the strength of which must be proportioned to the degree of sepsis already existing. In the lighter cases the weak (3 ^'/q) carbolic or (1 to 5000) bichloride solutions ; in the severer cases stronger solutions — 5 ^j^^ carbolic, 1 to 1000 bichloride, or 8^/^ chloride of zinc solution, are to be employed. Then drainage tubes are to be inserted everywhere, particularly in the tracks of the bullets, so as to secure the escape of discharge — 153 — from every part of the wound — after which the incisions in the skin can be for the most part sutured, but not too closely. Next follows an antiseptic compressive dressing, preferably of crumpled gauze, which is left until it is desired to remove the drainage tubes, and this should be done as soon as possible — in five or six days. In this way primai-y union is often successfully achieved, even under such circumstances as these. But if sepsis is already far advanced, if foul discharge, coating or gangrene of the surfaces of the wounds is already present, or if the contused soft parts are in a state of mortification, primary union must be relinquished, the wound sufficiently enlarged and left open, and covered with antiseptic materials (bichloride - gauze , iodofonn gauze), or stuffed with them (tamponnade). In large, open, sej)tic wounds (contusion and laceration by large shot, or machinery, etc.) antiseptic compresses (gauze compresses wet in solutions of acetate of alumina, bichloride, or carbolic acid) are to be employed, and the compresses must be frequently renewed (every hour), and the wound irrigated with the same solutions every time the dressing is changed. Or antiseptic baths are used — that is, the injured part is allowed to lie day and night, or at least for many hours every day, in a bath of antiseptic solution — in a 2 to 3 ^Iq solution of sulphide of sodium for example. But in the worst cases of acute septic suppurative inflammation (which sometimes appears in the first few days in cases with severe comminution, and with large diffuse extravasation of blood), in which quickly spreading gangrenous infiltration of the cellular tissue can be recognized by the hard, dark-red, painful, and oedematous swelling of the skin, extending rapidly over the entire limb, and accompanied by higlx fever, and by extreme loss of strength, permanent antiseptic irrigation sometimes renders excellent service. The object of this treatment is to c^use fresh quantities of an antiseptic solution to con- stantly penetrate the wound, and by it to wash out the foul discharge. To accomplish this, in addition to the measures already described, numerous small incisions ("^/^ to 1 ^/.-, inches long) must be made through the skin and fascia (multiple scarification), in order to open the wound more thoroughly, especially wherever the skin had been raised from the parts beneath, to obtain free escape for the discharge, and to allow the antiseptic solution to penetrate everywhere into the deeper parts. If the hemorrhage from the inflamed tissues is very severe, as it usually is, it will be best to control it at first by applying a firm bandage of gauze wet with antiseptic solution, which is to be left for some hours. Then rubber drainage tubes are to be inserted into the bottom of the wound through all the openings, and in some of them are to be introduced the nozzles of irrigators wliich hang over the bed and contain harmless antiseptic solutions — for instance, solutions of acetate of — 154 — alumina (1 to 0,5 ^j^^, of permanganate of potash (3*'/(j); or better, of hydrogen peroxide {^^Jq}, of boric acid (4 ^/q), or thymol (f^,l **/o} (Starke), for the two solutions first mentioned form sticky precipitates which obstruct the tubes and make a frequent washing out necessary. The poisonous antiseptics, carbolic acid, bichloride of mercury, etc., can not be used for this jDurpose without danger. A stream of these solutions, the force of which is regulated by stopcocks, is allowed to penetrate into the wound. The solution escaping from the other drainage tubes, runs over a waterproof cloth laid under the limbs (Fig. 58), or a board (Fig. 57), and is received in a jar standing below. Bardeleben's (Fig. 286), or Volkmann's (Fig. 285) suspension wire apparatus answers very well to support the limb for this purpose. Starke's apparatus for permanent irrigation, which is represented in Fig. 301, is very useful. It consists of a metal tube Fig. 301. Fiff. 302. Volkmann's drop- ping nozzle. Starke's apparatusjfor permanent irrigation. 20 inches long, and 2 inches in diameter, which has spouts for five rubber tubes; the latter are provided with glass nozzles which are in- serted into the drainage tubes. The force of the stream can be regu- lated by stopcocks attached to each tube , and the tubes can be given any curve by means of wires which are placed in them. ^^ Centralblatt fur Chirurgie, 1881, No. 18. — 155 — It is necessary to watch the working of the irrigating apparatus constantly. The antisei^tic solution should not run through in a con- tinual stream, but only in quick drops. To secure this, it is sometimes useful to put the glass dropping nozzle of Yolkmann (Fig. 302) in the end of the irrigator tube. When success in subduing the sepsis has been attained in some way or other, when laudable, not foul - smelling pus is discharged, and healthy granulations have formed , the stronger antiseptics can be given up, the wouads covered with mild antiseptic salves (ointments of boric acid, aluminium, or zinc} and the exuberant development of gra- nulations held in check by touching them with the nitrate of silver stick, or by sprinkling them with astringent powders (sulphate of zinc, sugar, etc.). To hasten the cicatrization of large granulating surfaces , the transplantation of skin by the method of Reverdin is employed with the best effects — small pieces being cut with scissors curved on the flat from the healthy skin of another part of the patient. The skin of limbs which have just been amputated can be used for this purpose. The pieces of skin should consist only of the epidermis and corium, and show no cellular or adipose tissue on the under surface. The granulating surfaces must have been made aseptic previously, by anti- septic compresses and irrigation. The pieces of skin, also asej^tic, are laid on the granulations at suitable intervals, with their natural under surfaces downwards, gently pressed upon, and covered with pieces of gauze, or oil silk, and must lie undisturbed under an antiseptic dressing for at least five days. If they adhere and live , the formation of epidermis sj)reads rajiidly from their edges in all directions. TREATMENT OF COMPLICATED INJURIES OF THE BONES AND JOINTS. In fresh penetration fractures and ordinary gunshot fractures, even of the articular ends, if there is no consideral)le extravasation of blood, and no emphysema in the neighborhood of the wound, simple antiseptic occlusion (page 150) may be attempted, but the broken bones must be carefully immobilized by splints or stiff dressings, especially when the jiatient has to be moved any distance. In severe compound fractures with considerable contusion and laceration of the soft parts, in gunshot fractures with great comminution, I)articularly of the articular ends, and also in ordinary gunshot fractures, — 156 — as soon as great pain, considerable infiltration of the neighboring parts, abundant discharge, high fever, and sepsis make their appearance, a thorough disinfection must be undertaken at once, as has been described above fpage 151). In carrying out this disinfection, the fractured ends of the bone must be projected through the enlarged wound by bending the limb, and carefully washed and disinfected. If the wound in communication with the fracture is not favorably situated for this manoeuvre, it is better to expose the fractured ends by a large incision at some other spot, where they lie more superficially, and merely to place a drainage tube in the track of the bullet. Any very sharp corners and points on the fractured ends are smoothed oif with the bone-cutting forceps. Only those splinters of bone are to be removed which are entirely detached, or remain in connection with the soft parts only hf narrow strips of periosteum. The larger fragments of bone which remain connected to the muscles and j)eriosteuni are not to be removed , but an attempt must be made to restore them to their proper positions. If muscles have been caught between the fragments , or if the latter have imbedded themselves in the muscles, they must be disengaged and restored to their jiroper places. To prevent the discharge of the wound from collecting about the fragments, the drainage tubes must be introduced as far as the ^^oint of fracture — • but not between the broken ends. Finally the entire wound is to be irrigated again with bichloride solution, until it returns clear from all the drainage tubes and apertiu'es ; then all the superfluous solution is to be squeezed out by pressure from every direction, and lastly a firm compressive dressing is to be aj)iDlied. If the ojJf ration has been performed by the bloodless method, and if all the vessels injured during the operation have been securely ligatured, the elastic band need not be removed until just before the completion of the dressing. If fissures (cracks) extend from the point of fracture into a neigh- boring joint, and this can usually be recognized by the joint being filled with blood (hemarthi'osis) ; or if the articular ends are them- selves comminuted, the joint must be freely opened, so that the entire synovial sac can be exposed with the aid of sharp hooks, and all its pockets can be examined. Then every blood-clot is washed out, every foreign body removed, and loose or crushed fragments of bone are also taken away. Lai^ge frag- ments of bone which are still in good connection with the soft parts, •are restored to their position after thorough disinfection, and perhaps fastened there with nails, and the cavity of" the articulation is carefully drained. — 157 — Those parts of the articular ends which are covered with cartilage may be left in place without disadvantage (^partial resection). If suppuration has already begun, all granulations are scraped away with the sharp spoon, after careful removal of the pus by ir- rigation. The contused parts of the capsule of the joint, and the parts which are infiltrated with pus, are extirpated with the scissors and knife: every suppurating pocket is opened, and, together with the cavity of the joint, furnished with free drainage by absorbable drainage tubes ; and a large antiseptic dressing , which also secures fixation, is applied. This dressing may remain for many weeks, if high fever or some other symptom of sepsis, or the penetration of the dressing by the discharge, do not make it necessary to renew it sooner. If rubber drainage tubes are inserted, they must be removed soon (in five or six days) otherwise they will delay the healing process. If the comminution of the articular ends is considerable, and the decomposition of the soft parts is very threatening, complete resection, and perhaps amputation of the limb, must be taken into consideration. INDICATIONS FOR AMPUTATION. The removal of a limb is generally only indicated when, by tliis means, the prospect of preserving the life of the patient is rendered really better than by conservative treatment. The decision of the question, whether primary amputation should be undertaken, depends more upon the state of the soft parts than upon that of the bones. Even extensive comminution of the bones no longer indicates that amputation is necessary if the soft parts are in good condition. But in some cases only an early removal of the limb above the boundaries of the dangerous process can save life — as, for instance, if a limb has been torn off by a heavy shot, or the soft parts have been lacerated and contused for a wide extent; if a smaller ball has comminuted the bone, and at the same time torn through large vessels and nerve trunks ; if gangrene has already appeared and threatens to spi'ead from the point of injury; or if acute septic infiltration of the cellular tissue begins to extend uncontrollably towards the heart. But if this indication for amputation is undoubtedly present, the oiDeration should be undertaken primarily, that is, as soon as possiljle, iind before the appearance of any inflammatory reaction. — 158 — FIXATION DRESSINGS IN COMPOUND FRACTURES AND INJURIES OF JOINTS. It is of course understood that the limb is well immobilized, and held in the position desired by extension and contra-extension exercised by reKable assistants during the application of the dressing. As antisepsis is of more importance than fixation in all severe injuries , at first , that part of the dressing which serves to hold the fragments of bone and the joints in position must be such as to permit the wound and its neighborhood to be enclosed in a large securely occluding antiseptic dressing, in the beginning of treatment, and to allow the latter to be easily removed and re-applied at any time. For this reason the simple slightly concave splints should be used at first — for instance , Volkmann's leg splint (Fig. 144) , my wire splints (Figs. 283, and 284), the j)lastic splints (of pasteboard, felt, gutta-percha, Beely's plaster of Paris splints), or the position apparatus (Figs. 214 to 226). The splints must be padded with cotton, or long, narrow cushions stuff'ed with antiseptic material (peat, moss, jute, wood fibre, etc.) which can be easily shifted by shaking, and covered with some water -proof stuff. The limb, antiseptically dressed, is firmly secured upon the splint with wet crinoline bandages. The interrupted and stirrup plaster of Paris dressings (Figs. 177, seqq.) may also be employed in these cases if there is time to apply them. It is also advantageous, especially in resections of joints, to include aseptic materials (glass spHnts, wood splinting, flower-pot trellis-work) between the layers of the antiseptic dressing, to stiffen it. For compound fractures of the thigh and injuries of the hip-joint» extension by weights, in combination with removable splints (Figs. 243,. seqq. page 119) forms the most suitable treatment — that is, in hospitaL For transport, the weights must be rej)laced by an elastic extension. (Figs. 249 to 253). The plaster of Paris dressing is suitable only in the first stages of penetration fractures and ordinary gunshot fractures , in which it is desired to attempt antiseptic occlusion ; but then an ojDening must be made in the splint at the proper time , so that the good condition of the wounds can be proved by examination. The fenestrated and interrupted plaster of Pai'is dressings render excellent service in the later stages of the treatment of compound frac- tures, if the wounds have remained aseptic and are healing well, but the fractured ends have not yet firmly united — for union often takes place very late under antiseptic dressings. — 159 — THE REMOVAL OF FOREIGN BODIES PROM WOUNDS. If the bullet has not passed entirely through the part of the body injured, but has remained in it, the wounded soldier is generally very anxious to have it removed, considers himself safe if this has been successfully accomplished, and rewards his physician with the greatest gratitude and thankfulness for its removal. The removal of a ball which can be felt under the skin is by no means a difficult operation. A bold incision is made with a sharp knife upon the ball, fixed by the left hand, until it becomes visible in the wound, when it is extracted with the dressing forceps or bullet forceps. If the ball has been very much altered in shape , and has ac- quired projecting points and teeth, the cellular tissue and the fascia must often be divided in several directions in order to extract it without force. Simple as this operation really is, and much as the young surgeon rejoices in its successful performance, and in the gratitude of the injured man, it is nevertheless unjustifiable to undertake it, according to our present oj)inions, unless it is possible to observe every antiseptic pre- caution , and this is as a rule impossible on the field of battle , and at the regimental dressing - station. In former wars, this little operation, and also the examination of the wound, if undertaken immediately after its infliction, and with dirty instruments, have doubtless often been the cause of septic infection. In future the first principle of medical treatment must also be observed on the field of battle — at least do no harm! — and the sur- geon must refrain from this little operation, as well as from the examination of wounds with dirty fingers and instruments. The extraction of deep-seated projectiles also presents no particular difficulty in modern times, for there is now no danger in freely dividing the soft parts if it is necessary. In fresh cases, bullets found in the wounds are removed at once, when the wound is prepared for antisepsis, and no other instrument is required for this purpose than the ordinary dressing forceps. But if it is necessary to remove balls which are at the bottom of a healthy granulating wound, and cause delay in its final cicatrization, or maintain obstinate sinuses, or cause trouble by pressure upon nerve trunks or other impoi-tant organs, the extraction may be very difficult, especially if the ball has been much altered in shape, lies in a dangerous' position, or is firmly iml)edded in some bone. Sometimes the first question to be determined is, whether there is a foreign body in the bottom of the wound , and what the foreign body is. If the finger can not reach the bottom of the wound, an at- tempt must be made to feel the foreign body with the probe. The 160 — ordinary small silver probe, with wMcli nothing can be accurately felt, and the fine point of which is apt to lead into false passages, should not be used for this purpose. Instead, a flexible tin probe, a foot long and in thickness from the size of a goosequill to that of the little finger (Fig. 303), should be employed, for, by delicate handling, no harm can be done with this instrument ^^ Fiff. 303. Large probe. These probes are also very useful for making counter -openings at the end of long suppurating fistulae, the end of which can not be reached by the finger or forceps. If it is desired to thoroughly dis- infect these sinuses, a wiper wet with strong carbolic or chloride of zinc solution is fastened to the middle of a strong thread, introduced into the sinus by the probe, and drawn back and forth until all the granu- lations have been rubbed away (Fig. 304). If the bullet is felt, an attempt must be made to seize it with a bullet forceps (Figs. 305 and 306), and to carefully extract it. If it is imbedded in a bone, it can be removed with the aid of a bullet screw (Fig. 307). But if it is very securely wedged in the bone, too much force must not be used, because dangerous inflammation of the bone is liable to be set up in that way. It is better to wait quietly until the projectile becomes loose of itself, by inflammatory absorption of the bone; or, after sufficient division of the soft parts, to cut away enough of the surrounding bone with the chisel and mallet to allow of extraction of the ball by the forceps, without violence. If there is doubt whether a hard body felt at the bottom of the wound is the bullet, the doubt may be removed either by the toullet probe of Nelaton (Fig. 308) the i:)orcelain knob of which will *) It is very dangerous to use the catheter which the dressing-case con- tains for these examinations, as I have frequently seen done in war. In the interior of this instrument there are generally infectious materials which have been left there from its previous use — in relieving retention of urine. 161 - Fiff. 304. Fig. 305. Fig. 306. v r • American bullet-forceps. von Langenbeek's bullet-forceps. Probe with wiper attached. Fio-. 308. Fiff. 309. ? V Porcelain bul- let probe of Nelaton. Bullet searcher of Lecomte-Liier. Fig. 307. "Bullet -screw of Baudens. U 162 — ^ — 163 — be marked with black if it is touched by lead ^) ; or by the bullet searcher of Lecomte-Liier (Fig. 309), with which a piece of lead can be gnawed from the ball; or, lastly, by the electric bullet probe of Liebreich (Fig. 310) which sets in motion the needle of a galvanometer whenever the two isolated ends of the probe (a), or the forceps (c) come in contact with a metallic body. If the bullet can not be felt through the wound, but can be felt under the skin elsewhere, and if there is doubt whether what is felt is the ball, or a piece of bone, the diagnosis may be made by inserting two steel needles on handles (acupuncture needles. Fig. 310, b) which are connected with Liebreich's bullet searcher. If the apparatus of Liebreich is not at hand, a similar one can be improvised (according to Longmore) out of a copper coin and a folded piece of sheet zinc, the two being separated by a piece of flannel wet with dilute acid. Two insulated copper wires are ^ connected with acupuncture needles, and one of the wires is wound several times around a pocket compass, the needle of which will move whenever the circuit is closed by touching the ball (Fig. 311). Fiff. 311. Longmore's bullet searcher. If bullets are to be removed which have remained imbedded in the bone for years, or pieces of dead bone which lie in cavities in the bone (very frequent after osteo - myelitis in consequence of gunshot- contusion of the bone) the bone cavity must be opened (operation for necrosis). >) In case of need the stem of a clay pipe can also be used for this purpose (von Nussbaum). — 164 — These operations can be most rapidly and conveniently performed with mallet and chisel , and the ordinary carpenter's chisels with han- dles are, in fact, much more useful than those supplied in surgical in- strument cases (^see Trephining), At any rate, in the absence of the latter, the necessary instru- ments can be procured from any carpenter or turner. The affected bone is exposed at a suitable place by a free in- cision in the skin, the thickened periosteum is pushed back on both sides with the raspatory (Fig. 312) and the cavity is opened by strong blows with the chisel until the dead bone is exposed, and can be drawn out with the sequestrum forceps (Fig. 313). If it is only a projectile which has to be removed from a cavity in the bone , the fistula which leads through the wall of bone to the foreign body can be most rapidly enlarged with a reamer (Marshall's osteotribe) (Fig. 314). Fiff. 312. Fiff. 314. Fiff. 313. Von Langen- beck's raspatory. Sequestrum forceps. Marshall's reamer. In operations for necrosis, it is not sufficient merely to enlarge the fir^tula (cloaca) so as to barely extract the fragment of dead bone (sequestrum). There is then no certainty that smaller or larger seques- tra do not remain in the corners and extensions of the bone cavity, which may subsequently make a repetition of the ojieration necessary. 165 — It is much better to chisel away the entire wall of the thick- ened bone forming the cavity, after exposing it, and to change the cavity into a large open shallow groove , so that no cavities in the neighborhood can escape discovery. When the operation has been completed , the depression iu the bone is stuffed with antiseptic gauze, or a firmly filled peat bag, a tight antiseptic dressing applied over it, and not until then is the elastic tube or constricting band, which has up to this time cut off the arterial blood supply, removed. The most extensive operations of this kind, formerly accompanied with great loss of blood, can thus be completed without the least hemorrhage, and if a rubber bandage is finally applied Qver the dressing , and the extremity is secured for some hours in a position of perpendicular elevation , very little blood (or none at all} Avill subsequently ooze from the injured vessels ; and when the dressing- is renewed after a period of some weeks , the cavity in the bone is usually already lined with healthy granulations. In any case, however, it requires considerable time for the large and deep cavities of the wound to fill up with granulations, and for cicatrization to be complete. To hasten the healing process , the skin on both sides of the wound can be raised from the fascia for a distance of some centi- meters, the flaps of both sides pushed into the cavity, and pressed firmly against the surface of the bone by a tightly applied dressing; or by a few short steel nails, which are driven through the skin into the bone ; or by strong catgut sutures introduced through the folds of the skin flaps where they lie in contact (folding-iu suture, Neuber) (Fig. 315). Fiff. 315. Fig. 316. Folding-in suture. Bone cavity filled by new tissiie. The space between the flaps of skin which have been turned ' in is stuffed with crumpled gauze, peat-gauze, moss or sawdust, and the compressive dressing applied. In this manner the entire extent of a large wound can some- times be made to heal by first intention. The cavity in the bone under the flaps of skin, which are at first deeply depressed, gradually fills up with newly Inniicd hone, — 166 — raising the skin to its original level, so that the final result is the same as in the slow healing by granulation (Fig. 316}. If, in the antiseptic examination of a wound, it is discovered that tendons or nerves have been completely divided (as happens especially in large stab - wounds , or incised wounds} these must be at once united by suture. SUTURE OF TENDONS. If the ends of the divided tendons have retracted into their sheaths , they must first be drawn out with forceps , so that they can be made to over-lap for some distance. In doing this, the points of attachment of the muscles must be approximated as nearly as pos- sible. The ends are united by sutures in this position (best with needles curved on the edge [Wolberg, Hagedorn] and chromic acid catgut} so that their lateral surfaces, which are richer in blood-supply than the cut surfaces , are in contact. After the wound in the skin has been sutured, a dressing must be applied which will relax the muscles of the injured tendons as much as possible (see , for example, Fig. 280}. SUTURE OF NERVES. After the ends of the divided nerves have been aj^proximated as much as possible by suitable position of the limb , the loose connective tissue around them is to be seized with forcej)s, and sutured on all four sides with fine catgut, so that the cut surfaces of the nerves are brought into exact contact (paraneural nerve suture}. If the injury to the nerve is an old one, the stumjJs, Avhich are often widelj^ separated, must be sought in the cicatrized wound and dissected free. A thin layer is then dissected from the end of the stumps , and the cut surfaces united by several fine catgut sutures, which are introduced with fine needles , curved on the edge , through the ends of the nerves themselves (direct nerve suture}. In this case , also , all tension upon the united ends must be relieved by the dressing. TREATMENT OF INJURIES OF BLOOD-VESSELS. (CONTEOL OF HEMOEEHAGE.) Severe hemorrhage from fresh wounds directly threatens life, and must be stojsped at once , preferably by ligature of the injured vessels. But if ligatures cannot be applied immediately as, for examj)le, in the press of battle, there are various means for controlling bleed- ing temporarily (provisional arrest of hemorrhage) and first of these is : — 167 — DIRECT COMPRESSION OF THE WOUND By the pressure of the finger ox^ of the hand. lu many cases this can be exercised by the wounded man himself. But pressure with the finger can not very well be continued for any length of time, therefore during transport of the wounded into hospital it should be replaced by : A dressing which exerts sufficient pressure upon the wound. But before a compressive dressing of this kind is applied, if the injury has happened to an extremity, the entire limb must be carefuUy bandaged from below upwards, preferably with cambric bandages, in order -to prevent dangerous extravasation of blood into the cellular tissue (infiltration of blood). A firm pad of antiseptic material (car- bolized , iodoform , or bichloride gauze) is laid upon the wound , and is firmly pressed upon it by a tightly applied bandage, best of some elastic material (rubljer bandage, elastic trouser-suspenders). Fiff. 317. If there is an injury of an artery of some size, it is safer to tampon the wound itself — that is , to press with the finger the middle of a piece of bichloride or iodoform gauze as deep into the wound as possible, and to quickly and firmly stuff into the cavity (after the finger has been withdrawn) first small, then larger antiseptic balls , until the last extend far above the level of the wound in the skin (Eig. 317). The tampon is then firmly secured by a bandage — elastic , if possible. As soon as the wounded man has reached the hospital, the tampon should be removed, and the hemorrhage, in case it recommences, immediately and permanently arrested. STYPTICS. Styptics, that is. substances which act partly by favoring the coagulation of the blood and the contraction of the walls of the vessels, partly by forming a firmly adherent scab, should be employed only in cases of imperative necessitj'-, when the hemorrhage can not be con- trolled by the tampon alone. For fresh wounds are generally greatly irritated, or even strongly cauterized by these drugs. In any case, they are useful only in combination with direct compression. Only such — 168 — styptics are to be used as have at the same time an antiseptic actiouy to these belong — liquor ferri chloridi, especially in the form of styptic cotton - — cotton saturated with it, tannin (Graf), creasote as Aqua Binelli (1 to 100 water) oil of turpentine (Baum, Billroth),. and chloride of zinc in concentrated solution. These substances are to be brought into as close contact as possible with the bleeding point, by first pressing a tampon saturated with the styptic into the bottom of the wound, and then proceeding as in making an ordinary tampon. THE ACTUAL CAUTERY. The actual cautery, which in earlier times enjoyed so great a reputation as a method of controlling hemorrhage, by no means deserves this reputation, for the slough caused by it is apt to be torn away again by the iron, if the latter is not white-hot. It is best suited for arresting parenchymatous hemorrhage, such as occurs with hospital gan- grene, or after venous thrombosis — Stromeyer's phlebostatic hemorrhage. If no cautery irons are at hand, they can be easily extemporized (accor- ding to Brandis) out of a piece of telegrajDh wire, by twisting up one end into a spiral, and sharpening the other so that it may be stuck into a wooden handle (Figs. 318 and 319). Fis. 318. Fig. 319. Cautery irons improvised from telegraph wire, according to Brandis. COMPRESSION or THE MAIN ARTERY. Compression of the main artery above the wound by the finger (digital compression) can only be exercised at points where a hard support is furnished by the bone underneath. The most important j)laces for digital compression are the following : • — Eor the common carotid, the anterior lateral region of the neck, between the larjmx and the internal edge of the sterno-mastoid, where the finger compresses the artery against the vertebral column (Fig. 320). For the subclavian, the supraclavicular fossa, in which, at the external edge of the sterno-mastoid, the artery can be pressed against the first rib, as it emerges from behind the scalenus. By pressing the shoulder and the clavicle forwards, the finger can reach the artery more readily (Fig. 321). Digital compression of the carotid. Fiff. 321. Compression of the subclavian. By strongly drawing the shoulder backwards and down- wards with the aid of the other arm, it is also possible to depress the clavicle to such an extent that the subclavian artery will be flat- 170 tened by it against the first rib. The hand is to be passed behind the back and made to grasp the elbow of the uninjured arm, the latter is then pressed forwards, and both arms secured in this position by handkerchiefs or bandages (Fig. 322). Fio-. 322. "Fii/. 323. Digital compression of the brachial. For the axillary artery, the anterior edge of the axillary fossa, where the artery can be compressed against the head of the humerus when the arm is elevated. For the brachial, the internal side of the arm in its entire length, where the artery can be easily compressed at any point against the humerus, along the internal edge of the biceps (Fig. 323). The abdominal aorta can be compressed against the vertebral column at the level of the umbilicus, when the abdominal walls are relaxed and the intestines empty. But generally the pressure can not be long endured without an anaesthetic. The same is true of the upper part of the external iliac — which can be compressed against the lateral edge of the brim of the pelvis. It can be occluded more easily and for a longer time just before its exit from the pelvis, above the middle of Poupart's ligament, against the upper edge of the horizontal ramus of the pubic bone. The femoral artery can be compressed with the greatest cer- tainty directly below Poupart's ligament, against the ileo - pectineal eminence (Fig. 324). It will be found at the middle of a line drawn from the anterior superior spine of the ilium to the symphysis pubis. — 171 — Fiff. 324. Fiff. 325. Digital compression of the femoral artery. Petit's tournicLtiet. In its course below, it can be compressed against the femur as far down as the lower third of the thigh, but digital compression is dif- ficult and uncertain on account of the thickness of the interposed soft parts — at least in fat or muscular individuals. As only a skilful and strong hand can continue digital compres- sion for a long time, and as it is impossible during transportation for any distance, attempts have been made to replace it by various means. Among these are : — The tourniquets, the most useful of which is the screw tour- niquet of Petit (Fig. 325), in which the pressure is exercised upon the artery by a pad, or rolled up bandage, and the amount of pressure can be regulated by a screw, and made as strong as desired (Figs. 32G and 327). In the absence of such an instrument, a stick tourniquet can be extemporized by tying a pocket handkerchief or a three-cornered cloth, in Avhich a hard knot has been tied or a stone wrapped uj), around the limb , and winding this up tightly by twisting it around with a cane, or any short straight object (dagger, ramrod, revolver), passed under the cloth (Fig. 328). For compression of the brachial artei'y, a proportionally lighter pressure will suffice — such as may be exerted by a stick against the internal surface of the arm (Fig. 329), pressing the bellies of the — 172 Fiff. 326. Fiff. 327. Compression of the brachial artery by a tourniquet. Compression of the femoraFartery by a tournicLuet. Fiff. 328. Fiff. 329. Comipression of the brachial artei'y by a piece of wood. Improvised tourniquet. — 173 muscles apai-t in front and behind, and flattening the artei'y against the bone. The club tourniquet of Volckers, which fulfils this object, ■can be easily improvised from two sticks and two handkerchiefs (Fig. 330). Fis. 330. Volckers' club tourniquet When the patient is in bed, and compression of the femoral artery is to be maintained for a long time (aneurism), pole pressure can be employed. A pole (lath , bi-oomstick , lance , or some similar object), the lower end of which has been wrapped with linen, is wedged in between the leg (in a position of outward rotation) and the ceiling of the room, so as to exert sufficient pressure upon the artery. The pole must be a little longer that tlie perpendicular distance between the ceiling and tlie point of compression (Fig. 331). If the ceiling is too high, a crossbeam is placed over the bed and a crutch wedged against this (Fig. 332). Finally, forced flexion of the limbs (Adelmann) is recommended as a means of controlling arterial hemorrhage — the artery being so Pole-pressure on the femoral artery, by means of a broom wedged against the ceiling of the room.. Ym. 332. Pole-pressure by means of a crutch wedged against a cross-piece over the bed. sharply bent that it will not allow the passage of the blood. If foi- example, in a case of arterial hemorrhage from the forearm, or the hand, the forearm (in supination) is strongly flexed, and tied tightly against the arm with a bandage or cravat, the pulse in the radial — 175 — ceases at once. In the same way, liemorrhage from the leg and foot can be instantaneously stopped by forced flexion of the knee; and that from the femoral by forced flexion of the thigh. In cases where other means of controlling hemorrhage are not available, this method can be successfully employed. But it is necessary to observe that the extreme position of flexion required for the reliable control of hemoi'rhage can not generally be endured for any length of time, and if at the same time the bones are fractured, it is impossible to make use of the method. The surest, and at the same time the simplest method of cutting oflf the circulation is to surround the limb with an elastic band (rubber tube or bandage). If the limb is several times surrounded in one place with such a band, tightly stretched, and its ends are secured so that they can not slip , all the soft parts and the vessels contained in them will be so firmly compressed, that not another drop of blood can pass through. It is self-evident that an elastic band continues in action permanently, while the band of a tourniquet soon stretches, and lengthens, and loses in power. The elastic band, too, can be applied with effect at any desired point ; its use therefore requires no accurate knowledge of anatomy. With the aid of elastic bandaging, moreover, the blood can be completely removed from an entire limb , and if the arterial supply is then cut off, extensive and prolonged operations can be performed without the loss of any blood whatever. THE BLOODLESS METHOD. The bloodless method^} is applied as follows: 1. After any wounds which may be present have been well cov- ered with cotton and water-proof material (varnished paper), the entire limb is firmly bandaged with elastic bandages from the ends of the fingers or toes upwards to a point above the site of operation , so that the blood is almost completely driven from the vessels. 2. AMiere the bandage ends , a rubber tube (constricting tube) is wound several times around the limb, with moderate tension, so that the arteries shall not permit the passage of any more blood. The ends of the tube are fastened together by a knot, or by a hook and chain (Figs. 333 and 334). ') This method, which I have named „the artificial Woodloss iiiotlioJ" (bloodless operation, blood- sparing method, temporary ischaeniia) lias been eniph)yed in all amputations, and taught by me since 1855. But it was not until 187.3, aiter I had begun to make use of the elasticity of rubber for cutting otV the arterial supply, as well as for emptying the vessels, that I con- ceived the idea that it could be employed with advantage in all operations upon the extremities involving "loss of blood. (Sec Volknuinn"s Sanimlung kli- nischer Vortrage, No. 58, Leipzig, 1873.) Esmarch's apparatus for the bloodless method. Fiff. 334. Esmarch's apparatus for the bloodless method. Fio. 335. ^%^Ji$^X\\X\ N-^ Rubber constricting band. 3. In most cases the arteries can be completely occluded l>y a rubber bandage (constricting bandage) firmly _ applied in several circular turns and then secured by a safety pin (Fig. 335). — 177 — 4. If the first rubber bandage is theu removed, the limb will present a pale, completely cadaveric hue, and any operation can be performed n^Don it without loss of blood, exactly as upon the cadaver, even if the operation be very tedious. Experience has taught that an •extremity, and even two extremities at once, can be kept deprived of blood for several hours without injury. 5. But parts wdiich contain pus, or decomposing matter, should not be firmly bandaged in this way, because infectious matters might thus be driven upwards into the cellular tissue, and the lymph channels. In these cases it must suffice to elevate the limb perpendicularly for some minutes , so as to diminish the amount of blood in the vessels before the constricting tube is applied. 6. Instead of the chain -fastening, a clam.p can be employed to secure the ends of the tube , as for example , a split ring of the same diameter as the tube in use, the slit being large enough to allow the stretched ends of the tube to enter easily. When the tension is re- laxed, both ends of the tube are firmly wedged in opposite directions (Figs. 336 to 339). Fig-. 337 Ficr. 336. Esmarch's brass clamp for the constrict- ing tube. Esmarch's clamp in iise. Fietween them, so that both ends can retract into the cellular sheatii. ,„. 13* %>^ Tying ttio ligature. DIRECTIONS FOR THE LIGATURE OF THE INDIVIDUAL ARTERIES. LIGATUEE OF THE LEFT COMMON CAEOTID AT THE LEVEL OF THE CEICOTHYEOn) LIGAMENT (Fig. .370). 1. Bend the head backwards, ty putting a cushion under the shoulders. 2. Incision 2^;, inches lone along the internal border of the sterno-mastoid, beginning at the level of the upper edge of the thyroid cartilage (Fig. 361, 1). 3. Divide the platysma and the cellular tissue (avoiding the superficial veins). 4. Draw the sterno-mastoid (st) outwards, the omohyoid (o) downwards. /, Fig. 370.' — 197 — 5. Draw the descending hrauch of the hypoglossal nerve (li), which courses downwards upon th-; artery, outwards. 6. Open the common cellular sheath, over the middle of the artery. The artery (c) lies internally, the internal jugular vein (j) externally and somewhat superficially, the pneumo gastric nerve (v) hetween the two and deeper. 7. The aneurism needle is to be passed around the artery from the outer side. LIGATUEE OF THE LEFT COM^IOX CAROTID BETWEEN THE TWO HEADS OF THE STERXO-MASTOID (Fig. 371). 1. Incision 2^^ inches long, between the two heads of the .sterno-mastoid, downwards to the clavicle. 1 inch external to the sterno- clavicular articulation (Fig. 361, 2). 2. Divide the platysma; open the space between the sternal and clavicular portions of the sterno-mastoid with the fingers, until ihe internal jugular vein (j) comes in sight. 3. Have the vein and the claviciilar head (cl) held carefully to the outer side by the finger of an assistant, and the sternal head (st), with the sterno-hyoid and sterno-thyroid muscles, drawn inwards. Fiff. 371. 4. Internal to the vein, appear.s the pneumogastric nerve (v): the artery (c) lies somewhat to the inner side and deeper. LIGATURE OF THE LINGUAL ARTERY (Fig. 372). 1. Incision, 2 inches in length, along the superior edge of the great cornu of tJje hyoid bone (Fig. 3(31, 3). — 198 — 2. Divide the platysma; draw the facial vein outwards. 3. Isolate the posterior belly of the digastric (d), and the hypoglossal nerve (hp) will appear behind and below it : draw the submaxillary gland (gl) upwards, the great cornu of the hyoid bone downwards and forwards with sharp hooks. Fio-. 372. 4. The hypoglossal nerve jDasses across in front of the hyo- glossus muscle (hg), accompanied b}' the lingual vein: below the nerve the lingual artery (a) passes behind the hyoglossus muscle. 5. Divide the fibres of the hyoglossus carefully, between the hypoglossal nerve and the great cornu of the hyoid bone (oh). The lingual artery lies immediately behind, accompanied by a vein. The artery can also be ligated in the submaxillary (digastric) triangle, between the posterior belly of the digastric muscle, and the lateral edge of the mylo- hyoid muscle (mh) after division of the hyo- glossus muscle (Hueter). LIGATURE OF THE LEFT SUBCLAYIAX IX THE SITPRACLA- YICULAR FOSSA (Fig. 373). [The artery appears from behind the scalenus anticiis (sc). and courses over the first rib (I.) downwards and outwards behind tlie clavicle.] 1. Place a cushion under the back; draw the arm downwards and the head to the opposite side. 2. Incision 2^/.^ to 3 inches long, curved,, from the outer margin of the sterno- mastoid to the outer third of the clavicle, crossing the supraclavicular fossa obliquely (Fig. 361, 4). 3. Cut through the platysma, and expose the external edge of the sternomastoid (st) ; the external jugular vein (jj must not be injured. 4. Divide the superficial layer of the cervical fascia, and of the fatty cellular tissue in the supraclavicular fossa. 5. Isolate the omohyoid muscle (o), and draw it upwards. — 199 — Fio-. 373 6. Dissect through fat and cellvilar tissvie (with veins) to tlie scalenus (sc), the tendon of which can be felt near the tubercle of the first rib. 7. The internal edge of the brachial plexus (pi) appears, and must be drawn upwards and outwards. 8. Between the scalenus and the brachial plexus, but some- what deeper than the latter, lies the artery; it wall come into sight after division of the deep layer of the cervical fascia. 9. The subclavian vein (vs) lies in front of and below the tendon of the scalenus, and directly behind the clavicle. NB. Avoid injury to the external jugular vein (at the outer edge of the sterno-mastoid), the suprascapular artery (near the clavicle), the transversalis colli (upon the brachial plexus), and the phrenic nerve (p), which courses downwards upon the scalenus. LIGATUEE OF THE LEFT SUBCLAVIAN IN THE INFEACLA VTCULAR FOSSA (Fig. 374). 1. Press the shoulder upwards. 2. Incision 2'/.> to 3 inches long, beginning at the coracoid process, parallel with tlie external half of the clavicle (Fig. 361, 5), exposing the triangular interval between the deltoid and the pectoralis (triangle of Mohrenhehu) through which the cephalic vein i)asses to join the subclavian. 3. Draw the cephalic vein (ce) and tlic edge of the deltoid muscle (d) outwards, the edge of the pectoralis major (pnij ) (which anay if necessary be separated somewhat from the clavicle) inwards. 4. After division of the fatty cellular tissue the coraeo- elavicular fascia appears beneath, and is to be carefully incised^ The external thoracic artery Avill generally require ligature. 5. The pectoralis minor (pmi), then appears, its internal (sup- erior) edge forming an angle, open internally, with the subclavian, muscle. Deep in this angle lies the artery (as), between the brach- ial plexus (pl)j and the subclavian vein (vs), the vein lying on the inner side, the nerves on the outer. NB. The pectoralis minor can be detached from the coracoid process (pc) if necessary, and the artery ligated nearer the axilla. In difficult cases the operation can be still further facilitated by temporary- resection of the clavicle (v. Langenbeck). LIGATURE OF THE EIGHT AXILLAEY ARTERY . (Eig. 375). 1. Incision 2 inches in length, along the internal border of the coraco-brachialis (the arm in a position of extreme elevation)' beginning vt^here that muscle crosses the edge of the pectoralis major at an obtuse angle (Eig. 361, 6). 2. After division of the fascia, a bundle of nerves appears^ surrounding the artery. The axillary vein (v) lies at the posterior margin of the plexus, and somewhat more superficially. 3. Incise the sheath of the bundle of nerves, draw the ant- erior cord (median and middle cutaneous nerves) forwards, the post- erior (uluar and musculo-spiral nerves) backwards, and open the sheath of the artery. In the middle of the axillary fossa the suhscapular (ss) and the posterior circumflex (cf) arteries are given off from the axillary artery posteriorly. LIGATUEE OF THE RIGHT BRACHIAL IN THE MIDDLE OF THE ARM (Fig. 376). 1 . Incision 2 inches in length, along the internal border of the hiceps muscle (Fig. 361, 7). 2. Draw the biceps (b) outwards with Llunt hooks. The median nerve (m) appears, lying directly upon the artery. Fig. 376. Fig. 377. — 202 — 3. Isolate the median nerve and draw it outwards Avith a Ijliint hook and open the sheath of the artery; the latter lies between two veins (brachial veins}, (t, triceps muscle). NB. Sometimes the brachial artery bifurcates into the ulnar and the radial as high up as the upper third of the arm; the radial then generally runs more sujDerficially than the ulnar, and more externallj' (upon the biceps), and the ulnar appears very small. LIGATURE OF THE RiaHT BRACHIAL IX THE FLEXLEE OF THE ELBOAV (AETERTA AXCOXEA) (Fig. 371). 1. Incision a little more than an inch long, \'- inch internal to the inner edge of the tendon of the biceps (Fig. 361, 8). Be care- ful to avoid injury to the median basilic vein (v). DraAv the latter downwards. 2. Divide the bicipital aponeurosis (a). The artery lies directly beneath it, upon the brachialis anticus, between two veins. The median nerve (m) lies a little more internally and passes under the pronator teres muscle. LIGATI'EE OF THE EIGHT EADIAL IX THE TPPER THIED OF THE FOEEAEII. (Fig. 378). 1. Incision beginning 1^^'^ inch below the flexure of the elbow, extending 1^/., inch in length upon a line which divides the radial from the middle third of the anterior surface of the supinated fore- arm (Fig. 361, 9). 2. After division of the fascia, look for the interval between tlie bellies of the supinator longus (s) and the flexor carpi radi- alis (f), and open it with the point of the forefinger. 3. At the bottom lies the artery, accompanied by two veins; at its radial side, the radial nerve (r). Pi^. 379. — 203 — LIGx'lTUEE OF THE RIGHT ULNAR ARTERY IN THE UPPER THIRD OF THE FOREARM (Fig. 379). 1. Incision Leginning l^j^ iuch below the flexure of the elbow, extending for a length of 1^/^ inch, along a line which separates the ulnar from the middle third of the anterior surface of the suplnated forearm (Fig. 36 L 10). 2. After division of the fascia, look for the interval betvp'een the bellies of the flexor carpi ulnaris (c) and the flexor digitorum sublimis (d), and open it with the point of the forefinger and with blunt hooks. 2. The artery lies at the bottom, accompanied by two veins; ou its ulnar side lies the ulnar nerve (n). LIGATURE OP THE RIGHT RADIAL ABOVE THE WRIST (Fig. 380). 1. Incision, 1^/^ inch in length, along the radial side of the flexor carpi radialis (Fig. 361, 11) 2. Divide the superficial layer of the fascia carefully. 3. The artery, accompanied by two veins, lies between the flexor carpi radialis (f) and the supinator longus (s). Fi^. 380. Fiff. 381. LIGATURE OF THE RIGHT ULNAR ARTERY ABOVE THE WRIST (Fig. 381). 1. Incision 1 '/^ inch in length, along the tendinous radial border of the flexor carpi ulnaris, which is attached to the pisiform bone (Fig. 361, 12). 2. Divide the superficial layer of the fascia carefully. 3. The artery, accompanied by two veins, lies between the tendon of the flexor carpi ulnaris (f), and that tendon of the flexor digi- torvim sublimis (d) which lies nearest to the ulna. On the ulnar side of the artery lies the palmar brancli of the ulnar nerve (n). — 204 — LIGATURE OP THE ABDOMINAL AOETA BELOW THE ORIGIN OP THE EENAL ARTERIES (Maas). 1 . Incision along the anterior border of the left quadratus lum- borum muscle, from the last rib to the crest of the ilium (Pi^. 361, 13). 2. After the abdominal muscles and the fascia transversalis have been divided, the wound can be held open with blunt hooks, so that the retro-peritoneal space can be inspected from the lower border of the kidneys downwards, and the aorta can be easily isolated. LIGATURE OP THE LEPT COMMON ILIAC (Pig. 382). 1. Incision 4 to 5 inches long, beginning 1^^'^ inch below and '' internal to the anterior superior spine of the ilium, and extending up- wards, slightly concave internally, nearly to the last rib (Pig. 361, 14). Fijr. 382. en liigature of the left common iliac artery. — 205 — 2. Divide the layer of fat, the thin superficial fascia, the muscles — obliquus externus and interntis, and transversalis, and the thin fascia transversalis , in succession , until the peritoneum is exposed. 3. The peritoneum (p) is carefully pushed inwards towards the umbilicus, and drawn with the fingers towards the inner edge of the wound. 4. The ureter (u) generally remains attached to the peritoneum; if not, it is seen obliquely crossing the bifurcation of the iliac^ in com- pany with the genito-irural nerve (sp) and any injury to it must be carefully avoided. ft. The common iliac artery now lies exposed in its entire length, from the aorta to its bifurcation, along the internal margin of the ilio-psoas (ram); on the left side of the body the iliac vein lies at the inner side of the artery; on the right side of the body, it lies behind the artery. NB. The internal iliac artery can also be ligated at this point. LIGATUEE OF THE EIGHT EXTEEXAL ILIAC AETEEY (Fig. 383). 1. Incisior., '/^ inch above Poupart's ligament, nnd parallel with it, 3 to 4 inches long, slightly convex, beginning 1^/^ inch internal to the anterior superior sjiine , and ending in the neighborhood of the internal inguinal ring — without exposing the latter and the spermatic cord (Fig. 361, 15). — 206 — 2. Divide the layer of fat, the thin superficial fascia, the strong tendinous aponeurosis of the external oblique, the muscular fibres of the internal oblique, then the horizontal muscular fibres of the transversalis in the outer angle of the wound. 3. Divide the subjacent thin fascia transversalis carefully. (In fat subjects, another thin layer of fat is met.^ 4. Press the peritoneum (p) carefully towards the umbilicus with the hooked fingers (NB. Without sejDarating the fascia iliaca, together with the large vessels, from the wall of the pelvis). 5. The artery lies at the internal border of the ilio-psoas; the vein (v) on its inner side; the anterior crural nerve (n), covered by the iliac fascia, on the outer side ; the genito-crural nerve (sp) passes obliquely across the artery. LIGATURE OF THE EIGHT FEMORAL BELOW POUP ART'S LIGAMENT {Pig. 384). 1. Incision, beginning halfway between the anterior superior spine and the symphysis, ^/j^ inch above Poupart's ligament, and extending 2 inches downwards (Fig. 361, 16). 2. Divide the superficial fascia. 3. Divide the fat, and dispose of the lymphatic glands by- drawing them aside, or by extirpation. Fio-. 384. 4. Divide the fascia lata. 5. Open the sheath of the vessels, ^/^ inch below Poupart's ligament (1) , because immediately below the ligament is the origin of' the circumflex iliac (ac), and the epigastric artery (ae). 207 6. The femoral vein (v) lies internal, the anterior crural nerve ui) external to the artery. LIGATUEE OF THE EIGHT FEMOEAL BELOAV THE OBKtIX of THE PEOFUNDA (p) (AT THE LOWEE ANGLE OF SCAEPA"S TEIAXGLE — Fig. 385). 1. Incision 2 inches in length, along the internal border of the sartorius. beginning the breadth of six fingers (3 to 4 inches) below Poupart's ligament (Fig. 361, 17). 2. Expose the border of the sartorius muscle (s) , and draw it outwards. 3. Open the sheath of the vessels. The femoral vein (v), lies on the inner side of the artery, and somewhat behind it; the long saphenous nerve (n) on the outer side. Yis. 385. Piff. 386. LTGATUEE OF THE EIGHT FEMOEAL IN THE MIDDLE OF THE THIGH (BEHIND THE SAETOEIUS) (Fig. 386). 1. Incision, 3 to 4 inches long, down to the sartorius, in the middle of an imaginary line drawn from the anterior superior spine to the internal condyle of the femur (Fig. 361, 18). 2. Open the sheath of the sartorius, isolate the muscle (s), and draw it outwards, until the posterior wall of the sheath of the muscle, which covers the vessels, appears^. 3. After opening the sheath, expose the artery. Upon the artery lies the long saphenous nerve (n), behind the artery, the femoral vein (vc). The saphenous vein (vs) lies more superficially and internallv. 208 LIGATURE OF THE RIGHT POPLITEAL ARTERY (Fig. 387). 1. Incision, 3 inches loug. at the outer edge of the semimem- branosus, extending downwards across the whole popliteal space (Fig. 361, 19). 2. Divide the thick layer of fat, until the internal popliteal nerve comes in sight. 3. The internal popliteal nerve (n) must be drawn to the outer side ; behind and somewhat internally lies the popliteal vein (v), which must be isolated and drawn a little to the outer side ; behind the vein, and somewhat internally, lies the artery. Fig-. 387. LIGATURE OF THE LEFT ANTERIOR TIBIAL ARTERY ABOVE THE MIDDLE OF THE LEG (Fig. 388). 1. Incision, 2-^/.-, to 3^l„ inches long, 1^/^ inch external to the crest of the tibia (halfway between tibia and fibula) (Fig. 361, 20). 2. Divide the fascia, following a white tendinous line which indicates the interval between the tibialis anticus muscle (ta) and the extensor proprius poUicis (eh); open the intermuscular space with the point of the index-finger until the deep fascia is seen. 3. After careful division of the deep fascia, the artery comes in sight between two veins ; on its outer side lies the anterior tibial nerve (n). LIGATURE OF THE EIGHT POSTERIOR TIBIAL ARTERY ABOVE THE MIDDLE OF THE LEG (Fig. 389). 1. Incision 3 to 4 inches long, -^/, inch internal to the inner "boi-der of the tibia (Fig. 361, 21). 2. After division of the fascia, draw the edge of the gastro- <5nemius''(g) backwards, sejDarate the soleus from the flexor digit- Flo-. 389. 14 ^ 210 — orum longus, and oiien the interval between these muscles with the point of the finger, until the strong deep aponeurosis appears, which consists of fibres of the tendon of the soleus and the fascia of the leg. 3. After division of this aponeurosis, the artery appears be- tween its two veins; somewhat more- posteriorly lies the posterior tibial nerve (n). LIGATURE OF THE LEFT ANTERIOR TIBIAL ARTERY IN THE LOWER THIRD OF THE I^EG (Fig. 390). 1. Incision 2 to 2^'o inches long, vertical, a finger's breadth external to the crest of the tibia (Fig. 361, 22). 2. Divide the fascia. Force the fore-finger into the interval between the tibialis anticus muscle (t a) aud the extensor proprius pollicis (eh), and by tearing up aud down, separate the bellies of the muscles down to the interosseous membrane (about 1 inch deep).' Fiff. 390. 3. The artery lies upon the membrane between two veins, ac- companied in front aud internally by the anterior tibial nerve (u). LIGATURE OF THE RIGHT POSTERIOR TIBIAL BEHIND THE; INTERNAL MALLEOLUS (Fig. 391). 1. Incision 1\/^ to 1''/^ inch long, halfway between the inter- nal malleolus and the tendo Achillis (Fig. 361, 23). 2. Divide the fascia (f) [strengthened by fibres of the annular: ligament (Ij]. 3. Directly beneath this lies the artery, between two veins; the posterior tibial nerve (n) lying behind it. NB. The tendon-sheaths of the tibialis posticus, the flexor longus digitorum, and the flexor poUieis longus must not be ojaened. BLEEDING (VENESECTION, PHLEBOTOMY). 1. The most prominent vein under the skin in the flexure of the elbow is generally opened for bleeding, and also for transfusion. 2. This is usually the median basilic vein. But as this vein generally crosses the brachial artery, and is only separated from it by the thin bicipital aponeurosis, it is advisable to feel the pulsation of the artery before the operation, and to open the vein either above or below the point where they cross. 3. Let the patient lie down, and the arm hang, so as to fill the veins. 4. Tie a bandage (or a folded handkerchief) around the middle of the arm, firmly enough to stop the return of venous blood, but not so tight as to cut off the arterial supply — the radial pulse should not be made to disappear. The . knot of the bandage must be made so that it can be untied by pulling on one end. 5. The operator steadies the arm by wedging his hand between the patient's arm and chest; and the vein, by pres- sing his thumb upon it below the point to be jiunctured. 6. A puncture is made through the skin into the vein with a lancet (Fig. 392), or still Fig-. 392. Venesection with the lancet. le — 212 — better with the phlehotome of Lorins (Fig. 393), and the opening is enlarged by raising the point so that the anterior wall of the vein is opened obliquely for abont ^/- inch, Fiir 393 Venesection with the phlebotome. , \ Fig. 391. Wi, \ 7. The blood should spout out in a strong stream; if it does not, the flow can be increa- sed by the alternate opening and closing of the hand. 8. When a sufficient quan- tity has been allowed to escape, remove the constricting bandage, push the wound in the skin some- what to one side of the vein, lay a small antisei^tic compress upon it , and secure the latter with a figure-of-eight bandage, the forearm being slightly flexed (Fig. 394). Dressing after venesection. 213 TRANSFUSIOnsr. After a sutldeu and severe loss of blood, caiised by injiu-y of some of tlie large vessels, the arterial blood-pressure sinks so low that tlie heart is no longer able to keep the contents of the blood-vessels in motion. It labors without effect, like an empty pump, and death, by hemorrhage follows, even while there is still a sufficient (piantitj^ of red blood corpuscles in the vessels to support life. Direct transfusion of blood from the artery of a healthy person into the vein of another dying of hemorrhage, would fill the vessels of the latter again, and preserve his life. But unfortunately it is impossible to avoid with certainty the formation of clots in the conducting canula, and these might cause dangerous obstruction of the vessels in the person receiving the blood. It is also seldom possible to find perfectly healthy persons, who are ready to furnish blood in this Avay, to save the life of another. Direct transfusion of the blood of an animal into the veins of a man, is to be rejected, because a poison is produced by the mixture of different kinds of blood, which quickly dissolves white and red cor- puscles, and not only causes coagulation of the blood, but may also result in hemagiobinaemia, generally fatal, and hemaglobinuria. According to recent experiments (Kohler, etc.) transfusion of deflbrinated blood, even human blood , is just as dangerous , because liy beating the blood to extract the fibrin , fibrin - ferment is set free, which causes coagulation of the circulating blood, and dissolves the coi^puscles (ferment poisoning, Kohler). Hence, according to our pre- sent opinions, every form of transfusion of blood is to be rejected. On the other hand, injection of a solution of common table salt (7 parts to 1000) into the veins, suffices to raise the blood pres- -ure within the vessels, so that the heart can again set the column of l)lood in motion, and carry the materials of nutrition to the various organs of the body (Kronecker). » To perform this operation upon a patient, a subcutaneous vein (for instance, the median basilic in the flexure of the elbow, or the great sajihenous vein in front of the internal malleolus) must be exposed, by cutting a Hap in the skin, and isolated, so that two catgut strands can be drawn under it. The peripheral end of the vein is ligatured with one of tlie strands of catgut, the other is placed under the central end. The exposed vein is opened by raising the upper wall Mitli a small toothed forceps, iind making an oblique cut underneath with the scissors, so as to form a small flap. This wound is held open by lifting the lh\p , and a canula (of glass, hard rubber, or silver) rounded at the point, is introduced into the central end, and secured by the second catgut thread (Fig. 395). — 214 - Fio-. 395. Introduction of tlie canula. The canula and a rubber tube attacbed to it, which has a female tip of hard rubber at the other end, are completely filled beforehand with salt solution, and closed by a spring clamp. A glass irrigator (see Fig. 12) is emj^loyed for making the injection of the salt solution, or a graduated glass cjdinder (Fig. 39G). which contains 10 to 15 fluid ounces, and ends below in a knob -like perforated end, to which is attached a rubber tube 16 inches long. In the lower end of the latter is a small nozzle of hard rubber or glass, which exactl}^ fits into the rubber female tip attached to the canula. After the vessel has been very carefully cleaned and disinfected, it is filled with a solution of pure table salt, 7 parts in 1000 of dis- tilled water, warmed to a temperature of 104*^ F. The nozzle of the tube is depressed until the water jets from it, and the point is firmly inserted into the rubber tip attached to the canula, already filled with the solution. After all the air -bubbles have been removed from the tube by l^ressing and stroking it ujiwards, the glass cylinder is raised with one 215 — Fio-. 396. hand and the clamp is loosened with the other, so that the column of water in the cylinder sinks very slowly — at the fast- est, 3 fluid drachms in a second. The clamp can also he entirely removed, and the rapidity of the flow regulated by elevating and depressing the glass cy- linder. To prevent the fluid from cooling during the operation, the hand which holds the cylinder can also hold around it a rubber bag filled with hot water (Fig. 396). As soon as the cy- linder is almost empty, the tube is closed by pressure between the fin- gers, and disconnected from the canula. The canula is then withdrawn from tlie vein, the central end of the latter ligated, the wound carefully cleansed and dis- infected, and an antiseptic dressing applied. ^ A syringe is less suitable for use in trans- fusion, (1) because the pressure is liable to be too strong, (2) because tlie piston is apt to infect the blood — by rancid oil, dried fluid from previous use, etc.. and (3) because its use increases the danger of air finding admittance to the vein. Before jjroceeding to transfusion, an attempt should be made to raise the low blood-pressure by bandaging one or several extremities of the patient, and thus forcing the blood Avhich remains in them into the rest of the vascular system (auto-transfusion — P. Miiller) (Fig. 397), so that the heart can again do efficient work. Graduated glass cylinder. Auto-transfusion. Sometimes tliis proceeding will make it possible to dispense Avith transfusion; sometimes the failing vitality can be thus maintained — at leasty until transfusion can be performed. THE REMOVAL OP LIMBS. (AMPUTATIONS AND DISARTICULATIONS,) GENERAL EULES FOR AMPUTATIONS. PREPARATION. 1. Every assistant must have his particular duty and position assigned to him. The patient must be so placed that he can be easily chloroformed, and that the operator and his assistants may have suffi- cient room for their work. 2. The cut surfaces of the limb to be amputated must be turned directly towards the light. 3. The operator is most advautageouslj' jjlaced when the amj)u- tated limb will fall at his right side. 4. Before the 023eration is Ijegun , the skin in the neighborhood of the place of amputation must be shaved, very carefully cleansed, and then thoroughly disinfected as has been descril)ed on page 7. .5. When anaesthesia has been j)roduced, the extremity is made bloodless far above the j^lace of amputation , and again washed with carbolic solution when the bandage has been removed. 6. During the entire operation, all the rules of antisepsis are to be most strictly observed. — • 217 — .DIVISION OF- THE SOFT PARTS. Tlie soft parts are to Ije divided so that tlioy will form tin abundant covering for the sawu eud of the boue. The muscles are hest cut through perpendicular to the loug axis of the limb, and the knife must not be made to act by pressure, but should be drawn back and forth as in carving a joint of meat. If the muscles are cut obli- quely, the vessels will also be obliquely divided, and it is theu not so easy to ligate them securely. For this reason, the methods most to be recommended are the circular metliod, and the methods by skin-flaps with circular division of the muscles. 1. CIECULAE :\IETHOD OF CELSUS. All the soft parts are divided down to the bone (Fig. 399) with a knife (Fig. "398),. the leugth of which is proportioued to the thickness of the limb. with, one stroke, and the bone immediately sawed through. Eut in order to allow the soft parts to be united over the Amputation knives. bone without tension, the bone must be again sawed off at a distance a'bove the first place equal to half the diameter of the limb. To ac- ompli>h this, the end of the bone is seized with lion-toothed forcep.s, aud the periosteum detached upwards with a raspatory until the necessarj'^ amount of bone has been exj)Osed (Fig. 400). Of all the methods, this one, in limbs with one bone, gives the -iiiallest and smoothest surface to the wound ^) ; but it is not suitable Kir limbs with a great amount of muscle, although very well adapted .(•patients who are emaciated and exhausted by long continued sup- puration. ') This method was rec soj^e catgut sutures (Fig. 422). / ^ First the deeper (Fig. 422), and Deep Periosteal^and muscular ^^^^^ ^j^^ ^^^^^ superficial layers (Fig. 423) of the muscular tissues are sewed to- gether with long slightly Fiff. 423. Fio-. 424. curved needles and thick catgut ; and finallj^ the cut edges of the skin are brought into exact apposition by a double continued suture (Fig. 424), but the lowest angle of the wound is left open a little, ^or else a couple of button- hole openings are made in the skin at each side,. as has been described on page 23 and represented in Fig. 41. Figs. 39 and 40 show the mode of action of the deep sutures. If this method is employed, the insertion of drainage tubes is unnecessary. If the antiseptic permanent dressing, as has been described on page 26, and as is represented in Fig. 425, is applied, and the constricting band not removed until then , the dressing can generally remain for several weeks, until union by first intention is complete, and then all the blood which the patient has lost in conseciuence of the amputation, is found in the form of a small odorless crust on the inner surface of the dressino'. Sunken muscular sutures. Suture of the skin. — 229 — Yvr. 425. Antiseptic cusMon dressing after amputation of the thigh... GENERAL RULES FOR DISARTICULATIONS. 1. The operator generally stands so as to face the patient, and holds the limb to be removed in his left hand. 2. For division of the soft parts the circular method is less suitable than the flap method. As there are gen-erally large surfaces of bone to be covered in these cases, proportionally large flaps must be formed; either of skin alone, or of skin and the under-lying muscle. 3. In some cases a large anterior and a small j)osterior flap is best (knee, shoulder, hip); in some cases the posterior flap must be the the larger (ankle, metatarsal joints). 4. For the smaller joints (fingers, toes), the oval method is peAiliarly Avell suited. 5. After division of the soft parts covering the joint, tlie latter is opened by putting the exposed ligaments strongly on the stretch by proper movements of the limb, and then dividing them with the knife. 6. The separation is completed by the division of the remaining ligaments, and of the capsule of the articulation, and finally a piece may be sawed off" from the joint surface which is left. In other respects the method of procedure is the same as in amputations. AMPUTATIONS AND DISARTICULATIONS OF THE UPPER EXTREMITY, a. DISARTICULATION OF THE THIRD PHALANX OF THE FINGER. ( Witli the formation of a palmar flap from without inwards.) 1 . The hand . is held in pronation ojiposite the operator , wlio seizes the end of the finger, and flexes the third phalanx. 2. A slightly curved incision is carried transversely across the liead of the second phalanx ^j^^ inch below the articular surfiicc. and opens the joint capsule (Fig. 426). 3. The point of tlie knife divides both lateral ligaments. The "blade is inserted behind the palmar surface of the third phalanx, the edge being directed downwards (Fig. 427), and with sawing strokes a well rounded flap is cut from the j)almar skin. (Fig. 428). Fiff. 427. Fisr. 428. b. DISARTICULATION OF THE SECOND PHALANX OF THE FINGER. (With formation of a flap from within outwards, hj transfixion. ) 1. The hand is held in supination ojjposite the operator, who seizes the end of the finger in extension , and thrusts a narrow knife between the skin and the joint, from one side to the other, under the crease at the joint, and carries the blade with sawing strokes first to- wards him, then uj)wards, so that a well-rounded flap is formed (Fig. 429). 2. The flajj is turned back, the joint over - extended , and the knife, beginning at the wound, divides with one stroke the lateral ligaments, the capsule, and the skin at the dorsal side of the joint (Fig. 430.) Fiff. 429. Fio-. 430. — 231 — «!C. DISARTICULATION OF THE FINGER AT THE METACARPO-PHALANGEAL ARTICULATION. - 1. OVAL METHOD. 1. The operator stands at the left of the limb, turns his Lack "fto the patient, and while an assistant separates the adjoining fingers, Fiff. 431. — 232 — seizes the injured finger witli his left hand, and over-extends it so that he can see the palmar surface. He then applies a narrow knife (from the right side) to the palmar surface of the first phalanx, cuts the soft parts here transversely at the level of the stretched web , carries the knife aroimd the right side of the phalanx to the dorsum , and then upwards in a cui've to the head of the metacarpal bone — which has been marked beforehand (Fig. 431). 2. The knife is then passed through under the left hand, at the left side of the finger, to the beginrdng of the first incision, inserted down to the bone, and carried at the level of the Aveb around- the , left side of the first phalanx to its dor- sal aspect, and there di'awn upwards in a curve to the end of the first incision (Fig. 432). 3. Both incisions are repeated in the same order, but penetrating more deeply towards the joint . and while the finger is drawn to the opposite side they divide the tendons, the lateral liga- ments, and the capsule of the joint. The wound presents the shape of the heart on playing cards (Fig. 433). Fij?. 433. 2. :\IETHOD BY FLAPS. 1. This method is best suited to the thumb, index, and little fi,ngers, because these are more accessible from the side. A large half-oval flap, the base of which lies at the level of the joint, is cut froiH the sldn of the palmar, dorsal, or lateral sides of the first phalanx and retracted. 2. A smaller skin flap is then form- ed on the opposite side, and also turned back (Fig. 434). 3. Finally, the tendons are divided at the level of the articulation, and the latter opened on every side. XB. The disarticulation -is repre- sented on the ring finger with two small lateral flaps , on the middle finger with the oval incision as seen on the palmar surface. (Fig. 434). — 233 — d. DISARTICULATION OF THE THUMB AT THE CARPAL JOINT. 1. OVAL METHOD. 1. The first incision begins on the ulnar side of the first phahinx, at the level of the web, is carried obliquely over the phalangeal-meta- carpal joint to the radial side of the metacarpal bone, and along this to its base. 2. The second incision is Fig. 435. carried from the same point around to the radial side, and meets the first in the middle line of the metacarpal bone (Fig. 435). 3. By repeated cuts in the same dii^ection along the bone, the latter is isolated from the muscles. 4. The articulation between the trapezium and the metacarpal bones is opened from the ulnar side, and in so doing, the edge of the knife must be kept close to the base of the metacarpal, so as not to open the joint between the trapezium and the metacarpal bone of the fore-finger — which communicates with the other carpal joints. b. The division of the ligaments of the radial side (Fig. 436) completes the operation, which leaves a linear scar (Fig. 437). Fiff. 436. Fiff. 437. 2. METHOD BY A LATERAL FLAP, ACCORDIXG TO Y. ^VALTHER. 1. The thumb is aljducted, the knife placed at the middle of the web, and carried upwards with sawing strokes between the first and second metacarpal bones until it reaches the ulnar border of the first metacarjial (Fig. 438). 'J. Avoiding the joint between the metacarpal bone of the fore- finger and the os trapezium, the point of the knife is carefully jiassed behind the base of the bone , and the carpo - metacarpal joint is thus ojiened. 3. The thumb can then be more strongly abducted, the knife passes through the articulation to the radial side of the metacarpal — 234 — bone, and is carried downwards again along this border, forming a radial flap, the ronnded end of which lies at the level of the web (Fig. 439). Fio-. 438. Fi^. 439. e. DISARTICULATION OF THE PflETACARPAL BONES OF THE FINGERS WITH PRESERVATION OF THE THUIWB. 1. A semicircular flap of skin is outlined in the palm of the hand with an oblique curved incision, which begins at the web of the thumb, and ends at the ulnar border of the base of the fifth metacarpal bone (Fig. 440). This flap can also be formed from Avithiu outwards hj transflxion at its base (Fig. 441). •Fia. 440. Fio-. 441. Formation of palmar flap by- transfixion. Palmar incision. Disarticulation of the metacarpal bones of the fingers. — 235 — 2. Au incision is made on the back of tlie hand, l)eghining at the web of the thumb , and passing obliquely upwards to the upper third of the seco7id metacarjDal. and thence over the three inner meta- carpal bones to the ulnar border of the hand, where it meets the pal- mar incision (Fig. 442). 3. After both flaps have been dissected ujd to the neighborhood of the carpo-metacarpal articulations, the latter are opened from the ulnar side , the hand being held in strong ■ adduction , until even the articulation between the second metacarpal and the os trapczimn is severed. In so doing, the cuts must be made very carefully and always against the two bones, to avoid injury of the joint between the OS trapezium and the metacarjial of the thumb. 4. The preservation of the thumb is of the greatest advantage for the usefulness of the stump (Fig. 433). Fig. 442. Fi^. 443. Dorsal incision. Appearance of stump. Disarticulation of the metacarpal bones of the fingers. f. DISARTICULATION AT THE WRIST. 1. CIRCULAR METHOD. 1. A circular incision surrounds the hand at the middle of the luetacarjius, 1 'j^ inch below^ the styloid processes. 2. The skin is dissected up with vertical cuts, until it can be turned back above the styloid processes like a cuff. 3. The hand is pronated and strongly flexed; an incision, sliglitly convex above . carried across the dorsum from one styloid process to the other, divides the extensor tendons and opens the wrist joint. — 236 — 4. The lateral ligaments are divided below each styloid process ;- and finally, the anterior wall of the caj)sule and all the flexor tendons are cut through with one stroke (Figs. 444 and 445). Fig. 444, Fio-. 445. ^j^^^'TITiiiitftir.Mii fi'lffiTr^ \ Stump after disarticulation at the wrist by the circular method. Disarticulation at the wrist by the cir- cular method. 2. METHOD BY FLAPS. 1. The operator seizes the lower part of the hand, pronates and flexes it, and makes a semicircular incision from the point of one styloid process to that of the other, across the middle of the dorsum (Fig. 446}. 2. The flap of skin is dissected from the extensor tendons, retracted, and the joint opened as in the circular method. 3. The bundle of flexor tendons is pressed into the M"ound by the point of the index finger in the palm, and carefully divided by drawing the knife back and forth ; and then a small flap of skin is cut from the palmar tissues, from the wound outwards (Fig. 447}. NB. It is well to mark out the palmar flap at the beginning of the operation by an incision in the skin. 3. METHOD BY A RADIAL FLAP (Walther, 1810). 1. A semicircular flajD is cut from the skin which covers the metacarpal region of the thumb, the base of which surrounds the radial third of the carpus, and the point of which reaches the base of the first phalanx. — 237 Fiir. 446. Fio-. 447. Disarticulation at the wrist, flap method (Ruysch). 2. After the flap has been dissected fi^om the muscles of the thumb and retracted, a semicircular incision surrounds the other two-thirds of the carpus on the ulnar side (Fig. 448). 3. The skin is well retracted, and the carpus separated from the bones of the forearm (Fig. 449). Fio-. 449. Appearance of the stump. Incision. Disarticulation at the wrist , according to Walther. — 238 — g. AMPUTATION OF THE FOREARM. 1. METHOD BY CIRCULAR FLAPS OF SKIN. (See page 218.) 2. MODIFIED FLAP METHOD. (See page 220.) Fig. 4oO. Transverse section of the right forearm in its lowest third, n. m. P\ ^- mj. ti- ed t p. I. : palmaris longus. 11. m.: median nerve. t. r. i. : tendon of flexor carpi rad. a. r. : radial artery. &.: supinator longus. n. r. s. : radial nerve. a.p.L: extens. os. metac. pollicis. r. e. I. : extensor carpi rad. long. r.e.'b.: extensor carpi rad. brev. e. d. c. : extensor commun. digit. m. u. e. : extensor carpi ulnaris. a. u. : ulnar artery. m. f. d. : flexor commun. digit, profundus. m.iLe. NB. Ill tlie figure, ulnaris internus = flexor cax'pi ulnaris; ex- tensor poll. bi*ev. = ext. primi internod. poll. ; and ext. poll. long. == ext. secundi internod. poll. ' 239 — Fig. 451. Transverse section of the right forearm through its middle. n.p.l. a.ti 4DV V JwllllpJ!s^/UWi£Ajl|| ,J^^^ m.e.p. m.^j. L: palmaris longus. n. m. : median nerve. a. r. : raclial artery. m. p. t. : pronator radii teres. ji. r. : radial nerve. t.r.: tendon of ext. carp. rad. long. ni.e.p.: extens. secuudi intemod. poll. a. M. : ulnar artery. NB. lu the figure, radialis iiiteruus = flex, carpi rad.; brachio- ratlialis =^ supinator longus; radialis exteruus brevis = extens. cai'pi rad. brev.; adductor long. poll. = ext. os. nietacarpi poll.; ulnaris in- tern. = flex, carpi ulnar. ; ulnaris externus =: ext. carpi, ulnar. ; extens. dig. c^uint. == ext. minimi dig. — 240 — Fig. 452. Transverse section of the right forearm in its uppermost third. ■n.'m. a. r.: radial artery. n. r. s. : radial nerve. n.r.p.: posterior inteross. nerve. a. u. : ulnar artery. n.u.: ulnar nerve. n.m.: median nerve. a.L: anterior interosseous artery. NB. In the figure, brachioradialis = supinator longus ; radialis extern, longus and brevis = extensor carpi rad. long, and brev. ; radia- lis internus = flexor carpi rad. ; ulnaris internus ^ flex. carp, ulnar. ; ulnar, externus = extens. carpi ulnar. ; ancon. quart. = anconeus. 241 — h. DISARTICULATION AT THE ELBOW. 1. CIRCULAR METHOD. 1. A circular incision divides the skin l^/g inch below the con- 'dyles of the humei'us ; the cuff flap is dissected up and retracted. 2. A transverse cut freely opens the over-extended joint. 3. A cut above the head of the radius divides the external lateral ligament; another below the internal condj^le divides the internal lateral ligament. 4. The joint gapes widely ; the olecranon is pressed into the wound: and a cut above the point of the latter divides the tendon of the triceps (Figs. 453 and 454). Fio-. 453. Fio-. 454. Disarticulation at the elbow by the circular method. Appearance of the stump after disarticulation at the elbow by the circular method. 16 — 242 — Fig. 455. Transverse section of the right elbow joint at the level of the condyles^ V h n.c.z.m. m.r. n.ja,. n, e. e. : ext. cutaneous nerve. V. c. : cephalic rein. n. r. : muscTilo-spiral nerve. v.m.: median vein. V. h.: basilic rein. n.e.m.i.: greater int. cutan. nerve. n.m.: median nerve. m.r.: flex, carpi radialis. 11. 11.: ulnar nerve. IsTB. In the figure . radialis externus = ext. carp. rad. long. ;.; bracliialis internus = bracli. auticus ; anconeus quartus = anconeus. 2. IIETHOD BY FLAPS. 1. A curved incision, whicli begins 1 inch below one condyle and ends 1 inch below the other, outlines on the anterior surface of the forearm a large semicircular flap of skin, which is dissected up and retracted. 2. The arm is strongly flexed at the elbow, and rotated so that the back part of the joint is directed forwards. 3. A slightly curved incision above the olecranon, exposes its- point (Fig. 456). 243 4. A transverse cut from one condyle to the other divides the tendon of the triceps and both lateral ligaments; a second divides all the soft parts on the anterior side of the articulation. Fig, 456. Disarticulation at the eibow — method by flaps. i. AMPUTATION OF THE ARM. 1. CIRCULAE METHOD OF CELSUS. (See page 217.) 2. METHOD BY CTECULAR SKIN -FLAP. (See page 218.) 3. MODIFIED FLAP METHOD. (See page 220.) 16^ ^ 244 -- Fig. 457. Transverse section of the right arm in its lowest third. n.r. iLC.e.s V.C.: cephalic vein, n. r. : musculo - spiral nerve. m.c.e.s.: ext. sup. cutaneous nerve. n.c.e.: ext. cutaneous nerve. a. &. : brachial artery. 11. TO.: median nerve. V. h. : basilic vein. n.e.ini.: greater int. cutan. nerye. n. u. iilnar nerve. NB. In the figure, brachialis internus = bracliialis anticus; an- conei = triceps. — 2 15 — Fig. 458. Transverse section of the right arm in its middle third- n.c.e.'p. v.c. n.r. v.c: cephalic vein. n.r.: musculospiral nerve. a. p.: profunda artery. n.c.e.p.: ext. outan. nerve. a. h. : brachial artery. n.m.: median nerve. ii.c.i.m.: greater int. cutan. nerve. V. 6. : basilic vein. n. u. : ulnar nerve. NB. In the figure, brachialis internus = brach. anticus ; anconeus internus, brevis, and longus = triceps, internal, external, and long heads. — 246 — Tig. 459. Transverse section of the right arm below the axilla. ^-=ir];X-"-^- V. c: cephalic vein. p.m.: pectoralis major. t. b. : -tendon of tlie biceps. n.p.: external cutaneous nerve. n.c.m.i.: greater int. cutan. nerve. n.m.: median nerve. V. 6.: basilic vein. a. 6.: brachial artery. n. u.: ulnar nerve. r. hr. : brachial vein. n. r. : musculo - spiral nerve. NB. In the' figure, brachialis internus = bracli. auticus; anconeus internus and longus = triceps, internal and long heads. k. DISARTICULATION OF THE ARM AT THE SHOULDER. 1. METHOD BY FLAPS. 1. The patient lies at the edge of the table , half turned upon his sound side, with the upper part of his body somewhat elevated. The more nearly in a ."ritting posture he is placed, the more convenient — 247 — it is for the operator, but the more dangerous for the administration of chloroform (see page 144). 2. On the outer surface of the shoulder, a square flap with roun- ded corners is outlined with the knife. The base of the flap extends — 248 — from the coracoid process to the root of the acromion, and the broadl lower edge extends beloAV the lower border of the deltoid muscle^ (Fig. 460). 3. With bold sweeps of the knife, which pass continually deeper into the deltoid, the flap is dissected up to the acromion, and turned back so as to expose the outer surface of the shoulder joint. 4. A bold cut upon the head of the humerus (which is forced, upwards) above the two tuberosities, divides the capsule and the tendons passing over it. 5. The head of the humerus is pressed outwards, and the knife,, applied behind it, cuts through the posterior part of the capsule. 6. The operator draws the head of the humerus towards him with his left hand, carries the knife w'ith long sawing strokes along the inner side of the bone, down to 2^/^ inches below the fold of the axilla, then turns the edge inwards (towards the thorax) and with one stroke divides all the soft parts — in which are contained the large vessels and nerves. 7. In cases in which it is impossible to control the supply of blood by compression of the subclavian, before the completion of the last cut, an assistant must thrust his hand into the wound from above,, and compress the axillary arterv against the skin with his thiimb (Fig. 461). 8. Fig. 462 shows the appearance of the wound after it has been closed by sutures. Fig. 461. Fig. 462. rormation of the second (internal) flap. Appearance of stump. Disarticulation at the shoulder — method by flaps. 249 — — 250 — 2. CIRCULAE METHOD. 1. The arm is abducted. A circular incision at the level of the lower border of the deltoid muscle divides all the soft parts down to the bone. 2. The bone is sawed off at the same level; all injured vessels are ligated, 3. A longitudinal incision, from the anterior border of the acro- mion down to the circular incision, divides all the soft parts down to the bone. 4. The lower end of the stump of the bone is seized with a strong bone forceps or with the left hand, and, while an assistant separates with sharp hooks the edges of the wound made by the longitudinal incision , the operator frees the bone from the articulation by the aid of strong rotary movements (Tig. 463). This isolation is accomplished by short cuts always directed against the bone; or, in suitable cases, by detaching the periosteum with elevator and raspatory. 5. Fig. 464 shows the appearance of the stump. The lower corners of the skin flaps can be cut rounded, if desired. AMPUTATIONS AND DISARTICULATIONS OP THE LOWER EXTREMITY. a. DISARTICULATION OF THE TOES. The toes are removed in the same way as the fingers (pages 229 — 235). b. DISARTICULATION OF ALL THE TOES IN THE METATARSO- PHALANGEAL ARTICULATION. 1. While the left hand seizes all the toes together, and bends them strongly upwards, a curved incision, which (in the left foot) be- gins at the internal border of the first metatarso-phalangeal joint, and ends at the external border of the same joint of the fifth toe, is made in the furrow between the sole of the foot and the base of the toes. (On the right foot this is reversed.) (Fig. 465). 2. The toes being strongly bent towards the sole, a similar in- cision is made on the dorsum across the base of all of them, its ends meeting the ends of the first (Fig. 466). Both cuts penetrate between the toes into the middle of the web. 3. The two semicircular flaps are then dissected up as far as the heads of the metatarsal bones. 4. Each toe is separately freed, the sesamoid bones at the head of the first metatarsal bone being left in situ. 251 — Eig'. 465. Fig. 466. Disarticulation of all the toes. Plantar incision. Fiff. 467. Disarticulation of all the toes. Dorsal incision. Stump after disarticulation of all the toes. 5. If there is not enough skin to easily cover the very promi- nent heads of the metatarsals, the latter can be cut off, one at a time, with the phalangeal saw. 6. Fig. 467 shows the ap- pearance of the stump. c. AMPUTATION OF ALL THE METATARSAL BONES. 1. A curved incision is made along the anterior marginal furrow of the sole from one border of the foot to the other, and the semi- circular flap dissected back to the point where the amputation is to be made. 2. A smaller semicircular flap is cut on the back of the foot, the ends of which meet those of the plantar flap at the sides of the foot. Instead of the dorsal flap, a cut can be made half way around — 252 — as in the circular metliod, if there is enough skin in the sole to cover the stump. 3. At the base of both flaps the soft parts on and between the metatarsal bones are carefully divided with a narrow knife. 4. The soft parts are strongly retracted with narrow strips of carbolized gauze or linen, drawn through between the bones by forceps, and all the bones sawed through at once, close to the point up to which they have been isolated (Figs. 468 and 469). Ficr. 468. Fiff. 469. Appearance of the wound after the bones have been sawed off. Sawing the bones. Amputation of the foot through the metatarsal bones. Fiff. 470. d. DISARTICULATION OF THE GREAT TOE WITH ITS METATARSAL BONE. 1. The oval incision is made in the same way as has been described for the disarticulation of the thumb (page 233). On account of the great breadth of the base of the first metatarsal, it is well to make a transverse incision over the joint, which lies about 1^/2 inch in front of the project- ing tuberosity of the scaphoid bone, at right angles with the oval incision at the upper end of the latter (Fig. 470), and to dissect back the upper and lower flaps so formed, until the entire bone and the joint are exposed. 2. The tendons of the extensor proprius, and the flexor longus pollicis are cut through at the joint, the latter opened on the dorsal Disarticulation of the great toe with its metatarsal bone. — 253 — side, and, the boue being strongly rotated to the opposite side, its connections with the first cuneiform bone are severed. e. DISARTICULATION OF THE FIFTH TOE WITH ITS METATARSAL BONE. 1. The flap method can be employed here in the same way as has been already described for the disarticulation of the thumb (^Jage 233). 2. The left hand strongly abducts the fifth toe from the fourth, while the right hand carries a narrow knife from the web upwards between the two metatarsal bones with a sawing motion, until it meets with resistance. 3. The ends of the incision must be extended Yj i^*^^ upwards, both on the dorsum and on the sole of the foot. 4. AVith strong abduction of the fifth metatarsal bone, its base must be first separated from that of the fourth metatarsal, then from the cuboid. 5. The knife is then carried around the tuberosity of the fifth metatarsal where it projects above, and thence downwards along the outer border of the bone, and close to it, with sawing strokes. It thus forms a tougue-shaj)ed outer flaj), the point of which must be rounded off exactly at the level of the first incision in the web (Fig. 471). Fiff. 471. ■^aa^-^ffiS^^s Disarticulation of the fifth, toe with its metatarsal bone. f. DISARTICULATION AT THE TARSO- METATARSAL ARTICULATION ACCORDING TO LIS- FRANC (Fig. 472). 1. At the outer border of the foot, must be found the joint be- tween the cuboid bone and the fifth metatarsal, which lies directly iu front of the tuberosity of the latter; and at the inner border of the foot, the articulation between the first cuneiform and tlie first meta- tarsal bones, which is situated 1'/., inch in front of tlie tuberosity of Disarticulation in the tarso-metatarsal joint, according to Lisfranc. the scaphoid. These two points are to be marked with India ink, or a small puncture with the knife. 2. The foot being elevated, a large semicircular flap is outlined with the knife on the sole of the foot, from one of these points to the other (from left to right), the convexity of the flap being j; situated over the heads of the metatarsal bones. 3. The foot is depressed and strongly extended, and the knife carried across the dorsum of the foot from one end of the sole flap to the other in a slightly curved line, cutting through all the soft parts down to the bone (Fig. 473). Fiff. 473. Fi?. 474. e^^ ^^ 4. The small dorsal flap is retracted, and repeated trials' are made with the point of the knife to open the joint which lies farthest — 255 — to the left (in the right foot, the fifth metatarsal joint), while the left hand strongly depresses the toes. 5. As soon as the joint gapes, the knife is carried on in a slight curve, convex anteriorly, opens the fourth and third joints fa), slips over the base of the second metatarsal bone, and opens the first joint (c) (Fig. 474). 6. The joint of the second metatarsal bone , which lies about ^/., inch higher than that of the first, is opened by a small transverse cut (b) ; the lateral connections of the bone with the first and second cuneiform bones, between which its base is inserted, are divided with the point of the knife - — the edge of the blade being directed upwards {Fig. 475). Fief. 475. Fiff. 476. Fio-, 478. Fiff. 477. Lisfranc's amputation. 7. Now all the articulations open more widely, the knife divides the rest of the ligaments at the sides and towards the sole, and cuts through the greater part of the muscular tissues in the sole ; its . edge is then directed forwards, to complete the plantar flap (Fig. 476). — 256 — Fig. 477 shows the appearance of the wound before it is closed, and Fig. 478 the appearance of the stump. g. DISARTICULATION THROUGH THE TARSUS, ACCORDING TO CHOPART. 1. The disarticulation takes place through the joint between the scaphoid bone and the head of the astragalus internally, and between. the cuboid and the os calcis externally (Fig. 479). Fiff. 479. Fio-. 480. Fit?. 482. Fis. 481. Fi^. 483. Chopart's amputation. 257 2. The line of the joint is found on the inner border of the foot, -^/^ inch above the tuberosity of the scaphoid, and on the outer border ^/^ inch above the tuberosity of the fifth metatarsal bone, and is marked before beginning the operation. 3. The foot being elevated, a curved incision is carried across the sole, passing forwards from the point marked nearest the left hand to a point situated behind the heads of the metatarsal bones as far as the thickness of the thumb, and then transversely across the sole; and, finally, at the outer side of the foot, backwards to the point marked nearest the right hand (Figs. 480 to 482). 4. The foot is lowered and pressed strongly downwards, and the knife is applied at the left angle of the wound and carried in a slight- ly curved line across the dorsum of the foot, dividing only the skin, to the right angle of the plantar incision (Fig. 483). Fiff. 484. Yis. 485. Appearance of the stump. Completing the plantar flap. Chopart's amputation. 17 — 258 — 5. The small dorsal flap is strongly retracted, a bold transverse cut across the joint divides all the tendons and penetrates at once- into the articulation, and it is most certain to first enter it above the- tuberosity of the scaphoid — which is plainly to be felt. 6. The joints open with a cracking sound under the edge of the- knife as it passes over the somewhat - — ^-shaped line of the articulation. The point of the knife divides the ligaments, put on the stretch every- where, the plantar side last of all, until the anterior part of the foot can be bent entirely back towards the heel. 7. After the plantar flap has been cut a little deeper at both sides of the foot, the blade of the knife is applied in the wound to the inferior surface of the isolated scaphoid and cuboid bones with the edge directed anteriorly, and carried forwards with a sawing motion to. complete the plantar flap (Fig. 484). 8. Fig. 485 shows the appearance of the stump. h. SUBASTRAGALOID DISARTICULATION OF THE FOOT ACCORDING TO IWALGAIGNE. ]. Two lateral flaps are formed by an incision which begins be- hind, close above the tuberosity of the os calcis, dividing the tendo- Achillis from it, then passes around the external malleolus in a sweep- ing curve, crosses the lower half of the os calcis (Fig. 486), thence- Fiff. 487. Fig. 486. Subastragaloid disarticulation of the foot according to Malgaigne. rises directly across the middle of the cuboid to the dorsum of the foot,, passes over the anterior border of the scaphoid (Fig. 487), and de- — 259 — scends vertically at the middle of the inner border of the foot (Fig. 488) until it reaches the center of the sole (Fig. 489). Thence, bending in a right angle, it runs backwards, and meets the commencement of the incision at the inner border of the tendo Achillis. Fia. 489. Fio-. 488. Subastragaloid disarticulation of the foot according to Malgaigne. 2. The two flaps are dissected from the bone, until both lateral surfaces of the os calcis and of Chopart's joint are exposed. In dis- secting them up, care must be taken not to come too near the lower end of the malleoli, for fear of injuring the ankle joint. Fio-. 491. Fi^. 490. Subastragaloid disarticulation of the foot. ^-^ssa^...,*.--^ Appearance of stump. 17* — 260 — 3. The anterior part of the foot is removed by cutting through Chopart's joint. 4. The anterior end of the os calcis is seized with a bone for- ceps, and while the bone is drawn downwards and supinated, the exter- nal lateral ligament is divided with a narrow knife, ^/g inch below the point of the external malleolus, and the knife is then inserted into the depression in front of the malleolus, and the strong calcaneo-astragaloid interosseous ligament is severed. Finally, while the os calcis is continu- ously rotated on its long axis, the posterior calcaneo-astragaloid ligament is divided about 1 inch below the internal malleolus (see the figure of the ligaments, under resection of the ankle). 5. In spite of the very irregular shape of the lower surface of the astragalus (Fig. 490) , this operation furnishes a stump which is very useful for walking. i. DISARTICULATION OF THE FOOT ACCORDING TO SYME. 1. The foot, flexed at a right angle with the leg, is well elevated, and a deep incision, penetrating to the bone throughout its course, is made from the apex of one malleolus (that to the left of the operator) to the other, crossing the sole of the foot transversely (Figs. 492 to 494). 2. The foot is lowered, pressed strongly downwards with the left , hand, and a second incision made transversely across the anterior sur- face of the tibio-tarsal joint from the apex of one malleolus to that of the other (Fig. 495). 3. A transverse cut across the articular surface of the astragalus opens the. joint in front; two cuts below the two malleoli divide the Fig. 493. Fiff. 492. Disarticulation of the foot according to Syme. 261 Fig. 495. Fiff. 494. Disarticulation of the foot according to Syme. lateral ligaments, and the upper articular surface of the astragalus comes out freely. 4. "While the left hand constantly forces the foot towards the back of the leg, and turns it on its axis alternately one way and the other, the os calcis is dissected from the cap of the heel-flap and divided Fij?. 496. Disarticulation of the foot according to Syme. — Dissecting out the os calcis. — 262 — ^ — 263 — from the tendo Achillis by cuts which are made close together, and alternately above, and laterally (and, when the bone has been nearly extracted, from below and behind), but always directed against the bone (Fig. 496). NB. In secondary operations it is well to shell out the os calcis from the periosteum with elevator and raspatory instead of using the knife. 5. The heel -flap and the skin are retracted above the malleoli; ^nd a circular cut, made just above the joint surface of the tibia, di- vides the rest of the soft parts (tendons and periosteum). 6. The saw cuts across the bone so as to remove only the two malleoli and a thin layer of cartilage from the articular surface of the tibia (Figs. 497 and 498). Or the malleoli alone may be removed with the bone - cutting forceps, as Syme has done several times. 7. After ligature of all the wounded vessels, the skin is perfora- ted at the outer edge of the tendo Achillis with a narrow knife, a drainage tube drawn through the opening , and then the wound brought together with sutures (Figs. 499 and 500). k. DISARTICULATION OF THE FOOT ACCORDING TO PIROGOFF. Amputatio tibio - calcanea osteoplastica. 1. The soft parts are divided in the same manner as in Syme's method. 2. After the joint has been freely opened, the foot is bent strongly Taackwards until the sustentaculum tali appears. Fig. 501. Disarticulation of the foot according to Pirogoff — sawing the os calcis. Lines of the saw-cuts. Fig. 503. 3. The saw is applied to the upper 1 surface of the os calcis directly behind the sustentaculum tali, and the bone sawed through exactly in the line of the incision in the sole (Figs. 501 and 502). 4. Both malleoli and a thin layer of the articular surface of the tibia are sawed off as in Syme's method. 5. The tendo Achillis is cut across just above its insertion and an opening made in the skin at the same place for the introduc- tion of a drainage tube. 6. Fig. 503 shows the apj)earance of the stump. I. gOnther'S modification of PIROGOFF'S methoo. 1. The incision in the sole begins and ends just in front of the malleoli, and passes transversely across the sole in the neighbor- hood of the posterior border of the scaphoid bone (Figs. 504 to 506). 2. The dorsal incision forms a small semi-circular flap which reaches to the scaphoid bone (Fig. 507). 3. After the joint has been opened, the soft parts are dissected up, obliquely upwards and backwards, as far as the attachment of the tendo Achillis — in this dissection, any injury to the posterior tibial artery must be carefully avoided. 4. Just in front of the attachment of the tendo Achillis, a meta- carpal saw is applied to the os calcis and the bone sawed obliquely from the posterior suj)erior part forwards and downwards. 5. The tibia and fibula are also sawed obliquely — from behind forwards, and from above downwards. Stump after PirogofPs amputation. — 265 — Fif?. 504 Fig. 505. Fig. 506. Fiff. 508 t'i Giinther's modification of PirogofTs operation. 6. By this method, the sawed surfaces of the hones can be easily applied to each other without division of the tendo Achillis. 7. In this operation and in the preceding, it is well to bore oblique holes through both bones with a fine awl, and to fasten them together with strong strands of catgut. — 266 m. LE FORT'S MODIFICATION OF PIROGOFPS OPERATION. (Altered by the author). 1. The plantar incision begins ^/^ inch below the apex of the external malleolus (on the right foot) , runs in a slightly convex line across the sole over the cuboid and scaphoid bones, and ends on the internal side l^j- inch in front of and below the internal malleolus (Pigs. 509 to 511). Fiff. 509. Fio-. 510. Flo-. 511. Le Fort's modification of PirogofTs operation. 2. The dorsal incision, between the same points, forms a slightly convex flaj) , the anterior edge of which lies in the line of Chopart's joint (Fig. 512). 3. The dorsal flap is dissected up to the tibio- tarsal joint, and the joint opened as in PirogofFs oj^eration. 4. The foot is turned backwards, and the upper surface of the OS calcis dissected out, sufficiently to allow a narrow saw to be applied "behind the uj^jjjer edge of the tuberosity of the os calcis, so that the superior third of the bone can be removed by a horizontal cut, directed from behind forwards (Fig. 513). 5. As soon as the saw enters Chopart's joint, the bones which form this articulation are separated as in Chopart's operation. — 267 — Fis. 512. Fiff. 513. .... . , Lines of the saw-cuts. Dorsal incision. 6. The two malleoli and the lower articular surface of the tibia are sawed off as in Pirogoff's operation. 7. Or the OS calcis can be sawed with the narrow saw, so as to form a concave surface ; and the bones of the leg , so as to form a convex one — as suggested by von Bruns (Fig. 514). 8. The stump furnished by this method has a very broad surface for walking (Fig. 515). Fiff. 515. Fiff. 514. Lines of the saw-cuts according to von Bruns. Stump after Le Fort's operation. — 268 — 9. In all these operations it is advisable, after tlie soft parts^ Lave been brought together, to fasten the bones to each other by a long steel nail, driven from the sole through the os calcis deep into the- tibia. "With antiseptic healing of the wound, the sawed surfaces unite- quickly, and the nail does not cause suppuration. n. AMPUTATION OF THE LEG. 1. METHOD BY CIRCULAE SKIN -FLAP. (See page 218). ■2. MODIFIED FLAP METHOD. (See page 220). Two lateral flaps of skin (see Fig. 408) are particularly suitable to amputation in the lowest third (above the malleoli). An anterior skin-flap is liable to be pressed upon from within, by the sharp angle of the sawed surface of the tibia. A posterior skin-flap draws the edges of the wound open by its weight. The formation of a lateral flap with a semi- circular incision on the opposite side (according to von Langenbeck) is very useful for th& two upper thirds of the leg. It is only necessary to remember that the base of the skin - flap should be somewhat less than half the circum- ference of the limb at the point of amputation (Fig. 516). Eiff. 516. Amputation of the leg with one lateral flap. — 269 — Fig. 517. Transverse section of the right leg in its lowest third. n.p.s n.p.s.: srperficiul peroaealnerve. a. p.: peroneal artery. l}.l.: peroneus longus. V. s. e.: ext. sapheuous vein, n. ss. m. : ext. saphenous nerve. t. a.: tendo Achillis. t. p. : tendon of the plaataris. n. t.pt.: post, tibial nerve, a. t. p. : post, tibial artery. V. s. i. : int. saphenous vain. n. sph. m. : int. saphenous nerve. a. t. a. : anterior tibial artery. NB. In the figure, ext. hal. long. = ext. proprius pollicis; and flexor halucis long. = flex. poll. long. — 270 — Fig. 518. Transverse section of the right leg in its middle third. a.t.a. m.f.d.cX. a.t.jp. A\v.s.i. xyriT.^-pli.ni. a. t. a. : anterior tibial artery. in. e. h. I. : extensor proprius poUicis. m. f. h. : flex. long. poll. a. p.: peroneal artery. n.c.p.: ext. post, cutaneous nerve. n. ss. m. : ext. saphenous nerve. V. s. e. : ext. saphenous vein. t. p. : tendon of the plantaris. n. sph. m. : int. saphenous nerve. V. s. i. : int. saphenous vein. a. t.p.: post., tibial artery. m.f.d.c.l.: flex. long, digitorum. NB. In tlie figure, gastrocnemius lateralis and medialis and int. Leads of ffastrocnemius. = ext. — 271 — Fig. 519. Transverse section of the right leg in its uppermost third. npp a to n.p.S: ^^^"l^i^^.^-ae.n.. l.p \ , n. ss. 111. v.s.e. n. p. p. : anterior tibial nerve. a. t. a. : anterior tibial artery. I. i. : intermuscular aponeurosis. 11. p. s. : niusculo-cutaneous nerve. n. c. c: post, cutaneous nerve. n. ss. in. : ext. saphenous nerve. V. s. e.: ext. saphenous vein. (. p.: tendo plantaris. a.e.n.t.p.: post, tibial artery and nerve. in. p. : popliteus. n. : int. saphenous nerve. V. s. i. : int. saphenous vein. 0. DISARTICULATION OF THE LEG AT THE KNEE BY THE CIRCULAR METHOD. 1. A circular incision divides the skin of the leg 3 inches below the patella, the knee being extended. The skin is dissected up on all sides as high as the lower edge of the patella, and the cufF-like flap is retracted. 2. Flexing the knee, the ligamentum patellae is first cut through just below that bone, then the anterior part of the capsular ligament and the two lateral ligaments are divided close to the edge of the femur, so that the semi -lunar cartilages and the greater part of the capsular ligament shall remain attached to the tibia. — 272 — 3. After the knee has been flexed still farther, the crucial liga- ments are cut away from the internal surfaces of both condyles of the femur; the knee is then extended again, and the remaining soft parts at the back part of the joint are divided with one stroke of the knife, from before backwards (Fig. 520). Fi^r. 520. Disarticulation at the knee by the circular method. 4. The wound can be united transversely (Fig. 522); and also in a line from before backwards, so that the cicatrix shall lie between the condyles (Fig. 523). 5. If it is desired to remove the patella and the upper pocket of the capsule of the joint, following Billroth, a longitudinal incision is made over the middle of the patella , after the circular incision has been completed, beginning l-^/„ inch above the bone, the patella is cut away from the extensor tendon, the latter is turned upwards, and that part of the capsule which lies underneath it is dissected out. p. DISARTICULATION OF THE LEG AT THE KNEE BY ANTERO- POSTERIOR FLAPS. 1. A semicircular flap, 3 inches long, is made on the back of the elevated limb by a curved incision which begins ^/.j inch below — 273 ~ Fig. 521. •Transverso section of the left thigh at the level of the condyles. h: p. 1). a. I. sm. 9' St. s.m. : Internal saphenous vein. : semimembranosus. : gracilis. : semitendiuosus. : popliteal artery. V. s. e. V. s. e.: ext. saphinous vein. n. t. : int. popliteal nerve. n.p.: ext. popliteal nerve. h.p.: praepatellar bursa. Fiff. 522. Fi^. 523. Stump after disarticulation at the knee by the circular method. Stump after disarticulation of the knee by the circular method with extirpation Oj. the patella. 18 274 the middle of one condyle, and terminates ^/g inch, below the middle- of the other condyle, and this flap is dissected from the fascia up to its base. 2. The limb is lowered, flexed at the knee, and a larger flap of skin, 4 to 5 inches long, is outlined on the anterior surface between the same points. This flap is dissected up to the lower edge of tlie^ patella, and turned upwards {Fig. 524). 3. The sejjaration of the articular ends of the bones is eflected in the same way as in the circular method. rig. 525 shows the appearance of the stump. Fis. 524. Fiff. 525. Stump after disarticulation at the knee- by the flap method. Disarticulation at the knee by antero- posterior flaps. 4. If skin is wanting to make sufficiently large flaps, or if the- lower surface of the condyles of the femur is diseased or injured, a piece can be sawed from the condyles of the femur — Garden's amputation through the condyles. The sharp angles of the sawed surface must be- rounded off afterwards with the saw or the bone cutting forceps. Or the bone can be cut in the first place with a narrow saw in a curves parallel to the articular surface of the condyles (Butcher). — 275 — If the patella is healthy, it can be made to unite with the sawed surface of the condyles, and the stump thus made longer (Gritti's os- teopastic lengthening of the femur). To accomplish this, the carti- laginous surface of the patella musb be sawed off and the latter securely nailed to the sawed surface of the condyles after the wound has been closed. The following methods are suitable for amputation of the thigh : The circular method of Celsus (see page 217). Method by circular skin-flap (see page 219). The modified flap method (see page 221). Fig. 526. Transverse section of the right thigh in its lowest third. a.c. n.s.m. n.p.: ext. popliteal nerve. n. f. : int. popliteal nerve. v.s.i.: int. saphenous vein. tt.s. m. : int. saphenous nerve. a.c: femoral artery. NB. In the figure, biceps femoris longus and brevis = long and short heads of biceps ; vastus iiiedialis and lateralis = internal and ex- ternal vastus. 18* — 276 — Fig. 527. Transverse section of the right thigh in its middle third. n.s.tn.: int. saphenous nerve. a. c. : femoral artery. n. i. : sciatic nerve a. p.: profunda artery. v.s.i.: saphenous vein. — 277 — Fig. 528. Transverse section of the right thigh in^its uppermost third. r. a. cj. a. c. : femoral artery. n. s. : int. saphenous nerve. a. p.: profunda artery. n. i. : sciatic nerve. s. : semi-membranosus. v.: int. saphenous vein. r. a. g. : branches of the sciatic artery. Fig. 425 shows a completed antisej)tic cushion dressing after amputation of the thigh, as described on page 27. Volkmaun's method for the application and renewal of the dres- sing after amputation of the thigh, is to be recommended. The patient is lifted up and a block of wood, or a hard cushion of cubical shape, covered with rubber, is put under the buttock of the sound side, so that the amputation stump swings free, and does not need to be held during the application of the dressing. This also leaves the region of the back so free, that the turns of the spica bandage of the thigh which holds the dressing in place, can be easily passed around the body (Fig. 529). Position of the patient during the application of the dressing. q. DISARTICULATION OF THE THIGH. 1. AVITH A LAEGE ANTERIOR AND A SMALL POSTERIOR FLAP, ACCORDING TO MANEC (METHOD BY TRANSFIXION). 1. The patient is so placed that the half of the pelvis on the injured side projects over the edge of the table. The upper part of the body must be well secured, and the scrotum drawn upwards, and towards the sound side (Fig. 530). 2. After the limb has been made bloodless in the manner descri- bed on page 175, a large anterior flap is cut from within outwards as follows: — The operator thrusts a long pointed amputation knife (see Fig. 398) into the limb, parallel with Poupart's ligament, entering it at a point halfway between the anterior superior spine of the ilium and the apex of the trochanter, and cautiously grazing the head of the femur (the capsule of the femur being opened in so doing); he then turns the point of the knife downwards and inwards, and brings it out on the inner side of the thigh near the perineum (Fig. 531). Carrying the knife downwards with quick sawing strokes, he cuts a well-rounded flap 7 to 8 inches long, which is immediately reflected above, and securely lield there. 3. The knife is passed under the thigh to its inner side, and a small posterior flap cut from without inwards, its convexity extend- — 279 — Fis. 530 Disarticulation at the thigh, with antero-posterior flaps. Fi?. 531. Formation of the anterior flap by transfixion. ing Ijelow the gluteal fold, and its base meeting the base of the other flap on the inner and outer sides of the limb (Fig. 532). 4. A bold cut, made perpendicularly upon the exposed head ^f the femur with a small knife (as if the operator intended to cut through the head, and leave its upper part in the acetabulum), opens the capsule of the joint, the limb being at the same time strongly over- — 280 — extended, and rotated outwards. The air rushes into the articular cavity^ with a sucking sound, the head of the femur comes half out of the acetabulum, and a cut through the ligamentum teres allows it to escape- entirely. Fis. 532. 5. The operator Seizes the head of the femur with his left hand^ draws it towards him , and cuts through the posterior part of the capsule, the muscles attached to the great trochanter, and all the soft j)arts which still remain undivided. 6. One end of a large drainage tube is placed in the acetab- ulum, and the other brought out of the middle of the wound, and the anterior flap turned down and united with the posterior edge of the wound, as is shown in Fig. 533. 2. DISAETICULATION AT THE HIP BY THE CmCULAR METHOD (Yetch). 1. All the soft parts are cut through to the bone by a bold circular cut, 5 inches below the apex of the great trochanter ; theu the bone is immediately sawed off at that point. stump after disarticulation at the hip with antero-posterior flaps. 2. All the vessels wliicli can be recognized, both arteries and veins, are seized with clamp -forceps and ligated with catgut (^see the transverse section of the thigh in its uppermost third — Fig. 528). yi Fiff. 534. Disarticulation at the hip by the circular method. — 282 — 3. In cases in wliich the bloodless method cannot be em- ployed, it is advisable to expose the artery and vein by a longitudinal incision in Scarpa's triangle before the circular incision is made (ac- cording to Larrey). When this is done, the vessels are secured with two clamp forceps and divided between them, the distal ends then being ligated, and the central ends held above until the operation is completed (Fig. 534). 4. If all hemorrhage is arrested after removal of the constricting band, an amputation knife is thrust down to the head of the femur, entering 2 inches above the apex of the great trochanter, and thence carried downwards along the middle of the trochanter to the circular incision, dividing the soft parts, and penetrating to the bone in its entire length (Dieffenbach). 5. The operator seizes the lower end of the stump of the bone with a strong bone forceps, and, while the edges of the vertical incision are drawn apart by assistants, detaches the periosteum from the bone on every side with the raspatorium, until he reaches the stronger attach- ments of the muscles, which will have to be separated from the bone by short cuts with a stout knife. 6. When the bone has been dissected free in this way, up to the capsular ligament, the latter is opened as has been described above, and the head of the femur freed (Fig. 535). The hemorrhage is usually slight in this part of the operation. Fia:. .53.5. Disarticulation at tlie hip. Fig. 536 shows the appearance of the stump. 7. If the muscles are very massive, instead of the circular method according to Celsus, the ordinary circular skin-flap method can be em- 283 — Fis. 536. Stump after disarticulation at the hip by the circular method. ployed; or a large anterior flap of skin can be formed , and the soft parts divided by a circular cut just below the gluteal fold. 8. If there are not enough soft parts in front , a large flap can also be made posteriorly (von Langenbeck), and a transverse incision made in front, below Poupart's ligament. In this case, however, it is necessary to introduce a large drainage tube as far up as the stumps of the psoas and iliacus muscles, which retract into the pelvic cavity, so that discharges may not collect there. r. REAMPUTATION. 1 . If not enough soft j)arts have been spared in an amputation, or if they have retracted during the healing of the wound in consequence of inflam- matorj^ swelling (ostitis) , or if they have been destroyed by gangrene, the so-called conical stump (Fig. 537) is formed — that is , the end of the bone projects so that complete healing is impossible (ulcus prominens), or the thin cicatrix which has finally formed breaks down again as soon as the patient uses an artificial leg. Stumps TV'hich remain after a limb has been destroyed by frostbite, or a burn, are ■usually of this kind. 2. In such cases it was formerly the custom to amjjutate again at a higher level, or to attempt to cover the scar by the transplantation of flaps of skin. But the former is generally unnecessary, and is just r. Szymanowsky's resection saw. Fijr. 553. von Langenbeck's bone hook. dlsturli the Avomid again. For tlie dressing after resection see page 158. 11. If the healing of the -wound after resection, instead '' of making rapid progress, entirely or chiefly by first intention, is com- pleted slowly and after prolonged suppuration, the long continued lixa- 19* — 292 — tion may cause the ligaments and tendons to shrink and form ad- hesions, the joints of the limb to grow stiff, and the muscles weak and atrophic (paralysis of disuse). To the inexperienced, the whole limb then appears to have be- come useless, and in fact it will remain in this worthless condition if nothing is done to relieve it. 3 2. To avoid this condition, or to relieve it, methodical pas- sive motion must be undertaken in all the joints of the extremity, immediately after the cicatrization of the wound. If there is great pain at first, chloroform anaesthesia should be employed (apolyse according to Neudorfer). 13. The joints of the upper extremity, especially the fingers, ia which it is desirable to have motion very early, can be kept movable from the beginning, by cautious movements, such as giving them a dif- ferent position every time the dressing is renewed. 14. The functions of the muscles and nerves can be restored by warm baths and the use of electricity. Methodical kneading of the limbs (massage) , preceded by a cold douche , and followed by gymnastic exercises, is generally still more efficacious for this purpose, 15. If too great mobility and relaxation of the resected joint (flail-joint) is the result of the operation, it can be lessened by a supporting apparatus. EESECTION OF THE INFERIOR ARTICULAR ENDS OF THE RADIUS AND ULNA. "With bilateral incision. 1. A longitudinal incision, beginning below the styloid process of the ulna, is carried through the skin for about 2 inches upwards, along the internal surface of the ulna (Fig. 554). 2. The periosteum is divided exactly in the same line, between the extensor and flexor carpi ulnaris muscles, and raised from the bone Hesection of the radius and ulna at the \PTist. Bilateral iucisiou according to Bouigery. 293 — Fisf. 555. flex, digit, suhl. art. ulnaris flex. carp, ulnar. Muscles and tendons on the ulnar side of the left wrist (according to Henke). Fig-. 556. Fiff. 557. 14 \A. y^\^ Dors^im. Ligaments of the right wrist. Palm. — 294 — with raspatory and elevator, on the posterior surface first, and then on the anterior surface (pronator quadratus) as far as the interosseous ligament (Fig. 555). The part of the ulna which is thus laid bare, is sawed off with the keyhole saw, or cut off with a strong bone-cutting forceps, below the uj)per angle of the wound. 4. This piece, when sawed off, is seized with the bone forceps, twisted around, and removed after cutting the interosseous ligament, the lateral ulnar ligament, and the anterior ligament of the wrist (Fig. 556 and 557). 5. A second longitudinal incision, beginning below the styloid process of the radius, divides the skin for 2 to 2Yi inches upwards, along the external surface of the radius. 6. The tendons of the extensor ossis metacarpi and primi inter- nodii poUicis , which cross the radius obliquely, are drawn aside while the hand is bent far backwards (Fig. 558). Fiff. 558. flex. carp. rad. supin. long. art. rad. ext. OS. metac. j}oU. ext. prim, internod. poll. ext. carp. rad. trev. ext. carp. rad. long. e:J.sec.internod.poll. Muscles and tendons of the radial side of the left wrist, the hand bent backwards (according to Henke). 7. The tendon of the supinator longus (Fig. 559) is cut from the styloid process of the radius, the periosteum of the radius is divided longitudinally, and is raised from the bone, together with the .sheaths of all the tendons, by raspatoi-y, elevator, and knife, first on the posterior, and then on the anterior surface (pronator quadratus), until the soft parts can be retracted, and the bare bone exposed on all sides, for a distance of 1^/., inch above the joint surface. — 295 — Fifr. 559. fiex. carp. rad. — - siqyin. long. — art. rad. ext. OS. metac. poll. ext x>ri"i- internod. poll. ext. carp. rad. long. ext. carp. rad. hrev. ext. sec. internod. poll. Muscles and tendons of the radial side of the left wrist, in extension (according to Henke). In primary resectiou, the periosteum is so adlierent to tlie bone that it is very difficult to separate it, while maintaining its connection with the tendon sheaths, and without injuring the latter. In this case it is advisable (according to Vogt) to separate a -thin layer of bone, together with the periosteum, with a sharp chisel, first from the posterior, and then from the anterior surface of the radius, and finally from the styloid process, under the extensor ossis metacarpi pollicis. 8. A wide strip of brass is passed through on the anterior side, between the bone and the periosteum, to protect the soft parts, and ■while the periosteum and the soft parts of the posterior side are drawn upwards with a similar striji or a blunt hook, the lower end of the radius is sawed off with a keyhole saw or a small resection saw (Fig. 560). 9. The piece sawed off is seized with the bone forceps, drawn out of the wound, and separated from the carpal bones by division of the capsule and ligaments of the joint — external lateral, anterior, and posterior ligaments (Figs. 556 and 557j — . Sawing off the radius. Fijr. 561. Vertical section of the right wrist. 10. If only tlie lower ends of the bones of the forearm are in- jured or diseased, the carpal bones are left untouched. But if even one of the intercarpal joints lias been opened, all the carpal bones (with perhaps the exception of the trapezium and the pisiform) must be re- — 297 — moved, for all the joints between the individual carpal bones, and be- tween them and the metacarpal bones, communicate with one another (Fig. 561). In this case complete resection of the wrist should be performed. COMPLETE RESECTION OE THE WRIST. With the dorso-radial incision of von Langenbeck. 1. The operator should be seated at a small table, upon which the hand is laid palm downwards, and slightly drawn towards the ulnar side. An assistant sits opposite to him. 2. An incision, beginning at the middle of the internal border of the OS metacarpi indicis, divides the skin, passing upwards for 4 inches, to a point on the middle of the posterior surface of the radius' above the epiphysis (Fig. 562). Fig-. 562. Hesection of the wrist according to von Langenbeck. 3. The incision is carried along the outer side of the extensor tendon of the index finger, and without injuring its sheath; higher up it passes along the internal edge of the extensor carpi radialis (where its tendon is inserted into the base of the third metacarpal bone), and divides the annular ligament just between the tendons of the extensor secundi internodii pollicis and the extensor indicis, as high as the upper border of the epiphysis of the radius (Eig. 563). 4. While an assistant draws the soft parts aside with small re- tractors, the capsule of the joint is incised longitudinally, and .then, together with the ligaments, it is separated from the bone as follows: — 5. First the fibrous sheaths which contain the tendons of the extensor secundi internodii pollicis, and of the extensor carpi radialis longus and brevis, where they run in grooves in the radius, and the tendon of the supinator longus, must be detached from the bone on the outer side of the incision, partly with the knife, partly with the elevator. — 298 Fig-. 5H3. extensor carpi radialis longus ext. sec. internod. pollicis ext. carpi rad. brevis annulcii' ligament Tendons of the back of the hand. 6. Next, on the inner side, the tendons of the extensors of the fingers, and the fibres of the annular ligament which surround them, are to be separated from the bone in the same way, together with the periosteum and the capsule of the joint, and drawn inwards. 7. The radio-carpal articulation then lies open. The hand is flexed so that the joint surfaces of the upper row of carpal bones appear. 8. By division of the intercarpal ligaments, the scaphoid bone is separated from the trapezium and the trapezoid; and the semi-lunar and cuneiform, from the os magnum and unciform; they are gently ex- tracted with a narrow elevator. The trapezium and pisiform may be allowed to remain (Fig. 564). 9. Next the bones of the lower row are removed. The rounded articular surface of the os magnum is seized with the fingers of the left hand, or with a dressing forceps, and, while an assistant abducts The bones of the carpus. the thumb, the ligamentous comiections between the trapezoid and the trapezium are divided. Then the knife is made to penetrate, on the inner side of the joint, into the carpo-metacarjaal articulations, by cutting through the ligaments on the extensor side of the upper end of the meta- carpal bones, while an assistant strongly flexes the latter. The three bones of the lower carpal row (trapezoid, os magnum, and unciform) can thus be extracted together. 10. Finally, the epiphyses of the radius and ulna are thrust out of the Avound by strong flexion of the hand, carefully bared of peri- osteum as has been previously described, and sawed off. In sawing the bones, care must be taken not to injure the large dorsal branch of the radial artery, which passes across the trapezium to the interval between the metacarpal bones of the thumb and index finger (Fig. 559). 11. After the operation is completed, and the antiseptic dressing iijjplied, the limb must be securely fixed upon one of the splints shown in figures 135, 293, 196 to 200, 204, and 205. Extension (see page 123), and passive motion of the joints of the fingers, must be begun as soon as jiossible. — 300 — EESECTION OF THE ELBOW ACCORDING TO LISTOX. "With the T-incision. 1. The posterior surface of the elbow, bent at an obtuse angle,. is held in front of the operator, by an assistant who seizes the forearm •with one hand, and the arm with the other (Fig. 565). Fisr. 565. Kesection of the left elbow joint. Detaching the periosteum from the internal condyle. 2. A longitudinal incision, about 3 inches in length, the middle portion of which lies along the internal edge of the olecranon, open& the capsule of the joint, between the olecranon and the internal condyle (Fig. 566). 3. "While the left thumb nail di'aws the soft parts covering the internal condyle strongly inwards, a short knife separates them com- pletely from the bone, with cuts directed perpendicularly to the latter, until the epicondyle is exposed in the wound (Fig. 565). During this part of the operation, the forearm must be flexed more and more strongly by the assistant. The ulnar nerve lies in the middle of the soft parts thus dissected off, and does not come in sight (Fig. 567). — 301 Fiff. 567. Fiff. 566. Resection of the right elbow. T-incision according to Listen. triceps flexor carpi ulnaris TJlnar nerve at the back of the left elbow. 4. By an incision carried in a semicircle below the internal condj^le, the internal lateral ligament (Fig. 568) is divided, together ■svith the attachment of the flexor muscles of the forearm. 5. The arm is extended again, and an incision is made directly across the olecranon, from the lower border of the external condyle to the middle of the first incision (see Fig. 565). 6. The periosteum is detached from the back of the ulna with the elevator, beginning at the intexmal border, and leaving it attached to the tendon of the triceps, which must be separated from the apex of the olecranon with the knife. 7. Both are then pushed outwards over the external condyle, the joint gapes, and a few cuts divide the annular ligament of the ra- dius (between the head of that bone and the ulna), and the external lateral ligament (Fig. 569). 8. The joint is now freely open ; the articular end of the hume- rus is seized with a bone forceps, and it is sawed off at the edge of the layer of hyaline cartilage. — 302 — Fiff. 568. Fis. 569. Internal aspect. External aspect. Ligamenls of tlie right elbow-joint. 9. The ujjper fibres of the brachialis anticus are divided by a cut directed against the point of the coronoid process of theidna; the olec- ranon is seized with the forceps, and the articular end of the ulna, including all that is covered with cartilage, is sawed off. 10. The head of the radius is also sawed off. 11. After arresting the hemorrhage, the tendon of the triceps is sewed, by means of the periosteum attached to it, to the periosteum of the stump of the ulna, with some catgut sutures. The transverse incision is sutured, but the longitudinal incision is sewed only at its two ends, while through the middle a drainage tube is inserted in the cavity of the wound. ST^BPERIOSTEAL RESECTION OF TJIE ELBOAV AC'COEDINC TO VOX LANGENBECK. With simple longitudinal incision. 1. An incision, 3 to 4 inches long, is made over the extensor surface of the joint just internal to the middle line of the olecranon, beginning l^j^ to 2 inches above the apex of the latter, and ending 2 to 2^2 inches below it, at tlie posterior border on the ulna. The incis- 303 Figr. 570. Resection of the right ion in its entire length penetrates through muscle, tendon, and periosteum to the bone (Fig. 570). 2. The periosteum of the ulna is first de- taclied on the inner side with raspatory and elevator, and the internal half of the tendon of the triceps is separated from the bone in ■ con- nection with the periosteum , by short, parallel, longitudinal cuts with the knife — always directed against the bone. 3. The soft parts which cover the inter- nal condyle and enclose the ulnar nerve, are drawn towards the point of the epicondyle with the left thumb nail, and detached from the bone by curved cuts, made close together, and directed against the bone, until the epicondyle is entirely exposed. The last incisions curve around the piojecting bony point, and divide the attachment of the flexor muscles of the forearm, and at the same time the internal lateral ligament, but with- out separating these parts from the periosteum. 4. After the detached soft parts have been returned to their original position, the outer elbov/ with von Langen- part of the tendon of the triceps is drawn out- ^ mcision. wards, and separated from the olecranon by short cuts, but left in connection with the periosteum of the outer side of the ulna, which is raised from the bone together with the anconeus muscle. 5. By successive cuts with the knife, directed against the bone, the fibrous capsule of the joint is separated from the edges of the articular surface of the humerus (first from the trochlea, then from the radial head) until the external condyle comes in sight. 6. Then the external lateral ligament, and the attachment of the extensor muscles of the forearm, are separated from the condyle, so as to leave all these parts in connection with one another, and with the 2:)eriosteum of the humerus. 7. When the external condyle has thus been laid bare, the joint is strongly flexed, the articular ends are made to protrude through tl'c wound, and sawed off in succession as before described. 8. If it is desired to saw off" the ulna below the coronoid pi-n- ccss, the upper fibres of the tendon of the Ijrachialis anticus must bo cut away from it. without detaching the tendon from the periosteum of the ulna. — 304 — EESECTION OF THE ELBOW ACCORDING TO HUTER. With bilateral longitudinal incision. 1. A longitudinal incision, 1 inch in length, exposes the internal condyle; a curved incision, passing around its base, divides the internal lateral ligament. 2. Another longitudinal incision on the external side of the joint, 3 to 4 inches in length , passes over the external condyle and the bead of the radius. 3. The soft parts are drawn apart, and the external lateral ligament is divided, together with the annular ligament of the radius. 4. The head of the radius is stripped of periosteum, and sawed off with the keyhole saw. 5. The' attachments of the capsule to the humerus are separated in front and behind, first from the edge of the radial head, and after- wards from the trochlea. 6. The humerus is thrust out of the wound by drawing the forearm inwards, and as this is done the ulnar nerve slips from the posterior surface of the bone. 7. The articular end of the humerus is sawed off. 8. The olecranon is stripped of periosteum and sawed off. AFTER- TREATMENT. After the antiseptic dressing has been applied, the resected arm is first laid upon one of the splints shown in figures 133, 135, 149, and 283, and secured with gauze bandages. The advice of Roser, to place the resected elbow in a position of extension at first, in order to avoid the development of a flail- joint, is excellent. In recent years, therefore, I have used for this purpose either the glass splint shown in Pig. 149, or a splint of simi- lar shape made of wire. But to avoid ankylosis in this position, as soon as the wound is healed, or nearly healed, the arm must be bent at the elbow, and treated with passive motion at every renewal of the dressing. If a flail -joint develops after resection of the elbow, firmness and usefulness can be restored to the arm by the use of Socin's sup- porting apparatus (Fig. 571). This apparatus has rubber rings attached, to produce flexion. .Socin's apparatus for flail-joint after resection of the elbow. EESECTION OF THE SHOTJLDEE. With anterioi" longitudinal incision according to von Langenbeck (older method). 1. The patient lies on his back, the shoulder is pushed forwards by a cushion, the arm being held in such a position that the external condyle of the humerus is directed forwards. 2. An incision is made, beginning at the anterior edge of the acromion, close to its articulation with the clavicle, running vertically downwards for 2 to 4 inches, and penetrating through the deltoid muscle to the fibrous capsule of the joint, and the periosteum (Fig. 572). In order to spare the fibres of the deltoid and the circumflex nerve, the incision can (according to Oilier) be placed more to the inner side, and carried obliquely downwards and outwards from the outer edge of the coracoid process. 3. The margins of the incision through the muscle are drawn apart with blunt hooks ; the tendon of the long head of the biceps is seen lying in its sheath (Fig. 573). 4. An incision on the outer side of the tendon opens its sheath; the knife, with its back turned towards the tendon, is made to run 20 — 306 Fig. 572. Fis. 573. Tendon of the long head of the biceps. Resection of the shoulder. Anterior longitudinal incision according to von Langenbeck. up the groove between the tuberosities, and divides the entire sheath, together with the capsule of the joint, up to the acromion. 5. The tendon of the biceps is hfted from its groove, and held to the outer side with blunt hooks. 6. While an assistant slowly rotates the arm outwards, the knife, with its edge directed against the bone, makes a curved incision around the lesser tuberosity, beginning at the incision in the capsule , and divides the capsule and the insertion of the subscapularis muscle (Fig. 574}.. Fiff. 574. Fiff. 575. — 307 — 7. Tlie arm is again rotated inwards. The tendon of the biceps is drawn inwards, and there dropped. 8. The knife is once more carried from the incision in the caps- ule, around and above the greater tuberosity, in a larger circle, and divides the capsule, together with the insertions of the supraspinatus, infraspinatus, and teres minor (Figs. 575 and 576). Fig. 576. sup7-aspinatus infraspinatus subscapularis tendo hicipitis teres major Muscles attached to tlie greater and lesser tuberosities, 9. The head of the humerus is thrust out of the wound by pres- sure from below, seized with a forceps (best with Faraboeuf s forceps, Fig. 546 and 577), and, after the posterior attachment of the capsule has been divided, is sawed off with the keyhole saw (Fig. 578). 10. If the head of the humerus has been separated by the bullet, it must be seized and drawn out with a sharp bone hook (see Fig. 553), or with a bullet screw (see Fig. 307). If it has been broken into several fragments, they can be seized singly by the forceps, and detached with the blunt pointed (Fig. 579), or the probe pointed knife (Fig. 580). 11. In most cases operated upon accoxxling to this method, a flail- joint is formed, with dislocation of the upper end of the humerus, or 20* — 308 — Fisf. 577. Fiff. 578. Sawing off the head of the humerus. an awkward articulation with the coracoid process. Free active mo- hility is much more likely to result when the connection of all the mus- cles surrounding the joint with the capsule, and the periosteum of the shaft of the humerus, is carefully preserved at the time of operation. This is the advantage of the following operation. Fiff. 579. Blunt-pointed knife. Fig. 580. Probe-pointed resection knife. THE SUBPERIOSTEAL OE STJBCAPSULAH EESECTION OP THE SHOULDER. According to von Langenbeck. 1 to 4 as in the preceding operation. 5. The periosteum is divided with the resection knife along the inner edge of the groove between the tuberosities, and carefully raised — 309 — Fiff. 581. Ligaments of the shoulder-joint. with the narrow elevator, from the lesser tuberosity to the great- er (Fig. 581). 6. The tendon of the suh- scapulai'is (Fig. 576) is separated from the bone with knife and mousetooth forceps , without de- stroying its connection with the detached periosteum. During this part of the operation , the arm must be slowly rotated outwards, and as the separation proceeds, the knife must be frequently alter- nated with the elevator. 7. The arm is again rotated inwards , the tendon of the biceps raised from its groove, and drop- ped on the inner side. 8. Tlie periosteum of the outer surface of the neck of the humerus is detached from the great tuberosity, in connection with the insertions of the supraspinatus, infra- spinatus, and teres minor, in the same way as in No. 6. This sepa- ration is somewhat difficult in primary resections, because the peri- osteum is usually very thin. 9. The head of the humerus is thrust out of the wound, and sawed off as in the operation previously described. If it is desired only to resect the head at the level of the upper border of the tuber- osities (and this always gives the best results), there is then, prop- ei'ly speaking, no separation of the periosteum. The attachments of the muscles are merely dissected fi'om the bone as far as is necessary, be- ginning in the cavity of the joint, and the only precaution required is not to cut them transversely, but to maintain their connection below with the bone. But as the head of the humerus can not then be made to protrude from the wound, it must be sawed off with the small keyhole saw, or with a chain saw. 10. After the hemorrhage has been arrested, an incision is made in the skin at the back of the wound cavity, at the posterior margin of the deltoid, through which a drainage tube is introduced into the cavity. The anterior wound can then be completely united with deep and superficial sutures. An antiseptic cushion dressing, the bandages securing the arm, flexed at the elbow, against the thorax like a sling, fully provides for the fixation of the extremity. — 310 — Fiff. 582. EESECTION OF THE AETICULAE SUEFACES OF THE SOAPIJLA. 1. In resection of the shoulder joint, nothing is removed from the scapula unless this bone has also been injured by the bullet. But if the articular surfaces of the sca- pula alone are comminuted, and the head of the humerus uninjured, it is only necessary to remove the former. 2. When the gunshot wound does not fas usual) indicate the site of the incision, the best method of opening the joint is the following : — 3. A curved incision, which sur- rounds the posterior edge of the acro- mion , and separates the fibres of the deltoid from it, exposes the posterior surface of the capsule of the joint (Fig. 582). 4. From the middle of this in- cision , the knife is directed upon the posterior -superior border of the glenoid process of the scapula, and cutting vertically downwards between the ten- dons of the su]Draspinatus and infra- spinatus to the middle of the great tuberosity, divides the capsule of the joint, and at the same time the skin aud the deltoid muscle — the latter in the direction of its fibres. 5. While the soft parts are strongly retracted, the tendon of the long head of the biceps and the cap- sule are separated from the margin of the glenoid process, in connection with the periosteum of the neck of the scapula, on every side, far enough to allow the removal of the articular surface with the keyhole saw, or the extraction of the fragments of the shattered bone with the knife. 6. The after - treatment is the same as in resection of the shoulder joint. Eesection of the glenoid pro- cess of the scapula. EESECTION OF THE ANKLE-JOINT. Subperiosteal, according to von Laugenbeck. 1. The foot rests upon its inner side, and a vertical incision 2-^/o inches in length, is made along the posterior margin of the lower end of the fibula; then, bending like a hook around the external malle- 311 — -olus, it extends up the anterior Fig. 583. margin for -^/.^ inch. This incision penetrates to the bone throughout its entire extent (Fig. 583). 2. The periosteum, together with the skin, the muscles, and the sheaths of the tendons, is raised with the raspatory and elevator from the anterior and posterior surfaces of the bone, until a keyhole or •chain saw can be introduced behind the fibula, at the upper end of the incision (Fig. 584). NB. The sheath of the tendon of the peroneus longus muscle must be spared if possible. Fi^. 584. ext. proprius pdllicis ext. dig. long. ■fibula annular ligament — head of the astragalus t. Aehill. peron. long, aid. dig. Y. j)eron. hrev. peron. tert. External aspect of the left ankle (according to Henke). 3. The fibula is sawed through, the piece sawed off is seized with the bone forceps, drawn forwards with gradually increasing force (Fig. 585}, and separated from the interosseous ligament. Finally, 312 — cutting from above and on tte inner side, the posterior inferior tibio- fibular ligament (the lower, very firm part of the interosseous ligament) (Fig. 586), and the three strong fasciculi of the external lateral ligament (Fig. 587), are divided close to the bone. Fig'. 5 J Dissecting out the lo\^er end of the fibula. Fig-. 586. Fibula lig. inteross. post.-inf. tibio-fii. lig. ext. laf. lig., middle fasciculus Tibia — lig. deltoid. — ext. lat. lig., post, fasciculus. Calcaneus. Ligaments ^of the ankle-joint (posteriorly). 4. The foot is turned so as to rest upon its outer side, and a semicircular incision, l-*/^ to 1^/^ inch long, is carried around the lower border of the internal malleolus (Fig. 588), and from the middle of this incision, a second vertical cut, 2 inches long, is made upwards, on the inner surface of the tibia (anchor-shaped incision). 5. The incision penetrates through the periosteum to the bone. The periosteum is detached in two triangular flaps, together with the Ligaments of the ankle-joint (externally). Fig-. 588. Incision over the internal malleolus. skin on the inner side (Fig. 589), witla tlie sheaths of the tendons of the extensors on the anterior surface, and with the sheaths of the flexors on the posterior surface of the tibia. Finally, the deltoid lig- ament is cut away from the edge of the malleolus (Fig. 590). 6. At the upper end of the longitudinal incision, the tibia is sawed across with the keyhole or chain saw — in an oblique direction, on account of the limited space. The piece which is sawed off is seized with the bone forceps, and while the elevator presses down the periosteal surface of the interosseous ligament from above, the fragment is gradually turned out of the wound. NB. The preservation of the interosseous membrane is espe- cially important for the regeneration of the bone (von Langenbeck). 7. The bone is now held only by the anterior and posterior attachment of the capsule of the joint. This is divided Avith the knife, and in so doing the tendon of the tibialis posticus must not be injured. t. Achill. „. m. tib. post. -- Y) m. flex. dig. 7 "// ~ m. flex. poll. 't If art. Kb. post. OS scaph. m. abd.poll. Internal aspect of the ankle (according to Henke). Fio-. 590. Ligaments of the ankle-joint (internally). 8. If it is desired to remove the upper articular surface of tlie astragalus, it should be done with the keyhole saw, sawing off the articular surface from before backwards, in the line of the semicircular incision in the skin, while the sole of the foot is held firmly against the top of the table by two hands (von Langenbeck advises to saw off the superior articular surface of the astragalus directly after division of the fibula, through the first incision, but not to extract it with the elevator until the tibia has been removed j. — 315 — 9. If the entire astragalus is comminuted, or its upper articular surface has been splintered, the whole bone must be removed. 10. To accomphsh this removal, the vei^tical incision on the inner side which passes over the point of the malleolus, is prolonged downwards in a curve convex below, parallel to the tendon of the tibi- alis posticus, as far as the tuberosity of the scaphoid. The tendon of the tibialis anticus, and the anterior tibial artery are drawn outwards ; and the fibres of the internal lateral ligament Avhich are attached to the scaphoid (Fig. 589), and the astragalo- scaphoid ligament (Fig. 590), are cut through. The joint between the astragalus and scaphoid is then opened from above and from the inner side. 11. Then the incision on the external side is also carried from the external malleolus horizontally across the depression below it, the strong ligaments of that region (external lateral ligament , anterior calcaneo-astragaloid ligament, and the interosseous calcaneo - astragaloid) (Fig. 587) are divided. Finally, while the bone is twisted out Avith bone forceps and elevator, the remains of the capsule of the joint are severed". 12. A short drainage tube is inserted on both sides into the cavity between the bones , after careful ligature of all the wounded vessels, and the wound is then sutured. 13. If it has been necessary to remove the whole of the as- tragalus, it is well to drive a long nail from the sole through the os calcis into the tibia, in order to secure the bones at right angles to each other. 14. The limb is secured by one of the dressings shown in fig- ures 144, 150, 188 to 190, 200 to 203, 284, so that the foot is at right angles to the leg. 0STE0-PLA8TIC EESECTION OF THE TAESUS. According to Mikulicz-Wladimiroff. In extensive injuries of the posterior part of the tarsus, as far back as the ankle, the anterior part of the foot can be preserved by this operation, and made to unite with the bones of the leg, after their articular surfaces have been sawed off, in a position like that of tali- pes equinus, so that when recovery has taken place the individual walks on the heads of the metacarpal bones. The operation is performed as follows : — 1. A transverse incision, which begins on the inner border of the foot in front of the tuberosity of the scajjlioid, and ends on the outer border behind the tuberosity at the base of the fifth metatarsal, divides tlie soft parts of the foot down to the bone. 2. A second transverse incision, which passes above the heel, from the posterior edge of the internal malleolus to the posterior edge — 316 — of the external malleolus, divides the tendo Acliillis, together with the other soft parts, on a level with the tibio-tarsal joint. Fio-. 591. 3. The ends of the two transverse incisions are joined by two cuts which run obliquely, from behind forwards, and from above down- wards, -and penetrate to the bone at one stroke. 4. The foot is strongly flexed, and the posterior part of the capsule, and the lateral ligaments of the tarso- tibial articulation, are divided by bold cuts. 5. The astragalus and os calcis are carefully dissected from the soft parts of the dorsum of the foot, and disarticulated at Choj)art's joint. 6. The malleoli are sawed off) together Avith the articular surface of the tibia; and then the articular surfaces of the scaphoid and cuboid are also removed (Fig. 592). Fig. 592. 317 — 7. All tlie injured vessels, especially the posterior tibial artery, and the peripheral stumps of the external and internal plantar arteries, are carefully ligated. 8. The foot is placed in the position of an extreme talipes equi- nus , bringing the sawed surfaces of the cuboid and scaphoid bones in contact with the bones of the leg. They are at once secured by strong catgut sutures, or are nailed together with a long steel nail, inserted obliquely, after the wound has been closed (Fig. 593}. Fio-. 593. Fi. 5 '^8. Bone -awl. 10. It is still better (according to E. Hahn) to secure the bones with nails. After the wound has been closed, and before the dressing has been applied, long steel nails (Fig. 599) (of which an assortment Fi£T. 599. Steel nails (Nos. 1 and 5). — 320 — of sizes must be at hand) are made to penetrate tlie skin on each side of the femur, and driven obliquely through both bones with a hammer (see also Fig. 50), 11. The bones will generally be found firmly united when the dressing is removed, during the fifth or fourth week. The nails have become loose in the meantime, and can be easily extracted by a slight twisting movement, and the small canals left by them heal in a few days. 12. The resected knee-joint is drained by two tubes which are inserted in the two angles of the curved incision, and a third which is introduced in front, in the pocket of the capsule lying under the extensors. An attempt is made to diminish the cavities of the wound .as much as possible, by deep sutures placed in different parts before the wound is closed. The drainage tubes may be dispensed with, if all the injured vessels, which are easily recognized when the operation is carefully performed with the bloodless method , are at the same time properly ligated . for simjoly leaving the angles of the wound open will suffice for drainage. 13. It is very important that the dressing should secure the bones in their position , exercise equable compression on every side of the cavity of the wound, and entirely prevent the entrance of the agents of decomposition. If the dressing accomplishes these ends, it may be allowed to remain until the wound has comjDletely healed — five to six weeks. 14. A cusMon-dressing is excellent (see page 27), and this is best applied in the position shown in Fig. 50, and in the following manner : — 15. Small cushions, or bunches of crumjaled gauze, are placed iipon every spot where the soft parts yield easily to the pressure of the finger, and over them a moderately large cushion, which surrounds the entire region of the knee on every side. The limb is to be surrounded with aseptic cotton batting, from the lower edge of the cushion to the ankle, and from its upper edge to the constricting band, which has been applied just below the fold of the groin, and then cushion and cotton are fii'mly bandaged with a gauze bandage wet with bichloride solution. 16. A well disinfected flower-pot trellis (Fig. 600) is placed over this inner dressing, and also firmly secured with a gauze bandage. This gives the dressing such rigidity, that the limb can be lifted by the heel, without disturbing the relative positions of the resected bones. 1 7. The large outer cushion is applied outside of this, enclosing the entire inner dressing , and is secured with wet starched gauze bandages. Flower-pot trellis, applied. 18. The limb is then very carefully placed upon a flat leg- splint (see Figs. 144, 146, 150, 188, and 284), upon which the padding must be so arranged that the parts whidfe are not enclosed in the ■dressing are well supported, and especially that the heel shall not suf- fer from pressure. The limb is secured in position on the splint with -wet gauze bandages , after the constricting band has been quickly removed. 19. Then the limb is raised to the perpendicular, in order to diminish the blood-supply. The patient is carried to his bed in this position, and the elevation is maintained for several hours afterwards. The patient can generally be spared all loss of blood by this method of treatment (compare pages 184 and 228}. But if the injured vessels have not been ligated with sufficient care, it may happen that the oozing blood will penetrate the dressing, and appear on its lower surface, a few hours after the extremity has been released from its elevated position. NB. Naturally the blood will first be seen in the interrupted "wire splints (Figs. 284 and 146), for in the solid splints (Figs. 144, 150, and 188) it will not become visible until it reaches the upper 2DOsterior edge of the splint. In such cases there must be no delay in immediately renewing the outer dressing, as has been described on page 40. After cutting the outermost bandage, the limb is lifted from the splint, the outer larger cushion is removed, the inner cushion and the flower-pot trellis are abundantly irrigated with carbolic or bichloride solution wherever they are stained with blood, a fresh large cushion is applied, and the limb again placed on a freshly padded splint. In these cases the advantage of the inner flower -pot trellis splint is particularly evident, for it renders it possible to renew the dressing without causing pain to the patient, and without disturbing the relative position of the bones. In cases where there are hopes of preserving a movable joint for the patient, subperiosteal resection of the knee may be attempted. 21 ~ 322 — SUBPERIOSTEAL OE INTEACAPSULAR EESECTION OF THE KNEE-JOINT. Witli lateral curved incision according to von Langenbeck. 1. A curved incision, 6 to 8 inches long, is made on the inner side of the joint (held in a position of extension), beginning 2 to 2^/^ inches above the patella, on the inner margin of the rectus muscle, passing over the posterior edge of the internal epicondyle with its con- vexity backwards, and ending 2 to 2^'.-, inches below the patella at the inner side of the crest of the tibia (Fig. 601). Fiff. 601. Eeseetion of the knee joint with, lateral incision according^to von Langenbeck. 2. In the upper part of the wound lies the vastus internus, and helow it appears the tendon of the adductor magnus ; in the lower part is seen the tendon of the sartorius; neither of these tendons should be injured (Fig. 602). Fig. 602. vastus rectus sartor, add. magn. Tendons at the inner side of the knee-joint. — 323 — 3. The internal lateral ligament is cut across at the level of the joint, the attachment of the capsule on the inner side is separated from the anterior margin of the internal condyle, up under the vastus internus, and the ligamentum alarium internum is also detached from the anterior edge of the tibia as far as the middle line (Fig. 603). 4. The knee is flexed, and, while it is slowly extended again, the patella is forcibly dislocated outwards. 5. The crucial ligaments are cut through; in order to divide the posterior crucial ligament from the intercondyloid spine of the tibia, the internal condyle of the tibia must be rotated forwards. 6. The external lateral ligament, with the neighboring part of the capsule, is cut through by a deep semi-circular incision, which is made a few lines below the point of the internal condyle (Fig. 604). Fi^. 603. Fis:. 604. Internal. External. Ligaments of the right knee-joint. 7. The joint gapes widely. The posterior part of the capsule is cut through, the articular eiids of the femur and the tibia .are in turn made to protrude, and as much sawed away as seems necessary. 8. If it is desired to remove the patella , the margin of its cartilaginous surface must be cut around with the knife, and the bone then extracted with raspatory and elevator from its periosteum, so that the latter remains in connection with the ligamentum patellae, and the tendon of the extensors. 21* — 324 Before the wound is closed, a large drainage tube is placed in the most dependent part. It is advisable also to make a small coun- ter-opening on the outer side, from which *the other end of the tube is made to project, and also to pass a drainage tube through the upper pocket of the capsule. If inflammation and suppuration of the synovial membrane develop after injury to the capsule of the knee-joint, without important injury of the bones, recovery with a movable joint can be obtained by drainage. DEAINAGE OF THE KNEE-JOINT. (Compare page 1.56). 1. In order to thoroughly irrigate the joint with antiseptic solutions, and to supply free outlet to the effused pus, it is enough in less severe cases to make incisions 1 to l-^j^ inch long on each side of the patella, and to insert short drainage tubes into them which are cut off at the level of the skin, and held in position by a suture or a safety-pin. 2. After the joint has been thoroughly irrigated through these drainage tubes, first with a solution of salt, and then with 1 to 1000 bichloride, a firmly compressing antiseptic dressing is applied which squeezes all fluid from the joint, and the entire limb is then well im- mobilized, as after a resection. 3. If the temperature then becomes normal again, and the pain disappears, the dressing may remain untouched for several days, even for weeks. Otherwise, the dressing must be renewed every day, and the antiseptic irrigation repeated. 4. In severer cases the upper pocket of the capsule, the bursa of the extensors, is drained by incisions on each side, above the pa- tella; and if the capsule has already burst, and the pus has made its way under the quadriceps femoris, this pus cavity must also be drained by sufficiently large incisions at its upper end. RESECTION OE THE HIP-JOINT. With j)Osterior curved incision according to Anthony White, 1. The patient lies upon the sound side. The incision begins half-way between the anterior superior spine of the ilium, and the great trochanter, is carried in a curve over the apex of the latter, and passes downwards along its posterior margin for about 2 inches (Fig. 605). 2. The tendinous attachments of the glutei medius and minimus, the obturators, the pyriformis, and the quadratus (Fig. 606) are de- — 325 — 'Ficr. 605. Fi^. 606. Resection of the hip-joint. Posterior curTed incision according to A. "White. Muscles behind the hip-joint, and the sciatic nerve. tached from the trochanter with a short strong knife, and the muscular masses drawn apart with retractors , so that the posterior superior surface of the neck of the femur and the acetabulum are visible. 3. A bold cut along the edge of the cartilaginous rim opens the joint, and as the thigh is flexed and abducted, the head of the femur comes half-way out of the acetabulum with a sucking sound. 4. With a narrow knife, which enters the acetabulum from be- hind and externally, the ligamentum teres is divided against the head of the femur, and the latter escapes entirely from the acetabulum. 5. The soft parts are held back with a strip of brass which is passed behind the neck of the femur, and the latter is divided by the keyhole saw or the chain saw, while the head is held by the bone forceps (Fig. 607). [For the conclusion of this opei-ation, sec the followinsrl. Heseetion of the Mp-joint. Sa'wing off tlie head of the femur -^vith the chain saw, while the soft parts are retracted -with a strip of brass. SUBPEEIOSTEAL EESECTIOX OF THE HIP-JOIN'T. With longitudinal incision according to von Langenbeck. 1. The thigh heing flexed to 45 ^, a straight incision, about 5 inches long, is made from the middle of the trochanter, upwards and backwards towards the posterior superior sj)ine of the ilium, in the direction of the long axis of the femur (Fig. 608). 2. The incision penetrates between the bundles of fibres of the gluteus maximus, and divides the fascia of the thigh, and the peri- osteum of the trochanter. 3. AVhUe the edges of the wound are strongly drawn apax't with retractors, all the muscles which are attached to the trochanter (on the anterior surface, the gluteus minimus, pyriformis, obturator iuternus, and gemelli (Fig. 609); on the postei'ior surface, the gluteus medius and quadratus femoris (Fig. 610)) are sej)arated with the knife through this incision, but the surgeon should endeavor to preserve their connection witli the fascia of the thigh and the periosteum of the femur. Eesection of the hip. Longitudinal incision according to von Langenbeck. Fiff. 609. pyriform. obturat. int. hi" • ''*~'S . ilio-psoas cruralis Upper extremity of the right femur with its muscular attachments (anteriorly). This fatiguing task can be considerably facilitated (according to Kiinig) by cutting off the superficial layers of the anterior and post- erior surfaces of the great trochanter with two strokes of a chisel, and, — 328 ilio-i)soas Tpectinaeus adductor trevii - vast. int. Fig. 610. oMurator ext. - glut. med. I '"''W~ quadrat, fern. glut. max. adductor magnus Tipper extremity of the right femur with its muscular attachments (posteriorly). Fi^. 611. without dividing the periosteum at the lower edge of the cuts, break- ing off both layers of bone by bending the chisel sideways like a lever. Then the three - cornered piece at the apex of the trochanter between the two is cut off transversely, and the neck of the femur is exposed. 4. A bold longitudinal incision is made upon the neck of the femur with a strong knife, and is repeated until the tough fibres of the capsule and the periosteum are completely divided. 5. Beginning from this incision, the periosteum, to- gether with the capsule and the attachment of the obtura- tor externus, is detached on all sides from the neck of the femur, with alternate use of the elevator and knife (Fig. 611). 6. The cotyloid liga- ment is then incised , and a piece removed from it on both sides, with the knife. 7. The thigh is next adducted and rotated inwards^ Ijigam.ents of the hip, anteriorly. — 329 — and, with a suckiug sound, the head of the femur comes half-way out of the acetabulum. 8. A long narrow knife is made to enter the acetabulum from behind and externally, and divides the tense ligamentum teres by a cut directed against the head of the femur, in a direction inwards and for- wards. The entire head then appears through the wound in the cap- sule and can be sawed off as described above. 9. If the neck of the femur has been shot away, the head must be fixed^and its movements directed with the resection forceps, a sharp resection hook, or a bullet screw (see Fig. 508). 10. If the great trochanter is also injured, a piece of it is re- moved at the same time as the neck of the femur, by giving an oblique direction to the saw. 11. A large drainage tube is inserted as far as the acetabulum, after arrest of the hemorrhage, being brought out through the middle of the wound. The remainder of the wound is closed with sutures. RESECTION OF THE HEAD OF THE FEMTJE. With anterior longitudinal incision according to Liicke and Schede. This method is suitable for those cases in which the bullet has entered from the front, and shattered the head or neck of the femur, or in which an abscess has formed in front of the joint after suppura- tion of the latter. 1. The incision begins directly below the anterior superior spine of the ilium, and one finger's breadth internal to it, and is carried straight downwards for 4 or 5 inches. 2. The internal edges of the sartorius and rectus femoris are exposed and drawn outwards. 3. Tearing the loose cellular tissue of the interval between the muscles apart with the finger or with the dressing forceps , the outer edge of the ilio-psoas is found, and drawn inwards with a retractor. 4. The limb being somewhat flexed, abducted, and rotated out- wards, the capsule of the joint appears. 5. The capsule is opened, and incised upwards and downwards as far as possible, with a probe-pointed knife. 6. The neck of the femur is strij)ped of periosteum with the elevator, and sawed transversely to its long axis with the keyhole saw introduced upon the finger — that is , the direction of the saw-cut should be from above outwards to below inwards. 7. The cotyloid ligament is divided by short strong cuts upon the edge of the acetabulum , and the head of the femur extracted with a forceps or sharp spoon after the ligamentum teres has been divided. 8. Hiiter has modified the method by making the incision from a point half-way between the anterior superior spine and the trochanter, obli- — 330 — quely downwards and inwards, along the external margin of the sartorius, for 4 — 6 inches. 9. Above, where the incision only divides the external fibres of the vastus internus, it penetrates to the bone at once, but in the lower angle of the wound it is shallower, in order not to injure the external circumflex artery of the femur, which runs transversely just below the trochanter. Fiff. 612. Supporting the patient during renewal of the dressing. 10. It is easier to remove the injured trochanter by this method than by the former. 11. In order to secure drainage, when the operation is performed according to these methods, drainage tubes must be introduced into the cavity of the wound posteriorly, through the middle of the gluteus — 331 — maximus, and internally, behind the adductors, with the aid of dressing- forceps. 12. After the completion of the operation, an extension dressing is at once applied in the position shown in Fig. 47, page 31, and ■counter-extension secured by elevating the foot of the bed. 13. The most difficult task of the after-treatment is to renew the dressing without interfering with the action of the extension. 14. This may be accomplished by having a strong attendant place his foot on the bed, and letting the body of the patient rest upon his flexed thigh while the dressing is changed (Fig. 612). Or the apparatus shown in Fig. 234 on page 115, may be employed, as it leaves the region of the hip free, so that the dressing can be easily renewed. 15. The action of the extension continues while this apparatus is in use. (In order to avoid complication, it is not represented in the figure.) 16. As soon as the wound is healed, the patient may be allowed to get up , and to go about with the protection of a plaster or starch ■dressing („ tutor"). TREPHI]Sri]SrG. 1. Resection of portions of the bones of the skull may be necessary : — a. To thoroughly clean fresh, compound fractures of the skull, and to disinfect the cavity of the wound; b. To correct depression of the bone which endangers life; c. To extract splinters of bone, or foreign bodies (projectiles, the tips of knives or daggers which have broken off, etc.) which have penetrated the dura mater and the bi-ain; d. To secure drainage for fluids which have collected (blood, pus); e. To arrest intracranial hemorrhage. 2. If there is an opening in the skull from fracture, but the piece of bone driven inwards is larger than the external opening, as is generally the case, the opening must be enlarged, in order to raise and extract the fragment. ■*" 3. The best instrument for this purpose is Liter's rongeur (Fig. 613), or Hoffmann's gnawing forceps (Fig. 614) if the outer opening is sufficiently large to permit the introduction of one arm of the forceps under the edge of the bone. Even if only a small portion can be gnawed from the edge at a time , the opening can be quickly enlarged in any direction. Gnawing the edge of the bone with Liier's rongeur. Eiff. 614. Hoffmann's rongeur. 4. If tlie opening in the >^kull to b'e enlarged, is merely a narrow fissure, a gouge is used for the purpose (the common car- penter's gouge with a wooden handle is the best) , and a wooden mallet , with which short quick strokes are given , the gouge being applied to the edge of the bone obliquely (Fig. 615). When the fis- sure has thus been carefully widened, so that the rongeur can be em- ployed, the opening is enlarged with that instrument as before described. 5. As soon as the object pressing upon or penetrating the dura mater has been sufficiently exposed, it is raised with the elevator, seized with a forceps or dressing forceps , and carefully extracted. If — 333 Fiff. 615. Gouging out the point of a dagger. Fiff. 616. 9ftfffiDK^^3 ' Trephine. — 334 — it is quite firmly -R^edged in the dura mater , it must not be forcibly removed, but should be released by incising the dura. If the base of the depressed bone is not completely broken across, it need not be taken away. 6. If a metal point -which has been firmly -wedged in the skull, and broken off close to the surface of the bone , is to be dra-wn out, it may be made accessible by cutting a-way the bone on opposite sides with the gouge (Fig. 615), so that it can be seized -with a strong forceps, or still better -with a small hand-vise such as -watch-makers use. Other foreign bodies also (hair, earth, pieces of cloth, etc.), -which are caught in fissures in the bone , must be removed -with the chisel in a similar way, so that no dirt shall be left in the wound. Prolapsed portions of brain tissue, if indeed they have not been reduced to pulp, should not be cut away, for they may retract into the skull during the process of healiDg. But they must be care- fully disinfected by irrigation with bichloride solution, etc. 7. Resection of a circular piece of bone (trephining) is only necessary in cases in which there is no opening in the skull. For this purpose the trephine is employed, and in almost all cases the smallest kind, to be operated by hand (Fig. 616), will answer. TVith this instrument a piece of bone as large as a five-cent piece can be removed. 8. If a wound in the scalp is already present where it is in- tended to trephine, it is enlarged by an incision penetrating to the bone. When there is no wound, it is best to make a semicu'cular incision down to the bone, and to detach the pericranium, together with the flap of the scalp , with the elevator , far enough to admit of applying the trephine (Fig. 617). The neighborhood of the longitudinal and transverse sinuses, and of the middle meningeal artery , is to be avoided on account of the danger of hemorrhage (Fig. 618). 9. In order to begin the sawing action of the crown of the tre- phine , the central pin (the pyramid) is first made to enter the bone. This can be facilitated by previously making a small hole with a bone screw, or an ordinary awl. As soon as the teeth of the crown have entered a little way into the bone , the pin of the trephine is drawn back into the crown. 10. The action of the trephine must be interrupted from time to time, partly to explore the depth of the cut in the bone with the flat end of a probe, or with a quill sharpened obliquely, partly to free the teeth of the crown from bone-dust, by brushing and washing it in carbolic solution, 11. If the bone has been entirely cut through at any point, the teeth must not be allowed to act upon that place,' but only on those parts of the circle where the internal table has not yet been divided — by inclining the handle to one side. But before the bone is 335 Fig. 617. Fig. 618. simcs longitudinalis sinus iransversus art. mening. med. Blood-vessels on the internal surface of the skull. Trephining. divided, a small bone screw (Heine's, Fig. 619) is screwed into the central hole made by the pin. 1 2. As soon as the button of bone is loose, ^. it is carefully lifted out with a hook bent at a right angle , which is inserted into the hole in the head of the bone-screw. "With the same hook it is ascertained if depressed fragments are movable (Roser), and an attempt to raise them or entirely remove them is made with it, or with a sti'onger elevator, or a forceps. 13. If serious hemorrhage from abnor- mally large veins of the diploe takes place in this operation , it can be arrested by plugging them with a ball of carbolized wax , softened in hot water, or a stout catgut thread. Hemorrhage from the branches of the middle meningeal ar- tery can also be arrested by a ball of wax, if Fi^. 619. Bone screw with Hoser's hook. — 336 — it should be impossible to seize and ligate the wounded vessel. Hemor- rhage from an injured sinus generally ceases after the application of a compressive dressing. 14. After completion of the operation, the entire wound, the in- jured dura, and even the exposed cerebral tissue must be irrigated with strong carbolic or bichloride solution, and a good antiseptic com- pressive cushion dressing applied, which is allowed to remain as long as possible. 15. If symptoms of increasing cerebral compression allow of the diagnosis of intracranial hemorrhage from the middle meningeal artery, the application of a ligature to its main trunk is indicated. To expose the artery, the skull must be trephined in the middle of the flat temporal surface, at the intersection of a horizontal line drawn I-'/, inch above the zygomatic process with a vertical line drawn */g inch behind the ascending root of the zygoma. A flap is formed at this place with its base downwards , and its convexity directed towards the vertex, exposing the temporal muscle, which is divided in the direction of its fibres, and detached from the bone with the periosteal elevator on both sides of the incision. The pin of the trephine is then set upon the point of intersection of the lines described above, and a button carefully removed from the bone. The groove for the artery will be recognized on the internal surface of this button. The vessel is imbedded in the dura, and must therefore be surrounded by a catgut thread passed under it with a curved needle. If the artery is not sufficiently exposed by this operation, the opening must be enlarged with the gnawing forceps, or with gouge and hammer. ' TRACHEOTOMY. 1. It is necessary to open the air-passages whenever respira- tion is dangerously interfered with, in consequence of injury of the larynx, the trachea, or its neighborhood, or by oedema of the glottis, or the entrance of foreign bodies into the air-passages. 2. This is most easily and quickly done by division of the crico- thyroid ligament (laryngotomy) , and this is satisfactory if it is only necessary to remove the immediate danger to life (Fig. 620). • ■ 3. If the opening is not sufficiently large, the cricoid cartilage may be divided at the same time (crico-tracheotomy). 4. The trachea is best opened above the thyroid gland (trache- otomia superior). 5. It is more difficult, and more dangerous, to open it below the thyroid gland (tracheotomia inferior) because in this situation the trachea lies much deej)er, and not infrequently the large blood- OS hyoideum m. sternohyoideus lig. erico-thyreoid. — cart, cricoid, - gl. thyreoid. — lig. hyo-thyreoid. cart, thyreoid. m. crico-fhyreoid trachea Larynx and trachea, anterior view. vessels are found in front of it, when they take an abnormal course f innominate, carotid, and thyroid arteries ; internal jugular and thyroid veins). 6. It is well to chloroform the patients for the performance of i;hese operations, if they have not already become too far asphyxiated. The administration of chloroform considerably facilitates the perfor- mance of the operation, because the movements of the larynx are thus rendered quieter. 7. The head being bent far back, an incision about l^j^ inch long is made through the skin, exactly in the middle line, and it may Ise marked with a pencil beforehand. 8. The cellular tissue in the interval between the muscles is lifted up between two forceps , and divided as has been described in the account of the operation for the ligature of arteries (page 191). The sterno - hyoid muscles are retracted with blunt hooks (strabismus hooks, or eyelid retractors). 9. Every bleeding vessel is at once ligated, or, in case of need, secured with a suture. If haste is necessary, the bleeding vessels are seized with artery clamps, and the latter allowed to hang at the sides. The edges of the wound are thus held apart. 10. If the central portion (isthmus) of the thyroid gland extends to the upper rings of the trachea, or upon the thyroid cartilage, the posterior layer of the central fascia of the neck is incised with a small transverse cut in the middle of the cricoid cartilage, and separa- ted from the trachea with a director, or with a strabismus hook (Fig. 22 — 338 — 621). In this way access is gained to the parts behind the thyroidi gland, and the venous plexus, without hemori-hage (Bose's retro-fascial dissection of the thyroid gland). Fiff. 621. Strabismus hook. 11. As soon as the trachea is exposed, it must be held firmly,, in order to open the anterior wall exactly in the middle line. It is best to steady it with a sharp hook (for instance, von Langenbeck's double hooks) (Figs. 622 and 623), the points of which are made- Fig. 622. Fig. 623. Tracheotomy. to seize the lower border of the uppermost cart- ilage. While the trachea is thus drawn upwards and steadied, the knife is inserted between the hooks, and made to penetrate about ^j^ iuch into the trachea, and then the anterior wall is divided double-hooks, as far as it has been exposed. Care must be taken not to cut the retracted cellular tissue, or the thyroid gland, for severe- hemorrhage would follow, and the blood might enter the open trachea! wound. The thyroid gland should therefore be drawn downwards with- a blunt hook. 12. The incision in the trachea is made to gape by separating the double hooks, and then the double tracheotomy tube of Luer- Liier's tracheotomy tube. (Fig. 624) is immediately inserted. The tube is fastened around the neck with a rubber band, 13. Instead of the double hooks, two small hooks can be used to steady the trachea ; or still better two toothed damp forceps (Fig. 625}, which are fastened in the wall of the trachea on each side of the middle line, and the sides of the incision at once separated when the knife enters. 14. If no tracheotomy tube is at hand, a thick drainage tube is inserted, the lower end of which is cut obliquely; or two hooks are quickly made of silver wire (as is shown in Fig. 626) and these are hooked in the incision in the trachea, and held apart by a rubber band around the neck. 15. If nothing of the kind is to be had, a stout suture, or silver wire, is passed with a curved needle through each side of the incision, beneath one of the tracheal rings, and the threads are kept on the stretch by means of a rubber band around the neck. 16. But these expedients must give place to a tracheotomy tube as soon as possible, if the air-passages are to be kept open for a long time. 17. If blood enters the air-passages, it can be removed by suction through an elastic catheter. 18. Bullets and other foreign bodies which have entered the air-passages are to be sought for, and removed with -forceps. Fis:. 625. Toothed clamp- forceps. Fiff. 626. Retracting hook of wire. 25* — 340 — 19. After tlie operation has been completed, a piece of moist bor- ated lint, or iodoform gavize, is laid upon the wound behind the tube, and the anterior surface of the neck is covered with a few layers of moist gauze. The inner tube must be removed from time to time and freed from mucus with a soft feather. OPERATIONS UPON THE CHEST. PARACENTESIS OF THE THORAX. 1. Penetrating wounds of the chest must be immediately closed with an antiseptic occlusive dressing. Even gunshot wounds of the pleura and lung may then heal without sepsis and without suppuration. The possession of an emergency dressing package (page 136) may be the means of saving life in such cases. 2. But if physical examination shows that air and fluid have entered the pleural cavity (haemo- or pyo-pneumo-thorax) and if the- accompanying symptoms (high fever, fetid discharge) make it evident that decomposition has taken place, or if troublesome symptoms of suffocation are caused by the increased internal pressure in the thorax, there must be no delay in securing sufficient outlet for the collected fluid by making a free opening in the chest. 3. First, any existing wound is enlarged by incising the skin on each side of it in the direction of the intercostal space, far enough to permit the finger to penetrate into the chest. If this is difficult, the intercostal muscles are separated with the dilating forceps. 4. If it is found that a rib has been shattered by the bullet, the comminuted pieces must be resected subperiosteally. But even if the rib has not been injured , it is advisable to resect a piece of the nearest rib in all cases of empyema , because it is not possible to keep the opening in the intercostal space sufficiently large by the introduction of a drainage tube or canula, until the termination of the suppuration, as the ribs are drawn together by the cicatricial contrac- tion of the wound. 5. When a free outlet is thus established, an attempt is first made to remove the secretion which has accumulated, and any chance foreign bodies (pieces of cloth, etc.) by abundant irrigation with warm salt solution. 6. Inflation with air by a syringe, and proper position of the body of the patient, so that the opening in the chest is at the most dependent point (both recommended by Boser) are efficient aids to the attainment of this object. 7. Then a large drainage tube, or several of them, are inserted into the chest, their ends are secured with silk thread or silver wire — 341 — to tlie suxTOunding skin , and finally the entire pleural cavity is again thoroughly washed out with an innocent disinfecting solution (aluminium acetate, chloride of zinc, thymol, borax). 8. The drainage tubes must not be hermetically closed. They may be covered with a large cushion dressing of absorbent antiseptic material (crumpled gauze, peat, sawdust, moss, etc.), and the antiseptic irrigation repeated once or oftener every day. Or a smaller india rubber tube is inserted in the drainage tube , the lower end of which is suspended in a vessel partly filled with cai'bolic solution, into which the discharge can flow continuously. If the wound is then surrounded with an antiseptic cushion dres- sing, it can sometimes be allowed to remain untouched for weeks. 9. If the external openings of the wounds have already cicatrized, or if they are in situations which do not permit free escape to the discharge (for instance , in the clavicular, or uj)per scapular regions) it is necessary to open the chest at some more suitable place (paracen- tesis thoracis). 10. The fifth or sixth intercostal space, half-way between the axillary and mammillary lines (Fig. 627) is preferred for this purpose; Fiff. 627. Anterior view of the thorax. or the neighborhood of the seventh rib, postei'iorly , just below the lower angle of the scapula. It must be positively ascertained, by phy- sical examination, that there is a collection of fluid, and not merely an adhesion between the lung and the costal pleura. In doubtful — 342 — cases this certainty can be obtained by aspiration with a hypoder- matic syringe. 11. An incision l^j^ to 2 inches long is made at this place, close to the upper margin of tlae lower rib of the two bet^yeen which it lies, because the artery and intercostal nerve run near the lower edge of the upper rib. A cautious dissection is made with the knife, until pus appears at some part of the wound, and then the opening is enlarged so as to secure free drainage. 12. But it is almost always necessary to resect greater or smaller portions of the neighboring ribs, in order to secure free drainage. RESECTION OP THE RIBS. Resection of the ribs is pex'formed as follows : — 1. An incision, 2 to 2^/„ inches long, made over the middle of the rib, parallel to its long axis, divides skin and muscles down to the periosteum. 2. The divided soft parts are retracted with sharp hooks. The periosteum is incised in the line of the wound, for a length of one inch or more. At each end of this incision, a transverse cut is made across the rib from one border to the other , and then the two peri- osteal flaps are detached upwards and downwards from the external surface of the bone, with the elevator. 3. The periosteum is then carefully separated from the internal surface of the rib with a sharply bent elevator, beginning at the lower margin of the rib , and avoiding injury to the intercostal artery, wliich lies in the groove of the rib , until the point of the elevator can be passed out in the upper intercostal space between the periosteum and the bone. 4. Under the guidance of the elevator, a sufficiently large piece of the rib is then resected with the keyhole saw (Fig. 628), or with the American pruning-shears (Fig. 629). 5. Finally, the intex'nal side of the periosteal cylinder, which now lies exposed in the bottom of the wound, together with the costal pleura wliich is adherent to it, is incised in the neighborhood of the upper mai-gin of the rib , so as to allow a large drainage tube to be introduced into the chest-cavity. 6. Portions of the sternum can be resected in a similar manner with Liier's rongeur (Fig. 613), if it appears necessary, in order to secure free escape to the contents of the pleural cavity , but it should be borne in mind that the internal mammary artery runs down be- hind the costal cartilages, along each side of the sternum, about ■'/.j inch from the edge of the latter (Fig. 620). — 343 Fiff. 628. Fiff. 629. Eesection of a rib with the keyhole saw. American prvining-shears. 7. If it is desired to ligate this artery for liemorrliage , it must te exposed in this line by resection of the costal cartilages which lie in front of it. INTESTIISTAL SUTURE. 1. If a loop of intestine protrudes through a wound of the ab- domen, it must be returned as quickly as possible, with every antiseptic precaution, and the wound enlarged with the probe-pointed knife as far as may be 'necessary for this purpose. As soon as the intestine has been returned, the abdominal wound is carefully closed with deep and superficial sutures , and a good, antiseptic, compressive dressing applied. The position of the patient which is most convenient for the application of such a dressing is shown in Fig. 49. 2. If the prolapsed loop of intestine proves to have been wounded, the wound must be closed witli sutures before the gut is returned. 3. Generally only the serous (peiitoneal) surfaces of the intestinal wall unite , therefore tlie suture must bring these surfaces into contact, and for a considerable extent. 4. In simple incised or punctured wounds, the edges of the wound are turned in a little, and the folds sewed together with a fine — 344 — round sewing needle , and a fine antiseptic thread. The stitches are- placed at intervals of about ^/g inch, and pass between the muscular layer and the mucous membrane (Lembei't's intestinal suture^ (Figs. 630 and 631). Fiff. 630. Fig. 631. Lembert's intestinal suture; 5. The continuous or glover's suture (Fig. 632), which can be more rapidly applied than the interrupted suture, may also be- employed with good results. 6. An improvement of the Lembert suture is the double in- testinal suture of Czerny (Fig. 633), which first brings the raw edges of the muscular and serous coats into contact, and, secondly, the serous surfaces. 7. If the entire circumference of the intestine has been in- volved in the wound, the edge of the lower end can be iuvaginated (according to Jobert), the upper end passed into it, and the two united with fine interrupted sutures, so that only the serous surfaces are in contact. As much of the mesenteric attachment of the two ends as interferes with the invagination, must be previously divided (Figs. 634 and 635). 8. If an injury of the intestine is suspected in penetrating ab- dominal wounds, it is proper to open the abdomen in the middle line immediately (laparotomy), draw out the injured loop, and make an — 345 Fig. 632. Fiff. 633. Continuous suture. Czerny's suture. attempt to prevent the threatening septic peritonitis by closing the wound in the gut, and by antiseptic irrigation of the abdominal cavity. Fiff. 634. Fiff. 635. Jobert's intestinal sutvire. 9. If, in recent cases , a portion of the intestine is discovered to have been so lacerated and contused by tlie bullet that there is no hope of success by suture alone, resection of the injured loop of intestine, with subsequent circular suture of the ends , may be practiced. 10. Even in the Middle Ages , attempts were made to facilitate these operations by uniting the ends of the intestine over cylindrical bodies, which wei'e placed in the interior of the gut, and were after- wards passed with the feces. The .,Four Masters" used the dried — 346 — trachea of an animal foi' this purj)Ose ; Jobert, a metal ring ; Amussat, a wooden cylinder with a groove. This method has been improved by Neuber, by the use of a decalcified bone tube provided with a groove, and has since then been employed in my clinic several times with excellent results in cases of resection for praeternatural anus. RESECTION OE THE INTESTINE "WITH CIECULAR SUTURE BY NEUEER'S METHOD. In a case of gunshot wound of the intestine, this method would be applied as follows : — 1. After the injured loop of intestine has been sufficiently drawn out of the large abdominal wound, and thoroughly cleansed and disinfected with an antiseptic solution, a thick compress of warm bichloride gauze is laid underneath and around the loop of gut, and this is pressed down upon the abdominal wound by the hands of assistants, so as to prevent the protrusion of the intestines , and the entrance of blood or intestinal contents into the abdominal cavity. Then a narrow elastic band is passed through a small opening made in the mesentery, close to the intestine , at a Suitable distance from each end of the piece of intestine to be removed, and tied around the gut just tight enough, to prevent the passage of feces. 2. The injured loop, together with a wedge-shaped piece of the corresponding mesentery, is then cut away with scissors, beyond the margins of the contusion. 3. After all the divided vessels have been carefully ligatured, the edges of the triangular wound in the mesentery are united by a continuous catgut suture. 4. Then, beginning at the mesenteric border, the edges of the intestine are united (from within) by Wolfler's internal intestinal suture (Figs. 636 and 637} until there is only just space enough left to permit Neuber's bone cylinder (Fig. 638) to be introduced into the intestine. 5. The remainder of the edges of the wound are united over the cylinder with Lembert sutures, from without. 6. In order to secure the united intestinal ends firmly upon the bone cylinder, a catgut thread is passed between the wall of the intes- tine and the united mesentery with a straight round needle, and tied circularly around the gut, so that it gently presses the edges of the wound, and the sutures, into the groove (Figs. 639 and 640). 7. Finally, a few sutures are applied through the peritoneum, so as to secure the folding in of the wound. 8. Then the two rubber bands are removed, and the sutured loop is returned to the abdominal cavity, after the latter has been very — 347 — Fia. 636. Fiff. 637. "Wolfler's internal suture Decalcified bone cylinder. Fio-. 639. Intestinal suture with bone cylinder r.Neuber). Fig. 640. Neuber's intestinal suture (schematic). — 348 — carefully cleansed in its entire extent with warm salt solution, and then irrigated with bichloride solution , especially if intestinal contents have already escaped into the peritoneal cavity. 9. If it is found that the bullet has wounded the intestine in several places, the same method must be applied to all. ^^ 10. If peritonitis is already present, openings must be made in the abdominal wall , in the lumbar region of both sides , and large drainage tubes inserted through them into the cavity, to prevent the collection of septic fluid. 11. Then the large abdominal wound is carefully closed with deep and superficial sutures. 12. The decalcified bone cylinder dissolves entirely, or in part, in the fluids of the intestine , and generally only portions of it appear in the feces. 13. If there is no decalcified bone available, other cylindrical bodies which can be dissolved by the intestinal secretions may be employed for this purpose — for instance, vaginal suppositiories of gelatine, a piece of the largest kind of maccaroni, a piece of a Carlsbad wafer (Weir). In gunshot wounds of the rectum, it is advisable to at once divide the sphincters posteriorly, as far as the apex of the coccyx (sphincterotomy), so that feces will not enter the wound. In order to facilitate the exit of feces, and of the discharge of the wound, a thick rubber tube wrapj)ed in iodoform gauze (Fig. 641) is introduced into the rectum , and is allowed to remain until it is removed by the gran- ulations of the wound. Daily injections are made through the tube with an irrigator, to wash out the rectum. • Fiff. 641. Kectal tube and tampon. ^) By performing laparotomy, Bull obtained recovery in the case of a patient whose intestine had been penetrated in seven places by a bullet. The operation was not undertaken until seventeen hours after the injury. See the New York Medical Journal, Feb. 14, 1885. — 349 EXTERNAL URETHROTOMY AND CYSTOTOMY. 1. Perineal incision of the urethra (boutonniere , ex- ternal urethrotomy) is absolutely necessary in injuries of the urethra i(contusion , laceration) , and when infiltration of urine threatens , or has already occurred. 2. A grooved staff (such as is used in lithotomy) , or a cath- eter, is introduced into the bladder (or, if this is impossible, down to the situation of the injury), and is held exactly in the median line. 3. The patient lies upon his back, with his buttocks at the edge of the table, his legs flexed and abducted (lithotomy position). 4. The index finger having been introduced into the anus as a guide, an incision about l^j^ inch long is made exactly in the median line (raphe), between the anus and the scrotum, which is held up by an assistant. The bulb of the urethra, however, must not be wounded, as that would occasion great hemorrhage. The incision is carried through the deeper parts by . cautious strokes of the knife . in the same line , until the groove in the staff is exposed (Pig. 642). Fiff. 642. hulhus urethroi art. pudend. pars memhranac. Grooved staff. Prostate 5. If it has been possil)le to pass the staff into the bladder, an /-^ - shaped director is introduced into the bladder along it, and after the staff has been removed an elastic catheter is placed in the blad- der, and allowed to remain some (two) dayy, until the danger of in- filtration of urine has passed. — 350 — 6. But if the previous introduction of the staff fails, because the rupture of the urethra was complete , the vesical end of the rup- tured urethra must be found, and this is often a very difficult task. 7. After the coagulated blood has been thoroughly removed from the -wound, and the latter irrigated with an antiseptic solution, the edges of the wound are retracted with sharp hooks. Sometimes the vesical end of the urethra can be recognized immediately, appearing as a movable projection of tissue infiltrated with blood, and resembling a firm blood clot. If it is not discovered at once, the patient is instructed to urin- ate, or if he is deeply chloroformed, an assistant presses strongly upon the distended bladder. An attempt is made to seize the edges of the ruptured urethra with toothed forceps or small hooks, where the urine makes its appear- ance, and to draw them apart. 8. If this manoeuvre succeeds, the "^-shaped Fig. 643. director is easily passed into the bladder, and along this as a guide , the elastic catheter. In order to secure the catheter in the bladder, a clove hitch (Fig. 643} is made with thick cotton thread, and the end of the catheter passed thi'ough it. When the ends of the thread are drawn tight,, and knotted once , the knot cannot loosen of its own accord. The ends of the thread are then secured to locks of the hair on the pubis , or to a loose half ring made of a strip of plaster, and . , fastened iust behind the glans penis; or they are Clove-hiteh. j.,iri- sewed to the loreskm. 9. But if the injury to the urethra has been inflicted behind the muscular part, in the prostatic urethra (in gunshot fractures of the pubic bone, for instance), it is generally impossible to find the vesical end of the urethra. But in these cases the danger of urinary infiltra- tion, even into the cellular tissue of the pelvis, is very great, because the deep pelvic fascia has also been injured. In such cases supra- pubic cystotomy must be performed, and retrograde catheterization practiced. 10. If retention of urine follows the injury, and the bladder is distended to the umbilicus, this oper-ation is very easy, for the peri- toneum is pushed up by the bladder, and is entirely out of reach of the incision. 11. The abdominal wall is incised above the symphysis, in the median line, until the bladder projects in the wound, the wall of the latter is picked up on each side of the middle line with small hooks^ or artery forceps, and is divided between the two, sufficiently to allow a large drainage tube to be introduced into the organ. The edges of — 351 — the incision in the bladder can be sewed to those of the wound in the abdominal wall with a few sutures. 12. There is then, generally, no difficulty in passing a bent catheter through the vesical entrance of the urethra towards the penis (retrograde catheterization). A thread or silver wire can be pulled through the bladder on withdrawing this instrument, and with the aid of the thread a rubber drainage tiibe can be passed out through the perineal wound, so that the urine can escape freely. 13. But if the bladder is empty, this operation is much more difficult, for the reduplication of the peritoneum has sunk below the upper edge of the symj)hysis. In such cases , after incising the ab- dominal wall, the dissection must be very carefully carried down until the peritoneal fold is found, and the latter must be drawn up to the upper angle of the wound with a retractor. 14. If a foreign body (for instance , a bullet) has penetrated into the bladder , it can usually be removed by an incision in the middle line of the perineum (median cystotomy of Allai-ton). 15. The urethra is incised from the perineum, as described above, and the prostatic portion is stretched by a slow boring motion of the index finger, until a small lithotomy forceps can be in- troduced, and the bullet extracted with it. 16. If the bullet has already remained in the bladder for some time, so that urinary concretions have formed upon it, it may be necessary to remove it by suprapubic cystotomy. HYPODERMATIC INJECTIONS. 1. The introduction of a solution of morphine into the sub- cutaneous cellular tissue, is one of the most successful operations, both at the dressing station , and in hospital , and is often the only means of alleviating the final sufferings of those who are hopelessly injured. 2. An injection of morphine (grain ^/g to -^j.^ , for adults) made about 10 minutes before the administration of chloroform is begun, ensures a quick, quiet, and lasting anaesthesia. 3. Every physician should carry a hypodermatic syringe, and a solution of morphine with him, and know exactly what dose of morph- ine is indicated by each division of his syringe. 4. After the proper quantity of the solution has been di'awn into the syringe, any air which has entered is expelled, by pushing the piston forwards while the point of the syringe is held upwards. A fold of skin is lifted on some part of the body (for instance, on the back of the forearm, or on the outer side of the thigh), the needle is quickly thrust through the base of the fold into the cellular tissue,. — 352 — moved sideways a few times to ascertain that the point has passed through the corium, and has not entered a vein, and the piston is then slowly pushed forwards, emptying the contents of the syringe (Fig. 644). Fiff. 644. Hypodermatic injection. 5. The needle is withdrawn, and the index finger placed for a few seconds upon the opening in the skin, to prevent the escape of the injected fluid; at the same time, slight pressure, and gentle rubbing with the middle and ring fingers, assists the division and absorption of the solution. 6. Even in this small operation, it is necessary that, not only the syringe, and the operator's fingers, but also the portion of skin chosen for the injection, should be p)reviously carefully cleansed and disinfected. Otherwise, subcutaneous abscesses are Kable to follow. OPERATIONS BY ARTIFICIAL LIGHT. 1. The sui'geon is often compelled in war to operate by night; and the operations necessary on board ship, during an engagement with the enemy, must usually be performed on the lower decks, by artifi- cial light. 2. An intense light upon the field of operation is absolutelj* necessary for most operations, and the surgeon must be jJi-epared to help himself by expedients, when, as is the rule, the light is insufficient. .3. A simple, but very good light is the wax taper (Fig. 645), which is made from an ordinary wax taper the size of a quill, by twisting three or four pieces of it into one. To protect the hand from the hot melting wax , the taper is passed through a hole in a piece of pasteboard, or thin wood. 353 4. An excellent illumination is given by the Ravoth operating candlestick (Fig. 646), a wax candle which is put in a tube with a strong spiral spring. Upon the end of the tube is an adjustable metal reflector, which throws the light upon the field of operation. Fiff. 647. Fiff. 646. Fiff. 645 "Wax taper. Eavoth's operating candlestick. Improvised reflector. 5. If this is wanting, an illuminating reflector can be improvised, by fastening a silver spoon to a wax candle, by means of a compress and bandage, as is shown in Fig. 647. 23 ERRATA. Page 30, line 6, for „ini", read „my". „ 31, „ 4, omit the semicolon after „necessary". „ 35, „ 11, from the bottom, for „apear", read „appear". „ 39, „ 18, for „fullfilled", read „ fulfilled". „ 40, „ 7, from the bottom, for „moicture", read „ moisture". „ 53, Fig. 71, for „sagittan", read „ sagittal". „ 54, Figs. 75 and 77 have the titles interchanged. „ 82, line 4 from the bottom, for ,,170*^ J.", read „170^ F.". „ 87, „ 2 „ „ „ , for ,,wood-sharings'', read „"wood- shavings". -o^- INDEX OF AUTHORS. (* illustrated.) o^ A. Adelmano, Compression of the arteries by forced flexion of the limbs 173. — * Plaster of Paris dressing 84. Albert, * Danger of circular bandage in frac- ture of the forearm 78. AUarton, Median cystotomy 351. Amnssat, * Clamp forceps 14. — Grooved wooden cylinder for use in suture of the intestine 346. Anschiitz, Plaster of Paris splints 85. B. JBardeleben, * Pelvic support 90. — Chloride of zinc pads 35. — *"Wire suspension splint for the lower extre- mity 135. /Bartsclier, Open treatment of wounds 41. Bandens, * Bullet screw 161. Bauni, Oil of turpentine 168. Beck, * Straw mats 126. Beely, * Removable plaster of Paris dressings 85. -- * Hemp-plaster splint for resection of the knee 95, 96. Bell, * Moulded concave splints 72. — * Splints 72, 120. Jiillroth, Battiste 28. — Disarticulation of the knee 272. — * Plaster of Paris dressing 85. — Adhesive iodoform gauze 96. — Turpentine 168. £ohni, Addition of chalk to water glass 82. Bonnet, *Wire breeches 107. — Wire-basket splints 79. .Bose, Ketrofascial dissection of the thyroid 338. Brandts, * Compression of the aorta 183. — * Improvised cautery iron of telegraph wire 168. Briinninghaasen, Amputation 217. Jiruns, Carbolic powder 39. — Absorbent cotton 26. — Preparation of materials for dressings in war 33. Bruns, v., * Modification of Le Fort's disarticu- lation of the foot 267. JBorggriive, Pasteboard dressing 81. Barow, Acetate of alumina as an antiseptic 37. — Open wound-treatment 41. Butcher, Disarticulation at the knee 274. — *Be8ection saw 291. c. iCarden, Amputation through the condyles of the femur 274. Celsns, * Circular method of amputation 217. Chassaignac, Drainage 19. Chiene, Improvised drainage with catgut strands 20. Chopart, * Disarticulation through the tarsus 256. Cline, Concave splints 72. Condy's Fluid 38. Cooper, Aneurism needle 195. Crosby, * Adhesive plaster extension 118. Czerny, * Intestinal suture 344. — Silk 16. D. Desault, * Dressing for fracture of the clavicle 56, 57. *Desault-Liston splint 118. Dieffenbach, * Disarticulation at the hip 282. Dobson, * Knee-support 109. Bonders, Epidermis suture 55. Dunireicher, v., *Flap splint for fracture of the forearm 77. E. Emniert, *Buckles 72. Esinarch, * Compressor for the aorta 181. — Apparatus for bloodless method 176. — *Pelvic support 89, 90. — * Bloodless method 175. — * Stirrup splint for resection of the ankle 103. — * I) !i )! I) )! n ■wrist 103. — * Chloroform inhaler 145. — * Double-inclined plane for the hospital 108. — * Double splint for resection of the elbow 104. — *'Wire breeches for transport 107. — * Triangular handkerchief for dressings, and mode of use 137, 139. — * Modification of Le Fort's disarticulation of the foot 266. — * Extension by elastic rings or tubing 120 to 123. — Plaster of Paris suspension splints for — — • — * Resection of the elbow 100. — — * Resection of the ankle 99. — — * Resection of the wrist 101. — *Heel support 30. — *Cold coil 44. — *Cold sheet 44. — * Material for splints 70. — * Sectional suspension splint for resection of the elbow 105. — *■ Spiral spring tourniquet 187. — * Adjustable inclined plane 42, 45, 46. — * Trouser-suspender-tourniquet 186. — * Extension dressing for use with a litter 121. 23* — 356 — Esiiiarcli, * Dressing-package for the soldier in the war of 18"°/,i 136. — -•= Irrigator 10. — * Sectional extension splint for the thigh 122. F. Faraboeuf, * Bone-forceps 290. Fergusson, * Lion-tooth forceps 290. Fischer, E., Naphthaline as an antiseptic 38. Foulis, * Clamp for rubber constricting band 177. G. Gamgee, * Arm of the coat used as a sling 130. Gerdy, Handkerchief dressing 59. Gooch, * Coaptation splints 72, 120. Graf, Tannin 168. Gritti, Osteoplastic lengthening of the femur 275. Giiutlier, * Disarticulation of the foot (Pirogoff) 264. H. Hagedorn, * Glass box for catgut 15. — Needle 166. Halin, * Resection of the knee 318. Heine, * Bone-screw 335. Heister, *Petit's fracture box 110. Hoffmann, * Rongeur 331. Hiiter, Resection of the elbow 304. — Resection of the hip 329. — Ligature of the lingual artery 198. Hunter, Indirect ligature 191. J. Jobert, * Suture of the intestine 344. — Metal-ring for suture of the intestine 346. K. Koch, Bichloride of mercury as an antiseptic 34. Kocher, Subnitrate of bismuth 39. — Juniper catgut 16. Kohler, Transfusion 213. Kilnig, Cliloride of zinc in hospital-gangrene 35. — Iodoform used on the drainage tube 19. — Resection of the hip 327. — Adilition of magnesium to water-glass 82. Kronecker, Transfusion of salt-solution 213. Kiister, Salicylic acid powder 39. L. Langenbeck, v., * Amputation of the leg 268. — * Double hooked retractors 338. — * Elevator 288. — Disarticulation at the hip 283. — -•= Bone-forceps 290. — * Bone-hook 291. — *Bullet-foiceps 161. — * Amputation-knife 221. — *Amputation with muscular flaps 223. — „ by oval method 223. — * Resection of the elbow 302. — * „ „ „ ankle 310. — * ,, n !i wrist 297. — * „ „ „ hip 326. — * „ „ „ knee 322. — * „ „ „ shoulder 305, 308. — * Periosteal raspatory 164. — *Keyhole saw 290. — Subperiosteal resection 288. -- Ligature of the subclavian 200. — *Retractors 152. Larrey, * Ligature of the femoral vessels before- disarticulation 281, 282. Laub, Stretcher 117. Lazarski, Volatility of bichloride 34. Leconite-Liier, * Bullet-searcher 161. Le Foi't, * Disarticulation of the foot (Pirogoff)- 266. Leiter, * Cold-coil 45. Lenibert, "■•= Intestinal suture 344. Liebreich, -'Electric bullet probe 162, 163. — Hypodermatic injection of strychnine 148. Lisfranc, * Disarticulation in the tarso- meta- tarsal joint 253. Lister, Antiseptic dressing 29. — * Lead-plate suture 22. — Borated lint 36. — Boric acid as an antiseptic 36. — Boric oinment 36. — Carbolic acid as an antiseptic 33. — Catgut 12, 16. — Chloride of zinc as an antiseptic 35. — Occlusive dressing 25. — * Disinfection of the air 5. — * Drainage-tube forceps 19. — * Elastic bandage 29. — ■-'■= Splint for resection of the wrist 113. — Bichloride-serum gauze 34. -- Oil-silk 28. Liston, *Mac Intyre's splint 110. — * Resection of the elbow 300. Longniore, * Improvised electric probe 163. Lorius, --Phlebotome 212. LoiTdhani, * Amputation by flaps of skin 220.. " Liicke, Resection of the hip 329. Liier, * Double tracheotomy tube 339. — * Rongeur 331. M. Maas, Ligature of the abdominal aorta 204. Mac Intyre, *Leg splint 110. Major, Triangular handkerchief 137. ■ — Handkerchief dressing for fracture of the patella 09. Malgaigne, *Subastragaloid disarticulation of: the foot 258. Manec, * Disarticulation of the thigh 278. Marsliall, * Osteotribe or reamer 164. Mathysen, Plaster of Paris dressing 83. Mayor, Wire basket splint 79. — Handkerchief dressing 59. Merchie, * Moulded pasteboard splints 75 — 7. Middeldorpf, * Triangle for fracture of the arm 113. Mikulicz-Wladimiroff, *Resection of the ankle 315. Mitscherlich, Water glass with cement added 82.. Mosetig, v.. Iodoform as an antiseptic 35. ■ — Iodoform powder 39. MilHer, P., *Autotransfusion 215. If. Jfelaton, *Method of inversion 148 — 9. — Bullet-probe 160 — 1. Jfeuber, * Intestinal suture 346. — Necrosis opeiation 165. — * Glass splints 80. — *Bone drainage tube 19. — "Bone cylinder for intestinal suture 346. — Peat as mateiial for dressing 26. Neudorfer, Apolyse 292. — Re-enforcement of the plaster dressing 87. Nicaise, * Constricting band 178. Nussbauni, v.. Improvised bullet-probe 163. — 357 0. 'Oilier, Subperiosteal resection 288. P. Pancoast, * Tourniquet for the aorta 181. Petersen, Oxide of zinc 39. Petit, * Fracture-box 42, 110. — * Screw-tourniquet 171. — Boot 78. — * Amputation by the circular method 218. Pinner, Acetate of alumina 37. Pirogoff, * Bridge-plaster-dressing 94. — * Disarticulation of the foot 263. — * Plaster of Paris dressing 84. Port, Carbolized lime 39. Porter, Sawdust as a material for dressings 26 — * Splints of telegraph wire 133. Pott, *Ijateral position 106. — Concave splints 72. Praraz, * Hypodermatic syringe 351. Preissnitz, Compresses 28, 44, 48. Q- Quincke, * Bathtubs G. R. Banke, Thymol as an antiseptic 38. Ravoth, *iiperatiug candlestick 353. Renz, T., Double-abduction splint for compound fracture of the femur 109. Reverdin, Transplantation of the skin 155. Richardson, *Atomizer 5. Bis, *Fenestrated plaster dressing 87. Roser, *Dorsal splint for fractures of the radius 74. — ■ *Wire splint for the lower extremity 79. — *Hook for bone screw 335. — * Handkerchief dressing for the chest 66. — * u n n n groin 68. — -'Dilating forceps 151. Rupprecht, Susceptibility of children to boric acid 36. s. Salomon, *Sheet-metal splints 79. Sayre, *Elevator 289. — * Adhesive plaster dressing for fracture of tlie clavicle 124 — 5. Scliode, Improvised drainage with glass wool 20. -— *Resection of the hip 329. Scheuer, * Leg-splints 111. Schnyder, * Material for splints 71. Schon, Splints of sheet zinc 79. Scultetus, * Many-tailed bandage 52. Seutin, Starch-dressing 81. Sicltold, Y., * Apparatus for lifting the injured lie. Silvester, * Artificial respiration 148, 149. ■Simpson, Administration of chloroform 144. Skinner, -'Apparatus for the administration of chloroform 145. Socin, * Supporting apparatus after resection of the elbow 304. — Oxide of zinc 39. Spencer Wells, Artery-clamp 13. Starke, * Apparatus for irrigation 154. Steiner, Electropuncture of the heart 148. Stromeyer, * Abduction splint 73. — *Hand splint 73. — * Cushion for fracture of the arm 111. — * Phlebostatic hemorrhage 168. — * Eight-angled splint for the forearm 73. — * Obtuse-angled „ „ „ „ 73. Syme, *Aneurism needle 195. — * Disarticulation of the foot 260. Szynianowsky, * Handkerchief dressing for frac- ture of the clavicle 66. — * Resection saw 291. T. Tliierscli, Boric and salicylic acid solution 36. — *Improvised irrigator 10, 11. — *Bead suture 22. — Salicylic acid as an antiseptic 37. Tronimsdorf, Hydrogen peroxide as an anti- septic 38. u. Unna, * Suspensory bandage 69. y. Telpeau, * Dressing for fracture of the clavicle 57. Verdnin, * Amputation by muscular tlaps 223. Vetch, * Disarticulation at the hip 280. Tolckers, *Ee-enforced plaster dressing 89. — * Club-tourniquet 173. Togt, Kesection, 295. — * Splint for resection of the knee 74. Tolkniann, *"Wire suspension splint for the arm 134. — * Sheet metal splint for the lower extremity 78. — Anterior splint for resection of the ankle 102. — * Padded pelvic support 29. — * Lifting frame 116 — 7. — Crumpled gauze 25. — Muscular paralysis caused by tight bandages 49. — * Retractors 152. — * Slide for extension 120. — * Supination siilint for the forearm 74. — • * Suspension-splint 42. — *Droppiug nozzle 154 — 5. — *Ilenewing the dressing after an amputation 277. w. Walther, v., * Disarticulation of the thumb 233. — * Disarticulation of the hand 236. Watson, * Plaster suspension splint for resec- tion of the knee 74, 96—8. — * Splint for resection of the knee 74. Weir, Improvised cylinder for suture of the intestine 348. Weissliach, Sheet zinc splint 79. • White, * Kesection of the hip 324. Wolf'ler, * Internal intestinal suture 346. Wyivodzofl", * Plaster bandage machine 85 — 6. -©J^g:?^- INDEX. (* illustrated.) C#D A. * Abduction-splint for fracture of the radiixs 73. Absorbent dressing 24. Adhesive plaster 16. — * Crosby's extension by 118 — 9. — *Sayre's dressing of, for fracture of the clavicle 124 — 5. — English 20. Air, * Disinfection of, by the spray 5. Air -passages, injuries of 397. Alcohol, absolute 38. Aluminium acetate 37. Amputations 216. — *by flaps of skin with circular division of muscles 220. — *by muscular flaps 223. — *by transfixion 223. — *by t^e circular method of Celsus 21.7. — * ,, ,_, „ „ „ I'etit 218. — * division of the soft parts in 217. — general rules for 216. — * knives for 217, 221. — indications for 157. — of the arm 243. — *of the foot 253. — of the forearm 238. — of the leg 268. — * of the leg, •with, lateral flaps, according to V. Langenbeck 268. — of the thigh 275. — * through the metatarsal bones 291. — preparation for 216. — * sawing the bones in 224. — *stumi5 with artery forceps 13. ^ — * suture of wound in 228. " Anaesthesia by chloroform (which see) 144. Aneurism, diffuse traumatic 188. — circumscribed traumatic 191. * Aneurism-needle 195. Ankle, * external aspect 311, — * internal aspect 314. — injuries of 286. — * ligaments of 312—4. — *resection of, osteo-plastic (tarsal) 315. — * „ „ subperiosteal (V. Langenbeck) 310. — splints and dressings for the 78, 81. — * stirrup-splint (Ksmarch) 102. — * anterior splint (Volkmann) 102. — *Esmarch's suspension splint 98. — * fenestrated plaster dressing with suspension 43. * Anterior splint for resection of the ankle, Volkmann's 102. Autiphlogosis 2, 41. Antisepsis 2. Antisepsis, in war 138. Antisepsis secondary 150. Antiseptics 30. — Absolute alcohol 38. — Acetate of alumina 37. — Bichloride of mercury 34. — Boric acid 36. - — Carbolic acid 33. — Chloride of zinc 35. — Iodoform 35. — Naphthaline 38. — Peroxide of hydrogen 38. — Permanganate of potash 37. — Salicylic acid 37. — Thymol 38. Antiseptic catgut 15. Aorta, abdominal, compression of 181. — * Tourniquets fo;-, Brandis's 183. — „ „ Esmaroh's 181. — „ „ Pancoast's 181. — „ „ Esmarch's improvised 185. — ligature of 204. Apolyse, Neudorfer 292. Arm, Amputation of 244. — „ „ * handkerchief dressing^ for 63, 64. — bandaging the 55. — * bath-tub for 6. — disarticulation of 246. — „ „ *with flaps 246. — • „ „ * circular method 250. ■ — „ „ *handkerchief dressing for 63, 64. — fracture of, see humerus. — * plaster of Paris dressing for, re-enforced 87. — * splint dressings for 70. — splints for, * of glass 80. — „ „ * of pasteboard 75. — „ „ „ „ * improvised 132. — „ „ *of telegraph wire 133. — *Stromeyer's cushion for fracture of 111. — * triangular „ „ „ „ 111. — * transverse sections of 244. — * wire suspension splint for (Volkmann) 135. * Arteries of the arm 190. — * I) !! head, neck, and axilla 188. — * „ „ leg 190. — * „ „ thigh 189. Artery, axillary, digital compression of 170. — * brachial, „ „ „ 170. — * common carotid „ „ ,, 168. — femoral, compression, digital 170. — ,, ,, *by improvised tour- niquet 172. — femoral, compression, * by pole-pressure 178. — ,, (I * !) tourniquet 171. — ,, ,, * ,, elastic band 175. — 359 — Artery, femoral * ligature before disarticula- tion at the hip (Larrey) 281—2. — external iliac, digital compression 170. — ligature of the aorta 204 ; * of the axillary 200; *of the brachial 201; * of the common carotid 196 — 7; * of the femoral 206 — 7; *of the iliac, common 204; *of the iliac, external 205; *of the iliac, internal 204; * of the lingual 197; * of the internal mammary 342; of the middle meningeal 336; * of the popliteal 208; *of the radial 202, 203; *of the sub- clavian 198-9; *of the tibial, anterior 208, 210; *of the tibial, posterior 209, 210; *of the ulnar 203. — * occlusion by suture 14. — *popliteal, position in resection of knee 319. — sheath of, how opened for ligature 193. — * subclavian, compression of 168. — * torsion of 14. * Artery-clamp, Spencer "Wells' 13, 14. Asepsis 1, 2. Asphyxia, from chloroform, convulsive 146. — ,, ,, paralytic 146 — 7. Atmosphere, purifying by spray 5. *Anto-transfusion 215. B. *Back, bandage for 57. Ball-dressing' 56. Bandages, application of 48. . — * elastic with Lister's dressing 29. — for the arm 55; *back 57; * chest 57; * eye 54; * finger 55; * finger, disarticulation of 56; foot 58; hand 55; *head 53; *jaw 54; leg 58; *neck 62; *nose 54; * shoulder 55. — forms of: — * circular 49, 50. — — * double-headed roller 17, 51, 53—4. — — * figure of-eight 51. — — * ,, ,, for disarticulation of finger 56. — — * four-tailed, for jaw 54. — — * knotted 54. — — * many-tailed 51. — — * rapid spiral 49, 50. — — *recuirent of the head 54. — — * sagittal 53. — — *spica 51. — — * spiral 49, 50. — — *Scultetus 51. — — *T-bandage 51. — * improperly applied and gaping 51. — materials for: — cambric 48. cotton batting 26, 48. — — flannel 48. — — gauze 20, 48. — — India rubber 29. — — linen 48. — — muslin 48. — standard, for soldiers dressing-package 140. — * strangulation by 49. Bath, full 6. Baths, antiseptic 153. — to reduce temperature 47. Bath-tub, * Quincke's 6. — *for tlie arm 6. — * „ „ leK 6. Battiste, Billroth's 28. * Bead-suture, Thiersch 22. *Beirs splints 72. Bichloride of mercury, attacks metal 31. — — gauze prepared with 140. — — poisoning by 34. — — solution in water, weak 34. — — ,, ,, „ strong 34. — ,, ,, alcohol 34. — with serum, for gauze (Lister) 34. Bismuth subuitrate 39. * Bloodless method, Esmarch's 175. — — * apparatus for (Esmarch) 176. * constricting band for (Foulis) 177. — - * ,, „ ,, (Nicaise) 178. — *in amputation of thigh 178. — * in disarticulation & resection of hip 180. — * ,, ,, ,, ,, „ shoulderl78. Bladder, urinary, foreign bodies in 351. — operations on 340. — median cystotomy (AUarton) 351. — suprapubic cystotomy 350. Bladders, Pig-, as ice-bags 44. Blood-letting, see venesection. Bone, * cylinder of, for suture of intestine 346. — — substitutes for 346. — * decalcified, drainage tubes of 19. — * sawing the bone in amputations 224. — splinters of, in wounds 156. *Bone awl 319. * Bone-cutting forceps 227. * Bone-file, Marshall's 164. * Bone-forceps 290. * Bone-saw 224. * Bone-screw, with Koser's hook 335. *Boot, military, as foot-support 121. Boot-splint, Petit's 78. Borated lint. Lister's 36. Boric acid, 36. — Ointment of, Lister's 36. Bouttoniere 350. Boxes, * Fracture-, for leg 110. — *Hagedorn's glass, for catgut 15. — Sheet-metal, instead of ice-bags 44. Brass, Strips of, as retractors 295. *ii ridge-plaster of Paris dresing (Pirogoff) 92, 94. * Buckles, Emmert's 72. Bullets in the body 159. — Removal of 160. * Bullet-forceps, American 161. — *v. Langenbeck's 161. * Bullet-probe, Nelaton's 160. Bullet-searcher, electric, *Liebreich's 163. — electric, *Lecomte-Liier's 163. — „ *Lougmore's improvised 163. — „ * with acupuncture needles 168. *Button-]iole openings for drainage 23, 24. Burns, liniment for 38. c. Cauula for tracheotomy, improvised 339. — *for transfusion 213. Carbolic acid 33. — poisoning by 33. — powder 39. — solution, for hands and instruments 33, 141. — spray 5. Carbolized lime 39. Carotid, common, ligature of 196. Catgut, Lister's chromic acid 10. — Kocher's juniper 16. — Bichloride, for dressing station 141. — *Hagedorn's glass box for 15. — sutures of 23. * Carpal bones 299. Catheter, elastic 349. — secured in urethra 350. Catheterization, retrograde 350. Cautery irons 108. — * improvised of telegraph wire 168. Cavities in wounds 20. * Chain-saw 334. Chest, * bandage for 57. — * handkerchief dressing for 67. Chest cavity, drainage of 340. — 360 — Chest cavity, incision of 340. — ■ penetrating wounds of 340. Cliirotheka 55. Chloride of zinc 35. — in jute pads (Bardeleben) 35. Chloroform, administration of, for anaesthesia 144. — asphyxia from 146. — *Esmarch's modified Skinner's apparatus for inhalation 145. — stages of excitement and toleration 145. — vomiting during anaesthesia by 150. — morphine combined with 144, 401. Chronic iniiammatory changes, treatment of 47. * Circular bandage 49, 50 * Clamp, Artery- 12, 13. — *for constricting band in Esmarch's method 207 — 8. Claricle, fracture of, *Desault's dressing for 56 — 7. — fracture of, * handkerchief dressing for 66. — „ „ *Velpeau's „ „ 57. — „ „ *Sayre's adhesive plaster dres- sinfc for 124. Cleanliness of the surgeon and his assistants 2. — of the surgeon's clothing 3. — „ „ „ mouth 3. ■ — „ „ wound (asepsis) 2. Cleansing the field of operation 7. — instruments 3. — patient 6. — sponges 9. * Clove-hitch, for securing catheter in the uretlira 350. Cold applications 42. — dry 44. *Cold coil, Esmarch's 44. — *Ijeiter's for the head 45. Cold sheet, Esmarch's 44. Collodion on strips of gauze 16. Compresses, antiseptic 153. — cold 42. — excitant 48. — Preissnitz's 44, 48. — * split, as retractors 263. Compression, direct (in the wound) 167. — by the fingers 167. — „ „ dressing 167. — * „ tampon 167. — indirect (on the artery above the wound) 168. — *by the constriciing band 175. — „ forced flexion 173. — * „ pole-pressure 173. — * „ tourniquet 171. Condy's fluid 38. Constricting baud (for the bloodless method) Kicaise's 178. Continuous suture 18. Cotton, absorbent (Bruns) 26. Cotton-batting 26. Cotton-pasteboard dressing (Burggrave) 81. Counter-extension 120, 123. *Cradle, protecting 113-4. — protecting, * improvised 114. •Crico-tracheotoniy 336. Crinoline bandages 26, 48. ^CrO»n, of the trephine 381. Curette, see sharp spoon. Cushion, *Middeldorpfs 112. — * Stromeyer's 111. Cushion-dressing 27. — antiseptic 59. — * „ for amputation of the thigh 229. D. Damar-variiish 87. *Desault-Liston splint 118. * Dilating forceps (Roser) 151. Disarticulation, general rules for 229. — *of the elbow 241—2. — of the finger, * dressing for 56; *metacarpo- I phalangeal 231, 232; * phalanx II, 330 * phalanx III, 229. — of the foot 253; *Giinther's method 264 *Le Fort's 266; * Lisfranc's 253 ; *Pirogoff'i 263; *Malgaigne's 258; *subastragaloid 258 *tarso-metatarsal 253; * through the tarsus 256. — of the *four external metacarpal bones 234. — of the hip, * by transfixion, Manec 278; * circular. Vetch 280. — of the knee, *by flaps 272; * circular 271. — of the shoulder, *by flaps 246; * circular 250. — of the * thumb 233. — „ „ *toes 250. — „ „ * wrist 235, 236. — subperiosteal 284. Disinfecting oven 30. *Dobson's knee-support 109. * Dorsal splint for fracture of the radius 74. *Double-abductiou splint for fracture of the thigh (V. Renz) 109. * Double-hook retractor, v. Langenbeck 838. Double-inclined plane 108. — *Dobsou's 109. -- * Esmarch's 108. * Double splint for resection of the elbow, Esmarch 104. Drainage 19. — of the chest 340. — „ „ knee-joint 324. — with catgut strands 20. — „ glass wool 20. — „ horse-hair 20. Drainage-tube *and tampon for lectum 393. — *of decalcified bone 19. — * india-rubber 19. — * Lister's forceps for 19. Dressing, *afier venesection 212. — * application of, position of patient in 30, 32, 135, 278. — antiseptic 25. — antiseptic jjowder- 39. — compressive 167. — * cushion- 27, 59, 229. — dry 25. — first on the field of battle 142. — *. handkerchief 58. •- immovable, *of plaster of Paris 83; starch 81; gutta-percha 82; * water-glass 82; cotton- pasteboard 81. — occlusive 25. — *on head 53. — permanent antiseptic 229. — protective 25. Dressings, materials for, absorbent, cotton 26 ; crumpled gauze 25; gauze 25; jute 26; oakum 26; peat 26; sawdust 26; wood-wool 26. — impermeable, Billroth-battiste 28; india- rubber 29 ; mackintosh 28 ; oil-cloth 28 ; protective silk 28; varnished paper 28 ; waxed cloth 28. — renewal of 40. Dressing-package for the soldier 136. *Dropping-bottle for the chloroform 145. * Dropping-tube, Volkmauu's 155. Dry dressing 25. — treatment 1. E. Ecxcma, from carbolic acid 33. — from bichloride 34. 361 — Elbow, disarticulation at 241, 242. by flaps 242. — — circular metliod 241. — * ligaments of 302. — injuries of 285. — resection of 300 to 304. — — Hitter's method 304. — — *Liston's method 300. — — - partial 285. — — *v. Langenheck's method 302. — sjilints and dressings for 73, 80, 134. — — *Esmarch's double splint 104. — — * „ plaster suspension splint 99, 100. — — *Esmarch's sectional suspension splint 105. — — * fenestrated plaster dressing 93. — — *handkercliief dressing 63. — — * obtuse-angled splint 73. — — *re-enforced plaster dressing 88. — — * stirrup plaster dressing 99. — * transverse section of 63, 242. Electricity, stimulation of inspiratory muscles with 148. Elevation of injured parts 42. j *Elevator.s 289. — *Sayre's 289. ♦Emergency splints 125. * Emergency dressings 124. Extension 138. — * dressings for 117. — * for fracture of metacarpal bones 56. — * „ thigh, elastic, Esmarch 120. — * „ „ by weights 119. — * „ wrist, elastic 123. — * „ „ by weights 123. — * sectional splint for 122. * Eye-bandage 54. *Eye, handkerchief dressing for 62. F. * Fascia nodosa 53. * „ sagittalis 53. * „ uniens 53. Femur, fractures of, see thigh. — * upper end of, with muscular attachments, 327-8. Fever, aseptic 40. — septic 40. * Fibula, dissecting out the lower end of, in resections 357. Figure-of-eight bandage 51. — — * handkerchief 63. — — * after disarticulation of finger 56. Finger, disarticulation of 229. *of phalanx II. 230. *of „ III. 229. — — *four internal metacarpal bones 234. — — *in the metacarpal-phalangeal joint 231 to 232. — * dressings for 55. — * Esmarcii's bloodless method for 178. — fractures of, treatment 55. — injuries of 55. Flail-joint 292. — * apparatus for 304. * Flap-splint for fracture of the forearm 77. * Flower-pot trellis-work, as splint 321. *Fold.suture 20. ^ Foot, * amputation of 251. -- bandages for 58. — disarticulation of, by * Giinther's method 204; *by Le Fort's method 266; *by Piro- goff's metliod 203; * by Syme's method 260; bubastragaloid (Malgaigne) 258; tarso-meta- tarsal (Lisfranc) 253; through the tarsus (.Cliopartj 250. Foot, *handkerchief dressing for 67. — * support for, improvised from boot 121. Forceps, *Amussat's 20; * artery clamp- 13; *bone 218; * bone - cutting 226 (and see rongeur); *bulletl60; *dilating, (Roser) 151 * drainage-tube (Lister) 23; * EaraboeuPs bone- 290; * lion-toothed (Fergusson) 290; tongue- 147; * toothed clamp- 339; * seques- trum 164; *v. Langenheck's bone- 290. Forearm, amputation of 238; * circular method 218; *by skin-flaps 220. — fractures of, * abduction splint for fracture of radius 73. • — * danger of circular bandage in 77 — 8. — * dorsal splint for fracture of radius 74. — *flap-splint for 77. — * pasteboard splint for 76, 88. — * right-angled splint for (Stromeyer) 73. — re-enforced plaster dressing for 93. Fractures, dressings for, Arm: — improvised 134; plaster of Paris 88; splints 70, 75, 80; Stromeyer's cushion 111; triangular cushion 113. — — Clavicle, adhesive plaster dressing 124 ; bandages 56 — 7; Handkerchief dressing 66. — — Finger; dressing for 55. — — Forearm; — plaster of Paris 93; splints 73, 76, 77, 132, 134. — — Jaw 54, 62. Leg: — concave splint 72; fracture-box 110; improvised 70; Mo Intyre's splint 110; pasteboard splint 81; plaster of Paris 85. — — Metacarpal bones 56. Patella 69. — — Radius, splints 73, 74. Eib 342. Skull 331, 334. -- — Thigh: — double-abduction splint 109; extension, elastic 121; extension splint 118; portable extension splint 122; Goooh's coaptation splints 120; plaster of Paris 89; splints 72, 76. Fuuda maxillae 54. i G. Gangrene, hospital- 35. Gauntlet-, or glove-bandage for the hand 55. Gauze, bandages of 26. — crumpled, dressing 25. — starched, bandages 26. * Genitals, male, bloodless method applied to 1 78. Glass bottles instead of icebags 44. — * irrigator 10. — * splints 80. — tray for instruments i. Glottis, oeddma of 336. Glover's suture 18. Gnawing forceps, for bone, see rongeur. *Gooch's splints 120. Gouge and mallet 332. — * for removing dagger-points, etc. from bone 332. Gunshot fractures 155. — wounds 150. (Jutta-pcrchii splint 82. Graduated glass cylinder 214. (Jraftiiig skin 18. Granny-knot 17, 60. Granulations, healty 155. Gymnastics, therapeutic 48. Gypsum, see plaster of Paris. H. Hair, removal of, around wounds 7. Halter bandage for the head 53. — 362 Haud, dressing for 55. — * elevation of 42. — * figure-of-eight handkerchief dressing for 63. — * handkerchief dressing for 63. — * Stromeyer's splint for 73. — * tendons on dorsum of 298. Uaudkercliief dressing for *aniputation of arm 64; * for arm 63 — 5; * clavicle 66; * elbow .63: *eye 62; *foot 67; * genitals 69; * groin 68; *hand 63; *head 60; *hip 67; *jaw 62; *knee 67; *neck 62; *pa- tella, fracture of 69; *pelvis 67 — 8; * shoulder 64; * thorax 66. Haudkercliief, large triangular 58. Head, * double-headed roller for 54. — * handkerchief dressing for 60. — * knotted bandage for 58. — * sagittal bandage for 53. Healing of wounds under the scab 39. Heart, paralysis of, by chloroform 145, 148. Heat, reduction of 42. Heel-support, Esmarch's 30. Heiuo-piieuiiio-thorax 340. Hemorrhage, arrest of, *by a suture (,,TJm- stechung") 14. by cautery 168. — — *by compression, direct 167; indirect 1C8. by ligature, direct 12, 187; indirect 191. — — by styptics 167. *by torsion 14. — death by 213. — from diploe of skull 335. — „ middle meningeal artery 336. — parenchymatous, cold water for 184. — secondary, after bloodless method 184. — ,, ,, resection of knee 321. — transfusion of blood, salt solution, etc. 213. Hip, * application of bloodless method to 180. — * disarticulation at, by circular method 280; *by transfixion 278. — * handkerchief dressing for 67. — injuries of 287. ■ — * ligaments of 328. — * muscles posterior to, (with sciatic nerve) 325. — resection of, dressings for 29, 118. — „ ,, *posterior curved incision 324. - — ,, ,, * anterior longitudinal incision 329. — ,, ,, * renewing dressings after 115, 331. — resection of *subi5eriosteal (longitudinal in- cision) 326. *Hooks, blunt, for retractors 152. — * improvised ,, ,, 152. — * sharp ,, ,, 152. ,, for bone 289. — silver wire, for, tracheotomy 339. — * strabismus 338. Hospital-Cfaiigreiie 42. HumerHS, fractures of, pasteboard splint for 133. — — splints for 70. ■ — — * Stromeyer's cushion for 111. * Triangle for, Middeldorpf's 113. — *head of, sawing oS, in resection of shoul- der 307 — 8. — * upper extremity of, with muscular attach- ments 307. Hydrogen, peroxide of 38. Hypcraeiiiia 42. Hypodermatic injections 351. I. *Icel)ag 44; improvised 44. *Ice->vater douche, for parenchymatous hemor- rhage 184. Illumiuatiou, see light, artificial. Immersion, antiseptic 158. — to reduce local temperature 47. Impermeable materials 28. * Impregnation of bandages with plaster of Paris 85. — of materials for dressings prepared with acetate of alumina 37; bichloride of mercury 34; boric acid 36; carbolic acid 33; iodoform 36; naphthalin 38; thymol 38. Incisions for ligature of the arteries, site of 191 — 192. Inclined plane, * double 108. — * double, Esmarch's adjustable 42. India-rubber bandages 29. — — cloths for use in operations 7, 8. — — materials 29. — — • * sleeves and aprons 3. tissue 28. — — *tube with knobs and hooks for exten- sion 121. — — tubes for drainage 19. Indications for amputation and resection 157. — for indirect ligature of arteries 191. — for operative treatment of injuries of the larger joints 284. Infection, septic 2. * Injections, hypodermatic 351. Instruments, cleaning the 3. * Interrupted plaster of Paris dressings 92. — * suture 17. Intestine, suture of, * continuous suture 344. — — *Czerny's (double) 344. — — *Jobert's 344. — — *Xeuber's 346. * Wolflers (.internal) 346. — resection of 345. — wounds of 343. * Inversion, Nelaton's method of 148. Iodoform 35. — ether 35. — gauze 36. — ,, adhesive, Billroth 36. — poisoning by 35. — powder 35, 39. Irrigation, * final, of wounds 24. — pevmaneiit antiseptic 37, 153. — * ,, ., Starke's apparatus for 154. — to reduce temjjeratuve 46. * Irrigator 10. — * improvised (Thiersch) 10. J. JaiTS, * four-tailed bandage of lower 54. — * handkerchief dressing for 62. — gunshot fractures of 62. — * pushing forward the, in anaesthesia 147. Joints, flail-, * apparatus for 304. — injuries of, treatment 158, 284: — ankle 286; elbow 285; hip 287; knee 287; shoulder 285; wrist 284. — resection of 288. Jute 26. K. *Keyliole-sa>T 290. * Knee-support, Dobson's 109. Knee, drainage of 324. — * handkerchief dressing for 67. — injuries of 287. — ,, ,, * interrupted plaster dressing for 94. — * ligaments of 318, 323. — resection of, *incision convex above 318; * anterior curved incision 317; subperiosteal 322. — 363 Knee, resection of, * interrupted plaster dressing for 94. — resection of, *interrupted plaster dressing for, of hemp 95. — resection of, * plaster suspension splint (Watson) 96—7. — resection of,* secondary hemorrhage after 321. — „ ,, * splints and dressing for 78 79 81, 96, 321. — resection of, * Watson's splint for 74. Knife, * amputation 217. — * ,, Langenbeck's 221. — * aseptic 4. — * blunt-pointed resection knife 353. — * interosseous 224. — * resection 289. — * ,, blunt-pointed 308. — * ,, probe pointed 308. Knots, * granny- 17, 60. — *proper method of tying, for ligatures 195. — * square, or reef- 12, 17, 60. — * Surgeon's 18. L. Laparotomy 344, 348. *Laryngotoiny 336. Larynx, *aiiterior view 337. — injuries of 336. * Lath-plaster dressing (Pirogoff) 93. *Leadplate sutures 22. Leg, amputation of, in lowest third 227, 268; in upper two thirds 225, 268. — bandaging of 58. — * bathtub for 6. — fracture of, dressings for: — * Bavarian splint 84; * Bell's splints 72; *box for 110; * glass splint 81; * hemp-plaster splint 85; * impro- vised 70 ; *IMac Intyre's splint 110 ; pasteboard splint 77; *Petit's leg fracture box 110; * reinforced plaster of Paris dressing 90; *Scheuer's leg-splint 111; * Schnyder's cloth splint 71 ; * sheet-metal splint 78; * telegraph- wire splint 134; * wire splint 79. * Lifting-frame, v. Yolkmann's Ii7. * Lifting, appaiatus for 117. Ligament, crico-thyroid, incision of 336. Ligaments, *of ankle 312 — 4; *elbow 302; *hip 328; *knee 318, 323; * shoulder 309; * wrist 293. Ligature, direct (in the wound) 187. — — * application of the ligature 190. — — bloodless method in 188. — — ,, ,, ,, with blood ,, reser- voir" 189. — — for diffuse traumatic aneurism 188. — — incisions for 187. — indirect (Hunter), in the continuity of the artery 191. — — * aneurism-needle, mode of using 195. — — * exposing and opening the sheath of the artery 193. — — * incision, making the 191. — — * ,, site of, for each artery 192. — — indications for 191. — — * isolating the artery with a probe 195. — — marking the incision l)eforehand 191. — — * separating the cellular tissue 191. — — square knot for ligature 195. — of the aorta 204; * axillary 200; * brachial 201; *brachial at tbe bend of the elbow 202; * common carotid at the level of the cricothyroid ligament 196; *do. between the heads of the sternomastoid 197. ■■ of the femoral, * before disarticulation of the hip (Larrey) 201; do., * below Poupart's liga- ment 206; *do., below the origin- of the profunda 207; * common iliac 204 : * external iliac 205; internal iliac 205. Ligature, of the internal mammary 342; middle meningeal 330 ; *linguall97; * popliteal 208 ; * radial, in upper third of forearm 202 ; * do., above the wrist 203; * subclavian, above the clavicle 198; *do., below the clavicle 199. — of the tibial, *anterior, above the middle of the leg 208. — of the tibial, * anterior, in the lowest third of the leg 210. — of the tibial, * posterior , above the middle of the leg 209. — of the tibial, *posterior, behind the internal malleolus 210. — of the ulnar, *in the uppermost third of the forearm 203. — of the ulnar, * above the wrist 203. * Ligatures, tying, with artery forceps hanging 13. Ligllt, artificial 352. — *from spriug-candlestick (Ravoth) 853. — * improvised reflector 353. — *wax taper 352. * Lion-toothed forceps (Fergusson) 290. Lithotomy position 349. Litter, * extension dressing for use on a, (Esmarch) 121. * Loins, handkerchief dressing for, (Koser) 68. M. *Many tailed bandage 51. *Mask for inhalation of chloroform 145. Massage 48, 33G. * Mattress-suture 20. Maxillary bones, gunshot fractures of 62. Mercury bichloride, see bichloride. Metal (Sheet-) boxes instead of ice-bags 42. — splints of 78. Mitella, see sling. *Mitra Hippocratis 54. Morphine with chloroform in anaesthesia 144, 150. — hypodermatic injections of 401. Moss (Torfmoos) for dressings 26. Muscles, * attached to upper extremity of fimiu- 327—8. — * attached to upper extremity of humerus 307. — division of, in amputations 220 ff. — flaps of, amputation, * Langenbeck's method 223; oval method 223 ; * Verduin's method 223. — * on radial side of wrist 294 — 5; *ulnar side 293; *of hip 325. — suture of 228. N. Naphthaline 38. Narcosis, see anaesthesia. Neck, dressings for 62. — * handkerchief dressings for 62. — * ,, )j )) with pasteboard splint 02. Necrosis, operation for 164. Needle, * aneurism 195. — Hagedorn's 166. — Wolberg's 166. Needles 17. Nerve, * ulnar, behind elbow joint 301. — * sciatic, at hip joint 325. — suture of 166. — stumps of, in amputations 227. * Nose, bandage for 54. 0. Oakum 26. Occlusive dressing 25. Oil-cloth 28. — 364 Operations by artificial light 352. — - * surgeon's dress for 3. — * table for 7. Os calcis, * dissecting out the, in Syme's opera- tion 261. — * sawing the, in Pirogoff's operation 263. — * ,, ,, ,, Giinther's ,, 265. — * ), ,, ), the Le Fort -Bruns operation 267. * Osteotribe, Marshall's 164. Oral method, in amputations (Langenheck) 223, 231, 233. P. *Pad for tonrniqnet, improvised 182. Paper, varnished 28. Paralysis of disuse 292. Parciinient paper for icebags ii. PassiTe motion 292. Pasteboard splints 75; *for arm 75: * forearm 76; *leg 77; moulded 75. Paste-dressings, see starch-dressings. Patella, *fractures of, handkerchief dressing for (Major) 69. Peat as a material for dressings 26. Peatmoss, as a material for dressings 26. Pelvis, support for, *Bardelebeu's 89, 90; *Es- marrh's 89, 90; *Volkmann's 29. — * handkerchief dressing for 69. Periosteum, *detaching a flap, of in amputations 217. — preservation of, in resection 288. — suture of 228. , Permanganate of potasli 37. Peroxide of hydrogen 38. * Phalangeal saw 227. *Plilebotonie (Lorins) 212. Phlebotomy 211. Pig-bladders as ioebags 44. Pin, Carlsbad hare-lip pin 21. — * safety 60. Plane, *inclined, adjustable (Esmarch) 42. — * inclined, double 108. Plaster, adhesive, Crosby's extension by 118. — diessiug of, for fracture of the clavicle 123 to 125. — English 16' Plaster of Paris, bandages 85; application of 85; preparation of 85 ; * machine for making 85. — * Bavarian splint of 84. — *box for 85. — *ijridgc-, or lath-dressing of, (Pirogoff), 93. — croam of, hardening 83; preparation of 83. — dressings, applicatirn of 85. — ,, * fenestrated 87, 91. — ,, * interrupted, for elbow 94: *for leg 93; *for resection of knee 91; *with stirrups 94. — dressings, *made with coarse sack-cloth 84. — ,, * re-en forcenient of 87, — ,, removal of 87. ■ — ,, * suspension of 92. — ,, waterproof 87. — ,, *with bandage of Scultetus 83. — Esmarch's suspension sjilint of, * for resec- tion of ankle 99; *of elbow 100; *of wrist 101. — * hemp-splints of, for resection of knee (Eeely) 95. — * knife for removing dressings of 87. -■ removable splint of 98, 99. — * shears for removing diessings of 87. — * Watson's splint of 98. — to restore when spoilt 84. Position of patient in applving dressing 30—2, 135, 278. Position, treatment of injuries of limbs by 106. Potasli, permanganate of 37. * Pott's lateral ijosition 106. Potvder-dressings, antiseptic 39. Pravaz syringe, see hypodermatic syringe 351. Preparation of dressings, see impregnation. * Probe, block-tin, with wiper attached 161. — * bullet, Xelaton's 160. — militai-y 160. Protective dressing 25. — silk (Lister) 28. *Pruning-shears, American 342. Pulse, in administration of chloroform 144, 146. * Pus-basins lo. — *kidiieyshaped 12. Pyo-pneumo-tliorax 340. R. Badius, fracture, of, * abduction splint for 73; * dorsal splint for 74. — *sawins off the, in resection of the wrist 296. * Raspatory 217, 289; *v. Langenbeck's 164. * Reamer for bone 164. Re-aniputatiou 283. * Rectum, drainage-tube and tampon for 348. — gunshot injuries of 348. * Reef-knot 17. — *tied in a handkerchief 60. Re-enforced plaster of Paris dressing *for arm 89; * elbow 93; * forearm 88; * thigh 89. * Reflector, improvised 353. Reflex of pneumogastric under chloroform 146. Resection of intestine 345, 346. — of joints and bones, general rules 288. — — ankle 310; * osteoplastic, through tarsus 315; * subperiosteal (v. Langenheck) 310; dressings for, see tinder ankle. — — elbow according to Hiitcr 304; *v. Langen- heck 302; *Listou (T-iucision) 300; partial 285 ; dressings for, see under elbow. — — forearm, * lower ends of its bones 292. — — ■ hip 324; anterior incision 329; *posterior curved incision 32 1 ; * subperiosteal (longi- tudinal incision) 326; dressings for, see under hip. knee 317, * anterior curved incision 317 ; incision convex above 318; * subperiosteal (lateral curveil incision) 322; dressings, see under knee. — — *portions of the skull 331, 334. *iib 342. — — * scapula, glenoid process of 310. — — shovrlder 305; * old method 305; * sub- periosteal 308. — — stump of bone, in re-amputation 283. — — wrist , complete 297 ; for dressings, see under ivrist. — * knife for 289; * probe-pointed 308. — partial (atypical) 157. — *saw for 289, 290, 291. — subperiosteal 288. — total (complete) 157. ■Respiration, artificial, * Silvester's method 148. — in chloroform anaesthesia 144, 146—7. Retractors, * blunt 152. — *cloih, for soft paits in amputation 225. — *improvised 152, 339. — * sharp 151 — 2. — *strii)s of brass for 289. — wire for, in tracheotomy 339. * Reversed bandage 50. Rib, comijouud fracture of 340. — * resection of 342. Rongeur, *Hot1mann's 331; *Luer's 331. Rubber, see india-rubber. Rushes, mat of, used as splint 126. — 365 — S. - * Safety-pill 60. Salicylic acid 37; powder 37; ointment 37; glycerine-ointment 37. — cotton prepared with 37. Salt-solntioii, transfusion of 213. * Sanitary corps with straw mats 128. Saw, *for amputation 224; * Butcher's 224; * chain 290; * key-hole 290; * phalangeal or metacarpal 227, 290; * resection 291; * small 227, 290; *Szymanowsky's resection 291. Scab, wounds heal under a 39. Scarification, multiple 153. * Sciatic nerve 325. *Scultetus, many-tailed bandage of 51. Section, transverse, * of arm 244—6; * elbow- joint 242: * forearm 238 — 240; *leg269 — 271; *thigh 275 — 7. Sepsis, symptoms of, in wounds 151. Sequestrotomy 164. *Sef|uestrnni-forceps 164. Shears, *Ame]ican pruning-shears 342. — *for plaster of Paris dressings 87. Shoulder, * bloodless method applied to 178, 180. — inflammation of, * re-enforced plaster dres- sing for 88. — injuries of 285. — * ligaments of 309. — *Itesection of 305; *handkeichief dressing for 63 — 4; *old method (v. Langenbeck) 305; * subperiosteal oiS; *of scapula 310. Silk, Czerny's antiseptic 16. Skill, cuff-like flap. * formation of 218. — * flaps of, amputation by 218, 220. — incisions in, * for ligature of the arteries 192. — ,, ,, * ,, operations, how made 191. — ,, ,, * ,, drainage 23. — stimulation of, to restore respiration 148. — * suture of 228. - transplantation of (Keverdin) 18, 155. Skull, *biood-Tessels on internal surface of 335. — injuries of 331. — ■ *trephioing the 334. Slide, * Volkniann's, for fracture of the leg 120. Sling, *",arge 65; *improvised 130; *triangular 63; * small 63. Soft parts, * division of, in amputation 221, 222. — * retracting the, in amputation, to saw the bone 226. Spica-bandage 51. Spiral bandage 50. Sponges, aitificial antiseptic 8. — at the dressing station 141. — cleansing the 9. Spoon, sharp 151. Splints, * anterior, for resection of ankle, V. Volkniann's 102. — * Bavarian 84. — * Bonnet's wire-breeches 107. — *Esmarch'8 wire-breeches for transport 107. — * ,, double-splints for resection of the elbow 104. — * Esmarch's sectional suspension splint for the elbow 105. — for the arm, pasteboard 75; wood 70. — — * elbow, obtuse-angled 73. — — finger 55. foiearm, *flap-8plint 77; * pasteboard 76 ; *Stromeyer's right-angled 73 ; supination- 74. — — *hand, Stromeyer's 73. — — *knee, Watson's 74. — — leg, * Bell's wooden 72; * emergency 70; * pasteboard 77; lower extremity, * of cloth 70; * glass 80; *tin 78; * wire 79. Splints, for the thigh, * Bell's concave wooden 72; *Desault-Liston's 118; *Gooch's 70, 120; * pasteboard 76. — for the upper extremity, *abduction, for frac- ture of radius 73; * dorsal, for same 74; * glass 80; wire-netting 79, 80. — improvised (emergency-splints), *of flower-pot trellis-work 127; *parts of the uniform 129, 130; * pasteboard 131 — 3; * rushes 126; *sheet-zinc 131; *straw 126; *telegraph- wire 133; *tvvigs 125; *weapons 129. — materials for, — cloth 71 ; glass 80 ; pasteboard 75; plaster of Paris (which see) 83; sheet metal 78; starch-paste 81; wire 79; wood 70. — * modeled 72. — * plaster of Paris suspension splint 92. — * sectional, for extension of thigh 122. — *stiirup-, Esmarch's, for resection of ankle and wrist 103. — * wire-sufpension 97 to 101, 134. Splint-material, *.-^chnyder's 71; Esmarch's 70. Spray, * apparatus for (Richardson) 5. — carbolic, use in the field 141. *Sfiuare-knot 17; *with handkerchief 60. Statt", grooved lithotomy- 349. Stagnation of blood and lymph 2. — venous 49. Starch-bandages 81. Starch-dressings 81; * removable 82. Starch-splints 81. * Steel nails for bones 319. Sterilization 30. Sterilizing oven 30. Stirrup bandage for the foot 58. Stirrup-dressing 103. =^' Strabismus-hook 338. * Straps with buckles, for splints 72, 120. * Straw-mats 126. *StraiT-spliiits 126. * Stretcher, for lifting the injured 114. *Stronieyer's cushion for fracture of the armlll. Stump after amgutations * by the circular method of Celsus 219; *by ciicular skin-flap 221; * conical 283. Styptics 167. * Supination splint 74. * Suspension of the foot 43; *hand, vertical 42 — 3; * lower extremity in a plaster dressing 92. — *wire for 98. *Suspeusion-spliuts 96. Suspension of injured part 42, 92, 95 — 103, 131, 133. Suspension splints, *improvised from telegraph wire 98; * sectional, for resection of the elbow 105; *Volkmann's 42; * wooden 96. * Suspensory-bandage, Dnna's 69. Sutures, forms of, — *bead (Thiersch) 22; combined 23; continuous, or glover's 18; *deep 20, 228; epidermis, of Bonders 55; *fold 20; * hare-lip 21; * interrupted 17; * lead-plate (Lister) 22 ; * mattress 20 ; * quilled 21; relaxing 23; sunken catgut 23; twisted 21. — *in amputations 228. — materials for 17. — of intestine 343; muscles 228; nerves 1G6; periosteum 228; temlons 100. Syncope, from chloroform 146. Syringe, *hypodeimatic 351. — for transfusion 215. T. Tampon, * antiseptic, for wounds 167. — * with drainage tube, for rectum 343. 366 Telegraph wire, * splints of 98; *for arm 134; *for leg 135. Temperature, reduction of 42. Tendons, *of dorsum of hand 298; *of knee, internal side 322; * of long head of biceps 306; of wrist 293—5. — - suture of 166. Testudo 55, 58. T]iigh, * amputation of 275. — * ,, „ position of patient for dressing after 278. — * bloodless method applied to 178. — * cushion dressing for amputation of 229. — * elastic extension of, with Esmarch's sectional splint 122. — * fracture of, double abduction splint (v. Renz) for 109. — *Desault-Liston splint for 118. — * extension by weights for 119. — *Gooch's coaptation splints for 120. — * re-enforced plaster dressing for 89. — *transverse sections of 273 — 7. Thoracocentesis 340. Thorax, * anterior view of 341. — * bandage for 57. — * handkerchief dressing for 66. Thumb, * disarticulation of 233. Thymol 38. Thyroid gland, retro-fascial dissection of 338. Toe, * disarticulation of great 252; * of fifth 253. Toes, disarticulation of 250. Tongue, *drawing it forwards in anaesthesia 147. — * forceps for the 147. Torf-moos for dressings 26. * Torsion of arteries 14. Tourniquet, * improvised club- 173; * improvised lever- 172; * metal spiral spring (Esmarch) 186 — 7; * screw- 171; *trouser-suspenders-185. Trachea, * anterior view of 337. Tracheotomy 336. Tracheotomy-tube, *Luer's 339; improvised 339. Transfusion of blood 213. — *of salt-solution 213. Transplantation of skin 18, 155. Trellis, flower-pot, *as splint for leg 126; *for knee 321. * Trephine 333; *mode of using 335. Trephining 331. * Triangle, MiddeldorpPs 111. Triangular handkerchief for dressings 59. Tupfer, see iviper. * Twigs, splints of 125. u. Urethra, rupture of 350. Urethrotomy, external 349. Urine, infiltration of 349. T. Tarnished paper 28. Vein, femoral, ligature of, * before disarticulation of hip (Larrey) 281. Vein, median-basilic 202, 211, 213. — * opening a, for transfusion 213. — * popliteal, relations to wound in resection of knee 319. Venesection, * dressing after 212. — with lancet 211; with phlebotome 212. Vomiting during chloroform anaesthesia 150. w. Water-proof materials for dressings 28. Water-glass dressings 82. *Wax taper 352. Waxed-cloth 28. Wet applications, see compresses. * Wipers, antiseptic 8. Wire-breeches, * Bonnet's 107. — * Esmarch's 107. *Wire mask for inhalation of chloroform 145. * Wire-netting, splints of 79, 80. *Wire suspension splint for arm 134; *for leg 135. Wood, sawdust of 26. — - splints of 70. Wood-wool 26. Wood-flbre 26. Wounds, amputation-, * uniting 227. — cleanliness of 2. — discharge of, removed absorbed by dressing 25. — dry treatment of 1, 25. — injurious influences 1. — cavities in 20. — contused and lacerated, of fingers 55. — gunshot, examination of 150. — healing under the scab 39. — suture of 17. — treatment of, open 41. — uniting edges of 16. Wrist, disarticulation of, *by flaps 236; *by radial flap 236; * circular method 235. — extension of, * elastic 124; *by weights 123. — injuries of 284. — * ligaments of 293. — muscles and tendons of, * radial side 293; * ulnar side 294 — 5. — * pasteboard splint for injury to palmar surface 132. — plaster suspension splint for resection, of, * Esmarch 103. — plaster suspension splint for resection of *Iiister 113. — * resection of 297. — * section through 296. by drainage 19; z. Zinc oxide of 39. — * sheet-, splints of 131. A. HOPi'ER, BUBU. \ COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as j provided by the rules of the Library or by special arrange- ment with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE , C28(i14i)m100 COLUMBIA UNIVERSITY LIBRARIES (hsi stx) RD 151 Es5 1888? C.I The surgpfin e h^nrii^nn!. nn f'-,p treatirient 2002131218 RD151 ismaroh Es5 1888?