,transcriber's ,note ,italic text displayed as3 italic ,bold text displayed as3 bold ,,the ,,essentials ,,of ,,bandaging2 ,,including ,,the ,,management ,,of ,,fractures ,,and ,,dislocations1 ,,with ,,directions ,,for ,,using ,,other ,,surgical ,,apparatus4 ,,illustrated ,,by #abb ,,engravings ,,on ,,wood4 ,,by ,,berkeley ,,hill1 ,m4,b4 ,,lond41 ,f4,r4,c4,s41 ,instructor in ,bandaging1 c41 in ,university ,college1 ,assistant ,surgeon to ,university ,college ,hospital1 and ,surgeon to ,out-patients at the ,lock ,hospital4 ,,second ,,edition1 ,,revised ,,and ,,enlarged4 ,,london3 ,,james ,,walton1 ,,bookseller ,,and ,,publisher ,,to ,,university ,,college1 #acg1 ,,gower ,,street4 #ahfi4 ,,london3 ,,bradbury1 ,,evans1 ,,and ,,co41 ,,printers1 ,,whitefriars4 ,,preface ,,to ,,the ,,second ,,edition4 ,in laying a ,second ,edition before the public1 ,i have decided not to alter the scope of this little work1 but simply to endeavour to increase its usefulness1 by remedying omissions1 and by adding new instructions where such appeared desirable4 ,i have ventured to insert1 as an ,appendix1 lists of the preparations requisite for the sick room and for the operating room before the ordinary operations of surgery are performed2 also1 lists of the instruments and appliances requisite1 or possibly useful1 in performing forty-nine different operations on the human body4 ,it is hoped that1 by giving the surgeon a list1 such as most operators draw up in manuscript for their private use1 whereby they may check their preparations before proceeding to operate1 some trouble may be saved4 #ad1 ,,weymouth ,,street1 ,w4 ,november1 #ahfi4 ,,preface ,,to ,,the ,,first ,,edition4 ,the descriptions and directions for using surgical apparatus in the following pages1 are those originally prepared for oral delivery in a short course of practical lessons in bandaging and the application of surgical apparatus1 given by me in ,university ,college ,hospital4 ,no attempt is made to include all efficient modes of treating surgical injuries3 it is merely proposed to supply the student or practitioner with instructions by which he may refresh his memory when about to employ the ordinary surgical appliances4 ,the drawings are by ,mr4 ,r4 ,w4 ,sherwin1 who has taken much pains to furnish exact representations of the apparatus1 as it was applied by myself for his delineation4 ,the directions for giving chloroform have had the advantage of ,mr4 ,clover's revision before publication4 #ad1 ,,weymouth ,,street1 ,w4 ,october1 #ahfg4 ,,contents4 ,,chapter ,i4 ,,bandaging4 ,,page ,general rules4--,different materials of bandages4--,position of the operator4--,mode of holding the bandage4--,varieties of turns2 the simple spiral2 the reverse2 the figure of #h4 #a-c ,bandaging the head4--,the common roller4--,the knotted bandage4--,the ,capelline bandage4--,the shawl cap4--,the four-tail bandage4--,fastening ice bladders to the head4--,compressing the jugular vein #c-h ,bandaging the trunk4--,the breast4--,the groin4--,after operation for hernia4--,for tapping the belly4--,the ,t-bandage4--,the strait jacket4--,manacles for delirious patients4--,to suspend the testicles #h-ac ,bandaging the upper extremity4--,the fingers4--,the thumb4--,the hand4--,the fore-arm4--,the elbow4--,the shoulder4--,the axilla4--,wound of the palmar arch4--,bleeding at the elbow #ad-bj ,bandaging the lower extremity4--,the foot4--,the leg4--,the thigh4--,the heel4--,the toe4--,the knee4--,a stump4--,extending a stump4--,the many-tailed bandage4--,elastic socks #ba-bd ,,chapter ,,ii4 ,,strapping4 ,general rules4--,strapping the breast4--,the testes4--,joints4--,ulcerated legs4--,scott's mercurial dressing #be-bi ,,chapter ,,iii4 ,,treatment ,,of ,,fractures4 ,the head and trunk4--,of the lower jaw2 by the external splint and bandage2 by interdental splints1 ,morell ,lavalle's plan2 fitting a cap to the teeth4--,of the ribs2 by plaster2 by a body roller4--,of the pelvis #cj-cg ,the upper extremity4--,of metacarpal bones2 by a gutta-percha glove2 by a ball of tow4--,of phalanges4--,of the lower end of the radius2 by the pistol splint2 by the gutta-percha gauntlet4--,of both bones of the forearm4--,of the olecranon2 by figures of #h and an inside splint2 by ,hamilton's plan4--,of the humerus near the elbow2 by lateral hollowed splints2 by a gutta-percha ,l-shaped splint4--,of the shaft of the humerus4--,of the anatomical or surgical neck1 and of the great tuberosity of the humerus1 by a cap for the shoulder4--,of the acromion4--,of the clavicle2 by an axillary pad and elevation of the elbow2 by a figure of #h behind the back2 the ,american ring pad #cg-ei ,the lower extremity4--,rupture of the tendo ,achillis4--,separation of the epiphysis of the os calcis4--,fracture of the fibula1 by ,dupuytren's splint4--,of the tibia1 by ,mc,intyre's splint2 slinging the splint2 elevating it on a block4--,transverse fracture of the tibia1 by lateral splints2 in the flexed position4--,of the patella2 by back splint and figures of #h2 by ,malgaigne's hooks2 by strapping plaster and stick4--,of the shaft of the femur2 by ,liston's method of using the long splint2 by using elastic extension2 ,coxeter's elastic perineal band2 elastic stirrup4 ,by continuous extension with the limb bent2 tendency to angular union2 double incline planes2 slinging the double incline planes in fracture of the neck of the femur2 by continuous extension of weight and pulley #ei-hj ,the starch bandage4--,the plaster of paris bandage4--,plaster of paris splint4--,gum and chalk and other stiffening mixtures4 --,sand-bags4--,cradles2 ,salter's swing cradle #ha-ij ,leather splints2 ,splint for the hip #ij-id ,,chapter ,,iv4 ,,dislocations4 ,general rules4--,of the lower jaw4--,of the clavicle4--,of the shoulder2 signs of dislocation into the axilla2 when beneath the clavicle2 when behind the scapula4 ,modes of reduction2 by the heel in the axilla2 by simple extension4 ,the clove-hitch knot4--,of the elbow1 signs when both bones go backwards2 distinctions between dislocation and fracture near the elbow2 the mode of reduction by the knee inside the fore-arm2 by extension at the wrist4--,of the radius1 only1 by extension at the wrist4--,of the thumb and fingers2 handle for commanding the phalanx4--,at the hip2 signs of dislocation backwards1 reduction by extension2 by manipulation or leverage2 signs of dislocation downwards1 mode of reduction2 signs of dislocation on to the pubes1 mode of reduction4--,of the knee2 incomplete1 lateral1 and posterior2 mode of reduction4--,of the patella1 mode of reduction4--,of the foot1 mode of reduction #id-aaj ,scarpa's shoes4--,varieties of talipes2 equinus1 varus1 valgus2 points to be attended to in fitting the shoe4--,casting in plaster of paris #aaa-aad ,,chapter ,v4 ,,miscellaneous4 ,the ,hair suture4--,the eye douche1 drops for the eye4--,syringing the ears4--,epistaxis2 ,ice-cold injection2 ,plugging the nares2 ,belloc's sound4--,drawing teeth2 varieties of forceps2 extracting incisors and canines1 bicuspids1 upper molars1 lower molars1 wisdom molars1 roots2 the elevator4--,stopping bleeding after extraction4--,sore nipples2 nipple shields4--,plugging the vagina2 ,kite's tail plug for vagina4--,injecting the urethra4 ,catheters1 silver2 different kinds of flexible catheters and bougies2 conformation of the urethra4--,passing catheters and bougies2 difficulties in doing so2 passing the female catheter4--,washing out the bladder4--,tying in catheters4--,position for lithotomy4--,bed-sores1 applications to prevent the formation of bed-sores2 the floating bed2 the water-cushion4--,the stomach-pump1 when used to empty the stomach or to inject food4--,transfusion of blood2 precautions2 mode of using the apparatus4--,tourniquets2 the ,ring2 ,petit's2 ,signoroni's2 ,carte's2 ,lister's2 the make-shift4--,mercurial fumigation2 general2 local4--,hot air baths4--,vapour baths4--,sick carriage4--,cupping4--,junod's boot4--,leeches4--,stopping leech bites4--,tents4--,setons4--,drainage tubes4--,issues4--,trusses1 requirements of1 inguinal1 femoral1 umbilical1 ,salmon and ,ody's4--,cauteries1 iron2 gas2 galvanic4 ,caustics4--,vesicants1 mustard1 cantharides1 iodine4--,corrigan's hammer4--,poultices and fomentations4--,lister's mode of dressing with carbolic acid4--,irrigation2 ,esmarch's irrigator4--,administration of chloroform1 precautions2 dangers2 methods2 ,clover's inhaler4--,artificial respiration4--,local ansthesia4--,ether spray1 pulverised fluids4--,chloroform vapour to the uterus4--,subcutaneous injection4--,collodion4 --,vaccination #aaf-aib ,,list ,,of ,,appliances ,,for ,,the ,,operating ,,room ,,and ,,the ,,sick ,,room4--,,list ,,of ,,sedatives ,,and ,,restoratives4--,,for ,,the ,,arrest ,,of ,h,,morrhage #aie-aig ,,list ,,of ,,instruments ,,employed ,,in ,,operations-- ,,on ,,the ,,head ,,and ,,neck4 ,trephining the skull4--,operations on the eye4--,hare-lip4--,resection of the jaw4--,excision of the tongue4--,cleft palate4--,excision of tonsils4--,laryngotomy4--,tracheotomy #aih-bjb ,,on ,,the ,,trunk4 ,removal of breast or tumours4--,nvus4--,tapping the pleura4--,tapping the belly4--,colotomy4--,ovariotomy4--,csari an section4--,strangulated hernia4--,radical cure of hernia4--,hmorrhoids4--,fistula in ano4--,cleft perinum4--,extirpation of the cervix uteri4--,amputation of the penis4--,circumcision4--,excision of testis4--,tapping a hydrocele4--,vesico-vaginal fistula4--,retention of urine4--,external urethrotomy4--,lithotomy4--,lithotrity4- -,for removing foreign bodies from the urethra and bladder #bjc-baj ,,on ,,the ,,limbs4 ,ligature of the larger arteries4--,resections3 of the head of the humerus1 the elbow1 the hip1 the knee4--,removal of necrosed bone4--,amputations3 at the shoulder-joint2 arm2 fore-arm and wrist2 metacarpus2 hip2 thigh and leg2 ,syme and ,chopart's operation2 metatarsus and toes #baa-bae ,,the ,,essentials ,,of ,,bandaging1 c4 ,,chapter ,i4 ,,bandaging4 ,,general ,,rules4--,ordinary bandages are strips of unbleached calico #f or #h yards long1 having a breadth of inch for the fingers and toes1 #b inches for the head and upper limb1 #c inches for the lower limb1 and #f inches for the body4 ,these1 when tightly rolled for use1 are termed rollers4 ,besides these rollers for general use there are special bandages1 such as rollers of muslin for using with plaster of paris1 of stocking-webbing when elasticity is needed2 four- and many-tailed bandages for particular fractures1 c4 ,messrs4 ,j4 ,j4 ,cash1 the cambric frilling makers of ,coventry1 now make a very firm light bandage of unbleached cambric woven in the necessary widths and lengths for use2 these are very cool and pleasant1 and a decided improvement on the ordinary calico strips generally used4 ,position of the ,operator4--,he should place himself opposite his patient1 not at the side of the limb to be bandaged2 the limb too should be bent to the position it will occupy when the bandage is completed4 ,before applying any kind of apparatus1 the surgeon should see that the limb is carefully washed and dried4 ,how to hold a ,roller4--,when applying a roller it is best to begin by placing the outer surface of the roller next the skin 7see fig4 #a1 page #c71 for it then unwinds more readily1 and the first turns are more easily secured2 moreover the bandage should be carried from the inner side of the limb by the front to the outer side1 for the muscles are thus more firmly and pleasantly confined than by turns passing in the opposite direction2 of course this observation supposes the hand and forearm to be in their usual position of semi-pronation4 ,varieties of ,turns4--,in carrying a bandage up a limb1 it is necessary1 in order to support the parts evenly1 to employ a combination of three different turns4 ,the simple spiral1 reverse1 and the figure of #h4 ,the simple spiral turn is used only where the circumference of the part increases slightly1 as the wrist2 but when the limb enlarges too fast to allow the fresh turn to overlap the previous one regularly1 the turn must be interrupted1 and the bandage brought back again by reverse1 or by figure of #h4 ,to reverse the bandage1 the thumb of the unoccupied hand is placed on the lower border of the bandage while the roller is turned over in the other1 and then passed downwards to overlap and fix the previous turn evenly4 ,at the moment of reversing1 the bandage should be held quite slack1 and not unrolled more than is necessary to make the reverse4 ,all the reverses must be carried one above the other along the outer side of the limb1 and only employed where really necessary4 ,figures of #h are made1 as their name implies1 by passing the roller alternately upwards and downwards as it enwraps the limb 7see fig4 #a74 ,they are adopted where the enlargement is too great and irregular for reverses to sit evenly1 over the ankle and elbow joint for instance4 ,illustration3 ,fig4 #a4--;,figure of #h turn4 ,,the ,,head4 ,bandages for the ,head4--,a roller is commonly applied in three different ways to the head4 #ast4 ,for keeping simple dressings in place4 ,apparatus4--#a4 ,a roller #b inches wide1 and of the usual length4 #b4 ,some pins4 ,a turn is first carried round the head1 over the brows and below the occipital protuberance1 and fastened by a pin2 this being done1 the roller is carried across the dressing1 and getting into the line of the first turn1 is passed round the head again1 then across the dressing1 and round the head by horizontal and oblique turns alternately1 the former to fix the latter1 and prevent their slipping off the dressing 7see fig4 #b74 ,in the figure the oblique turns have been doubled1 and would fix dressings on each side of the head4 ,knotted ,bandage4--,this is used when pressure on the superficial temporal artery is required4 ,apparatus4--#a4 ,a roller #h yards long1 #b inches wide1 one-third being rolled into one head1 the rest into another head4 #b4 ,some lint4 #c4 ,a piece of a wine cork one-third of an inch thick4 #d4 ,needle1 thread1 and pins4 ,illustration3 ,fig4 #b4--;,bandage for retaining dressings in position1 showing two sets of oblique turns4 ,the cork is folded in a double thickness of lint2 over this are placed six or eight more folds of lint of gradually increasing size1 and the whole are kept in shape by a stitch passed through them and through the cork4 ,this forms a graduated compress1 and is then laid on the wound small end downwards4 ,one head of the roller is taken in each hand1 its middle laid over the compress on the injured temple1 say the right2 the ends are carried round the head1 one just above the eyebrows to the left temple1 and the other backwards below the occipital protuberance1 to the same point2 the ends are then crossed and changed from one hand to the other to be brought to the wounded temple4 ,here they are again tightly crossed1 one end being carried under the chin and by the left side to the vertex1 there meeting the other end1 which has passed over the head1 in the opposite direction 7see fig4 #c72 at the right temple the ends are again crossed or 8knotted10 but this time they are passed horizontally round the head4 ,having done this the ends are pinned and cut off1 or if necessary the knots repeated before fastening2 the first pair1 if tightly drawn1 usually suffice as well as several4 ,illustration3 ,fig4 #c4--,knotted ,bandage4 ,the ,capelline ,bandage is rarely required1 but is used when the restlessness of the patient renders it difficult to keep dressings or ice-bags in place4 ,apparatus4--#a4 ,a double-headed roller1 #b inches wide and #ab yards long4 #b4 ,some pins4 ,illustration3 ,fig4 #d4--;,capelline ,bandage4 ,the middle of the roller is laid against the forehead just above the brows1 and the ends passed behind the occiput1 where they are crossed1 and while one continues the circular turns round the head1 the other head of the bandage is brought over the top along the middle to the front1 passing under the encircling turn1 which fixes it4 ,it is then carried back to the occiput1 on one side of the first transverse band1 when again fixed behind by the circular band it is brought forward on the opposite side of the first1 and fixed in front4 ,this arrangement is repeated until the head is covered in a closely fitting cap 7see fig4 #d74 ,in beginning this bandage1 it is necessary to keep the first circle low down1 close to the brows in front1 and below the occipital protuberance behind1 or the cap will not fit firmly over the skull4 ,a ,shawl ,cap is readily improvised with a silk or cambric handkerchief folded diagonally into a triangle2 the base of the triangle is then carried over the brow1 the apex let fall behind the occiput1 where the ends cross1 and catching in the apex1 come round to the front to be tied on the forehead4 ,illustration3 ,fig4 #e4--,shawl ,cap4 ,the ,four-tail ,bandage4--,instead of applying the handkerchief in the manner just described1 it may be split from each end to within six inches of the middle1 and so converted into a broad four-tail bandage2 the middle is laid on the top of the head1 the hinder ends tied under the chin1 and the forward ones behind the nape of the neck 7see fig4 #f74 ,or a piece of calico1 #a yards long and #d or #f inches wide1 is split from each end #c inches short of the centre--one pair of tails being rather wider than the other4 ,if used on the face1 the middle is put against the point of the chin1 the two narrow tails are carried backwards to the nape1 crossed1 and pinned together on the forehead above the brows4 ,the two broader tails are carried upwards in front of the ears1 where they turn round the two narrow tails1 to be either tied or pinned at the vertex4 ,four-tail bandages are used elsewhere1 as in the axilla1 to keep poultices in place1 c4 ,illustration3 ,fig4 #f4--;,four-tail ,bandage4 ,to retain ,ice ,bladders on the ,head4--,this is done by folding a thin napkin over the bladder1 which is then laid against the head or part to be kept cool1 and the ends of the napkin are pinned tightly down to the pillow at each side4 ,in this way the bag cannot slip1 and its weight is at the same time prevented from pressing on the head4 ,to compress the ,jugular ,vein after bleeding4--,after vensection of the external jugular vein it is requisite to keep a compress of lint on the wound4 ,this is done by fastening the bandage on the neck with two simple turns1 then carrying it in a figure of #h round the neck1 over the compress and under the axilla of the opposite side1 then round the neck again2 if the figure of #h is passed pretty firmly1 sufficient pressure is made in this way without interfering with the circulation through the vessels1 and the turns round the neck of course must not be tight4 ,,the ,,trunk4 ,to bandage the ,breast4 ,apparatus4--#a4 ,a roller #c inches wide and #h yards long4 ,the roller is first carried once round the body below the breast1 beginning in front and passing towards the sound side4 ,when the bandage is fixed1 the roller ascends over the lower part of the diseased breast1 to the opposite shoulder1 and comes back by the arm-pit to the horizontal turn2 it is then passed round the chest to fix the oblique turn4 ,having done this1 it again is carried up over the breast and shoulder1 and round the body in alternate turns until the breast is fully compressed1 each turn over the breast being carried higher than the preceding one1 and each turn round the body overlapping the oblique turn to keep it in place 7see fig4 #g74 ,illustration3 ,fig4 #g4--;,bandage for a ,breast4 ,to bandage both ,breasts4--,this is readily done by first bandaging one breast and then1 carrying the roller over the shoulder of the side already bandaged1 bringing it across the sternum and under the second breast on to the horizontal turns1 which it follows alternately with the oblique ones1 as was done in bandaging the first breast4 ,the only difference is1 that in compressing the first breast the bandage was passed obliquely upwards1 for the second it is carried obliquely downwards over the breast4 ,spica ,bandage4 ,apparatus4--#a4 ,a roller or #b or #c inches wide4 #b4 ,some pins4 ,lay the end on the groin to be bandaged1 carry the roller between the great trochanter and the crista ilii round the pelvis to the other side1 passing there also between the crista ilii and trochanter2 next take the roller downwards in front of the pubes to the injured groin1 then outwards round the thigh below the trochanter to the gluteal fold1 and pass it up between the thighs to the groin1 where the figure of #h is completed4 ,a second and a third are to be passed in the same way1 carrying them exactly one over the other1 round the body and below the buttock 7see fig4 #h72 at the groin they should overlap1 each lying a little above the preceding turn4 ,a pin1 when the necessary number of turns is completed1 fastens down the end4 ,illustration3 ,fig4 #h4--,spica for the ,groin4 ,hernia ,spica4--,the spica bandage is usually required to keep dressings and compresses in place over wounds after operation for strangulated hernia1 sinuses1 c41 in the groin2 when the figure of #h has been put on the first time it may be cut across in front2 and1 the dressings being changed1 the ends may be fastened together by pins4 ,if additional strips are laid across and fastened to the figure of #h underneath1 the required pressure is obtained1 and much tedious lifting of the patient is saved 7see fig4 #i47 ,illustration3 ,fig4 #i4--;,hernia ,spica4 ,body bandage for tapping the ,belly in ,ascites4--,this is made of two thicknesses of stout flannel1 #b feet wide in the middle1 where it forms a continuous sheet for #ah inches1 but beyond that it is split into #c tails1 #f inches wide and #c feet long4 ,in the middle line1 #d inches below the centre1 is a round hole #b inches across1 through which the surgeon reaches the skin to insert the trocar4 ,when in use1 the middle of the bandage is placed in front with the hole in the mesial line of the body1 and midway between the umbilicus and pubes2 the ends of the right side are passed behind the back to the left1 interlacing with those from the left side4 ,when all is ready1 an assistant standing on each side of the bed pulls steadily on the ends to keep up continuous pressure on the abdominal viscera as the fluid escapes4 ,after the fluid is evacuated the ends are wound firmly round the body in front1 while the puncture in the wall of the belly is closed by a fold of lint attached with a strip of plaster4 ,the ,t ,bandage is used to apply dressings1 compresses1 c41 to the anus or perinum4 ,a roller #c inches wide is fastened by a couple of turns round the pelvis1 and then fixed by a pin at the middle line in front4 ,from this point the roller is carried tightly over the dressings to the corresponding point behind1 and returned once or twice more until sufficient pressure is gained1 when it is fastened off4 ,the ,strait ,jacket is made of jean or stout canvas4 ,it is cut long enough to reach below the waist1 around which a strong tape is carried to be drawn tight and tied after the jacket is put on4 ,the sleeves are several inches longer than the arms1 and their ends can be drawn close by a tape which runs in the gathers2 a similar tape confines the garment round the neck1 and it is tied behind by tapes down the sides4 ,when the jacket is to be put on a patient it is first turned inside out1 then one of the nurses or assistants thrusts his own arms through the sleeves1 and facing the patient1 invites him to shake hands2 having thus obtained possession of the patient's hands he holds them fast while a second assistant1 standing behind the patient1 pulls the jacket off the first assistant on to the patient1 whose hands are thus drawn through the sleeves before he perceives the object of the manuvre2 the jacket is next tied round the neck and behind1 the tapes of the sleeves are carried round the body1 drawn tight till the arms are folded across the chest1 and fastened to the bed on each side1 or tied round the body4 ,manacles for ,delirious ,patients4--,instead of the strait jacket a double leathern muff is now generally used to restrain unruly patients4 ,it irritates them less1 and is far more easily applied4 ,illustration3 ,fig4 #aj4--,manacles for confining the arms of delirious patients4 ,in wearing it the arms are crossed in front1 and a strap drawn tight round both wrists4 ,each hand is thrust into a stout leathern glove1 or muff1 connected with the wrist-strap1 and capable of being tightened over the fingers by a strap and buckle across the glove4 ,to suspend the ,testicles4--,suspensories are made specially for this purpose4 ,the best are fastened round the neck by a loop of elastic tape1 but a very efficient one can be improvised with a pocket handkerchief and a piece of bandage4 ,the bandage is tied tightly round the hips for a girdle1 the handkerchief is folded three-corner wise1 and its longest side slipped behind the testes1 the ends being passed over the girdle 7see fig4 #aa71 and tied again behind the scrotum4 ,the loose apex of the handkerchief is drawn up in front over the girdle and pinned to it1 which is all that is required 7see fig4 #ab74 ,illustration3 ,fig4 #aa4--,shawl ,suspensory for the ,testes1 in the first stage of application4 ,illustration3 ,fig4 #ab4--,suspensory for ,testes completed4 ,when the patient is recumbent1 the testes may be supported by a strip of diachylon plaster #b feet long and #d inches wide1 passed across from hip to hip underneath the scrotum and testes1 which lie supported on a shelf4 ,another way of raising the testes is to place a soft pincushion between the thighs1 and allow the swollen gland to rest on the cushion4 ,,upper ,,extremity4 ,bandage for the ,fingers and ,thumb4 ,apparatus4--,a -inch wide roller4 ,the fingers are bandaged to prevent dema when splints are tightly attached to the fore or upper arm4 ,a roller inch wide is passed once round the wrist and then carried over the back of the hand to the little finger2 then wound in spirals round it to the tip and returned up the finger1 completed by a figure of #h round the wrist and the root of the finger1 and returned to the wrist before being brought across the back of the hand to the next finger1 to which it is applied in the same manner till the four fingers are covered4 ,it is a good precaution to place a shred of cotton wool between each finger before carrying the figure of #h turn round the root2 it prevents the bandages from chafing the tender skin4 ,the thumb is bandaged rather differently3 the roller is commenced in the same way round the wrist1 but the first turn is carried at once beyond the last joint1 turned once or twice round the last phalanx1 and continued by reverses to the metacarpo-phalangeal joint2 the ball of the thumb is then covered by figures of #h round the thumb and wrist4 ,this is called the spica for the thumb4 ,illustration3 ,fig4 #ac4--,spica for the ,thumb4 ,this plan is sometimes employed to compress bleeding wounds of the ball of the thumb1 and is applied without previously covering the phalanges1 as in fig4 #ac4 ,the ,hand and ,arm4 ,apparatus4--#a4 ,a roller #b inches wide for an adult1 but narrower for a child4 #b4 ,some cotton wool4 ,a little cotton wool should fill the palm before applying the roller4 ,the bandage commences with figures of #h carried round the hand and wrist4 ,the roller is first passed across the back of the hand from the radial border of the thumb to the root of the little finger 7see fig4 #ad71 and then across the palm1 reaching the back of the hand between the thumb and forefinger4 ,illustration3 ,fig4 #ad4--;,commencing to bandage the hand4 ,when the hand is covered by these figures of #h the bandage is passed up the forearm by reverses placed over the extensor muscles till the elbow is nearly reached4 ,before going further a dossil of cotton wool is placed in the bend of the elbow1 and on the inner condyle2 the joint is bent to the degree that will be required by the splint1 and the patient told to grasp some part of his dress1 or the sleeve of the other arm1 that he may not unconsciously extend the joint again while the bandage is being rolled round it4 ,the elbow is covered by first carrying the roller round the joint1 so that the point of the olecranon rests on the centre of the turn 7see dotted lines1 fig4 #ae74 ,the bandage is then continued in figures of #h1 passing above and below the first turn until the elbow is covered in and the bandage of the forearm is completed4 ,illustration3 ,fig4 #ae4--;,bandage covering the elbow4 ,the first turn over the point of the elbow is shown by the dotted lines4 ,illustration3 ,fig4 #af4--,spica ,bandage for the shoulder4 ,the arm is covered by spirals and reverses till the armpit is reached4 ,before bandaging the shoulder the armpit is protected by cotton wool or a double fold of soft blanket2 the roller is then carried in front of and over the shoulder1 across the back to the opposite axilla1 where also some wool should be placed1 then across the chest to the top of the shoulder again1 and under the armpit to the front 7see fig4 #af74 ,these figures of #h are repeated as often as necessary to complete the covering4 ,the bandage is applied in this method for dressings2 but when pressure is needed the first turn may be carried at once to the root of the neck1 and each succeeding turn made to overlap below the last1 until the point of the shoulder is gained1 as in fig4 #cg1 p4 #ee4 ,these are called the spica for the shoulder4 ,wound of the ,palmar arch4--,bleeding from this wound can usually be stopped by pressure on the bleeding point1 when this fails an attempt should be made to tie the vessel at the wound1 and if this be impracticable the arteries of the forearm must be deligated4 ,for compression the following is necessary3-- ,apparatus4--#a4 ,petit's tourniquet4 #b4 ,straight wooden splint4 #c4 ,rollers #b inches wide1 and inch wide for fingers4 #d4 ,pad and cotton wool4 #e4 ,lint4 #f4 ,a slip of a wine cork4 #g4 ,scissors and needle and thread4 #h4 ,lunar caustic4 ,step #a4 ,first apply the tourniquet to the brachial artery1 to control the hmorrhage while the apparatus is being adjusted4 ,step #b4 ,make a graduated compress by folding a sixpence or slip of a cork in two or three thicknesses of lint1 trim the lint into circular disks and prepare a dozen similar disks of increasing size2 lay these one on each other to form a round cone about one inch high with the piece of cork at the apex1 and fasten them together by a thread4 ,step #c4 ,clean and dry the wound1 then rub its surface carefully with nitrate of silver1 to lessen the suppuration4 ,step #d4 ,bandage the fingers and thumb1 and prepare the splint1 which should be straight1 as broad as the forearm1 and long enough to reach from the elbow to the tips of the fingers2 it should be lightly padded4 ,step #e4 ,envelope the wrist with a little wool2 next lay the graduated compress on the wound1 the small end downwards1 and press it firmly in with the left thumb1 while the splint is applied to the back of the hand and forearm4 ,these are then fixed by a roller carried in figures of #h round the hand and wrist across the compress until that is tightly pressed into the wound and the splint fixed to the limb4 ,the roller is then carried along the forearm1 a fold of wool laid in front of the elbow1 the tourniquet removed and the roller carried to the axilla while the forearm is raised1 flexed across the chest1 and fastened to the side4 ,this apparatus is worn without being disturbed for three or four days if bleeding do not return2 but at the end of this time it should be examined2 if painful or if discharge ooze out at the wound1 the bandage should be removed and readjusted less firmly than before1 a piece of wet lint replacing the graduated compress4 ,vensection4--,bandage and bleeding at the bend of the elbow4 ,apparatus4--#a4 ,lancet4 #b4 ,tape4 #c4 ,pledget of lint4 #d4 ,dish4 #e4 ,staff4 ,in opening a vein at the bend of the elbow1 the median basilic is selected1 simply because it is usually the largest1 but any branch that is superficial1 and well filled with blood1 may be opened4 ,the patient should sit or stand1 in which positions1 syncope1 one of the objects of bleeding1 is attained by the abstraction of a less amount of blood than in the horizontal posture4 ,the surgeon places a graduated bleeding dish on a chair or stool within his reach1 and a pledget of lint in his waistcoat pocket2 he next gives the patient a heavy book1 or staff to grasp in his hand4 ,the arm being bare to the shoulder1 a tape1 inch broad and #a yard long1 is tied round the arm tight enough to impede the venous1 but not the arterial flow4 ,the surgeon standing opposite his patient and grasping the arm to be bled with his left hand1 so that his thumb controls and steadies the swollen vein1 takes his lancet between the right forefinger and thumb2 then going through skin and vein at one stroke1 carries the lancet upwards for about inch along the vein4 ,the puncture of the lancet should be quite vertical1 and the extraction also made quite vertically1 that the slit in the vein may correspond to the slit in the skin4 ,this being done1 the operator lays aside his lancet1 and takes up the dish1 holding it so that the blood shall flow into it3 when the dish is placed1 he lifts his left thumb from the vein cautiously or the sudden spirt of blood will fall outside the dish and be lost4 ,when the desired amount is drawn1 the operator compresses the vein again with the left thumb1 and setting down the dish1 puts the pledget of lint over the wound4 ,he keeps the pledget in place with his left thumb1 while he releases the tape round the arm and places its middle obliquely across the pledget4 ,his left thumb presses the pledget on the wound1 while the right hand takes the end of the tape which is farthest from his left1 and passes it under the forearm below the elbow to his left fingers1 which grasp it tightly4 ,he then takes the other end with his right hand 7see fig4 #ag71 and bringing it round the arm above the elbow1 carries it across the pledget3 as he does this1 he replaces his left thumb on the compress with his right forefinger1 which he keeps there while he brings up the end of the tape he has already in his left fingers1 and throws it over the arm above his right forefinger1 then passing his left hand below the right forefinger1 he catches the same end of the tape again and draws it back4 ,the two ends thus locked in a loop over the compress1 are secured by tying them in a bow outside the elbow and the operation is finished 7see fig4 #ah74 ,illustration3 ,fig4 #ag4--;,adjusting the tape after bleeding4 ,illustration3 ,fig4 #ah4--,the bandage completed4 ,,the ,,lower ,,extremity4 ,for adults the most useful width for the rollers is #c inches1 and the length the ordinary one of #h yards4 ,the ,foot is usually bandaged without covering the heel1 and the bandage is begun as follows3-- ,the roller being held in the right hand for the right foot1 or in the left hand for the left foot2 the unoccupied hand takes the end1 and passing it under the sole1 brings it up on the back of the foot just behind the toes1 where it is made fast by carrying the roller outwards over the back4 ,when one turn is completed1 the bandaging is continued by reverses until the metatarsus is covered1 then one or two figures of #h round the foot and ankle carry the bandage to the leg1 where it proceeds upwards by spiral turns round the small of the leg1 and by reverses up the calf4 ,the reverses lie at equal distance up the leg1 on the muscles1 not over the bone1 that the skin be not pinched between the crease of the bandage and the bone4 ,when the calf is passed1 the roller is continued by figures of #h above and below the knee1 until that joint is covered in1 then by reverses up the thigh to the groin1 where the bandage terminates by a spica round the body 7see page #i74 ,this is the ordinary bandage for the lower limb4 ,there are some varieties for particular parts1 these are3-- ,to cover the ,heel4--,holding the roller as for the foot1 pass the end behind the heel1 bring it out by the outside over the front of the ankle-joint1 and complete the turn with the roller4 ,in doing this1 the point of the heel must catch the middle of the bandage4 ,if the foot is a long one1 the roller should be three inches broad2 but a narrower bandage is more easily fitted on a small foot4 ,after the first turn1 the bandaging is continued by carrying the roller in figures of #h round the foot and ankle1 passing alternately above and below the first turn until the ankle is covered as in fig4 #ai4 ,illustration3 ,fig4 #ai4--;,covering the ,heel4 ,to bandage a ,toe4--,take two turns round the foot1 with a bandage one inch wide1 then go round the toe to be raised1 and back again round the foot4 ,this figure of #h lifts a toe above the rest if taken from the dorsal1 and depresses it if taken from the plantar surface4 ,the ,knee is bandaged by beginning with a simple turn round the leg above the calf1 then carrying the roller across the patella to the thigh above the knee3 and next entwining it in a circular turn round the thigh before descending over the patella to the leg below the knee1 where this is repeated until the knee is covered4 ,to bandage a ,stump4--,the flaps are first supported by two or more strips of plaster1 one inch wide and ten or twelve long1 carried from the under surface of the limb over the face of the stump1 and a slip of wet lint and oilskin is applied to the wound4 ,the muscles and soft parts are next confined by a bandage4 ,this is first fixed by simple turns below the nearest joint1 and brought downwards in figures of #h round the limb till the end of the stump is reached1 which is next covered in by oblique and circular turns carried alternately over the face of the stump and round the limb1 as is shown in fig4 #b for bandaging the head4 ,or1 if a double-headed roller be used1 in the manner directed for the capelline bandage on page #e4 ,extending a ,stump4--,when the soft parts fall away from the bone they may be drawn down by attaching a weight by cord and pulley1 as described for extending the hip-joint 7see fig4 #hj74 ,the stump should be lightly bandaged and the cord fastened to its upper and under surface4 ,the weight is very small at first1 and should be increased from time to time as required4 ,many-tail1 or #ah-tail ,bandage1 or bandage of ,scultetus4--,a roller is cut into short lengths long enough to encircle the limb and to let the ends overlap #b or #c inches2 these are applied separately1 the lowest first1 the next overlapping it1 and the next overlapping the second until the requisite number are applied4 ,sometimes the tails are attached to each other before they are applied4 ,to do this1 the tails are laid out on a table1 so that the second overlaps one-third of the width of the first strip1 and the third strip overlaps the second1 and so on4 ,when all the tails are arranged1 a strip is laid across their middle and fastened to each tail by a stitch2 but this is not a necessary part of the bandage1 and it prevents single tails from being removed4 ,this bandage is used in compound fractures and other wounds1 as the soiled strips can be replaced without raising the limb to pass the roller under it4 ,elastic ,socks and ,stockings are made to support varicose veins of the legs4 ,they are woven of india-rubber webbing with silk or cotton4 ,the latter are the lowest priced and often even the most comfortable to wear4 ,the stockings should fit carefully everywhere1 especially at the small of the leg1 where they generally are too slack1 while they cut at the upper end below the knee4 ,,chapter ,,ii4 ,,strapping4 ,strapping is a method of supporting weak or swollen joints and other parts4 ,sheets of calico1 wash-leather1 or white buckskin1 spread with lead or soap plaster1 are prepared for this purpose4 ,a sheet should be rubbed with a dry cloth before using1 to remove adherent dust1 c4 ,it is then cut into strips varying in width between inch and #b inches1 according to the evenness of the surface to be covered3 narrow strips fit best over joints and irregular surfaces4 ,when applied to a limb1 the strips should be about one-third longer than its circumference4 ,each strip or strap is first warmed by holding it to a fire1 or by applying its unplastered side to a can of boiling water2 when hot1 the strip is then drawn tightly and evenly over the part4 ,if the surface to be strapped be irregular1 it is best to dip each strip of plaster in hot water before applying it1 being thus quite supple the strap fits the limb more exactly4 ,when the limb is thickly beset with hairs1 it is a good plan to shave the part where the plaster will lie before putting on the straps4 ,strapping the ,breast4--,strapping is put on the breast in the same way as the bandage 7page #h74 ,the straps should be not more than #b inches wide1 and long enough to pass forward under the axilla and breast from the lower angle of the scapula on the same side as the injured breast1 across the chest as far as the spine of the other scapula4 ,the strips are then warmed and laid on alternately over the breast and across the chest1 until the former is fairly supported4 ,strapping has this advantage over a bandage--its circular strips do not pass round the chest completely and thereby hamper the breathing as the roller does4 ,to strap the ,testicle4 ,apparatus4--#a4 ,strips of soap plaster spread on calico1 or better1 on wash-leather1 inch wide and #ab inches long4 #b4 ,a can of boiling water4 #c4 ,razor and soap4 ,illustration3 ,fig4 #bj4--,strapping the ,testis4 ,first1 shave the scrotum2 then tighten the skin over the testis with the left thumb and forefinger passed above it2 take a strip of plaster #f inches long and inch wide1 and encircle the cord tightly with it2 next pass another strap of the same width1 #i or #aj inches long1 from the back of this ring1 over the testicle to the front1 drawing it tight also 7see fig4 #bj74 ,the strapping is continued by laying fresh straps over each other until the whole testis is covered in4 ,lastly1 take a strip #ae or #bj inches long1 and1 beginning at the ring above1 wind it round and round the testicle until all the vertical strips are confined in place by this spiral strip4 ,the strapping should be re-applied the second or third day1 as the testicle by that time will have shrunk within its case4 ,illustration3 ,fig4 #ba4--,strapping an ,ulcer4 ,illustration3 ,fig4 #bb4--,strapping the ,ankle4 ,strapping ,ulcers and ,joints4--,cut strips of plaster one-third longer than the circumference of the part to be strapped2 if that is irregular1 as the ankle or wrist1 they must be narrow3 commonly the width varies between inch and #a inch4 ,the strips are warmed1 the middle passed behind the limb1 the ends crossed in front 7see fig4 #ba7 and drawn tight1 but with sufficient obliquity for the margins of the strip to lie evenly4 ,the strapping is begun as low down the limb as requisite1 and continued upwards by laying on more strips1 each overlapping about two-thirds of the preceding strap4 ,when the process is finished1 the ends should meet along the same line1 and all the uppermost ones be on the same side4 ,the ankle is strapped differently4 ,strips are prepared about inch wide2 one is carried behind the heel and its ends brought forward till they meet on the dorsum of the foot2 a second1 encircling the foot at the toes1 secures the first2 a third is again carried behind the heel above the first1 and is fixed by a fourth round the foot4 ,this is continued until the foot and ankle are firmly supported 7see fig #bb74 ,strapping a ,joint with ,mercurial ,ointment4 7,scott's ,bandage47 ,apparatus4--#a4 ,mercurial ointment4 #b4 ,diachylon plaster4 #c4 ,lint4 #d4 ,spirit of camphor4 #e4 ,cotton wool4 #f4 ,freshly scalded starch1 or solution of gum4 #g4 ,binder's millboard4 ,spread the ointment on a piece of lint large enough to cover the joint1 and to extend four or six inches above and below it2 then wash the joint with warm water and soap and dry it carefully2 next sponge it well with the spirit of camphor for five minutes4 ,tear the lint into strips and wrap it round the joint2 then strap the part firmly from below upwards over the lint with strips of diachylon plaster1 each overlapping the preceding4 ,lastly1 envelope the joint in a thin layer of cotton wool1 and roll a bandage soaked in starch over all4 ,if the patient wears no other kind of splint the bandage may be strengthened by laying a piece of millboard well softened in boiling water along each side of the joint before the starch bandage is applied4 ,as the enlargement of the joint shrinks1 this application must be renewed1 usually every fortnight is often enough4 ,,chapter ,,iii4 ,,fractures4 ,,head ,,and ,,trunk4 ,fracture of the lower ,jaw4--,the ,external ,splint and ,bandage4--,a method requiring the lower jaw to be firmly fixed against the upper one while the broken bone knits4 ,apparatus4--#a4 ,one and a half yards of bandage four inches wide4 #b4 ,a piece of gutta-percha1 sole leather1 or binder's millboard4 #c4 ,dentists' silk or wire4 #d4 ,boiling hot1 and cold water4 ,step #a4 ,the fracture is first reduced4 ,while the apparatus is being fitted1 the recurrence of the displacement is prevented by the hands of an assistant1 or by lacing the teeth together with stout silk or wire4 ,it is well also to wet the patient's chin with a sponge and cold water1 to prevent the gutta-percha from sticking to his beard while it is soft4 ,step #b4 ,a piece of gutta-percha is prepared #b inches wide and long enough to reach from one angle of the jaw to the other when passing in front of the chin4 ,this is softened thoroughly by immersion in boiling water1 and when quite pliable should be quickly removed from the hot and plunged for a moment into cold water3 if a towel be previously laid in the hot basin1 the gutta-percha can be lifted on it without stretching4 ,it should be laid on a table1 and its surface sponged with cold water to prevent it sticking to the skin1 it is then slit from each end into tails #a inch and #a inch wide1 leaving #b inches uncut at the centre4 ,so prepared1 the splint is applied to the jaw with the middle pressing against the chin1 the narrower ends being carried horizontally backwards to the angles of the jaw2 the broader part is next bent up beneath the chin1 its ends overlapping the horizontal ones4 ,while the splint is still soft1 the surgeon presses it firmly upwards that the gutta-percha may mould itself accurately to the chin4 ,when set1 the splint is removed1 trimmed1 and punched with holes here and there for evaporation4 ,a covering of wash-leather may be added1 if desired4 ,when the splint is finished1 it is replaced on the chin4 ,if sole leather or pasteboard be used instead of gutta-percha1 they must be prepared in the same way1 but allowed to remain on the chin twenty-four hours that they may set before the final trimming and adjustment4 ,step #c4 ,a bandage1 #d inches wide and #a yard long1 and slit from each end to about #b inches from the centre1 is then applied to the splint1 and a small pad of folded flannel should be placed at the nape of the neck to protect the skin from the crossed bandage4 ,when all is ready1 the two upper ends are carried behind the neck1 crossed1 drawn tight1 and tied or pinned on the forehead2 the lower ends are carried upwards1 taking a turn round the first pair at the temples1 and fastened at the vertex 7see fig4 #bc74 ,illustration3 ,fig4 #bc4--,outside splint for fracture of the lower jaw4 ,the ligatures that may have been used on the teeth can now be removed1 or if they cause no pain1 they may be left for a week or two4 ,it is a useful precaution to place a piece of soap plaster spread on soft leather1 under the chin and along the throat1 to protect the skin from the chafing of the splint while it is worn4 ,sometimes the jaws close too nearly to allow food to be taken between them4 ,it is then necessary to place a thin wedge of softened gutta-percha1 #a inch long1 inch wide1 and about inch thick1 between the molars on each side4 ,the gutta-percha must not be softened much1 or when the bite is taken the teeth will pass through it4 ,these plugs should be omitted unless absolutely required1 as the fragments keep a better position without them4 ,on emergency1 when gutta-percha1 leather1 or pasteboard are not at hand1 the jaw may be set1 and then kept in position by a four-tail bandage1 made from a pocket-handkerchief1 until more complicated apparatus can be prepared4 ,the apparatus must be worn five weeks before it is laid aside and mastication permitted4 ,interdental ,splints4--,in cases of unusual difficulty1 interdental splints may be employed4 ,to fashion some of these1 the mechanical skill of a dentist is requisite1 unless ,morel ,lavalle's plan is resorted to4 ,he applied a mould or socket to the line of the teeth1 and kept it in place by pressure underneath the jaw4 ,he first brought the fragments into apposition by means of threads and wire4 ,then he took a piece of gutta-percha1 about inch thick and inch broad1 and long enough to extend1 when bent along the lower jaw1 from one wisdom molar to the other4 ,this was softened in water1 and pressed on the teeth2 next a well-padded horse-shoe plate was placed under the chin1 reaching from one angle of the jaw to the other1 and two wires were passed through the side of this plate opposite the angle of the mouth2 these were drawn through the plate by a screw nut2 their upper ends being curved into hooks with sharpened points4 ,the points catch into the gutta-percha2 by screwing up the nuts1 the chinplate was raised1 and the teeth driven up and bedded into the splint4 ,this method1 however1 has its disadvantages4 ,if the fracture take place behind the first molar1 the bearing on the upper fragment is too slight to keep it down in its place4 ,in the ,new ,york ,medical ,journal for ,september and ,october1 #ahff1 ,mr4 ,gunning1 of that city1 has published a mode of applying caps fitted to the teeth for fracture of the jaw-bone4 ,external support is abandoned wherever it is possible4 ,in simple fractures1 the caps or interdental splints1 being accurately fitted1 require no fastening to the teeth4 ,the jaw should be adjusted in its splint as quickly as possible after the accident4 ,the fragments are first brought into their true position4 ,gaps through loss of teeth at the line of fracture1 are filled by plugs of hard wood1 and the fragments kept in place by wiring the teeth together tightly4 ,continued strain on the teeth causes much pain2 hence all means for keeping the fragments in place while the splint is being fitted should be removed when that is accomplished1 though ligatures used solely to support loosened teeth may be left1 as there is no traction upon them4 ,stumps1 and teeth loose before the accident are best taken out1 if they interfere with the arrangement of the splint4 ,illustration3 ,fig4 #bd4--,vulcanite ,interdental ,splint to fit the arch of the teeth of the lower jaw1 seen upside down4 ,the holes marked a pass through to the upper surface1 to allow water to be injected between the splint and the teeth1 while it is worn1 for cleaning4 ,the next thing is to take a mould of the lower jaw in wax softened by heat1 holding the wax in an ordinary dentist's tray4 ,from this mould a plaster cast of the jaw is made4 ,if the line of teeth be uneven in the cast1 it is to be sawn through1 the pieces raised to the right level1 and cast again4 ,in this cast a vulcanite plate is made exactly fitting the teeth 7see fig4 #bd74 ,the margins of the mould or splint should be carried down below the line of the gums1 to grasp the jaw beyond the alveolar border2 and when the fracture takes place behind the teeth1 its outer side should be prolonged backwards as far as the muscles will allow1 to prevent the displacement of the anterior fragment outwards which muscular action produces in these fractures4 ,holes should be made in the top of the splint1 to permit a stream of water to be sent between the splint and the teeth daily1 for cleanliness4 ,also1 in difficult cases1 a hole should be cut opposite a tooth in each fragment1 for ascertaining from time to time that each part continues in its proper position while the splint is worn4 ,metal is used for the plate by ,english dentists1 instead of vulcanite4 ,it can be made thinner1 and is less brittle than the latter4 ,the perfect fit thus secured suffices1 in simple fracture1 to keep the parts in close apposition2 while the movements of eating and speaking are very little interfered with4 ,illustration3 ,fig4 #be4--,showing the method for supporting externally the jaws in the splint1 when the teeth are not fastened to it by screws1 ,e4 ,upper wing2 ,g4 ,lower wing2 ,h4 ,mental band to keep the jaw up in the splint2 ,i4 ,neck-strap to keep the band back2 ,k4 ,balance-strap to hold skull-cap in place4 ,the upper wings are of course dispensed with1 when a single splint only is used4 ,when the displacement is considerable the fragments are held in place by riveting one or more teeth to the cap1 or1 when circumstances prevent support being obtained in this way1 external support is supplied to the splint by steel wings1 fixed into the splint at the angles of the mouth 7see fig4 #be71 and carried outside the cheek to the angles of the jaw4 ,a piece of stout jean or canvas1 cut to fit under the chin1 is then connected with these wings1 and also fastened by a tape behind the neck4 ,if the case require that a bearing be made on the upper jaw as well as the lower one1 as in fracture of both jaws in edentulous persons1 the two splints are articulated behind1 so that they may open and shut with the lower jaw4 ,each piece then carries a wing1 the lower one supporting a chin-piece1 and the upper one being connected by strings attached at the temples to a close-fitting skull-cap4 ,the skull-cap is prevented from slipping forward by connexion with a strap fastened to both shoulders4 ,a fractured ,rib is very well treated by strapping the injured side alone1 without enrolling the chest in a tight bandage1 which harasses the patient by impeding respiration4 ,apparatus4--#a4 ,diachylon plaster4 #b4 ,can of boiling water4 ,illustration3 ,fig4 #bf4--,strapping a broken ,rib4 ,strips of plaster long enough to reach from the spinal column to the sternum1 and #b inches wide1 are to be firmly drawn round the injured side4 ,the first strip should be carried as high as can be managed under the arm-pit4 ,the next strip overlaps it about an inch 7fig4 #bf71 each succeeding strip overlapping and fixing the preceding one until the lower ribs are covered in4 ,the arm should then be bandaged to the side1 and supported in a sling4 ,a second mode of treating fractured ribs1 is to take a flannel roller #f inches wide1 and #h yards long1 and carry it firmly round the chest in successive spirals1 beginning at the armpits1 and passing down till the waist is reached4 ,the turns of the roller may be kept from slipping down by throwing across the shoulders two strips of bandage like a pair of braces1 and stitching each turn to the brace in front and behind4 ,the arm should be confined to the side as in the other method4 ,this plan has the inconvenience before mentioned of interfering with respiration4 ,in ,fracture of the ,pelvis1 the fragments are kept in position by a broad roller carried several times round the pelvis and fastened4 ,,the ,,upper ,,extremity4 ,fracture of the ,metacarpal ,bones4 ,apparatus4--#a4 ,a piece of gutta-percha4 #b4 ,a roller #b inches wide4 ,in treating this fracture it is important to keep the broken bone in place without confining the wrist or fingers4 ,a pattern of the palm and dorsum of the hand is cut out of paper1 which is doubled round the radial side1 letting the thumb out through a hole of convenient size to clear it 7see fig4 #bg74 ,the piece of paper is then laid on a sheet of gutta-percha inch thick1 and the requisite quantity cut off2 a hole as big as a pea is next punched in the gutta-percha in the middle1 about #a inch from the lower border1 or at a point corresponding to the hole in the paper for the thumb4 ,the fragments are then pushed into place and held so by an assistant1 while the surgeon softens the gutta-percha in boiling water2 when thoroughly soft1 he draws the thumb through the little hole punched in the gutta-percha1 and moulds the splint to the palm and back of the hand1 bringing the ends of the gutta-percha together at the ulnar side of the hand2 the fragments are held carefully in position till the splint is set4 ,the splint is afterwards removed and trimmed4 ,a few holes should be punched in it after it is moulded to allow perspiration to escape4 ,the splint may then be covered with wash-leather1 and a pair of straps with buckles stitched on to keep it in place4 ,it is worn for three or four weeks1 or until the fragments are united4 ,illustration3 ,fig4 #bg4--;,gutta-percha ,glove for fractured ,metacarpal ,bone4 ,should gutta-percha not be at hand1 another plan is effectual4 ,apparatus4--#a4 ,a firm ball of tow large enough to fill the palm1 stitched in old linen4 #b4 ,a roller #b inches wide4 ,the broken bone is first replaced2 then the hand and fingers bound on to the ball by carrying the roller around them until they are all immoveably confined4 ,this plan has the disadvantage of confining the whole hand for the fracture of one metacarpal bone2 the gutta-percha allows free use of all but the metacarpal bones4 ,broken phalanges are treated by bandaging them on to a slip of wood long enough to reach into the palm2 the slip must be well padded1 that the somewhat concave anterior surface of the digit may accommodate itself on the flat splint4 ,if more than one finger be injured1 and the fracture be compound1 the splint should then reach up the palmar aspect of the forearm and hand4 ,fingers should be cut in it to correspond with the fingers to be fastened to the splint4 ,fracture of the lower end of the ,radius4--,colles' ,fracture4--,the displacement in this fracture is mainly due to the lower end of the radius and the carpus being carried backwards while the shaft projects in front4 ,apparatus4--#a4 ,a straight splint of wood4 ,a second splint1 curved at its lower end4 #b4 ,pads and cotton wool4 #c4 ,a roller #b inches wide4 #d4 ,a sling4 #e4 ,a strip of plaster4 ,the objects to be attained in treating this fracture are to press the lower fragment forwards and to draw 7adduct7 the hand towards the ulnar side of the limb4 ,for this purpose a straight and a curved splint are used4 ,no bandage should be placed under the splints in treating any fracture of the shaft of the radius or ulna1 lest the broken ends be pressed into the interosseous space4 ,step #a4 ,prepare the splints4 ,the straight splint should reach1 when the arm is bent1 to a right angle with the thumb upwards1 from a little below the inner condyle to the lower end of the upper fragment or shaft2 the curved or pistol splint extends from the outer condyle to the joint of the first and second phalanges4 ,the width of both splints should slightly exceed that of the forearm4 ,the bend of the lower end of the pistol splint should be abrupt1 and directed towards the ulnar border opposite the wrist1 where the margin of the splint should make an obtuse angle of about #a right angles 7see fig4 #bh74 ,illustration3 ,fig4 #bh4--,pistol ,splint for fracture of the ,radius near the lower end4 ,pads used with these and other wooden splints are made of layers of cotton wool1 carded sheep's wool1 tow1 or folds of old blanket4 ,these materials should be stitched in old linen or calico1 and covered outside with oiled silk where likely to be stained with the discharge from wounds4 ,the pads must be thicker below than above1 to keep the splints parallel along the forearm2 and that of the pistol splint is thickest opposite the carpus1 to push the lower fragment forwards4 ,fixed deformity opposite the wrist is usually present from impaction of the fragments2 moderate extension may be employed to remove this1 but forcible or continued efforts give great pain and do harm1 by further straining the already wrenched ligaments4 ,after these preparations the splints are applied4 ,step #b4 ,put a very little cotton wool in the palm and across the root of the thumb1 before the roller is begun1 lest it chafe the carpus in front4 ,the curved splint1 with the barrel or longer part inclined downwards below the forearm1 is next attached to the back of the hand by a roller carried in figures of #h round the hand and root of the thumb1 but not above the wrist 7see fig4 #bi74 ,this is made fast by a pin4 ,illustration3 ,fig4 #bi4--;,fracture of the ,radius4 ,step #c4 ,raise the straight part of the outside splint till parallel to the forearm1 thus adducting the hand to the ulnar side2 and fix the splint by a strap of plaster an inch wide carried round it and the forearm below the elbow4 ,step #d4 ,apply the inside straight splint next1 keeping the front of the carpus and of the lower fragment exposed4 ,draw the two splints together by simple spiral turns of a roller1 begun just below the elbow and carried down to the lower end of the inside splint1 there fasten it off4 ,step #e4 ,put a narrow sling under the forearm between the elbow and the wrist to support the limb comfortably4 ,when the apparatus is finished the position of the broken fragments should be visible 7see fig4 #bi7 and not concealed by bandage4 ,the hand should also be quite free of the sling1 lest it be drawn from its proper adducted position4 ,the fragments are in good position when the hollow on the anterior aspect of the wrist and the prominence on the corresponding posterior surface are removed4 ,the ,gutta-percha ,gauntlet is another plan of treating fracture of the lower end of the radius that may often be adopted from the first1 and may always replace the wooden splints and bandage when the swelling has subsided4 ,it was contrived by ,mr4 ,heather ,bigg1 and permits the patient to use his hand to some extent while the bone is uniting4 ,apparatus4--#a4 ,a piece of gutta-percha inch thick1 wide enough to enwrap the metacarpus and wrist1 and long enough to reach up the lower half of the forearm4 ,two thirds across the width1 and about #a inch from the lower end1 a small round hole is punched4 ,the sheet is then softened in hot water1 and applied to the hand1 the thumb being thrust through the hole punched to receive it1 which rapidly enlarges when soft4 ,the gutta-percha is then adjusted to the hand and forearm1 its borders meeting at the ulnar side of the limb1 rather nearer the inner border of the arm than is depicted in fig4 #cj4 ,illustration3 ,fig4 #cj4--;,gutta-percha ,gauntlet for ,colles' ,fracture4 ,if the fracture is recent1 it must be reduced while the splint is soft by extending the hand and holding the parts in the required position until the gutta-percha is set4 ,before removing the splints superfluous edges should be marked1 and1 when the splint is off1 trimmed away with a knife4 ,holes must also be punched at frequent intervals that the perspiration may escape4 ,the splint is next lined with wash-leather1 and fitted with a pair of straps and buckles to keep it in place4 ,by this plan the fingers are left free1 and some motion allowed also to the thumb4 ,the only joints kept immoveable are those of the carpus and wrist4 ,apparatus of some kind must be worn three weeks continuously2 then for a fortnight longer1 while it is removed every day to allow passive motion of the fingers and gradually of the wrist also to be practised4 ,care should be taken to warn the patient that pain and stiffness last long in these fractures1 lest he blame the surgeon because he does not quickly recover full use of his arm4 ,fracture of the ,shaft of one or both ,bones of the ,forearm4 ,apparatus4--#a4 ,two straight wooden splints4 #b4 ,pads and wool4 #c4 #b-;inch wide roller4 #d4 ,sling4 ,the treatment is the same whether one or both bones are broken4 ,caution has been already given against bandaging the forearm underneath the splints4 ,step #a4 ,prepare two straight wooden splints2 one to go in front of1 and one behind the forearm4 ,the posterior or outside reaches from the external condyle to the end of the metacarpus2 the anterior or inside splint from a little below the internal condyle only as far as the wrist1 keeping clear of the ball of the thumb4 ,the splints should be slightly broader than the forearm1 and well padded2 towards the lower end the padding should be thicker than above4 ,the forearm is bent to a right angle and the thumb put upwards4 ,step #b4 ,reduce the fracture by gentle slow extension at the wrist2 this being effected1 apply the splints to the forearm1 and let an assistant hold them while the bandage is rolled on4 ,step #c4 ,when a little wool has been wrapped round the hand and wrist1 fasten the dorsal splint by figures of #h carried round those parts2 then draw the two splints together by simple spirals continued to the elbow 7see fig4 #ca74 ,illustration3 ,fig4 #ca4--;,fracture of both ,bones of the ,forearm4 ,step #d4 ,support the forearm in a sling1 to complete the apparatus4 ,the splints are worn three weeks2 after this1 passive motion may be practised daily1 and the splints finally abandoned ten days later4 ,but a sling is still required some ten days after the splints are laid aside4 ,when the ulna alone is broken1 an anterior splint reaching from the inner condyle to the tips of the fingers often suffices without a second one4 ,when the shaft of the radius is broken high up 7a rare accident7 the displacement is sometimes very difficult of reduction unless the wrist be well supinated4 ,to preserve this position it may be necessary to use a wooden angular splint1 and to fix the vertical part to the arm behind the elbow1 while the horizontal part is carried along the back of the forearm4 ,fracture of the ,olecranon4--,this fracture1 if seen early before effusion takes place1 may be put up at once1 but if delay till the joint is swollen has occurred1 the limb must be kept quiet on a pillow1 or on a splint in an easy position with evaporating lotions1 until the effusion is absorbed1 before any means can be taken to restore the position of the olecranon4 ,though the straight position of the elbow is usually employed1 it is not essential for even very close union of the fragments4 ,in treating this fracture the following plan is useful4 ,apparatus4--#a4 ,straight hollow splint4 #b4 #b-;inch rollers and finger rollers4 #c4 ,pad1 wool1 and lint4 #d4 ,strapping plaster4 #e4 ,pins4 ,step #a4 ,bandage the fingers2 wrap the hand in cotton wool and bandage it4 ,when the wrist is passed1 fasten the bandage for a time by a pin1 and straighten the arm4 ,step #b4 ,push the olecranon down as close as possible to the rest of the ulna1 and put a dossil of lint over it4 ,place the middle of a strap of plaster an inch wide and #af inches long1 on the lint1 and carry its ends round the forearm in a figure of #h2 to some extent this alone fixes the fragment4 ,step #c4 ,continue the bandage up the forearm by reverses1 keeping the elbow straight2 and pass the joint by figures of #h carried over the compress of lint and the forearm1 to draw down the olecranon 7see fig4 #cb74 ,when this is secured1 prolong the bandage to the deltoid1 to confine the action of the triceps muscle4 ,step #d4 ,pad lightly a hollow splint about #b inches wide1 reaching from the axilla nearly to the wrist1 and apply it along the anterior aspect of the limb1 then fix it by a second roller4 ,this completes the apparatus4 ,illustration3 ,fig4 #cb4--;,bringing down the ,olecranon with ,figures of #h4 ,the splints and rollers should be removed on the fourth or fifth day1 that the positions of the fragments may be examined and the roller again applied to draw them closer together4 ,after ten or twelve days1 passive motion of the wrist and fingers1 with pronation and supination of the radius1 should be adopted1 but great care is to be taken that the patient does not inadvertently bend the elbow joint while free of the splint4 ,the splint must be worn1 with the frequent removals directed above1 for five weeks1 by which time gentle flexion of the elbow may be practised4 ,hamilton notches his splint at each border about its middle so that the notches shall be #c inches below the tip of the olecranon 7see fig4 #cc74 ,he begins the bandaging by fastening his splint on to the hand and forearm1 as high as the notches2 here the roller is carried above the olecranon and again down to the notches2 this is repeated again and again1 each turn below the last1 until the notches are all covered1 he then continues the bandage upwards by circular turns until the top of the splint is reached4 ,illustration3 ,fig4 #cc4--;,hamilton's ,splint for fracture of ,olecranon4 ,fractures of the ,humerus near the ,elbow4--,these resemble dislocations of the ulna and radius backwards1 but are distinguished from them by the ease with which the bones slip into place and again slip back from it when left to themselves2 by crepitus2 and1 when the fracture is above the condyles1 the common accident1 by those projections retaining their natural relation to the olecranon4 ,in children and youths the articulating surface of the humerus may separate from the shaft without carrying the rest of the lower epiphysis with them4 ,in this rare accident the main distinctions from the usual fracture are1 the projection of the olecranon behind the condyles2 from dislocation1 the absence of the hollow of the sigmoid notch1 and facility of reduction4 ,in ordinary cases1 where the deformity is reduced without much difficulty1 and the injury to the joint is not severe1 lateral rectangular splints of leather1 hollowed wood1 or wire gauze1 answer very well4 ,these are placed both inside and outside the limb1 and reach from the axilla and shoulder to the wrist4 ,they are applied in the following manner3-- ,apparatus4--#a4 ,lateral hollowed angular splints4 #b4 ,pads and wool4 #c4 ,rollers #b inches wide for the arm1 and #a inch wide for the fingers4 #d4 ,sling4 ,step #a4 ,the splints must be prepared4 ,wooden and wire gauze splints are double4 ,one1 inside the arm1 reaches from the axilla to the wrist1 the forearm being bent to a right angle4 ,the other extends1 on the outside1 from the deltoid to the wrist4 ,they are better if provided with hinges opposite the elbow1 so that their angle can be altered1 if desired1 in the later stage of the treatment4 ,splints of wood or wire gauze must be evenly and lightly padded before application4 ,step #b4 ,bend the arm to a right angle with the thumb upwards4 ,an assistant next reduces the fracture1 and holds it in position4 ,then apply the splints4 ,when adjusting the inside splint1 care must be taken that the internal condyle is eased from pressure by sufficient padding above and below it4 ,next fasten on the splints by a roller begun at their lower end1 leaving the hand free1 and carried up to the elbow4 ,before turning round that joint a soft pad must be placed in the hollow of the elbow to push the lower end of the humerus back1 and the length of the arm should be measured against the unbroken one to make sure that the shortening is reduced4 ,extension is kept up the whole time the splint is being fixed to the arm1 which is done by carrying the roller round the elbow with figures of #h and simple spirals up to the axilla1 where it is finished off4 ,step #c4 ,lastly1 the forearm is supported in a sling under the wrist1 leaving the elbow free 7as in fig4 #ce1 page #eb74 ,after three weeks of complete immobility1 passive motion should be applied to the elbow daily1 during a fortnight or three weeks more in which the splint is still worn4 ,if the displacement returns very easily1 it is better to use an ,l-shaped splint passing behind the arm and below the forearm4 ,this may be made of wood1 or of leather1 or of gutta-percha1 in the mode about to be described4 ,the ,l-shaped splint of gutta-percha1 or leather1 is made as follows3-- ,apparatus4--#a4 ,sheet gutta-percha inch thick4 #b4 ,a tray or wide wash-hand basin4 #c4 ,a basin of cold water4 #d4 ,a kettle of boiling water4 #e4 ,a towel4 #f4 ,a knife4 #g4 ,a sheet of newspaper4 ,cut a pattern of paper reaching1 while the elbow is bent and the thumb upwards1 from the arm-pit down the back of the arm and under the elbow and forearm to the wrist4 ,the sides must be brought forward to the biceps and front of the forearm as seen in fig4 #cd4 ,next cut from the sheet of gutta-percha a piece to match the pattern4 ,prepare the tray with the hot water1 lay in it the towel1 and then soften the gutta-percha by laying it in the tray and covering it with almost boiling water1 adding more water as the first cools2 this may be done by an assistant1 while the surgeon directs another assistant to grasp the forearm and reduce the fracture4 ,the assistant keep extension while the surgeon lifts the softened gutta-percha with the towel from the hot and plunges it a moment into cold water1 then lays it on the limb1 which the assistant keeps at a right angle1 and the bone in place1 while the splint is setting to the limb4 ,this done1 the splint is removed to be trimmed1 perforated1 and covered with wash-leather4 ,it is then ready for use4 ,illustration3 ,fig4 #cd4--;,gutta-percha ,splint for fracture at the lower end of ,humerus4 ,leather takes so much time to set that it should not be used in recent fractures4 ,when the bone is partly set1 leather is a useful substitute for wood4 ,it is prepared from a pattern in the same manner as the gutta-percha1 but is trimmed before soaking1 not after it is moulded1 like gutta-percha4 ,if possible it should have twenty-four hours soaking in water before being fitted to the limb2 but when this cannot be done1 immersion in hot water1 into which a teacupful of vinegar has been thrown1 will make the leather quite supple in a quarter of an hour4 ,the leather splint must be worn twenty-four hours while it sets1 and then be removed for covering 7see ,leather ,splints74 ,fractured ,shaft of the ,humerus4 ,apparatus4--#a4 ,four straight hollow splints4 #b4 ,rollers #b inches wide1 and #a inch for the fingers1 or straps and buckles4 #c4 ,pads and wool4 #d4 ,sling4 ,when broken below the attachment of the deltoid and coraco-brachialis muscles the displacement of the bone is commonly prevented with ease2 neither shoulder nor elbow-joint need be fixed1 and it is not necessary to apply the splints so tightly as to risk interference with the venous circulation4 ,if the pectoral muscles or deltoid be connected with the lower fragment1 the displacement is sometimes obstinate2 in such cases it is necessary to buckle the splints lightly4 ,for this to be done1 the fingers1 hand1 and forearm must be previously bandaged to prevent dema2 with this addition1 the method of treatment is the same in both varieties of fracture4 ,step #a4 ,select the splints2 they should be hollowed1 of wood1 perforated sheet zinc1 or wire gauze1 about #b inches broad1 lightly padded1 and provided with straps and buckles4 ,the external one reaches from the acromion to the outer condyle2 the inner one from the axilla to the inner condyle2 a third shorter one is placed behind the arm1 and if there is much projection forwards of the lower fragment1 a fourth very short one is added in front4 ,the patient should sit on a chair while the apparatus is being put on4 ,step #b4 ,the fingers and thumb are bandaged2 then1 the hand and forearm1 first padded with a little wool in the palm and over the wrist1 are evenly bandaged to the elbow1 round which the roller is carried while the joint is well flexed2 this being covered in1 the roller is made fast4 ,the first step of bandaging the hand and forearm before applying the splints is better omitted if the compression requisite to procure the natural position of the bone does not interfere with the circulation4 ,step #c4 ,an assistant grasping the elbow in one hand1 pulls down the lower fragment1 while he steadies the shoulder with the other4 ,the displacement thus reduced1 the surgeon applies the splints1 taking care that the inside splint does not reach too high into the axilla1 lest it compress the axillary vein4 ,in simple cases1 the splints should be drawn close by straps and buckles2 where the muscles are powerful1 a roller should be wound round the splints instead of straps4 ,illustration3 ,fig4 #ce4--;,fractured ,shaft of the ,humerus4 ,step #d4 ,a #b inch wide roller is fastened to the arm above the elbow1 and then carried round the trunk to the arm again1 to steady the limb against the body4 ,step #e4 ,the hand and wrist are supported by a sling over the shoulders1 the elbow being allowed to hang 7see fig4 #ce74 ,this apparatus is worn three weeks1 when the bandages are removed from the forearm1 and the splints replaced less tightly than before4 ,they may be substituted by a sheath of gutta-percha moulded to the arm from the acromion to the elbow1 and buckled on to the limb4 ,the arm must be supported by splints for five weeks1 but passive motion of the elbow and wrist should be adopted after the third week4 ,the wrist especially should be set at liberty as soon as possible4 ,in treating this fracture great care is necessary that the bone be kept in accurate and close position1 as the humerus is specially prone to remain un-united for many months4 ,fracture of the ,anatomical or ,surgical ,neck of the ,humerus1 of the ,great ,tuberosity1 and of the ,neck of the ,scapula4 ,these fractures are similarly treated4 ,apparatus4--#a4 ,paper for pattern4 #b4 ,gutta-percha1 leather1 or millboard4 #c4 ,pads4 ,a soft thin pad1 #aj inches long1 #e inches wide 7a double fold of thick flannel or blanket answers very well71 is wanted to line the axilla4 ,if the cap is of leather or gutta-percha1 a lining of wash-leather should be added after the splint is made4 #d4 ,rollers1 #b inches and #a inch wide for the fingers4 #e4 ,scissors4 #f4 ,a tray1 and kettle of hot water4 #g4 ,a towel1 and basin of cold water4 #h4 ,sling4 #i4 ,cotton wool4 ,step #a4 ,cut out a paper pattern of the splint on the limb to be fitted4 ,the pattern should reach along the clavicle to the root of the neck1 and over the scapula to its posterior border1 and be continued down the arm to the elbow1 tapering as it goes1 but having its anterior and posterior margins brought sufficiently to the inner side of the arm to give the splint a good grasp of the limb in descending4 ,the end should be left long enough to turn a couple of inches round the point of the elbow 7see fig4 #cf74 ,a notch must be cut at the upper end of the paper pattern to make it fit on the shoulder between the clavicle and the spine of the scapula2 this should not be repeated in the gutta-percha1 as that can be moulded on without2 and for that reason the cap is much more serviceable when made of gutta-percha than of leather1 where a notch must be cut and stitched together when the leather is set4 ,the gutta-percha1 when cut to pattern1 must be softened in the manner described in making the splint for the elbow at page #ej1 fig4 #cd2 then accurately adjusted to the shoulder as high as the root of the neck1 and turned under the point of the elbow a couple of inches 7see fig4 #cf71 while the forearm is well raised across the chest4 ,illustration3 ,fig4 #cf4--;,cap for fracture near the ,shoulder4 ,when set1 the splint must be removed that it may be trimmed and lined with wash-leather4 ,if of gutta-percha1 it must be perforated with small holes2 if of leather1 the notch at the shoulder must be stitched together4 ,next prepare a soft thin pad1 #e or #f inches broad1 and #h or #aj inches long1 to fill the axilla4 ,step #b4 ,bandage the fingers and thumb separately1 then1 putting a little wool in the palm and round the wrist1 bandage the hand and forearm to the elbow1 where the bandage is fastened4 ,step #c4 ,apply the splint4 ,first get on the cap2 then put the soft pad in the axilla1 filling it out if the arm-pit is very hollow with cotton wool1 and bend the elbow till the hand lies on the breast of the opposite side4 ,then1 while an assistant holds the limb and apparatus in position1 fasten them all in place by continuing the roller of the forearm in figures of #h round the elbow until the splint is well fixed to it2 and carry the roller up the arm by reverses to the axilla4 ,step #d4 ,a little wool or piece of flannel having been placed in the opposite arm-pit to prevent chafing1 a spica for the shoulder is then applied 7see page #af71 beginning at the root of the neck and working downwards4 ,careful extension is continued by the assistant all the time this bandage is being put on1 until the head of the bone is well drawn into the cap4 ,illustration3 ,fig4 #cg4--;,fracture at the upper end of ,humerus4 ,the apparatus completed4 ,step #e4 ,the arm is drawn to the side1 and the forearm fixed against the chest by a roller carried round the arm and trunk and over the shoulder 7see fig4 #cg74 ,after three weeks the forearm may be released1 but the cap and axillary pad must be continued to be worn two or three weeks longer while the arm is well drawn to the side1 and the wrist carried in a sling4 ,fracture of the ,great ,tuberosity of the humerus is difficult to treat1 on account of the tuberosity being carried backwards by the muscles and the humerus being rotated forwards4 ,hence the parts must be braced together with a firm cap of gutta-percha moulded on to the shoulder while soft1 and while the fractured parts are held in apposition1 which may be done by the fingers1 or by putting on a wet roller firmly over the shoulder as a spica before the splint is set4 ,when the splint is hard the bandage may be taken off1 and the splint removed and finished ready for application4 ,in doing this1 the steps are the same as for fracture of the surgical neck of the humerus1 and the necessity for fixing the arm well to the side of the body as great as in that fracture4 ,fracture of the ,acromion is treated very much like fracture of the clavicle1 that is1 the arm is well raised by a sling under the elbow1 and then fastened to the side4 ,it is not necessary to fill the axilla with a pad1 as in fracture of the clavicle1 for in this case the shoulder is not drawn inwards4 ,fracture of the ,clavicle4 ,apparatus4--#a4 ,axillary pad4 #b4 ,roller1 #c inches wide4 #c4 ,sling4 #d4 ,wool4 ,fractures of the clavicle nearly always leave some deformity after union2 this is best avoided by keeping the patient on his back on a flat couch with the head alone supported by a cushion1 and the arm fixed to the side until union has taken place4 ,as most persons will not submit to a fortnight or three weeks' confinement in bed for this accident1 the fragments must be kept in position as nearly as possible by apparatus while the patient goes about4 ,the displacement of the outer fragment is inwards1 downwards1 and forwards4 ,many varieties of apparatus are employed to prevent this displacement during union2 the following mode is perhaps as effectual as any other in accomplishing this object4 ,step #a4 ,fix in the arm-pit a firm wedge-shaped pad of bedtick filled with chaff2 #e inches broad1 #f inches long1 and #a or #b inches thick at the thick end1 or just enough to fill the axilla and throw out the humerus without compressing the axillary vein1 hence the thickness varies with the hollowness of the axilla 7see fig4 #ch74 ,a band and buckle are stitched to the thick end1 which is uppermost4 ,when in use1 this band is passed over the opposite shoulder and keeps the pad in place4 ,a little wool should be put under the band1 where it crosses the root of the neck1 to prevent chafing4 ,illustration3 ,fig4 #ch4--,wedge-shape pad for broken ,collar-bone1 attached to the ,american ring-pad4 ,step #b4 ,the elbow is elevated by an assistant1 who keeps the arm vertical and lays the fingers on the breast bone4 ,a roller attached to the arm by a couple of turns is carried behind the back round the trunk1 and over the arm above the elbow1 drawing that close to the side4 ,step #c4 ,to support the elbow1 the longest border or base of a three-cornered handkerchief is carried under it1 one end passes in front1 the other behind the body2 both are then drawn tightly and crossed over the opposite shoulder1 where one end is taken under the axilla1 and tied in front4 ,in giving this direction the ring-pads shown in the figures are supposed not to be at hand4 ,lastly1 the loose corner at the wrist is folded neatly and pinned up 7see fig4 #ci74 ,illustration3 ,fig4 #ci4--;,apparatus for broken ,clavicle finished4 ,this apparatus must be watched from time to time1 and re-adjusted if any part slips4 ,the sling and pad are to be worn for four weeks4 ,union sometimes takes place in three weeks or less1 in which case the pad may be removed so much the earlier2 but a sling should be worn for a fortnight after the bandage and pad are laid aside4 ,in children the pad must be very much thinner and shorter than that described2 the sling should be replaced by a bandage carried alternately round the body1 and over the opposite shoulder4 ,after it is put on the turns should be well stitched together1 and smeared over with stiff starch4 ,in bandaging children1 great care must be taken to protect with wool the parts likely to be chafed4 ,figure-of-#h bandage4--,many surgeons still employ a figure-of-#h bandage carried under each axilla and crossed behind the back4 ,under any circumstances this is exceedingly irksome to the patient1 but is least so if two silk handkerchiefs be substituted for the bandage1 one being passed round each shoulder and the ends of both braced tightly together behind the back4 ,the wedge-shaped pad may be dispensed with if the shoulders are braced back1 but the elbow must still be raised and drawn to the side4 ,the ,american surgeons have a very good plan for attaching the sling to the sound shoulder4 ,instead of carrying the ends of the sling round the shoulder and under the axilla1 they pass over the shoulder a loose but well-stuffed collar or ring-pad 7see fig4 #ch71 to which they fasten the ends of the sling in front and behind2 this prevents all cutting or chafing under the armpit1 and distributes the strain evenly4 ,,lower ,,extremity4 ,ruptured tendo ,achillis is treated by extending the foot and flexing the knee2 for this purpose the patient wears a high-heeled slipper4 ,a band is sewn to the heel1 drawn tight1 and fastened to a buckle and strap round the thigh1 just above the knee4 ,the patient should not walk for a month unless he will use a wooden leg on which he can kneel1 with the knee bent4 ,separation of the ,epiphysis of the ,calcaneum1 which sometimes occurs instead of rupture of the tendo ,achillis1 is treated in the same way4 ,fracture of the ,fibula4--,dupuytren's ,splint4--,when the fibula only is broken1 it may be treated in several ways2 this1 however1 is the common plan3-- ,apparatus4--#a4 ,straight wooden splint4 #b4 ,pad and wool4 #c4 ,a roller4 ,step #a4 ,the splint should be about #c inches broad1 and long enough to reach from the head of the tibia to #d inches beyond the sole of the foot4 ,a notch #a or #b inches deep is generally cut at the lower end of the splint to catch the bandage in4 ,the splint is then padded1 care being taken that the padding is sufficiently thick to prevent galling at the upper end against the inner condyle of the tibia1 and that it becomes thicker as it descends along the leg1 for that to rest easily against the splint2 lastly1 the pad should end in a thick boss or projection opposite the internal malleolus1 beyond which it should not reach1 lest it interfere with the rotation and adduction of the foot inwards4 ,step #b4 ,the splint1 when thus prepared1 is applied along the inner side of the leg1 taking care in doing this that the internal malleolus is against the middle of the splint1 and not allowed by the assistant to slip towards the anterior or posterior border4 ,step #c4 ,a roller is then carried round the limb and splint1 beginning below the knee and continuing in simple spirals for three or four turns1 when it is fastened and cut off4 ,step #d4 ,a light layer of wool is wrapped round the outside of the ankle1 heel1 and dorsum of the foot4 ,then a roller1 beginning at the splint1 passes outwards in front of the ankle over the external malleolus1 behind the heel and the splint2 then over the dorsum to the outer margin of the foot1 next under the sole through the notch of the splint to the front of the ankle joint again1 where it repeats the same course three or four times4 ,each turn must be tightly applied and made to draw the foot well inwards to the splint1 and in doing so to tilt outwards the broken part of the fibula 7see fig4 #dj74 ,this splint is cumbersome1 hence after two or three weeks1 should be replaced by a light starch or gum casing for the foot and leg1 leaving the knee free4 ,illustration3 ,fig4 #dj4--;,dupuytren's ,splint for fracture of the ,fibula4 ,fractures of the ,tibia with or without the fibula1 and fractures at the ankle joint4 ,these fractures are often from their obliquity difficult to keep in good position2 in such cases ,mc,intyre's ,splint is very generally used in the early part of the treatment4 ,for this splint the following apparatus is required3-- #a4 ,mc,intyre's splint4 #b4 ,pads for the double incline plane and foot-piece4 #c4 ,sock of flannel for the foot4 #d4 ,rollers1 #c inches wide4 #e4 ,wool1 pins1 needle and thread1 strapping plaster4 #f;a4 ,a sling-cradle1 or #f;b4 ,board1 block1 gimlet1 screws and screw-driver4 ,the ,mc,intyre's ,splint may be used either bent or straight1 whichever position of the knee most relaxes the tension of the muscles on the fragments4 ,as a general rule the straight position is best if the fracture is high up1 and the bent one1 when near the ankle joint4 ,step #a4 ,a splint of suitable length is selected1 by measuring the sound leg4 ,the joint of the splint should be put opposite the patella1 and space be left below the foot for the foot-piece to slide along the slot when extension is made4 ,the splint is next padded1 the hollow where the lower part of the calf and small of the leg will come being well filled1 that the leg may be thoroughly supported2 but the space behind the heel and tendo ,achillis must be left quite clear4 ,a small pad is then fastened by a strip of strapping or by needle and thread to the foot-piece4 ,step #b4 ,the limb having been first cleaned and dried1 the dorsum of the foot and ankle are wrapped in an even layer of cotton wool4 ,a sock or boot made of flannel is next put on the foot4 ,this may be readily extemporised by cutting off the foot of an angola stocking1 slitting it up along the back to the toes1 and sewing on to the sole1 one inch in front of the heel1 the middle of a piece of tape inch wide and #ah inches long4 ,the foot is then wrapped in the sock1 the edges drawn together by a needle and thread1 care being taken that the sock fits closely round the ankle and dorsum of the foot4 ,a little wool having been wrapped round the knee1 the limb is next raised1 while the splint is placed under it2 the screw is turned until the inclined planes are at an angle suited for the maintenance of the fragments in position1 and the foot-piece is pushed up to the foot with its screw-pin loose1 that it may be adjusted to the amount of flexion or extension necessary for the foot2 this being ascertained1 the screw is tightened to keep it so while the foot is fastened to the foot-piece4 ,for this the strings of the sock are brought over the top of the foot-piece1 and drawn tight before tying them4 ,illustration3 ,fig4 #da4--,mc,intyre's ,splint4 ,the thigh fixed ready for extension of the leg4 ,the position of the heel is very important4 ,it should not sink below the splint1 or it will rest on the bandage2 neither should it be drawn up too high1 or the weight of the leg will hang on the sock1 instead of resting on the pad2 both frequent causes of pain at the heel4 ,when the proper position is obtained1 the strings are made fast to the pin behind the foot-piece1 and the foot is steadied by two or three turns of a roller carried round it and the foot-piece 7fig4 #da74 ,step #c4 ,the thigh is next fastened to the thigh-piece by a roller carried from the top of the splint downwards along the thigh to the knee1 or below that joint if the fracture is near the ankle4 ,in doing this the roller is passed inside the screw1 should that be placed underneath the splint1 as in fig4 #dc page #fe1 and not at the side as in fig4 #da1 for the screw will be wanted free for further adjustment4 ,illustration3 ,fig4 #db4--,mc,intyre's ,splint slung in ,salter's ,cradle4 ,step #d4 ,an assistant grasps with both hands the foot and foot-piece1 and pulls them downwards until the shortening is removed4 ,while doing this1 he tilts the foot up or down as the surgeon finds necessary for adjusting the fragments1 who also bends the knee and raises or lowers the foot until a good position is attained4 ,the general rule is to keep the great toe in a line with the patella4 ,this done1 the surgeon tightens up the screw-pin of the foot-piece1 and completes the attachment of the foot by continuing his roller with figures of #h round the foot and ankle2 these turns should not however pass above the fracture1 and be no more than sufficient to secure the position of the foot and of the lower fragments 7see fig4 #db74 ,step #e4 ,the bandaging usually ceases with what has been already done2 but if the limb swell1 a separate roller may be carried along the leg to support the muscles and restrain dema1 otherwise the leg is best left bare1 that the position of the fragments may be watched1 and evaporating lotions applied4 ,illustration3 ,fig4 #dc4--,mc,intyre's ,splint raised on a ,block4 ,step #f;a4 ,this consists in slinging the limb1 for which ,salter's ,cradle is very convenient 7see fig4 #db71 or an ordinary bed cradle answers very well1 from which the limb can be slung on pieces of bandage carried underneath the splint at the knee and ankle4 b4 ,instead of elevating the limb by a sling1 it is also customary to raise and fix the splint on a block 7fig4 #dc71 #f1 #h1 #aj1 or even #ab inches high1 as may be necessary2 this block slides in a groove on a board #c feet square1 put between the mattress and bedstead1 to afford a firm support for the block4 ,in ordinary cases the limb is kept on the splint three weeks1 until the irritation has subsided1 and partial union is attained2 the splint may then be replaced by a starch bandage1 and the patient may leave his bed4 ,transverse ,fracture of the tibia alone1 or even of both bones1 when the displacement is small1 is very well treated by a hollow splint on each side4 ,both splints are cut away opposite the malleoli1 and the foot-piece of the inside one should not extend beyond the tarsus2 that of the outside passes to the toes4 ,the splints reach on each side to the head of the tibia1 but ought not to extend above the knee-joint 7see fig4 #dd74 ,illustration3 ,fig4 #dd4--,outside lateral ,splint for the ,tibia4 ,step #a4 ,they are padded lightly and evenly along their whole length1 and applied to the limb on each side4 ,step #b4 ,they should then be fastened by figure of #h round the foot and ankle until the foot is securely fixed in them4 ,the bandage should then be fastened off1 and extension made by an assistant1 who grasps the foot and ankle with both hands while the surgeon fixes the splints to the limb above the fracture1 beginning his roller at the top just below the knee1 and continuing it downwards with spiral turns until the fracture is reached1 above which it should terminate 7fig4 #de74 ,after the apparatus is applied1 the limb may be either supported upright by sand-bags1 or slung in a cradle1 for three weeks1 after which the splints are advantageously replaced by a starch bandage for three weeks longer4 ,illustration3 ,fig4 #de4--,lateral ,splints for simple transverse fracture of the ,tibia4 ,flexing the ,leg for ,fracture of the ,tibia4 ,sometimes1 when there is unusual difficulty in preventing displacement of the fragments while the limb is nearly straight1 the bones can be readily kept in position if the patient lies on the same side as the injured limb and the knee is well flexed4 ,for such cases these splints are very suitable2 they should be applied after the limb has been bent and the fragments brought into apposition4 ,when the splints have been put on1 a roller may be carried round the leg and thigh to keep the limb in its bent position4 ,fracture of the ,patella4--,when this bone is broken there is usually much swelling from effusion into the knee-joint2 while this is present1 rest1 with cold lotions1 and elevation of the foot1 are alone applicable4 ,when the effusion has subsided1 the upper fragment must be brought down to the lower one1 by some means like the following4 ,apparatus4--#a4 ,straight wooden splint with a foot-piece4 #b4 ,pads4 #c4 ,diachylon plaster4 #d4 ,roller4 #e4 ,lint and wool4 #f4 ,two hooks or screws1 gimlet1 and screw-driver4 ,step #a4 ,the splint is first fitted2 it should reach from the buttock to the heel1 at which point a foot-piece rises for the foot to rest against2 at the back of the splint a line should be marked #c inches above1 and another #c inches below the knee-cap1 into which a stout screw or hook is inserted before the splint is put on4 ,it is then well padded1 to support the calf and leg1 while the heel is left free1 and a pad is put between the sole and the foot-piece4 ,a firm crescent-shaped pad is prepared to sit like a saddle above the upper fragment4 ,step #b4 ,the limb is laid on the splint2 an assistant draws the patella as nearly as possible into its place1 and the surgeon lays the crescentic pad on the thigh above the patella1 and takes a strap of plaster #b inches broad and #bj long1 warms it1 and lays the middle across the compress1 drawing each end tightly around the limb1 and then downwards and forwards in a figure of #h2 a similar strap is then fixed below the lower fragment4 ,the knee1 shin1 ankle1 and foot are then protected by a layer of cotton wool1 and the bandaging begins4 ,step #c4 ,the roller first fastens the foot against the foot-piece by figures of #h1 then passes up the leg by reverses until opposite the lower hook1 where it is fastened4 ,illustration3 ,fig4 #df4--;,fractured ,patella1 drawing down the upper fragment4 ,step #d4 ,a second roller is then begun at the top of the thigh and brought down the limb till it reaches the compress over the patella2 from this point it passes below the lower screw at the back of the splint and makes one circular turn round the limb2 the roller is then taken upwards across the compress 7as shown in fig4 #df7 to the upper screw1 where it also makes a circular turn2 having done this it again descends to reach the lower screw1 and is returned as before4 ,each of these turns should be drawn tightly to bring the upper fragment as near the lower one as possible2 when this is done the bandage is completed over the knee by figures of #h4 ,it suffices to fix the lower fragment1 which cannot be drawn up to meet the upper one2 the latter must descend to it4 ,step #e4 ,the limb is lastly put into position by elevating the heel and by raising the body with pillows till it is in a half-sitting position4 ,the patient wears this splint four weeks1 during the first fortnight of which the bandage should be perseveringly re-applied every three or four days until the upper fragment is brought into apposition with the lower one4 ,after this the splint may be changed for a light starch or gutta-percha case1 to be worn for six weeks more1 and then replaced by a back splint of leather and knee-cap1 that must not be laid aside for another period of three or four weeks4 ,if the patient can be persuaded not to bend his knee for four months1 the union of the fragments will be less likely to yield afterwards4 ,he should be also warned that much stiffness will result from the long fixed position necessary to procure good union between the fragments2 but the stiffness will all subside in time1 notwithstanding the long-enforced rigidity4 ,strap and ,spiral ,bandage4 ,e4 ,k4 ,samborne's ,plan of drawing ,patella ,fragments together4--,a strip of diachylon plaster #d feet long and #b in4 wide is applied to the front of the limb from #b in4 below the groin to the small of the leg1 leaving a free loop or doubling opposite the patella4 ,beneath this loop a firm compress or horseshoe pad is placed above the upper fragment4 ,a roller is then carried round the limb to keep the strap in place1 but leaving the loop at the knee exposed4 ,this done1 the body is propped up in a half-sitting position1 and the limb elevated on an incline4 ,a stick1 #f inches long and inch thick1 is inserted into the loop of plaster1 and then twisted round and round till1 by shortening the loop1 the loose tissues of the thigh1 and with them the upper fragment of the patella1 are drawn down to the knee4 ,the stick is prevented from untwisting by a roller lightly carried round the knee4 ,as the plaster slackens1 the stick may be tightened from time to time and the fragment brought in a few days into its proper place4 ,illustration3 ,fig4 #dg4--,malgaigne's ,hooks4 ,malgaigne's ,hooks 7fig4 #dg71 for drawing closely and holding together the fragments in transverse fracture of the patella1 or of the olecranon1 often procure a closer union than any other method4 ,they should not be inserted until effusion is absorbed and the soreness has subsided4 ,to insert them1 one pair of hooks should be bedded in the ligamentum patell1 and catch against the lower edge of the bone2 the skin is then drawn up the limb1 while the upper pair of hooks is passed through it and behind the upper fragment2 the two ends are then approximated by turning the screw4 ,the fragments usually do not come quite close the first day1 but the next they can be drawn so firmly together that if one is moved the other goes with it4 ,in applying the hooks care should be taken that the upper pair go well through the skin and fascia behind the bone1 or when they are screwed up the upper fragment is apt to ride unevenly over the other1 and exact junction is lost4 ,the pain of the insertion soon passes off1 and the hooks can commonly be worn without annoyance for five or six weeks1 until union is secured4 ,fracture of the ,shaft of the ,thigh-bone4--,the long ,splint4 ,apparatus4--#a4 ,a wooden splint4 #b4 ,rollers1 #c inches wide4 #c4 ,perineal band4 #d4 ,strapping1 needle1 and thread4 #e4 ,pad and wool4 ,the splint for an adult should be #b or #c inches wide1 and long enough to reach from the nipple to #d or #e inches beyond the heel2 two round holes inch diameter are cut at its upper end1 and at the lower one two notches #b inches deep4 ,liston's ,mode of applying the ,long ,splint4 ,step #a4 ,the end of a roller is split for a few inches1 and tied in the holes at the upper end4 ,the roller itself is carried down the inside of the splint and attached temporarily to the notches at the other end2 a pad is then fastened on1 by drawing the margins together with needle and thread across the outside of the splint1 or by tying strips of bandage round the pad and splint at short distances4 ,step #b4 ,the limb having been washed with soap and water1 well dried1 and afterwards dusted with starch powder1 especially at the perinum1 the ankle and dorsum of the foot are wrapped in a layer of cotton wool1 and the splint applied along the outside of the body4 ,the bandage which was fastened to the splint is now released from the notch2 and1 taking with it the end of the pad1 is carried under the sole1 then over the ankle joint to the splint1 and behind the ankle round the internal malleolus to the dorsum of the foot1 then through the lower notch of the splint to the inside of the foot again4 ,this figure of #h is carried four times over the dorsum of the foot1 twice through each notch of the splint1 and is made fast by a pin or a stitch4 ,in doing this1 care must be taken to keep the leg and splint parallel1 and that the splint does not ride over the back of the foot2 the external malleolus should be midway between the margins2 moreover1 the bandage must fit firmly round the ankle and splint1 not spreading over the dorsum more than can be helped1 to avoid straining the front of the ankle4 ,means for more effectually preventing this will be afterwards detailed4 ,step #c4 ,next apply counter-extension2 for this1 the perineal band is used4 ,the band consists of a silk handkerchief or napkin folded into a flat ribbon1 #a inch wide and covered for about #a foot of its length with oiled silk4 ,a piece of smooth brown paper1 #a foot long and #d inches wide1 folded into a ribbon one inch wide1 makes an excellent foundation for the silk handkerchief to be folded upon4 ,a band thus prepared is too stiff to become a cord after it has been worn a few days1 which a simple handkerchief is apt to do4 ,one end of the band is passed in front in the groin1 and one behind the buttock1 so that it bears on the tuber ischii in the perinum2 the ends are then drawn separately through the holes in the splint4 ,all being ready for extension1 an assistant1 grasping the leg and splint above the ankle1 pulls out the shortening till the broken bone is in a good position2 the ends of the band are then tightened and made fast in a knot4 ,step #d4 ,first protecting the bony points with cotton wool1 the muscles about the hip are confined by a spica carried round the body and the splint1 not merely a simple figure of #h as depicted in the figure1 but a series of overlapping turns which ascend and cover in the hips well4 ,afterwards the upper end of the splint is drawn close to the body by a few turns of a broad roller carried round the chest from above downwards 7see fig4 #dh74 ,illustration3 ,fig4 #dh4--,the long splint1 with elastic stirrup extension at the foot4 ,bandage carried up to the seat of fracture4 ,step #e4 ,it is customary to carry the bandage further than the ankle1 but this is not an essential part of the apparatus1 which is simply to keep up the extension in the direction of the axis of the limb4 ,this subsidiary bandage has the disadvantage of concealing the limb1 and the position of the broken ends of the bone2 but it steadies the limb on the splint1 and confines the muscles1 thereby preventing pain and perhaps hindering rotation outwards of the upper fragment4 ,before putting it on1 some cotton wool is wrapped round the knee1 and laid along the shin2 the application of the roller is then begun at the ankle where it first terminated1 and is carried up the leg1 over the knee1 and along the thigh by reverses until the groin is reached1 where it finishes4 ,the perineal band must be changed whenever it gets soiled1 and the skin washed before a clean one is adjusted4 ,after the first few days the band need not be very tight2 it suffices if not slack or loose4 ,mr4 ,coxeter makes india-rubber tubes in the shape of a perineal band2 these are filled with water when in use 7see fig4 #di74 ,illustration3 ,fig4 #di4--;,coxeter's elastic perineal band4 ,stirrup extension is a mode of relieving the strain on the front of the ankle1 caused by the lower end of the splint being attached to it4 ,a #c-;inch wide roller or bit of wood of the same breadth is laid against the sole of the foot1 and a stout india-rubber ring #b inches in diameter is slipped over it4 ,a piece of strapping plaster1 #b feet long and #b inches wide1 is passed half-way through the ring1 and its ends carried up the leg inside and outside2 the plaster is kept in place by a roller or second strip laid on in spirals up the limb as in fig4 #ej1 and the india-rubber ring is hitched against a hook at the end of the splint4 ,by this means the strain is transferred to the leg1 and the ankle is quite free4 ,it is perfectly successful1 and very easy to the patient4 ,the long splint is to be worn continuously for six weeks2 or1 what is better1 after the first three weeks it may be replaced by a starch bandage1 and the patient allowed to get about on crutches with his leg slung from his neck4 ,illustration3 ,fig4 #ej4--,mode of fastening the stirrup to the leg1 to avoid straining the ankle4 ,continuous ,extension with the ,limb flexed4--,the muscles attached to the upper end of the femur sometimes cause so much flexion and rotation outwards of the upper fragment that union of the bones in this position produces a result approaching that in fig4 #ea1 drawn from a preparation in the museum of ,university ,college4 ,this crooked union is prevented by bending the thigh and relaxing the muscles of the hip4 ,this object is accomplished by using the double incline planes or the double incline planes1 slung1 shown in figs4 #eb and #ec4 ,illustration3 ,fig4 #ea4--;,fracture below the trochanters2 bone in angular union4 ,double incline planes are sometimes employed alone4 ,the limb is raised over a wooden frame about #h inches broad1 with a double slope high enough at the apex for the leg and foot to hang unsupported down the further side 7fig4 #eb74 ,it is well padded before being applied1 and the leg and thigh secured to it by a roller passed round the limb and plane1 or better1 a trough of gutta-percha may be moulded to the limb while it is on the plane1 and when set1 screwed down to the wood at one or two points2 in this the limb rests securely4 ,illustration3 ,fig4 #eb4--;,double incline planes4 ,slinging the double incline planes was practised many years ago by ,mayor of ,lausanne1 and has been much used recently4 ,it is an apparatus very easy for the patient1 and particularly well suited for compound fractures of the thigh1 for fractures near the trochanters that require a flexed position1 or for fractures of the neck of the femur where the patient's feebleness does not permit the constraint of the long splint4 ,apparatus4--#a4 ,a bent wire frame 7see fig4 #ec7 with a separate foot-piece4 #b4 ,two pulleys1 a rope with tent stretchers passing up to hooks in the ceiling1 or some suitable support4 #c4 ,one long and one short soft pad4 #d4 ,strapping plaster1 and some ends of bandage4 ,step #a4 ,the limb is washed and dried1 and the short pad fitted to the foot-piece1 which is furnished with some hooks at its lower surface1 where ends of bandage or tape can be fastened1 for fixing it to the wire frame4 ,the frame is next prepared by passing strips of bandage across it from side to side at short intervals1 to make a support on which the limb is laid2 if there is no wound1 a soft pad may be put on the frame first1 but if one be present1 the limb should rest immediately on the strips of bandage1 which can be changed whenever soiled1 and replaced by clean ones without disturbing the limb4 ,these strips should be tacked on with a needle and thread1 that1 when the limb is placed on the apparatus1 they can be shortened or lengthened till the leg bears evenly on them 7see fig4 #ec74 ,illustration3 ,fig4 #ec4--;,double incline plane1 slung4 ,step #b4 ,the foot-piece is adjusted and fastened to the foot by straps of plaster carried round it and up each side of the leg1 as was done for the stirrup extension in the 8long splint0 7p4 #gf74 ,step #c4 ,the limb is next placed in the cradle formed for it1 to the lower end of which the foot-piece is tied securely2 the ropes are rove through the pulleys and tightened till the limb swings easily4 ,the point of attachment of the ropes must not be just above the limb1 but beyond it1 that the leg may be drawn away from the body along its own axis4 ,the weight of the body makes counter-extension sufficient to remove all shortening in a few days4 ,the relief from the constraint attending the absolute immobility of the long splint1 renders this apparatus a particularly easy one for the patient2 and union is found to take place without any shortening of the limb4 ,where there is no wound1 the limb and frame may be kept together by a roller bandage carried round them from the toes to the knee1 after the limb has been adjusted in the splint4 ,continuous ,extension in the straight position is employed for fractures of the femur and in hip-disease4 ,it is procured as follows4 ,a stirrup is fastened to the leg in the way described at page #gf2 to this a cord and weight are attached below the sole of the foot1 and passed over a pulley fixed to a tripod frame 7fig4 #ed71 or any convenient object below the bed1 in a line with the axis of the limb4 ,the weight should balance the contraction of the muscles1 and usually varies between #b and #f lbs4 ,a perineal band fastened behind the patient's head keeps the body from following the limb4 ,the weight may be a common scale weight1 or a bag with a hole at the bottom closed by a string1 and filled with shot or sand1 or a can with a tap at the bottom filled with water3 these arrangements allow increase or lessening of the weight1 without slackening the cord and moving the limb4 ,this apparatus requires no bandages1 which are so difficult to keep clean in children1 and exerts a very even and continuous strain on the limb4 ,illustration3 ,fig4 #ed4--;,fracture of the femur4 ,extension by weight and pulley4 ,the perineal band may be often dispensed with1 by laying the patient on a flat mattress and raising the foot of the bedstead a few inches higher than the head2 the body then sinks towards the head of the bed and resists the extension of the leg4 ,starch ,bandage4--,the following mode of applying the starch bandage and pasteboard splints may be used in all varieties of fracture2 the length of the splints and the number of joints that should be included depend on the bone that is broken4 ,some surgeons apply the starch apparatus immediately after the fracture has happened1 others wait until partial union is procured and the irritability of the muscles has subsided4 ,apparatus4--#a4 ,sheets of bookbinder's millboard4 #b4 ,rollers suitable for the size of the limb4 #c4 ,cotton wool4 #d4 ,a basin of freshly scalded starch4 #e4 ,a long strip of plaster1 to reach as high as the bandage will extend up the limb4 #f4 ,if the fracture be recent1 a wooden splint will generally be necessary to keep up extension while the starch is drying4 ,as a general rule1 the joint at the lower end of the fractured bone should always be fixed1 and that at the upper end also1 if the fracture is near that point4 ,for an example of the mode of fitting1 let us suppose the femur is broken between the middle and lower thirds as in fig4 #ef4 ,step #a4 ,the limb is first measured for the splints4 ,the length from the top of the sacrum to the heel1 from the tuber ischii to the inside of the foot1 and from the iliac crest to the outside of the foot1 should be taken1 and three strips of millboard prepared of corresponding lengths2 the posterior one being #c inches wide above and #b inches1 or1 if the limb is small1 #a inches wide at the heel4 ,the inner and outer strips of similar width must be cut with side pieces for the foot1 and these side-pieces stop short of the roots of the toes4 ,for a child's thigh1 the foot need not be included1 it suffices for the splints to reach the small of the leg1 though to prevent shortening in an adult it is usually necessary to include the whole limb4 ,the splints are readily cut1 by first marking on the sheet of millboard1 the required width and length of the strips1 then bending the sheet over the edge of a table along these lines4 ,the two lateral splints may be first taken from the sheet in one wide strip1 after allowing for the foot-piece2 the two strips are separated through a diagonal line1 so that the broad end of one splint is taken from the other 7see fig4 #ee74 ,illustration3 ,fig4 #ee4--;,diagram showing the mode of cutting out splints from a sheet of millboard4 ,when the strips are cut they should be laid on a large tea-tray1 boiling water poured over them1 and a minute or two later1 some boiling hot thin starch2 this soon soaks into and softens the millboard till it is thoroughly pliant4 ,when somewhat softened1 the edges should be thinned by peeling off little strips along them1 after which some more boiling water may be poured on and allowed to soak in while the limb is prepared4 ,two or three rollers should then be unwound1 and passed as they are rolled up again through the basin of starch2 these1 thoroughly soaked in starch1 are used for the first layer1 dry rollers serve very well for the second layer4 ,step #b4 ,the limb is washed and dried2 a strip of diachylon plaster one inch wide is laid along the front to protect the skin when the case is being cut open after it is dry2 the limb is next wrapped evenly in cotton wool1 putting a scrap between each toe4 ,this is best done by unrolling a sheet of wadding1 splitting the sheet into a layer of suitable thickness1 which is torn into strips about three inches broad1 that are then wound evenly round the limb as high as the splints will reach4 ,step #c4 ,the splints are next adjusted and moulded to the limb1 being temporarily secured by a few ends of bandage tied round them4 ,one assistant grasps the splints and foot at the ankle and keeps up extension1 while another holds the thigh4 ,the surgeon then proceeds to roll the bandages1 first round the foot and ankle1 and then up the leg1 rubbing in the warm starch as he proceeds4 ,each turn of the roller should be made as tightly as possible1 for when the case dries it always grows loose by the evaporation of the water it holds4 ,as reverses are always difficult to cut through afterwards1 they should be avoided1 and the bandage laid on in simple spiral or figure of #h turns4 ,when the perinum is reached1 the surgeon wraps round the pelvis a broad strip of cotton wool1 while an assistant on each side of the patient supports his body on a folded sheet or jack-towel1 and a third holds the broken limb4 ,the bandaging is then continued in a well-fitting spica1 and ended by a few circular turns round the body4 ,if the splint touches the crest of the ilium it should be shortened till it clears that point1 or it will gall the patient afterwards4 ,a fold of soft lint in addition to the cotton wool should line the splint at the perinum1 or the sharp edge of the bandage1 when it is dry1 will chafe there also4 ,when the first bandage is complete1 the limb should be smeared again with starch1 and a dry bandage rolled over it from below upwards1 which must be similarly saturated with starch as it is laid on the limb1 and when finished the whole is well covered with starch4 ,if the fracture is recent1 and no union has taken place1 a long splint should be put on outside the case1 fastened to the foot and extended by a perineal band1 while the starch is drying1 that the limb may not shorten4 ,with children it is best to apply the wooden splint in all cases1 as they are apt to wriggle about1 or sit up in bed and disarrange the case while it is in a pliant condition4 ,if the wood splint is not used1 the limb should be supported in a good position by sand-bags laid along its sides4 ,illustration3 ,fig4 #ef4--,starch ,bandage4 ,in three days the starch is quite dry1 but the drying may be hastened by hot-water bottles or hot sand-bags laid in the bed4 ,it must then be cut up along the front from bottom to top2 it will often be found loose1 especially where swelling had existed before2 this is best remedied by paring the overlapping edges with scissors4 ,if any projecting part is chafed1 an accident that ought not to happen1 the case may be lifted from the sore part by a little more wool laid around1 not on the part pinched4 ,the limb being in a satisfactory position1 and the case fitting properly1 a roller is carried up over the whole to keep it in place while it is worn 7fig4 #ef74 ,the patient need not now be confined to bed2 on the contrary1 the limb should be supported by a sling round his neck1 while he gets about with crutches1 if his leg be the part injured4 ,the fracture should be examined from time to time1 and at the end of three weeks some of the joints previously confined in the splint may be released by cutting off the part covering them2 but if the part is a dependent one1 such as the leg1 it should be supported by a bandage after the splint has been removed4 ,the limb may also be washed with soap and water1 and then anointed with simple ointment1 if the skin be roughened or irritated by long confinement4 ,in six weeks the starch splint may usually be discarded1 and a roller alone worn for a few weeks longer4 ,plaster of ,paris ,bandage4 ,apparatus4--#a4 ,freshly burned white plaster of ,paris4 ,if the plaster have become stale by keeping in improperly closed vessels1 and it be impossible to obtain fresh plaster1 the water the plaster has absorbed from the atmosphere can be driven off by heating the powder in a dry oven to about #bjj ,f4 to #bfj ,f41 but not higher1 as greater heat destroys the power of 8setting40 #b4 ,rollers1 about #b inches wide1 of muslin with a coarse open texture4 #c4 ,a roller of ,welsh flannel #c inches wide and #f yards long4 #d4 ,basin of cold water1 sponge1 and a kitchen spoon4 #e4 ,soft lard or spermaceti ointment4 ,step #a4 ,the muslin rollers are prepared by being loaded with dry powder just before they are used4 ,to do this the roller should be gradually unrolled on a table while one person rubs in the powder1 and a second rolls the loaded bandage up again4 ,when three or four are loaded they should be plunged for a minute into cold water1 and then are ready for use4 ,while this is being done the limb should be thoroughly washed and dried1 supported1 if the fracture be recent1 by sand-bags4 ,illustration3 ,fig4 #eg4--,plaster of ,paris ,bandage1 for simple fracture of the tibia1 and common bed cradle4 ,step #b4 ,the surgeon carefully greases the limb wherever the plaster will reach1 and rolls a ,welsh flannel roller round it for about #c inches at the point where the plaster roller will cease4 ,this protects the skin from the rough edge of the plaster splint when the apparatus is set and hard4 ,indeed1 if the whole of the surface to be covered with plaster be enveloped in a flannel roller1 the apparatus is more comfortable to the patient1 and in this case the grease may be dispensed with4 ,when the limb is prepared the surgeon intrusts it to assistants1 who will maintain reduction while he lays on the plaster rollers1 wetting them freely as they are laid on1 with a sponge at hand in a basin of cold water4 ,usually two layers of roller give sufficient rigidity to the apparatus2 but if the limb is heavy1 the case should be strengthened1 by smearing over it a coating of plaster1 prepared by shaking the powder into a basin of water kept constantly stirred1 till it has the consistence of cream4 ,the surgeon must watch that the fractured bones are kept in position till the plaster is set1 a process sufficiently advanced in five minutes1 when the bandage1 supported by sand-bags1 may be left to dry4 ,when the plaster is quite set the bone is immoveable and may be carried about without risk of displacement4 ,in deciding what joints should be included in the bandage1 the same rules obtain in this as for the starch bandage2 no more joints should be rendered immoveable than are necessary to obtain command of the broken bone2 when the fracture is near a joint1 that must be confined to prevent the bones being moved with the movements of the joint2 when the fracture is far away from it1 sufficient control can be exercised over the bone to prevent the broken ends moving1 and the joint may remain free4 ,if the plaster apparatus is applied over a wound1 the latter should be covered with greased lint1 and its position noted before the rollers are applied2 when the apparatus is set1 the plaster must be dissolved around the wound by touching it with strong nitro-hydrochloric acid2 when this is carried completely round1 the isolated fragment of plaster may be removed1 and the wound exposed4 ,for removal1 the roller can be unwound again readily1 or it can be softened by acid along a line1 and slit up with scissors1 when the apparatus comes off in a piece4 ,should bandages of loose texture not be at hand1 common rollers can be made to answer the purpose tolerably well in the following way4 ,having washed and dried the limb1 and reduced the fracture2 the bones are held in position by assistants1 while the limb is greased and enveloped in a dry roller by simple turns and figures of #h4 ,a basin of plaster is prepared by shaking the powder into water till a thin cream is formed1 which is laid on the bandage with a spoon1 or the hands4 ,then a second but wetted roller is put on in the same way quickly before the plaster has set1 and covered in its turn1 until a case of sufficient thickness is procured4 ,this bandage is much improved if the first roller be of flannel instead of calico4 ,the flannel roller may be unrolled and loaded with dry plaster1 like the muslin1 and wetted before using2 in this way it contains nearly as much plaster as the loose webbing rollers of muslin4 ,in the ,army ,medical ,reports for #ahfe 7#ahfg71 ,mr4 ,moffitt describes a very ready method of employing the plaster splints for recent fractures4 ,instead of bandaging the limb1 an envelope of ,welsh flannel is fitted to the part to be supported4 ,the flannel should envelope the limb1 except for a longitudinal space about inch in width between the edges of the flannel4 ,the dotted lines in the accompanying figure show the shape of the flannel when fitted to the leg4 ,the limb being thoroughly greased1 the flannel is well soaked in thin plaster cream1 and laid on a table while the creases are smoothed out of it4 ,when ready it is applied accurately to the limb1 so as to fit everywhere1 but leaving a narrow open space along the whole length of the limb4 ,the flannel must be held steadily till the plaster is set1 which takes place in about five minutes1 and the splint is complete4 ,if one layer is not stiff enough1 a second may be laid over the first in the same way4 ,when the splints are fitted1 they are kept in place by a roller applied lightly over them4 ,if instead of soaking the second layer of flannel in plaster1 it be thickly spread with strong solution of ,british gum 7dextrine71 and the gummed side laid next the first flannel1 the splint is tough enough to stand any ordinary strain without breaking4 ,illustration3 ,fig4 #eh4--,moffitt's method of applying plaster of ,paris splints4 ,copied from ,army ,medical ,reports for #ahfe4 ,gum thickened with powdered chalk1 glue1 silicate of soda1 ,hides' leather felt and stiffening solution1 paraffine1 c41 are also employed for stiffening bandages and flexible splints1 after they are moulded to a limb1 but none of them are as readily procured or have much advantage over starch and plaster of ,paris4 ,a detailed description of the mode of using them is unnecessary4 ,sand-bags are very useful1 when laid along an injured limb1 to prop it up on either side4 ,for this purpose they are better than pillows1 as their weight prevents their slipping from under the part they support4 ,they should be made of macintosh cloth about #d or #f inches diameter1 and in lengths varying from #a to #d feet1 well closed that the sand may not escape through the seams2 the macintosh should be covered with flannel1 renewed from time to time4 ,the sand should be washed and well dried before the bags are filled1 that it may not rot the cloth containing it4 ,moreover1 the bags should be only three quarters full1 or they will be too hard to adapt themselves to the limb when in use4 ,cradles are light arched frames of wire or cane to support the bedclothes over an injured limb4 ,on emergency an efficient cradle can be constructed from a band-box1 by knocking out the bottom and putting the leg through it4 ,if used to protect a foot1 a notch may be cut with strong scissors1 not a knife1 for that splits the wood4 ,if the cradle is stout enough1 it is useful to sling a broken limb in its splint1 and often great relief is thus given to the patient4 ,dr4 ,salter's ,swing ,cradle is specially contrived for the purpose1 and is shown1 fig4 #db1 page #fd4 ,leather ,splints4--,for these sole leather1 to be purchased at any leather dealer's1 is used4 ,in preparing them1 the required length should be first noted down1 then a series of transverse measurements taken at the widest and narrowest parts of the limb and over the projections of joints1 c41 or a pattern may be first cut in paper and laid on the sheet of leather from which a corresponding piece is cut4 ,the splint should always be so arranged that its edges do not bear on any bony point1 the shin1 or malleoli1 for example1 but either fall short of or pass beyond them4 ,the hair side of the leather should go next the skin1 as it is the smoothest and least irritating4 ,the edges of the splint must be thinned by bevelling off the outside for about an inch all round1 and no sharp corners should be left4 ,when the leather is prepared it should be soaked1 if the time can be spared1 for twenty-four hours in cold water1 but when wanted quickly it can be softened in a few minutes by soaking it in warm water to which a little vinegar is added--this1 however1 renders the leather brittle when dry1 and apt to curl at the edges4 ,when the leather is softened1 a very thin even layer of cotton wadding or of lint is laid on next the skin2 the splint is then moulded to the limb with the hands1 and bandaged firmly2 in twelve hours it will be dry and rigid4 ,the roller is then unwound1 and any parts of the splint pressing on bony projections are marked before removal4 ,it is then trimmed1 and laid between two layers of wash-leather stitched together round the edges4 ,the splint is now finished1 and can be either fastened on by a roller or by two or more straps and buckles stitched to it4 ,when support is required for a joint1 the splint should be fitted on the sides1 where the leather may have the rigidity of its width rather than only that of its thickness to prevent bending4 ,leather ,splint for the ,hip4--,this joint is by far the most difficult to fit4 ,the hip splint should obtain a good grasp of its fixed point1 the pelvis1 and a stiff bearing on the front of the thigh where its pressure is to be exerted4 ,there are many plans of procuring a satisfactory fit2 the following is one of the best4 ,first cut a pattern on a sheet of paper from which to shape the leather4 ,if possible the patient should stand while the pattern is fitting4 ,take a sheet of paper large enough to reach round the body1 and long enough to extend from the waist to the leg below the knee4 ,lay it against the diseased hip1 carry its vertical margin a little beyond the middle line in front towards the sound side1 and the other part round the body behind1 till the front is reached on the sound side4 ,feel for the anterior iliac spine1 and mark with a pencil the point midway between it and the pubis2 from this draw one horizontal line inwards to the border of the paper1 and a second obliquely to the perinum4 ,then seek for the junction of the sacrum and iliac bone behind1 which corresponds pretty nearly to the point first found in front2 from this mark the gluteal fold4 ,next carry a line vertically from the upper border of the sheet of paper to the great trochanter2 and lastly1 mark the level of the pelvis4 ,lay the sheet on a table and slit it with scissors along the lines marked1 apply it a second time to the body and bend the thigh part round the thigh1 making its anterior margin reach well to the inside of the limb1 while the posterior part should almost meet it from behind4 ,the splint should also reach downwards to the back of the knee4 ,the paper is then trimmed down to these dimensions4 ,the hip part is next trimmed so that it clears the buttock on the sound side and passes round to the anterior iliac spine of that side4 ,the pattern being complete1 cut a piece of sole-leather to correspond1 arranging that the hair or short side of the leather will lie next the skin2 bevel off the outer edge all round1 and soak the leather till thoroughly soft in water1 wipe it dry1 and bandage it carefully first to the trunk and next to the thigh4 ,when it is set1 superfluous and overlapping edges must be marked before removal2 lastly1 the sides of the vertical notch1 between the hip and trochanter1 are stitched together1 and the splint is covered with wash-leather4 ,illustration3 ,fig4 #ei4--,leather splint for the hip4 ,when extension of the hip is required 7see page #hj71 it can be applied to the leg below the splint without lessening the support that affords4 ,the accompanying figure1 #ei1 is drawn from a splint fitted by ,mr4 ,heather ,bigg on the plan just described4 ,gutta-,percha may always be substituted for leather in these splints1 and the same plan of fitting is used1 except that the notching requisite in leather is not necessary in using gutta-percha2 for the directions to use this material see page #ej4 ,,chapter ,,iv4 ,,dislocations4 ,the main obstacles in reducing dislocations are entanglement together of the displaced bones and contraction of the muscles2 the entanglement of the bones determines the direction in which extension must be made1 and also of the counter extension1 or point at which the body is fixed to resist the traction practised on the limb2 this should be exactly opposite the direction in which the limb will be drawn4 ,the muscles can always be relaxed by chloroform1 hence it is better when they are powerful1 not to use the limb as a lever to prize the head of the bone into its place4 ,steady extension instead is better1 to disengage the bone from the parts against which it is caught1 and to bring it opposite its socket1 into which the hands of the surgeon guide it with less risk of laceration of the soft parts than attends forcible leverage4 ,lower ,jaw4--,this bone is dislocated on one or both sides2 when the condyle has slipped forward from the glenoid fossa1 the contracted temporal muscle keeps the bone from regaining its proper position1 and causes the coronoid process to hitch against the malar bone4 ,treatment4--,apparatus4--#a4 ,a towel4 #b4 ,a four-tail bandage4 ,illustration3 ,fig4 #fj4--;,dislocation of the jaw4 ,the patient should be seated in a high-backed chair1 resting his head against the back4 ,the surgeon winds the towel round both thumbs1 and standing immediately in front of his patient1 places a thumb on the second molar of both sides1 if the dislocation be double1 or on one side only1 if that be alone displaced 7see fig4 #fj74 ,he then presses steadily downwards until the condyle is released1 when it slips back to its place4 ,the return of the bone may be aided by pushing up the chin with the fingers after the ramus of the jaw has been lowered4 ,when the jaw is replaced1 a four-tail bandage or split handkerchief should be tied over the nucha and vertex of the head1 to keep the jaw closed 7see fig4 #bc1 page #cb74 ,biting or chewing should not be attempted for ten days or a fortnight4 ,the patient should be warned also that when the jaw has been once dislocated it very readily slips out of place again2 he must thenceforth avoid gaping or opening the jaw very widely4 ,the ,clavicle is rarely dislocated1 nevertheless both the inner and the outer end may be displaced4 ,the signs are obvious--the end of the bone is felt in its new position4 ,the treatment for all is the same4 ,apparatus4--#a4 ,roller1 #b inches wide4 #b4 ,a piece of old blanket4 ,the blanket should be torn into strips about a foot square1 and folded thrice1 thus making a long soft pad to line the axilla1 one for each armpit4 ,the patient is next seated on a stool2 an assistant standing behind1 draws back the shoulder while he presses on the spine with his knee2 the dislocation being reduced1 the surgeon fixes the bone by a figure of #h carried round the shoulders and across the back4 ,the forearm is then bent and fastened to the body by a few turns of the roller round it and the chest4 ,this prevents the pectorals from acting on the bone4 ,the apparatus may be laid aside at the end of a week1 but the arm must be fixed to the trunk for a fortnight longer4 ,this bone is often difficult to keep in place after dislocation1 and even the most accurately fitted apparatus sometimes fails to effect its object1 hence many varieties of collar and yoke have been devised by different surgeons to accomplish this purpose4 ,the ,shoulder is dislocated in three directions1 downwards1 inwards1 and backwards4 ,these have subordinate varieties1 but the signs depend chiefly on the direction of the greatest displacement4 ,signs of dislocation into the axilla4 ,when the bone is displaced below the glenoid fossa the acromion is prominent2 underneath it1 the surgeon feels a hollow instead of the head of the humerus1 which the finger detects in the axilla4 ,movement of the shoulder is very limited and painful ,if the elbow is rotated while the finger is in the armpit1 the head will be found to move with the rest of the bone4 ,if the head of the bone is carried more inwards on to the ribs1 it can be seen and felt near the clavicle2 the hollow is again readily detected below the acromion1 while the axis of the arm is altered1 being directed inside its proper position4 ,when the bone is carried backwards the head is plainly felt on the scapula below the spine4 ,for the reduction of these dislocations several plans are employed4 ,when recent the two first displacements can generally be restored without chloroform1 but if the patient is muscular it often saves time and pain to produce anesthesia before attempting to replace the bone4 ,illustration3 ,fig4 #fa4--,reducing a dislocated shoulder by the heel in the armpit4 ,by the heel in the axilla 7fig4 #fa74--,the patient lies flat on a couch2 the surgeon pulling off his boot from the left foot if he has to reduce a left dislocation1 and vice vers the right boot1 seats himself on the couch facing the patient4 ,putting his unbooted foot into the armpit1 he grasps the forearm with both hands and pulls steadily downwards4 ,when the head of the bone is disengaged the muscles draw it into the socket1 and the movements of the limb become at once easy and natural4 ,the arm must then be fixed to the side by a roller for a fortnight1 and the shoulder is wetted with an evaporating lotion to allay the pain and inflammation resulting from the laceration of the soft parts4 ,should the surgeon's strength be insufficient for the requisite extension1 a jack towel may be attached in a clove hitch round the wrist and held by an assistant1 who standing behind the surgeon draws steadily in the same direction4 ,to make a clove hitch4--,grasp the towel in the left hand1 the little finger being downwards1 then pronating the right hand till the little finger is upmost1 seize the towel below the left hand2 if the wrists are then rotated in opposite directions the towel will be drawn into two loops1 of which the ends cross above the connecting part between the loops 7see fig4 #fb72 if one hand holds the loops and the other pulls the ends1 the loops will be found not to slip1 however tight the ends are pulled4 ,illustration3 ,fig4 #fb4--,the ,clove-hitch knot4 ,reduction by simple extension4--,the patient again lies flat on his back1 a jack towel is passed round his body and fastened behind the opposite shoulder for counter-extension1 while a second towel is attached to the wrist by a clove hitch and intrusted to two or three assistants1 who are desired to pull quietly and steadily directly away from the patient's body4 ,the surgeon meanwhile watches the progress of the extension1 altering its direction as he finds the head more or less engaged against the scapula1 and finally with his hands thrusts the head into its socket4 ,sometimes there is much difficulty in getting the head back to the glenoid fossa1 even when the humerus is completely disengaged from the scapula2 this difficulty is often overcome if an assistant rotates the humerus backwards and forwards1 while the extension at the wrist and the pressure on the head of the humerus is steadily maintained4 ,when the limb is replaced it is fixed to the side as before directed4 ,illustration3 ,fig4 #fc4--;,dislocation of the shoulder reduced by simple extension4 ,if the dislocation has existed more than a few hours1 relaxation of the muscles by chloroform and extension of the limb carried directly away from the body are more sure of success than the heel in the axilla1 because they allow greater power to be exerted in a steadier manner than is possible by the other mode4 ,the ,elbow4--,the signs of dislocation at this joint are tolerably evident1 but there is often coexistent fracture of the coronoid or olecranon processes4 ,separation of the articulating surfaces of the humerus from the shaft is sometimes mistaken for dislocation of the forearm backwards4 ,in dislocation of both bones backwards the olecranon is very plainly felt behind the lower end of the humerus2 the sigmoid notch is generally to be made out1 and the forearm is fixed at a right angle4 ,the altered relation of the olecranon to the condyles suffices to distinguish dislocation from fracture of the humerus at its lower end1 where the olecranon also goes backwards1 but the condyles go with it4 ,the immobility of the joint distinguishes it from separation of the lower articular surfaces of the humerus from the shaft1 an accident1 moreover1 only met with in children4 ,other subordinate distinctions between dislocation and fracture are1 the limited movement1 the difficulty of restoring the bones to their natural position1 and the absence of crepitus2 lastly1 the peculiar form of the articular surfaces can sometimes be made out4 ,in reducing the backward dislocations the patient sits on a chair on which the surgeon rests his foot1 pressing his knee against the forearm at the elbow for a fulcrum2 then1 grasping the wrist with one hand1 and steadying the arm with the other1 he flexes the elbow to dislodge the coronoid process from the fossa at the back of the humerus2 when this is done1 the articulating surfaces slip into place4 ,this plan is commonly adopted when the olecranon is displaced1 but if it fails to reduce the dislocation1 direct extension at the wrist must be employed1 as for the following dislocation4 ,when the radius only is displaced1 the body should be fixed by a jack towel carried under the armpit of the injured side1 and over the shoulder of the sound side4 ,a wetted bandage is rolled round the forearm1 and a second towel is attached by a clove-hitch 7see fig4 #fb1 page #ii7 to the wrist for extension1 which is made in the axis of the limb until the radius can be slipped into its place on the outer condyle4 ,illustration3 ,fig4 #fd4--,reducing dislocation of the elbow round the knee4 ,in all dislocations of the elbow1 when the bones are returned the limb should be bent to a right angle and put on a lateral angular splint for a week or ten days1 after which time it should be worn in a sling a fortnight longer4 ,illustration3 ,fig4 #fe4--;,handle for obtaining grasp of the thumb in dislocation4 ,the ,thumb and ,fingers4--,when the first phalanx is dislocated from the head of the metacarpal bone it is sometimes very difficult of reduction4 ,the most effectual mode is steady extension1 which is procured by fastening the thumb to a piece of wood1 which serves as a handle to give command of the phalanx1 and is contrived as follows3 the thumb is first bandaged with a narrow wetted roller over the two phalanges1 and a thick layer of cotton wool is rolled round it2 a piece of stiff wood1 #a inch wide1 inch thick1 and #ab long1 is perforated at one end with three pairs of holes inch distant from each other and from the end2 through these1 three stout tapes1 inch wide and #b feet long1 are threaded1 leaving three loops on one side of the piece of wood 7fig4 #fe74 ,the wood is then applied to the palmar aspect of the phalanges1 the loops passed over the thumb1 their ends drawn tight1 and tied1 not in a bow as the figure represents1 but wound round the end of the stick4 ,the stick thus attached becomes a good handle for extending the digit1 and also a long lever for altering the direction of the phalanx if desired4 ,langenbeck of ,berlin employs a pair of forceps to seize the thumb1 instead of the wooden handle just described4 ,but with the greatest care and perseverance it is sometimes impossible to replace the bone unless the constricting bands be divided with a tenotome4 ,hip-joint4--,there are three chief directions in which the hip is dislocated4 ,first backwards on the dorsum ilii1 or further on to the sciatic notch4 ,in this dislocation the limb is shortened1 moved with difficulty1 drawn inwards over the other1 and its great toe touches some part of the back of the other foot4 ,the hip itself is altered1 the great trochanter being nearer to the crista ilii1 and more prominent than on the uninjured side1 and the head is often plainly felt in its new position4 ,resistance to extension of the limb1 limited movement of the hip1 with rotation inwards1 are the distinguishing points between this dislocation and fracture at the neck of the femur4 ,treatment4--,apparatus4--,a complete apparatus for this purpose is contrived and sold by instrument makers1 but a sufficiently serviceable one can be extemporised when the former is not at hand2 it consists of3-- #a4 ,a rope running in two pulley blocks4 #b4 ,three jack towels4 #c4 ,two stout hooks to screw into the wall1 or some firm object1 to obtain fixed attachment4 #d4 ,a wetted roller #c inches wide4 ,the complete apparatus is as follows3-- ,apparatus4--#a4 ,a set of multiplying pulleys4 #b4 ,a leathern padded girth1 #b inches wide and #c feet long1 having at each end an iron ring4 #c4 ,a stout leathern belt about #f inches broad1 furnished with buckles1 straps1 and rings to fasten on to the thigh above the knee2 a rope is run through the rings to connect the hook of the pulleys with the thigh4 #d4 ,two strong iron hooks to screw into the wall1 for fixing the apparatus4 #e4 ,half-a-dozen yards of stout cord4 #f4 ,a hook1 fitted with a buckle and strap1 and hinged so that1 by turning a pin1 it at once disengages itself4 ,if this is interposed between the pulleys and the hook fixed in the wall1 the limb may be instantaneously released if desired4 ,illustration3 ,fig4 #ff4--;,dislocation of the dorsum ilii4 ,treatment4--,step #a4 ,the patient is laid on a flat couch1 and put under the influence of chloroform4 ,when he is narcotised1 a jack towel1 or if it be at hand the pelvic girdle1 is carried across the perinum1 arranging it to bear on the tuber ischii behind and the pubes in front1 its ends being attached to one of the hooks screwed into the wall behind1 and about six inches below the level of the patient4 ,this towel should be put slightly on the stretch1 that the pelvis may be kept in the position first assigned to it when the pulleys begin to draw4 ,a wet roller is put on the lower third of the thigh1 the jack towel slipped up the leg to the bandage1 and fastened in a clove hitch4 ,another jack towel is then doubled and passed up the limb to the perinum4 ,the patient is next turned on to his sound side1 and the belt of the thigh connected by the disengaging hook to the pulleys1 which are drawn out from each other as far as their cord will allow1 and attached to a hook fixed a little above the level of the patient1 on a line carried from the hip across the junction of the middle and lower thirds of the uninjured thigh 7see fig4 #ff74 ,step #b4 ,the surgeon being ready1 an assistant draws on the pulley cord1 getting gradual extension of the limb as required by the surgeon1 who1 keeping his hands on the hip and great trochanter1 watches the progress of the head of the bone towards the acetabulum4 ,step #c4 ,when the bone has reached the edge of the acetabulum1 a second assistant slips the doubled jack-towel over his shoulders1 and by raising his body1 lifts the femur away from the brim of the acetabulum1 while the surgeon1 grasping the foot and knee1 makes a few movements of rotation backwards and forwards to ease the head into its socket4 ,when a reduction is effected1 the limb should be put in a long splint or starch bandage for three weeks1 and the patient not allowed to exercise the limb freely or violently for a month afterwards4 ,reduction by ,manipulation4--,when the patient is not very muscular1 and the dislocation recent1 the bone can often be speedily returned by movements of flexion and rotation4 ,the patient is put fully under chloroform and brought to the foot of the bed2 the surgeon grasps the ankle in one hand1 and the knee in the other1 bending that joint till the heel reaches the thigh2 he next flexes the thigh on the abdomen1 in doing this he carries the knee outwards away from the body1 and then rotates the limb by pushing the foot outwards1 on which the head often slips into the acetabulum4 ,if this plan do not quickly succeed it is better to have recourse to extension1 by assistants if pulleys are not at hand1 but the irregularity of the force when assistants are employed renders the traction of pulleys much preferable to manual strength4 ,dislocation downwards into the ischiatic foramen4 ,the limb is lengthened1 capable of little motion2 the knee is bent2 the toe points forwards1 and away from the other foot4 ,here the reduction is best managed by extension2 the apparatus required being the same as that employed in dislocation backwards1 but it is differently arranged4 ,step #a4 ,the patient lies on his back1 the pelvic girth1 or towel1 is carried round the pelvis and fastened to the wall on a level with his body1 opposite the uninjured side4 ,a jack towel is put round the upper part of the dislocated thigh1 and attached to the pulleys outside1 which are fastened to the wall opposite 7see fig4 #fg74 ,illustration3 ,fig4 #fg4--;,dislocation into the foramen ovale4 ,step #b4 ,extension is then made by an assistant1 the surgeon grasps the leg above the ankle1 and rotating the limb inwards and outwards1 but without lifting it from the bed1 guides the head into the acetabulum4 ,here1 as after dislocation backwards1 a long splint should be worn on the limb for three weeks before the patient is allowed to move about at all4 ,dislocation on to the ,pubes4--,the limb is easily moved at the hip1 shortened1 rotated outwards1 and the head of the bone is felt in the groin4 ,the same apparatus is used in this as in the dislocation on the dorsum ilii4 ,it is applied as follows3-- ,step #a4 ,the patient lies on his back 7fig4 #fh71 with his legs separated4 ,the pelvic band is passed over the perinum and pubes1 and attached above the patient1 in a line passing from the pelvis a little to his sound side4 ,a double jack towel is slipped up the limb to the perinum2 the pulleys are fastened to the thigh above the knee and fixed1 in the manner directed on page #ajf1 to the wall below and external to the injured side of the body4 ,illustration3 ,fig4 #fh4--;,dislocation on to the pubes4 ,step #b4 ,extension is then steadily made1 while the surgeon watches the head getting free from the pubes1 over the edge of which a second assistant slipping his neck through the doubled towel1 raises the bone a little outwards4 ,the surgeon in the meantime encourages the bone by rotation to enter the socket4 ,a splint is necessary here also after reduction4 ,the ,knee4--,these dislocations are rarely complete1 and are easily reduced2 the lateral ones by flexing the thigh on the belly1 straightening the leg1 and rotating it a little from side to side4 ,another ,plan4--,apparatus4--,two jack towels4 ,this is more useful when the tibia is carried backwards4 ,lay the patient on his back1 and slip a jack towel in a clove hitch up the leg to the ham1 and another round the small of the leg2 the thigh is bent and retained in a semiflexed position by an assistant holding the jack towel at the ham1 while a second pulls on the one at the ankle and so disengages the bones from each other1 when the surgeon readily slips them into place4 ,after reduction is accomplished1 the limb should be fixed in a leathern back splint until the inflammation subsides4 ,dislocation of the ,patella4--,the displacement of this bone on to the outer or inner condyle is generally easily reduced if the knee is straightened and the vasti relaxed by bending the thigh on the belly4 ,when the patella is turned on its own axis1 the side1 not the under surface1 is locked against the condyle1 and reduction is sometimes extremely difficult or impossible4 ,the same movements must be adopted as for simple lateral displacement1 and the surgeon must endeavour to release the bone by pressing its upper edge downwards with his thumbs4 ,after their reduction1 all dislocations about the knee-joint must be treated by rest1 straight splints1 and evaporating lotions4 ,the ,foot is very rarely dislocated from the leg without fracture of the malleoli4 ,its reduction requires simple extension of the foot on the leg1 with the knee bent2 the surgeon grasps the heel in one hand1 the foot in the other1 while an assistant fixes the thigh in the half-bent position4 ,the foot is first drawn downwards to disengage it from the tibia1 and then directed into its place4 ,after reduction the limb should be put in a ,mc,intyre's splint1 in the way described for fracture of the tibia near the ankle-joint4 ,scarpa's ,shoes are instruments for restoring deformed feet to their natural shape4 ,the shoe 7fig4 #fi7 consists of a flat metal sole broader and longer than the foot1 furnished with a rest for the heel4 ,a rod1 attached to the side of the sole beneath the ankle1 reaches up the limb1 to which it is secured by one broad band and buckle below1 and by a second above the knee1 opposite which joint the iron stem moves on a free joint backwards and forwards4 ,opposite the malleoli are set the centres of movement required for the restoration of the deformity2 they are moved by a key4 ,the foot is fastened to the sole by straps across the instep and ankle2 the toes are restrained by a strap passing round them and fixed to a horizontal toe-bar by the side of the foot4 ,in fitting one of these shoes1 which of course must always be made specially for the limb it is to control1 the points to be attended to are--#ast1 the centres of the joints must be so arranged that1 when traction is made1 the foot shall revolve back again round the same centres it has passed in reaching its distortion4 ,for example1 if the heel is raised1 as in talipes equinus1 the fore part of the sole of the shoe must be capable of elevation1 by moving a joint that rotates in a plane parallel to the rotation of the astragalus on the tibia4 ,in most cases of talipes1 the bones of the foot have been displaced round several centres2 hence1 the apparatus must be furnished with power of traction along all of these1 or along the lines resulting from these different directions acting simultaneously4 #bnd4 ,the heel must be got thoroughly into its place at the back of the sole to ensure that the foot will follow the shoe in all its movements4 ,the treatment of talipes frequently requires division of tendons before extension is attempted1 if they are too firmly contracted to permit the bones to regain their proper position until they are lengthened by division4 ,thus1 in varus1 the tibiales and tendo achillis2 in valgus1 the peronci2 in equinus1 the tendo achillis2 are often divided4 ,the limb must not be very tightly braced into the shoe1 slight tension1 if continuous1 suffices to overcome the resistance2 and in children if the straps are drawn tight the skin almost invariably inflames1 and even sloughs where it is compressed4 ,before the instrument is applied1 the limb should be bandaged with a soft cotton1 or ,domett's flannel roller4 ,the foot is first fixed to the sole or shoe1 and then the leg to the rod4 ,traction is increased gradually with frequent small alterations1 as the foot yields to the tension and regains its natural position4 ,the accompanying figure 7,no4 #fi7 represents an instrument made by ,mr4 ,heather ,bigg4 ,it shows the shoe restoring a much elevated heel to its proper position after division of the tendo achillis4 ,there are three common varieties of talipes--equinus1 or horse-heel1 where the heel is drawn up and the toes only touch the ground2 varus1 club-foot proper1 where the foot is twisted inwards2 and valgus1 splay-foot1 in which the foot is drawn outwards4 ,equinus is often associated with varus1 and sometimes also with valgus1 and consequently for such cases the instrument must provide the mechanism proper to each direction of displacement4 ,in ,equinus the heel is raised by the extreme extension of the ankle1 and the sole of the foot is shortened by the metatarsus being drawn backwards4 ,in this kind of deformity the shoe must have a joint to bring the astragalus forwards on the tibia1 and the sole of the shoe must be well padded beneath the scaphoid and metatarsal bones1 that1 as the foot is released from its position of extreme extension at the ankle-joint1 the anterior parts of the foot may be thrust upwards into their proper relation to the astragalus and os calcis4 ,illustration3 ,fig4 #fi--,shoe for reducing talipes equinus4 ,in ,varus1 or rather ,equino-varus1 for varus without elevation of the heel is rare1 the displacement is compound1 the ankle is extended1 the heel raised1 the scaphoid and metatarsus are drawn inwards and downwards1 so that the scaphoid lies immediately beneath1 sometimes even in contact with the internal malleolus4 ,the astragalus and cuboid are drawn forwards so as to lie in front of their natural position against the tibia and os calcis4 ,to bring down the heel the upright stem passes outside the limb1 the toe of the shoe can be raised by a circular joint on the stem opposite the malleolus1 which by its revolution raises the toes and depresses the heel4 ,a second joint working outwards and upwards elevates the outer border of the foot1 and restores the scaphoid to the front of the head of the astragalus4 ,lastly1 the metatarsus is drawn outwards by a horizontal spring toe-bar along the outer border of the foot1 to which the toes are fastened4 ,in ,valgus1 the plantar arch is flattened or even rendered convex downwards by the sinking of the scaphoid1 and in extreme cases1 by rotation outwards and upwards of the tarsus4 ,the shoe here has the vertical rod inside the limb1 and if necessary1 an axis for rotation below the inner malleolus1 and an elastic arched pad under the scaphoid to lift it into its natural position4 ,casting in ,plaster of ,paris4--,it is often convenient1 when ordering an apparatus for deformity1 to send the instrument-maker a cast of the deformed part4 ,this is readily made in the following way3-- ,apparatus4--#a4 ,two packets of freshly burned plaster of ,paris4 #b4 ,some pasteboard1 an old bandbox1 or several newspapers4 #c4 ,olive oil4 #d4 ,a basin of cold water4 ,step #a4 ,the part to be modelled should be laid in an easy position1 thoroughly oiled1 and a shell or trough of pasteboard roughly built round it to contain the plaster till it sets4 ,step #b4 ,the plaster is then prepared by shaking the powder into cold water1 till a thick cream without lumps is formed2 this is secured by constantly stirring the water as the plaster is shaken in4 ,the cream is then poured into the trough1 little by little1 that it may make its way into the inequalities and recesses under the limb1 until the limb is half immersed1 leaving the projecting parts1 such as joints1 half exposed1 so that the halves of the mould may separate opposite them4 ,this first instalment is then allowed to set1 and a fresh supply of plaster is prepared4 ,step #c4 ,the surface of the hardened mould is oiled1 that the fresh cream may not stick to it1 and the whole of the limb is then covered by pouring the cream on a second time4 ,plenty of plaster should be laid over the projecting parts that the mould may be strong enough for use4 ,it should be inch thick everywhere1 and #a inch thick along the sides4 ,when the second half is set1 the trough or shell is cleared away1 and the two halves of the mould removed from the limb separately4 ,for casting1 the mould is well oiled inside and filled with cream1 which sets into the cast required4 ,while the plaster is liquid1 the mould should be well shaken1 that the air-bubbles may be all driven from the surface of the cast4 ,,chapter ,v4 ,,miscellaneous4 ,hair ,suture4--,this is useful to bring the margins of small scalp wounds together1 where plasters are not employed4 ,it consists in taking a lock of hair or of an inch on each side of the wound1 and tying them together over a double thickness of lint2 by this means the margins of the wound are kept together1 and the dressing in place4 ,the slits left after the removal of small sebaceous tumours are very conveniently treated in this way4 ,illustration3 ,fig #gj4--;,eye ,douche4 ,the ,eye ,douche is a small elastic bottle fitted with a nozzle and flexible tube1 ending in a rose1 through which1 by means of a valve1 the water is drawn from a vessel and driven in a fine spray over the eye held open to receive it 7see fig4 #gj74 ,the syringe in fig4 #gj is very useful for a variety of purposes4 ,eye-,drops4--,little bottles are sold by chemists for this purpose1 with a tubular stopper2 at one end of the stopper is a fine jet1 the other is closed by a piece of indian rubber stretched over it2 on pressing this a drop escapes from the jet4 ,in dropping astringents into the eye the patient should put his head well back2 while the surgeon raises one lid from the eye1 drops in the lotion1 and then raises the other and drops it in again1 and tells the patient to move his eyelids about a little to force the lotion over the whole conjunctiva4 ,illustration3 ,fig4 #ga4--,syringe for sending a continuous current into the nose or ear1 c4 ,syringing the ,ears is best performed by a syringe having a long nozzle to direct the current of soap and water down the meatus on to the wax4 ,figure #ga consists of a syringe with double opening and air chamber2 when in action it supplies a continuous gentle current1 which breaks up the concretions more speedily and with less discomfort to the patient than the intermitting jet of a common syringe2 but an important part of the apparatus is the long slender nozzle to direct the stream well into the meatus4 ,the instrument-makers supply a little spout or shoot to hang under the ear1 to turn off the water into a basin clear of the neck4 ,if time permit1 the patient should keep the ear charged with olive oil for a few days before syringing1 that the wax may be softened4 ,after the wax is removed1 the irritation of the canal is best allayed by a little glycerine or olive oil put into the meatus1 and covered by a pledget of cotton wool1 large enough to fill the concha and too large to enter the passage1 where it may be lost sight of4 ,ice-,cold ,injection4--,in obstinate epistaxis the nares are sometimes plugged1 but1 before proceeding to this painful mode of treatment1 a simpler plan should first be tried2 namely1 the injection of ice-cold water into the nostril along which the blood flows4 ,the stream should be directed upwards that the water may first dislodge the clots entangled in the meatuses1 and then flow over the bleeding surface4 ,this is best done by employing a clyster or douche bottle 7see fig4 #ga71 one tube of which lies in a vessel of ice-cold water 7containing solution of gallic acid or other styptic if desired1 though cold water alone usually suffices71 the other tube1 having a long narrow nozzle1 is passed up the nostril and directed upwards among the spongy bones4 ,with this apparatus the water is injected steadily for half an hour1 before being abandoned as unsuccessful4 ,the patient is kept still1 sitting upright in a cool room4 ,if these means fail to check the flow of blood1 the nares may then be plugged4 ,plugging the ,nares4 ,apparatus4--#a4 ,a flexible catheter1 ,no4 #g1 or ,belloc's sound4 #b4 ,whipcord4 #c4 ,lint4 #d4 ,scissors4 ,step #a4 ,roll up a strip of lint tightly into a mass1 #a inch broad and an inch thick1 trim the ends away with scissors till the mass is of a size to enter a posterior naris1 then tie the wedge in the middle of a yard of doubled whipcord4 ,if blood trickle down both nostrils both must be plugged1 and two such plugs must be prepared2 next1 make two similar rolls of lint1 and tie these up with a short piece of silk or twine to prevent their unrolling4 ,step #b4 ,pass along the interior of the catheter a yard of twine1 and draw its end through the eye of the catheter a few inches1 then introduce the catheter through the naris directly backwards1 not upwards nor downwards1 because1 when the patient is upright1 the floor of the nose is nearly horizontal4 ,when the catheter has reached the pharynx1 the finger1 or a forceps1 must be passed through the mouth to catch the string hanging from the end of the catheter and bring it out of the mouth1 where it is held while the instrument is withdrawn from the nose4 ,the step is repeated in the other nostril if required4 ,step #c4 ,next wash out the nostrils with a few syringefuls of ice-cold water1 in which some tannin is suspended4 ,step #d4 ,fasten the double string of the plug to the end of twine hanging out of the mouth 7see fig4 #gb71 and then draw out the other end through the nose2 this will carry the plug to the pharynx1 where the finger guides it over the soft palate and thrusts one of its ends into the naris1 where the strings draw it tight4 ,the plug for the anterior nostril is then put in place1 and the strings tied tightly over it 7see fig4 #gc74 ,thus the plug in front keeps the plug behind in place and vice vers4 ,the end of string from the posterior nares1 left hanging out of the mouth1 must next be tied to the string of the anterior plug to keep it out of the patient's way1 till wanted to withdraw the posterior plug1 when that is to be removed4 ,if blood run from both sides1 the other nares are stopped by a repetition of this operation4 ,illustration3 ,fig4 #gb4--,plugging the nares4 ,belloc's sound passed through the nares1 and projecting at the mouth4 ,this apparatus is very painful1 and1 if borne so long as a couple of days1 should always be taken out then4 ,if bleeding recur1 which is very unlikely1 fresh plugs must be introduced4 ,sometimes the posterior plugs are soaked in styptic solutions2 this is bad1 because the bleeding part is not at the posterior nares1 and the styptics increase the soreness the plugs themselves produce4 ,illustration3 ,fig4 #gc4--,plugging the nares2 the strings from the posterior plug tied over the anterior plug4 ,illustration3 ,fig4 #gd4--;,belloc's ,sound1 for drawing a thread from the mouth along the nares4 ,belloc's ,sound4--,fig4 #gd is a curved silver cannula like a female catheter1 furnished with a long spring stylet1 that arches round in a circle when thrust out of the cannula1 and has a hole at the end to carry a thread4 ,the long stylet can be unscrewed into two parts1 when not in use4 ,the figure represents the instrument with the stylet ready for protrusion1 and the same arching forwards after it is protruded4 ,the cannula is passed along the nares till the end reaches the pharynx1 then the stylet is protruded and arches forward till it reaches the teeth1 when a thread is passed through the hole1 and the stylet being withdrawn1 the thread is carried with it into the pharynx and through the nostril1 where it can be used to draw the plug into its place at the posterior nares4 ,tooth ,drawing4--,a surgeon is frequently required to draw a tooth on emergency1 and should be provided with instruments 7see fig4 #ge74 ,seven pairs of forceps and an elevator are sufficient for all he is likely to deal with4 ,they are differently shaped for the different teeth1 which vary much at the neck1 the part grasped in the forceps4 ,illustration3 ,fig4 #ge4--,tooth ,forceps4 ,for the operation the patient should be seated in a high-backed chair2 the surgeon stands at his right side1 holds the jaw with his left hand1 while with the right he thrusts the beaks of the forceps between the gum and the tooth on its lingual and buccal aspects2 having reached the neck1 he holds the tooth firmly1 pushing it inwards and outwards with a rotary motion of the wrist 7except for the molar teeth74 ,sudden tugs break the tooth and leave the fang behind2 when loosened by rotation and lateral motion1 the forceps readily lift the tooth out of its socket4 ,for the upper incisors the beaks of the forceps are straight1 slightly hollowed inside1 to give them hold of the teeth1 and have crescentic edges 7see fig4 #gf74 ,the upper incisors and canines can be drawn by the same pair1 as the shape of these teeth at the neck varies to a small extent4 ,for the lower incisors a very narrow forceps is necessary4 ,the beaks 7fig4 #gg7 should be curved at the joint sufficiently to form an angle of #be with the handles1 that the latter may clear the upper jaw4 ,the edge of the beaks is crescentic1 similar to that of the upper incisors4 ,these forceps are also very useful for removing roots1 as their fineness enables them to sink between the stump and the alveolus with ease4 ,illustration3 ,fig4 #gf4--,upper incisor tooth and forceps4 ,illustration3 ,fig4 #gg4--,lower central incisor and forceps4 ,illustration3 ,fig4 #gh4--;,external aspect of upper bicuspid tooth1 and bicuspid forceps4 ,for the bicuspids1 beaks with crescentic edges also are used1 but the inside of the beak is more hollowed to fit the round neck of these teeth 7see fig4 #gh74 ,all the bicuspids can be drawn with the same pair1 but it is convenient to have forceps bent at the joint to clear the upper jaw when extracting a lower bicuspid 7see fig4 #gi74 ,illustration3 ,fig4 #gi4--,lower bicuspid forceps4 ,for the upper molars two forceps are required1 one for each side of the jaw2 the beaks of these are well hollowed to admit the crown of the tooth4 ,the inner beak terminates in a crescentic border to fit the large internal fang 7see figs4 #hj #ha72 the outer beak has two smaller grooves separated by a point1 that passes between the two external fangs4 ,in drawing these teeth the forceps should be thrust as high as possible and held firmly1 while the fangs are loosened by moving the tooth from side to side1 but from the multiplicity of fangs1 rotary motion is not available4 ,illustration3 ,fig4 #hj4--,left upper molar tooth and forceps4 ,illustration3 ,fig4 #ha4--,right upper molar forceps4 ,the wisdom molars are often difficult to seize from being almost buried in the jaw2 as they resemble a bicuspid in shape1 bicuspid forceps 7fig4 #gh7 should be employed2 if this fails to penetrate between the tooth and the alveolus1 the narrow incisor forceps 7fig4 #gg7 can be driven up till it grasps the tooth4 ,not unfrequently the fang of this tooth in the lower jaw is curved backwards and prevents extraction when the tooth has been loosened2 this difficulty may be overcome by pushing the crown of the tooth a little backwards so as to tilt the fang forwards out of place4 ,when the molars are closely set1 or the tooth to be extracted is overhung by its neighbour1 it is often difficult to avoid tearing the gum extensively and even carrying away more than one tooth2 tearing the gum is easily avoided by lancing it before applying the forceps1 and slow and steady movements of the wrist usually prevent the latter accident1 or the overhanging tooth may be filed away before the forceps are applied4 ,the inferior molars 7fig4 #hb7 have forceps1 whose beaks are doubly grooved and pointed1 to enable them to seize the neck on each side between the two fangs4 ,illustration3 ,fig4 #hb4--;,inferior molar tooth and forceps4 ,illustration3 ,fig4 #hc4--;,elevator4 ,in raising stumps1 so much decayed that the forceps will not hold them1 the elevator must be employed2 this instrument 7fig4 #hc71 straight1 pointed1 and a little grooved at the point1 is thrust down between the alveolus and the tooth2 the jaw being then the fulcrum1 the elevator is the lever to push forwards the fang2 when thus loosened it is easily lifted out4 ,in working with an elevator there is some risk of thrusting the point through the alveolus1 and wounding the tongue or floor of the mouth1 hence it should always be guided and covered by the left forefinger4 ,in removing the fangs of incisors the narrow forceps are most useful1 and should it not be possible to penetrate between the fang and the alveolus1 the alveolar border may be included in the grasp of the forceps and brought away with the tooth4 ,the injury thus inflicted is very unimportant and much pain is saved4 ,after the tooth is extracted the mouth should be well washed with warm water a few times1 the attending bleeding being of no importance1 except in individuals of hmorrhagic diathesis1 in whom measures should be at once taken to arrest the flow4 ,to stop a bleeding socket the alveolus must be well cleared of clots1 and fragments of sponge1 soaked in a solution of perchloride of iron1 one part of the salt to three of water1 packed into the cavity4 ,a plug of cork is placed between the jaws1 and a four-tailed bandage 7see page #cb7 carried round the head to keep them firmly closed4 ,should this plan fail1 the socket must be cleared again1 and the wire of the galvanic cautery pushed well down to the bottom and then heated till it has cauterised the cavity 7see page #afh74 ,nipple ,shields and ,artificial ,nipples made of flexible ivory1 vulcanized india-rubber1 c41 are required when the nipple is chafed and excoriated by the child's sucking1 especially if his mouth be attacked by thrush1 as is usually the case4 ,when the nipple is sore it should be well washed and dried after suckling1 covered with glycerine of starch or plastic collodion and protected by a shield4 ,if much inflamed it may be wrapped in lint dipped in alum water or solution of sulphate of zinc 7one grain to the ounce71 and deep chinks should be freely rubbed with lunar caustic4 ,the breast should be regularly emptied by the breast-pump if the child's sucking gives much pain1 lest the accumulation of milk in the ducts cause milk abscess4 ,plugging the ,vagina is employed in cases of rapid hmorrhage from the womb1 c4 ,apparatus4--#a4 ,a silk pocket-handkerchief4 #b4 ,a dry new fine sponge or pellets of cotton wool4 #c4 ,silk thread4 #d4 ,a body roller or folded sheet4 ,the sponge should be cut into pieces the size of nuts2 if the sponge is compressed it answers better4 ,when prepared1 the vagina should be cleared of coagula by a syringeful of ice-cold water2 the handkerchief1 unfolded and thrown over the right hand1 is passed up the vagina till its centre reaches the os uteri1 the borders and ends then project from the vagina4 ,the interior of the handkerchief is next filled by firmly packing the sponge in bit by bit until the vagina is distended by the mass2 the ends of the handkerchief are then tied together4 ,the sponge swells as it absorbs the blood1 and compresses the bleeding vessels by its distention4 ,the abdomen and uterus are then supported by a body roller1 or folded sheet1 wrapped tightly round the hips and waist1 while the patient1 lightly clad1 is kept quiet in a cool chamber4 ,when the plug has answered its purpose it is removed1 by withdrawing the sponge bit by bit1 and the vagina is washed with tepid water4 ,the kite's-tail plug4--,masses of cotton wool the size of a hen's egg are tied at two inches distance from each other along a long string4 ,when about a dozen are tied on1 a speculum is introduced1 and the first ball of wool is passed to the bleeding point and pushed firmly against it1 and then another1 and so on1 until the vagina is firmly packed4 ,an end of string is left hanging out of the vulva1 whereby the plug may be removed when necessary4 ,each mass comes away successively with ease as the string is pulled out of the vagina4 ,injecting the ,urethra often fails from the inefficient mode in which it is done4 ,the syringe employed should be short enough to be worked easily with one hand1 and need not contain more than one or two tea-spoonfuls1 as the capacity of the urethra does not exceed that amount4 ,one of such a size is just #b inches in length1 and easily worked by one hand4 ,the opening through the nozzle should also be wide1 that a forcible stream may be injected into the urethra4 ,the patient should fill the syringe1 then place on a chair or stool before him a chamber pot1 and1 having just made water to clear out the discharge collected in the urethra1 he inserts the slightly bulbous nozzle into the meatus urinarius4 ,he then grasps the sides of the glans with the left forefinger and thumb to close the mouth of the passage4 ,the right forefinger next presses down the piston slowly1 so that the whole of the injection passes into the canal and distends it2 keeping the meatus shut with his left finger and thumb1 the patient lays down the syringe and rubs the under part of the penis backwards and forwards1 that the injection may be forced into any folds or follicles of the mucous membrane4 ,having thus occupied about thirty seconds1 he releases the mouth of the passage1 when the fluid is ejected sharply into the vessel placed ready to receive it4 ,this rapid ejection is a test of the proper performance of the operation4 ,in counselling the use of astringent solutions1 the surgeon should always caution the patient not to employ one that produces severe smarting1 which lasts more than a few minutes after injection4 ,if it causes much pain1 the solution is too strong4 ,catheters and ,bougies4--,silver catheters are made in sizes1 increasing from ,no4 to ,no4 #ab1 the first having a diameter of #jfd inch1 the latter #jbe inch4 ,larger ones than these are seldom employed4 ,illustration3 ,fig4 #hd4--,silver catheter4 ,illustration3 ,fig4 #he4--;,english ,flexible catheter4 ,the curve preferred by different surgeons varies much2 that depicted in fig4 #hd is the one used by ,sir ,henry ,thompson2 it begins at #c inches from the point1 and ends when the point is at right angles with the stem4 ,each catheter is fitted with a wire stylet4 ,the flexible catheters are of many kinds2 the ,english gum-elastic 7fig4 #he71 the ,french black flexible 7fig4 #hf71 and the vulcanised india-rubber 7fig4 #hg71 catheters1 being the three varieties most generally employed4 ,english flexible catheters should be kept on stylets well curved at the last #c inches1 that1 when the stylet is withdrawn1 for the catheter to be passed1 the latter may retain sufficient curve to pass over the neck of the bladder easily4 ,illustration3 ,fig4 #hf4--;,french bulbous-ended catheter4 ,illustration3 ,fig4 #hg4--,vulcanised india-rubber catheter4 ,sounds are solid1 being of steel1 plated or gilt4 ,their curve varies1 and is generally #bj or #cj degrees more obtuse than that of the catheters4 ,bougies are made of the same materials as the flexible catheters2 they are kept straight1 and the more supple they are the better1 the black bulbous-ended bougies being the most useful variety for dilating the urethra4 ,illustration3 ,fig4 #hh4--,the ,olive-headed bougie4 ,olive-headed ,bougies 7,bougies olivaires7 are used for exploring the urethra in cases of gleet1 where the discharge is often kept up by a stricture or a tender patch of chronic inflammation of the mucous membrane4 ,they are made of metal1 or of black gum mounted on a very flexible leaden wire2 the latter kind are far preferable4 ,the stem of the instrument is slender1 no bigger than a ,no4 #c or ,no4 #d bougie2 the end terminates in a conical point about or of an inch long1 expanding at its base to any required size4 ,these bougies are most useful from ,no4 #d to ,no4 #af of the ,english scale1 or from ,no4 #aj to ,no4 #bd of the millimetrical scale4 ,the stem should be marked with white rings an inch apart1 so that when the instrument is passing over a tender part1 or is arrested by a stricture1 the distance of the impediment down the urethra can be at once estimated4 ,in withdrawing the instrument1 the wide base of the olive shows the exact position and length of those strictures which are not too narrow for the olive-head to slip by1 for it is nipped by the stricture and released as soon as the narrowing is passed4 ,by using instruments large enough to fill the normal urethra1 an induration beneath the mucous membrane can be detected in its earliest stage before it has produced symptoms diagnostic of stricture4 ,rigid instruments have one advantage over flexible ones1 in that their points can be guided by the surgeon2 the points of flexible instruments cannot be directed1 hence the introduction of the latter into a stricture is less easily managed1 consequently bougies with various kinds of points should be kept4 ,but flexible instruments cause far less irritation than rigid ones1 and should always be employed instead of the latter when possible3 with patience and practice much of the difficulty attending their introduction is overcome4 ,the ,french bougies1 with tapering ends and bulbous points1 slip more easily through a stricture than instruments having the same diameter throughout1 and bougies with fine tapering points can sometimes be introduced where others fail4 ,passing ,catheters4--,in passing instruments along the urethra the conformation of its interior should be borne in mind4 ,from the meatus to the triangular ligament1 the normal urethra1 when gently stretched1 becomes a straight tube2 having1 nevertheless1 just within the meatus1 a pouch in the roof1 the lacuna magna1 where the point of the instrument may catch if not turned downwards4 ,at the bulbous part the urethra enlarges in capacity by having a slight downward curve in its floor1 just before the triangular ligament is reached4 ,in this depression1 the beak of the catheter is apt to sink below the level of the passage through the ligament1 which is always a fixed point4 ,beyond the triangular ligament the urethra curves gently upwards1 has a floor beset with irregularities1 in which the point of the instrument easily catches1 if not raised as it passes along the curve4 ,a ,silver ,catheter is passed most easily while the patient is in a horizontal position1 with the shoulders low and the thighs separated4 ,the surgeon stands on the left side of the patient1 and holds the catheter1 previously warmed and lubricated with oil or lard1 lightly between the thumb and two first fingers of the right hand1 the beak downwards and the stem across the patient's left groin4 ,then taking the penis between the middle and ring fingers of the left hand1 the palm being upwards1 he pushes back the foreskin with the thumb and forefinger1 and steadies the meatus while introducing the beak of the catheter4 ,this done1 he draws the penis gently along the catheter as the point is lowered to the perinum1 but without raising his right wrist until the instrument has travelled #e or #f inches along the passage and reached the triangular ligament4 ,the surgeon then carries his right wrist to the middle line of the patient's body1 and while pushing the point onwards1 raises the hand round a curve till it again sinks between the patient's thighs4 ,when the bladder is reached he withdraws the stylet that the urine may escape4 ,three points of difficulty are usual in passing catheters2 the lacuna magna just within the meatus1 the triangular ligament1 and the prostatic part of the urethra just before the bladder is reached4 ,the first is escaped by keeping the beak along the floor of the urethra for the first two inches2 the second is best avoided by raising the wrist as the instrument passes the triangular ligament1 and directing the beak against the upper surface of the urethra1 lest1 being in the enlarged bulbous part1 it sink below the opening in the ligament2 the third difficulty is overcome by depressing the hand well as the point approaches the bladder4 ,to pass the catheter in the upright position1 the patient is placed against a wall or firm object1 with his heels eight or ten inches apart and five from the wall1 that he may rest easily during the operation4 ,the surgeon sets himself opposite the patient and grasps the penis with the two middle fingers of the left hand1 the palm upwards2 he next exposes the meatus with the thumb and forefinger1 and his right hand holding the catheter by its middle obliquely across the left side of the patient1 he draws the penis on to the instrument till the triangular ligament is gained4 ,he then carries the shaft of the catheter to the middle line and1 holding it by its end1 brings the right hand downwards and forwards1 to carry the point upwards over the obstruction at the neck of the bladder4 ,the operation should be done slowly and with great gentleness1 giving the urethra time 8to swallow the instrument10 as the ,french surgeons express it4 ,hasty or forcible movements tend to thrust the point against the wall of the urethra1 where it hitches1 if it does not penetrate and make a false passage4 ,however easy the introduction may have been1 the withdrawal of the catheter should be always done slowly to avoid giving pain to the patient4 ,when the canal suddenly contracts1 as from a stricture1 the point of the sound often stops at the obstruction2 by withdrawing the instrument a little1 and diverting its point to another side or along the upper part of the urethra1 a part where the obstruction is less abrupt will often be found to let the catheter glide into the stricture4 ,the floor of the urethra should always be avoided1 as false passages nearly always branch off from the floor close to the stricture4 ,difficult narrow strictures are most easily overcome by injecting a drachm of warm olive oil into the urethra1 and then passing fine black gum or whalebone bougies 7bougies filiformes7 along the urethra4 ,these1 from their fineness 7their diameter is only or of a millimetre1 about #a_/ajj inch71 are very apt to catch in false passages2 if so1 the bougie should be left engaged in the false passage1 and held in the left hand while another bougie is passed along the urethra2 if1 in its turn1 this one gets into a false passage1 it also should be left1 and a third passed2 and so on till all the false routes are occupied1 or a bougie enters the stricture and reaches the bladder1 which is known by the readiness with which it will pass backwards and forwards4 ,the other bougies should then be withdrawn1 and the bougie which has passed the stricture be tied in for twenty-four hours1 until the passage is sufficiently dilated to allow a small catheter to replace it4 ,if the patient is not suffering from retention of urine1 there need be no anxiety about evacuating his bladder1 as urine will find its way alongside the bougie when he attempts to make water4 ,in passing to relieve retention1 ,no4 ,english flexible catheter should be used instead of bougies2 but when the stricture is too narrow for these1 a bougie may still be tried1 as the urine will generally dribble alongside the bougie with sufficient rapidity to relieve the patient4 ,english flexible ,catheters should be kept on stylets curved as represented in fig4 #he1 that the first #c inches of the instrument1 when the stylet is withdrawn1 may retain sufficient curve to ride over the impediment at the neck of the bladder4 ,in warm weather1 after being oiled1 they should be dipped in cold water just before using1 to render them a little stiffer1 and less likely to lose their curve while traversing the urethra4 ,they may also be passed while the patient lies or stands1 and the movements are the same as for the silver catheter4 ,bulbous-ended or probe-ended ,catheters and ,bougies 7,bougies boule7 are always straight2 their suppleness1 their tapering ends1 and their smooth rounded point enable them to glide along the urethra1 and to accommodate themselves readily to the windings of the passage2 for which reason they are the easiest to pass both for the patient and the surgeon4 ,in passing them they are slightly warmed1 if the weather is cold1 to restore their flexibility1 and gently pushed along the canal till the bladder is reached4 ,vulcanised ,india-,rubber ,catheters 7fig4 #hg7 are used when the bladder is to be kept empty2 their suppleness renders them very unirritating1 and as phosphates crust on them very slowly1 they may be worn for a week without being changed4 ,they are easily passed by threading them on a stylet with the appropriate curve1 and lubricating them with white of egg or water1 not with grease1 which injures them4 ,the stylet is withdrawn after they are passed4 ,to pass a ,catheter in the ,female4--,the patient may lie on one side or on her back2 if on her side the knees should be well drawn up2 if on her back1 the thighs must be somewhat separated4 ,before introducing the catheter1 a wine bottle or narrow-necked bed urinal should be placed in the bed ready to receive the urine4 ,if the ordinary slightly curved female catheter be not at hand1 a ,no4 #g or #h flexible one does just as well4 ,having oiled the instrument1 go to the patient's back1 and take the catheter in the right hand if the patient lies on her right side1 and in the left hand if she lies on her left side2 if she lies on her back1 go to either side and take the catheter in the hand nearest her feet4 ,hold the stem of the catheter in the palm1 so that the beak lies against the tip of the forefinger1 while the thumb and second and third fingers grasp the stem4 ,then passing the hand under the bed-clothes1 seek the buttock2 from that pass the forefinger to the perinum1 and let it enter the vulva1 keeping the back of the finger against the posterior part1 then pass it between the nymph to the entry of the vagina4 ,this is known by the tip of the forefinger being lightly grasped1 unless the vagina is very wide4 ,keeping the finger just within the entry1 feel for the arch of the pubes in front2 having found this1 withdraw the tip of the finger slightly from the vagina3 in doing this1 it will strike a small projection of mucous membrane hanging just at the anterior margin of the entry4 ,keep the finger steady against this1 while the other hand pushes the catheter gently onwards1 which then rarely fails to enter the urethral opening close above the projection of mucous membrane4 ,having penetrated the urethra1 arrange the catheter in the receptacle for the urine1 and push the instrument into the bladder4 ,to ,wash out the ,bladder4 ,apparatus4--#a4 ,a flexible catheter2 ,nos4 #h or #i are convenient sizes2 but a smaller one can be employed4 #b4 ,a caoutchouc bottle1 holding six ounces1 and fitted with a tapering nozzle and stop-cock4 7,fig4 #hi47 ,illustration3 ,fig4 #hi4--;,elastic india-rubber bottle for injecting4 ,during the operation the patient should stand1 if possible1 as the mucus is thus more easily cleared from the bladder4 ,the surgeon first fills his bottle completely with tepid water1 that no air may remain2 then directing his patient to stand against a wall or some firm object1 passes the catheter and draws off the urine4 ,he next inserts the nozzle into the catheter1 and1 turning the cock1 compresses the bottle slowly until two or three ounces of water have run into the bladder2 this he lets escape by removing the bottle for a minute1 and then repeats his operation till the water returns clear1 without exhausting the patient's strength4 ,three or four small injections wash the sediment and mucus from the bladder as quickly1 and with far less fatigue or risk of spasm than a prolonged flow of water through a stiff double current catheter4 ,in this way the bladder may be washed twice or thrice daily to the great comfort of the patient4 ,injections of solutions of nitrate of silver1 carbolic acid1 alum1 c41 in the proportion of #a part to #ajj1 or to #ej of water1 can be used instead of water for this purpose4 ,to ,tie in a ,silver ,catheter4 ,apparatus4--#a4 ,a few yards of tape inch wide4 #b4 ,a roller4 #c4 ,a spigot of wood2 or1 #d4 ,a yard and a half of fine india-rubber tubing4 ,illustration3 ,fig4 #ij4--;,a silver catheter tied in the urethra4 ,a narrow roller is tied round the hips2 from this1 on each side1 a tape is passed round the thigh at the groin1 and fastened before and behind to the roller round the hips 7see fig4 #ij72 a narrow tape run through the rings of the catheter connects them with the loops in the groins4 ,the tapes are tied short enough to prevent the catheter slipping out2 a yard or two of narrow india-rubber tubing1 fixed on to the end of the catheter1 conveys the urine to a pan under the bed1 and keeps the bed dry1 or a spigot of wood fitted to the catheter may be inserted1 for the patient to draw out when he desires to void his urine4 ,to ,tie in a ,flexible ,catheter4 7,fig4 #ia47 ,apparatus4--#a4 ,a piece of soft twine1 or ,berlin wool1 about #ae inches long4 ,illustration3 ,fig4 #ia4--;,a flexible catheter tied in the urethra2 the string fastened behind the corona glandis1 and concealed by the foreskin4 ,a catheter is first passed into the bladder1 and the urine runs off4 ,the catheter is then gently withdrawn1 till the stream ceases1 that the end of the instrument may remain just without the neck of the bladder4 ,the string should be tied round the catheter an inch from the meatus1 its ends gathered together and tied in a knot about #a inch farther on4 ,the foreskin is then drawn back1 the ends passed beneath the glans and tied round the penis behind the corona2 the superfluous string is snipped off1 and the foreskin brought forward4 ,the catheter is cut off obliquely an inch beyond the string and then stopped with a spigot1 direction being given to the patient to withdraw the spigot1 and push the catheter a little further in when he wants to make water4 ,to ,tie a ,patient in ,position for ,lithotomy4 ,apparatus4 ,two bandages1 each #c yards long and #b inches wide1 of calico or saddle-girth1 with tapes sewed on the ends4 ,illustration3 ,fig4 #ib4--,tying for lithotomy4 ,the patient is laid on his back1 a slip-knot made in the middle of the bandage and passed over the wrist2 the hand is then made to grasp the foot1 the thumb above1 the fingers under the sole 7fig4 #ib72 one end of the bandage is carried behind and inside the ankle to the dorsum of the foot1 where it meets the other end passing in front of the ankle4 ,the ends are then carried under the sole1 brought up and tied in a double bow over the back of the hand4 ,bedsores are best treated by great cleanliness1 and by washing the skin exposed to the discharges with spirit of wine every day4 ,brown-,sequard recommends cold and heat to be applied daily1 by means of an ice bag for ten minutes1 followed by a warm poultice for an hour4 ,the pressure of the skin over the sacrum or trochanters is prevented by a ring of soft thick felt1 covered on one side with adhesive plaster1 and applied like a corn plaster around the prominent bone4 ,in addition to these local applications1 the pressure of the body should be evenly distributed over its under surface by placing the patient on a water cushion1 or1 better1 on ,arnott's water-bed4 ,illustration3 ,fig4 #ic4--,water-bed4 ,arnott's ,floating ,bed4--,in the hydrostatic or floating bed of ,dr4 ,arnott1 the patient floats on the surface of a trough of water1 into which he sinks until he has displaced his own weight of water2 his floating apparatus1 or raft1 so to speak1 being a sheet of waterproofing1 and a thin mattress or folded blanket1 on which he lies4 ,the bed consists of a trough running on large castors1 about #h feet long1 #b feet #h inches wide1 and #a deep1 with a tap at the bottom for letting out the water1 and a spout in one corner to fill it by4 ,over the top a macintosh cloth is spread1 its edges being firmly nailed to the margin of the trough1 but the cloth is left slack enough to float easily on the surface of the water when the trough is partly filled4 ,this slackness is requisite to allow the water displaced by the weight of the patient's body to rise up around him without tightening the cloth1 or the floating principle of the bed is not carried out1 and the pressure of the patient's weight not evenly distributed over his body 7see fig4 #ic74 ,three or four blankets are laid evenly over the macintosh1 and these again protected from the moisture of the patient by a macintosh under-sheet4 ,if a mattress is used1 it must be very thin1 and supple enough to let the surface of the water adjust itself to the patient's body and receive the pressure evenly4 ,the water employed to fill the bath should be about #ej4 ,illustration3 ,fig4 #id4--,water-cushion4 ,water ,cushions are flat cushions of stout macintosh cloth1 half or two-thirds full of water1 and laid on the mattress beneath the blanket and sheet 7see fig4 #id74 ,they are more portable than the water-bed1 but they are simply soft pillows1 and do not counter-balance the weight of the patient in the manner of the floating bed4 ,the ,stomach-,pump is used for emptying the stomach1 or for injecting fluid food when patients refuse to swallow4 ,it consists of a brass syringe holding #d ounces1 of which the nozzle is connected with two tubes1 one at the end1 the other at the side4 ,the passage through these is directed by a valve which is governed by a lever lying on the barrel 7see fig4 #ie74 ,when the lever is at rest1 the current passes in and out of the syringe by the lateral tube2 when depressed1 by the direct tube4 ,the elastic tubes with smooth nozzles1 about #b feet long1 are fitted to the syringe4 ,there is also a gag of hard wood1 having a hole in the middle1 through which the tube passes on its way to the stomach1 to protect it from the patient's teeth4 ,illustration3 ,fig4 #ie4--,the stomach-pump4 ,when the pump is employed to remove the contents of the stomach1 two washhand-basins are placed at hand1 one empty1 one full of tepid water4 ,the patient is seated in a high-backed chair to steady his head2 one assistant holds his hands1 while a second screws the small end of the gag between the teeth and forces open the mouth1 across which it is then easily fixed4 ,the flexible tube1 being well oiled1 is next passed across the pharynx and down the gullet slowly and cautiously1 without staying for any effort of vomiting it may induce2 when about #bj inches are passed through the gag the nozzle has reached the stomach4 ,first1 two or three syringefuls of water are injected into the stomach2 then1 removing the second tube from the basin of water to the empty basin1 the action of the syringe is reversed1 by pressing on the lever as the piston is raised1 and letting it fly up when the piston is depressed4 ,thus two syringefuls may be withdrawn1 then fresh water is again injected and withdrawn1 until the contents of the stomach are removed and the water returns clear4 ,precaution must be always taken not to exhaust from the stomach before water is injected1 lest the coats of that organ be injured by being sucked against the nozzle of the tube4 ,if desirable1 antidotes may be dissolved or suspended in the water injected4 ,when the pump is used for feeding patients1 one or two pints of beef tea1 eggs beaten with milk or wine1 ,liebig's soup1 c41 are the kinds of food suited for the purpose4 ,each time the pump is used1 it should be thoroughly cleaned by syringing through it plenty of warm water1 and the tubes must be unscrewed to wipe the joints carefully4 ,transfusion of ,blood4--,the points of greatest importance in performing this operation are3-- #a4 ,that the supply of blood come from a vigorous adult4 #b4 ,that the transfer be made within two minutes of the blood's escape from the vein of the supplier4 #c4 ,that1 to prevent coagulation1 the blood should pass over as small a surface1 and suffer as little exposure as possible in transit4 #d4 ,care must be taken to prevent air entering the vein with the blood4 ,the apparatus described below is that devised by ,dr4 ,graily ,hewitt1 and depicted in the ,obstetrical ,society's ,transactions for #ahfd1 page #acg4 ,it consists of a glass syringe holding two ounces 7fig4 #if71 with a piston easily attached and removed2 its nozzle is curved and fits the mouth of a cannula of silver4 ,the nozzle of the syringe is provided with a little stopper attached by a chain2 a stylet likewise fills the cannula1 to be withdrawn when the blood is injected through the latter4 ,illustration3 ,fig4 #if4--;,graily ,hewitt's syringe for transfusion of blood4 ,the success of the operation depends in great measure on the rapidity with which it is performed1 and requires the aid of two assistants that the various steps may follow each other as quickly as possible4 ,apparatus4--#a4 ,syringe1 cannula and stylet4 #b4 ,lancet4 #c4 ,scalpel4 #d4 ,forceps4 #e4 ,three yards of tape1 one inch wide1 and lint4 #f4 ,a silver wire suture4 #g4 ,a basin of cold water4 #h4 ,brandy and ,sal ,volatile4 ,step #a4 ,see that the piston-rod works properly in the syringe1 and that the instrument is fit for use2 then place it in the basin of cold water with the cannula to lie till wanted4 ,step #b4 ,place the person supplying the blood on a couch or easy chair in the same chamber1 but so that he cannot see the recipient1 lest he faint and his blood consequently flow feebly4 ,tie up the arm as for venesection2 lay ready the lancet1 and direct the assistant1 in charge of the supplier of blood1 to keep his thumb on the vein when it is opened1 that the flow may be checked when blood is not required4 ,step #c4 ,place a tape round the arm of the recipient1 above the point for injection1 and another below it at a convenient distance1 and lay bare a vein 7usually the median basilic7 for an inch and a half of its course2 holding the vein by the forceps1 make a slit with the scalpel and introduce the cannula1 which is then intrusted to the second assistant4 ,the stylet is withdrawn1 and a minute drop of blood escapes through the cannula1 showing that the point has been properly introduced into the vein4 ,the assistant replaces the stylet and slackens the ligature1 while the surgeon proceeds to fill his syringe4 ,step #d4 ,the surgeon1 going to the supplier of blood1 makes a large opening in the vein with a lancet1 or if the first assistant be a surgeon also1 he may do this while the chief operator is preparing the vein of the recipient4 ,when the vein is open and the blood flowing freely1 the barrel of the syringe is inverted over it and filled with blood2 when full1 the nozzle is stopped by the plug and the piston attached while the syringe is carried to the recipient4 ,step #e4 ,this being reached1 the plug is pulled out1 the nozzle inserted into the cannula1 and the blood slowly injected by depressing the piston gently1 but without quite emptying the syringe4 ,a minute should be spent in injecting one ounce and a half1 and a pause of five minutes ensue before a second supply is introduced4 ,this interval may be employed in cleaning the syringe1 c41 and procuring a fresh supply of blood2 #c-d ounces of blood are usually sufficient1 but #aj ounces have been injected on some occasions4 ,the perturbation of the supplier 7generally a near friend of the recipient71 renders it necessary he should drink freely of brandy and water1 that the blood flow forcibly when required4 ,step #f4 ,when sufficient blood has been introduced1 both patients' wounds are dressed1 as after venesection 7see page #bj71 the long incision of the recipient being closed by a point of suture under the pad4 ,tourniquets4--,tourniquets are of several kinds4 ,the ,ring ,tourniquet 7fig4 #ig7 is used when pressure is desired on the main artery of such a limb as the arm4 ,it is less easily displaced than the ,signoroni1 but1 like that1 soon becomes irksome by its continual pressure4 ,illustration3 ,fig4 #ig4--,ring tourniquet4 ,when hmorrhage has to be temporarily arrested1 that of ,petit 7fig4 #ih7 is generally used4 ,it consists of a strap of stout webbing and buckle1 that can be rapidly tightened by a few turns of a screw4 ,to use this tourniquet1 lay a roller over the artery and carry the end once or twice round the limb to steady the roller1 then pass the strap over the roller1 keeping the buckle about two inches away from the screw and the screw on the anterior or outer aspect of the limb1 not over the pad1 lest that be displaced when the screw is tightened4 ,the tourniquet should be screwed up as quickly as possible1 that the limb be not charged with blood by obstructing the venous1 before the arterial flow is checked4 ,illustration3 ,fig4 #ih4--,petit's tourniquet applied to the popliteal artery4 ,illustration3 ,fig4 #ii4--,the horse-shoe tourniquet4 ,in ,signoroni's ,horse-shoe tourniquet 7fig4 #ii7 the extremities of the shoe can be approximated to each other by a rack screw working a hinge4 ,the ends are furnished with pads1 one broad and flat to bear on the limb away from the artery1 the other rounded to compress the vessel itself4 ,this tourniquet does not arrest the whole circulation in the limb4 ,it can therefore be applied for a longer time than ,petit's4 ,however1 it easily slips out of place1 and soon becomes very irksome and painful4 ,illustration3 ,fig4 #ajj4--,lister's tourniquet for compressing the aorta4 ,the ,abdominal ,tourniquet of ,professor ,lister is a very effectual contrivance for compressing the aorta during amputation through the hip joint1 and operations where a tourniquet cannot be placed on the limb4 ,it consists 7see fig4 #ajj7 of a semicircular bar1 with a broad pad to fit on the lumbar vertebr behind1 while in front it holds a long screw-pin carrying a pad4 ,this instrument passes round the left side1 and its pad is forced down into the abdomen1 one inch to the left of the umbilicus1 until the aorta is compressed against the spine4 ,illustration3 ,fig4 #aja4--;,carte's tourniquets for femoral aneurism4 ,carte's ,tourniquets 7fig4 #aja7 are employed to control and diminish the flow of blood through an aneurism4 ,they are intended to be worn for several days1 and are fitted with many contrivances for obtaining a continuous pressure on the artery without completely arresting the flow of blood4 ,they are always used in pairs2 in the figure1 one presses the external iliac on the pubes1 the other the femoral artery4 ,the first is fastened to the body round the hips1 the second round the thigh4 ,they are constructed as follows3 an arm attached to a pad reaches round the limb to the artery1 over which it supports a ball and socket joint turning in any direction1 but fixed by a screw clamp4 ,this joint has a long screw carrying the compress down to the artery4 ,there is a little play of the screw in the ball of the joint1 controlled by india-rubber bands1 that the compress may yield slightly before the arterial pulse4 ,in the solidification of an aneurism by this means1 the flow of the blood is intended to continue2 hence the current through the vessel need not be completely obstructed by the pressure of the tourniquet1 and the elastic bands prevent that pressure from becoming insupportable4 ,when the tourniquets are applied1 the patient must lie on a flat hair mattress1 have his limb well washed and dried1 lightly but evenly bandaged1 and somewhat raised4 ,if the thigh is hairy it should be shaved where the pads will press1 and dusted with powdered ,french chalk4 ,the tourniquets are next adjusted1 as seen in fig4 #aja2 the patient is taught to change the pressure when it grows irksome1 by screwing down the second pad1 and then releasing the first4 ,to improvise a ,tourniquet4--,a tourniquet may readily be formed on emergency from a handkerchief1 a stone1 and a stick4 ,fold a stone the size of an egg in the middle of a handkerchief1 lay it over the main artery1 tie the ends of the handkerchief round the limb1 slip the stick underneath and twist it round1 till the tightened handkerchief draws the stone on to the artery and arrests the flow of blood 7see fig4 #ajb74 ,illustration3 ,fig4 #ajb4--;,an improvised tourniquet4 ,fumigation4--,mercurial vapour baths are contrived in various ways4 ,the following plan succeeds perfectly well when the whole surface of the body is to be exposed to the vapour 7fig4 #ajc74 ,illustration3 ,fig4 #ajc4--,mercurial fumigation4 ,illustration3 ,fig4 #ajd4--,lamp for fumigating4 ,apparatus4--,a ,langston ,parker's lamp made by ,savigny and other instrument makers4 ,in this a spirit lamp1 holding the required amount of spirit is protected in a cage1 on the top of which is a receptacle for the calomel1 and a small saucer for water 7fig4 #ajd74 ,the flame beneath boils the water and volatilises the calomel4 ,water is added1 because the calomel vapour1 when associated with steam1 acts more efficiently than with dry air4 ,the lamp is placed under a high wicker chair1 on which the patient sits undressed1 and round his neck1 a frame is tied1 made of cane hoops1 with a calico cover sewn over them2 this falls to the ground and encloses his body in a chamber1 where the vapour is confined while absorbed into the skin4 ,a blanket thrown over the frame completes the preparation4 ,if a hoop frame be not at hand a lady's wire-hooped petticoat answers the purpose quite as well4 ,illustration3 ,fig4 #aje4--,lamp for local fumigation4 ,the patient1 in four or five minutes1 usually breaks into a violent perspiration1 his pulse quickens much1 sometimes even syncope occurs2 hence1 he should not be left alone until the bath is over4 ,this1 if the flame is strong and the quantity of calomel not very great--one or two scruples being a common dose--occupies a quarter of an hour4 ,when the bath is over the patient should at once get into bed1 and lie there a few hours2 then he may rise and be well sponged with tepid water4 ,moderate but tolerably speedy mercurialisation of the system is thus induced4 ,local ,fumigation is employed when the disease is confined to a few obstinate patches of eruption4 ,for this purpose an earthenware alembic 7fig4 #aje7 is fitted to the lamp used for general fumigation2 the calomel is thrown into the bottom of the alembic4 ,the flame plays over the outside1 and heating it1 sublimes the calomel2 which reaches the mouth of the alembic and condenses on any part to which it is applied4 ,the throat may be fumigated by inhaling the vapour as it escapes from this alembic1 or by sucking air through the spout of an earthenware teapot in which the calomel has been placed1 and heated by a spirit lamp underneath4 ,the ,hot ,air-,bath is easily obtained by undressing the patient1 putting him to bed on a mattress1 and fastening across the bed two or three lengths of cane or stout wire1 over which a blanket is next thrown4 ,the patient's body is thus enclosed in a small chamber1 the air of which is then heated by putting inside1 on an earthenware plate1 a spirit lamp1 surrounded by a kitchen lemon-grater to protect the bed clothes from its flame4 ,sheets should be dispensed with while the lamp is alight1 lest they catch fire4 ,the temperature of the air should be watched1 lest it grow hot enough to scorch1 but it must be kept up till the patient breaks into a sharp perspiration1 when the lamp may be removed and the patient allowed to cool slowly down4 ,the action of the bath is greatly accelerated by sponging the patient all over as he lies in bed with tepid water1 when the air grows warm4 ,lamps protected with wire gauze1 and furnished with a cradle to keep the bed clothes up1 are sold at the instrument-makers1 but the above arrangement answers just as well as more elaborate apparatus4 ,the ,vapour ,bath4--,the patient is put to bed as in the hot-air bath1 and a few feet of vulcanised india-rubber tubing1 fastened to the spout of a tea-kettle on the fire1 bring a supply of vapour into the bed4 ,the vapour bath may precede the hot-air bath1 and will quicken the action of the latter very greatly4 ,illustration3 ,fig4 #ajf4--;,dr4 ,horace ,swete's village ambulance or sick carriage4 ,carriage for transporting the ,sick4 ,the army ambulance and the carriage of the ,invalid ,carriage ,society are excellent means for transporting sick from their homes1 or wounded persons from the scene of injury to the hospital4 ,as their cost is somewhat considerable1 a cheap carriage 7see fig4 #ajf7 has been devised by ,dr4 ,horace ,swete1 of ,weston-super-,mare1 for the use of the district in which he is residing1 and which may be kept for use at workhouses1 hospitals1 and in remote districts4 ,it is constructed of varnished wood and iron1 and in the following manner4 ,the dimensions of the carriage are--length1 #g feet #f inches2 breadth1 #c feet #i inches2 height1 #d feet #i inches4 ,its weight is under #c cwt41 and its total cost #bal4 ,the body is like a skeleton hearse1 without fixed floor or sides4 ,the sides are closed by vulcanised india-rubber curtains1 or by glass sliding panels4 ,the back1 a wooden panel1 opens like a door4 ,a wooden tray slides on three rollers at the bottom1 and on this a mattress covered with vulcanised india-rubber is placed to receive the patient4 ,for infectious cases straw should be used instead of the mattress1 as it may be burnt when the patient is removed4 ,the tray is narrow1 and fitted with handles1 that it may be carried up a narrow staircase4 ,the vehicle runs on four wheels1 is fitted with lamp1 handle1 shafts1 and driving box1 and is well hung on good springs4 ,the material of the carriage admits of being washed1 and thus readily purified1 after conveying an infectious case4 ,cupping--,dry1 and ,bleeding ,cupping4 ,apparatus4--#a4 ,a series or nest of exhausting glasses4 #b4 ,different sized boxes of lancets for incising the skin1 called scarificators4 #c4 ,a spirit lamp 7fig4 #ajg74 ,the glasses are #f oz41 #d oz41 #b oz41 and #a oz4 in size1 of rounded shape1 with thick smooth edges4 ,in dry cupping the object is to relieve internal congestion by drawing the blood into the subcutaneous cellular tissue4 ,the back and loins1 where the skin is tolerably loose1 are most suitable places for this proceeding4 ,illustration3 ,fig4 #ajg4--;,cupping glasses1 lamp1 scarificator1 and spirit bottle4 ,the ,operation4 ,step #a4 ,light the spirit lamp1 direct the patient to sit forwards1 and lay bare the back ready for the glasses1 which should be placed on the bed within reach of the operator's right hand4 ,step #b4 ,rarify the air in a glass by plunging the flame into it a few moments1 and then quickly clap the mouth of the glass on the skin2 leave it there while a second and third glass are heated and applied1 when the first should be removed and its vacuum restored before it is replaced4 ,in putting the glasses on again1 their rims should not lie exactly in the rings marked on the skin by previous applications1 or the bruises may inflame and slough afterwards at these parts4 ,the application and removal of the glasses should be done as lightly as possible to prevent all unnecessary pain4 ,a few repetitions of this incomplete vacuum causes the skin to puff up readily into the glasses1 and much blood is thereby attracted into the cellular tissue4 ,bleeding or ,bloody ,cupping4--,when it is desired to take blood from the body the skin is punctured or scarified by the scarificators1 half a dozen incisions being made at a blow by as many lancets protruding from a box1 when a spring it holds is touched2 the glasses are then laid over these incisions1 and the necessary amount of blood removed by their exhausting power4 ,illustration3 ,fig4 #ajh4--;,junod's vacuum boot for attracting the blood to the lower extremities4 ,junod's ,boot is a tin case1 shaped like a boot 7see fig4 #ajh71 but capacious enough to allow a limb when placed within it to swell freely4 ,it is sometimes employed to draw blood and serum into the lower extremities during congestion of internal organs4 ,when used1 the leg is passed into the boot1 and the mouth of the boot closed round the limb by a packing of india-rubber tied firmly round the boot and limb1 and well smeared with simple ointment4 ,the air is then exhausted from the inside of the boot by a small brass syringe1 which screws into a hole in the leg of the boot1 as depicted in the figure4 ,the patient should wear the boot some two or three hours1 while the vacuum is kept up by an occasional exhaustion of the syringe4 ,both limbs may be subjected to exhaustion1 but the patient must remain in bed for twenty-four hours after the operation2 this is generally necessary for other reasons1 and he must wear a bandage for a few days when he gets about4 ,leeches4--,each leech should draw about #b drachms of blood1 and if the bite is well fomented1 another drachm will escape from the wound afterwards4 ,before the leeches are applied1 the skin should be well washed with soap and warm water1 and carefully dried4 ,the leeches should not be taken from their box1 but the box inverted over the part1 when they will quickly fasten themselves4 ,if the leeches are applied in a dependent position1 a soft napkin may be pinned round the box to support them as they grow heavy1 and to enable them to suck as long as possible4 ,they should be allowed to drop off2 if pulled off they are apt to tear the wound1 or leave part of their suckers in it1 which causes much irritation afterwards4 ,the leech is put in a little glass when applied to the gums or the cervix uteri1 and held against the part he is to suck4 ,if the leeches do not bite readily the part should be smeared with blood or warm milk1 and the leeches put into lukewarm water a few minutes2 immersion in small beer is also said to stimulate them to bite4 ,if the bites bleed longer than is desired1 they may be stopped by pinching the skin between the finger and thumb1 wiping the bite thoroughly dry1 and filling it with a little bit of amadou or fine sponge1 soaked in solution of perchloride of iron2 a larger piece of amadou is placed over the first1 and the whole compressed with a turn of a bandage or long strip of plaster4 ,if this fails1 a sewing needle may be passed through the skin beneath the floor of the bite1 and the bleeding surface constricted by twisting a thread round it under the needle4 ,leech-bites should never be left bleeding1 especially in children1 for a dangerous amount of blood may be lost from them in a few hours4 ,tents are instruments made of some substance that enlarges as it absorbs liquid2 they are employed to dilate apertures of sinuses or natural passages1 as the cervix uteri1 c41 and are generally short rods #b to #c inches long1 and #a_/aj to inch in thickness1 made of a whalebone stem1 wound round with compressed sponge1 which is smeared with wax to keep it in shape4 ,slips of gentian root1 or of laminaria digitata1 which rapidly enlarge as they imbibe moisture1 are also employed for this purpose4 ,setons are strips of varnished calico1 #f or #h inches long and broad2 a thread is fastened to each end1 which are tied together while the seton is worn4 ,it is employed to excite irritation either along the course of a sinus1 or in some superficial situation1 as the nape of the neck1 to relieve congestion of internal parts4 ,in sinuses1 a few threads of silk usually produce the required amount of irritation4 ,chassaignac's ,drainage-tubes are a form of seton2 they are india-rubber tubes of the calibre of a wheat straw1 of any requisite length1 and perforated with holes at frequent intervals2 they are carried into the cavity to be drained1 by hitching the prong of a forked probe1 made for the purpose1 through one end of the tube and thrusting it along the sinus1 or across the abscess4 ,the skin is then incised over the further end of the sinus to bring the probe out1 and the ends of the tube are tied together4 ,the advantages of these tubes are1 the small amount of irritation they provoke1 and the ready exit furnished for the matter along their interior4 ,issues are a contrivance for keeping up irritation of the surface4 ,a piece of diachylon plaster the size of a half-crown1 with a hole in the centre as large as a pea1 is laid over the skin where the issue is to be formed4 ,a bit of potassa fusa is laid in the hole and kept in sit by a second plaster1 for an hour or till the skin is destroyed under the hole4 ,the plasters are then removed1 the wound washed1 and a fresh piece of the same size put on1 having at its centre a slit inch long1 under which a pea is slipped into the sore and covered over by another smaller piece of plaster4 ,the discharge that soon sets up must be washed away twice daily1 and the plaster and pea renewed from time to time as they become soiled4 ,trusses for ruptures4 ,these are various1 in shape1 strength of spring1 c4 ,whatever variety of truss is employed1 care should be taken that the pressure is made in the right direction1 and that it is sufficient1 but not too great for the strain it has to support4 ,in reducible hernia the pressure for inguinal rupture should be exerted on the inguinal canal and directly backwards 7see fig4 #aji74 ,for umbilical rupture1 the pressure should be also backwards1 and confined as much as possible to the aperture in the wall of the belly4 ,in femoral rupture the pressure should be directed upwards as well as backwards into the femoral ring 7see fig4 #aaj74 ,the pad in all should be large enough to well cover the passage through which the rupture passes4 ,the ease and comfort of a truss much depend on the completeness with which it fulfils these conditions4 ,illustration3 ,fig4 #aji4--;,inguinal truss4 ,illustration3 ,fig4 #aaj4--;,femoral truss4 ,the adequacy of a truss should always be tested by directing the patient to separate his legs1 lean forward over the back of a chair1 and cough or strain deeply4 ,if the truss support the rupture during this exertion it fits satisfactorily4 ,for irreducible hernia large air-1 or spring-padded trusses are made1 which prevent further descent of the viscera1 but they are exceedingly difficult to fit and often unsatisfactory in use4 ,in inguinal hernia the truss consists of a pad1 a spring1 and a neck1 with guide straps4 ,the pad is made of various materials1 fine carded wool is among the best when well stuffed into a proper shaped leather pad1 and in most cases a fixed pad is better than a moveable one4 ,the pad should compress the canal and be convex if the patient is stout4 ,its size ought to be sufficient to compress the canal and the margins for a short distance on each side1 but the pad should be as small as will ensure fair compression4 ,a very flaccid bellywall1 and a large gap or protrusion require a large surface on the pad4 ,the spring should be supple and padded behind to rest on the two sacro-iliac synchondroses1 without bearing on the spine4 ,the spring1 narrowing as it comes forward1 embraces the pelvis2 and opposite the anterior iliac spine inclines downwards1 because the hernia is a little lower than the resting-place of the spring behind4 ,when the rupture is almost reached1 the spring takes a slight elbow or bend 7the neck71 that its pressure may be directed against the hernia more fully4 ,understraps1 generally not necessary1 should be omitted if possible4 ,in trusses for children when the testis is not descended1 the pad should have a notch at its lower border in which the testis may rest uncompressed4 ,in the truss for femoral hernia1 the spring bears behind the body and encircles the hips in the same manner as in the inguinal truss1 but when opposite the femoral artery it turns abruptly downwards to reach the saphenous opening4 ,the pad should fit the hollow where the rupture issues and be not oval1 but rounded4 ,the under-strap should be attached to the stud at the lower end of the pad1 and pass round the perinum and fold of the buttock1 and be attached to the neck of the spring close to the pad4 ,it should be made of knitted bandage that it may be changed and washed frequently4 ,when measuring a patient for an inguinal truss1 the circumference of the body round the hips 7between the crista ilii and the great trochanter7 should be first taken1 and then that between the symphysis pubis and the anterior iliac spine1 half of which distance denotes the position of the internal abdominal ring1 which with the inguinal canal has to be supported by the pad of the truss4 ,for a femoral hernia the same measurement should be taken round the body1 and also the distance of the saphenous opening from the symphysis pubis and from the anterior superior iliac spine4 ,this will enable the maker to put the pad at the proper angle with the spring1 so that it compresses the saphenous opening1 and clears the crest of the pubes4 ,every patient should1 while he wears a truss1 show himself from time to time to the surgeon to see that any defect in his apparatus may be quickly remedied4 ,it is a useful precaution also to keep two trusses at hand1 so that if one breaks1 the patient may at once apply the other4 ,salmon and ,ody's truss consists of a spring passing round the hip from a circular pad b1 which bears on the sacrum to a second oval pad a4 ,both pads are attached to the spring by a ball and socket joint4 ,there is also a slide for shortening or lengthening the spring if desired 7fig4 #aaa74 ,this truss is worn round the sound side of the body and reaches beyond the middle line to the hernial opening1 with the object of directing the pressure of the spring outwards and backwards1 or exactly counter to the course of the hernia inwards4 ,illustration3 ,fig4 #aaa4--,salmon ,ody's truss4 ,umbilical hernia4--,spring trusses are not adapted for restraining umbilical hernia4 ,the support consists of a broad belt fitted to the belly1 made in front of elastic webbing1 and on each flank1 of white jean4 ,behind1 the belt is fastened by straps and buckles1 or by lacing1 the better plan4 ,in the centre1 the elastic part carries a nearly flat air-cushion1 measuring about #c inches transversely and #b vertically4 ,this cushion is placed against the aperture of the belly1 and presses back the protrusion4 ,the size of the pad varies with the size of the hernia1 but it should always largely exceed the extent of the gap in the abdominal wall4 ,the pad1 when the apparatus is used for an infant1 should not be too prominent1 as it is then more difficult to keep in place1 and also by pressing into the aperture hinders it from closing4 ,the pad for an infant is best made of a disc of ivory1 #a inch broad and an inch to #a inch thick1 stitched in a little case in the centre of the girdle4 ,the quantity of elastic tissue should be much less in the infant's belt than in those for adults that the belt may be frequently washed4 ,the difficulty of keeping the belt in place is obviated by attaching two bands to the upper border1 to pass over the shoulders and cross behind before fastening to the belt1 like braces4 ,two similar ones may be fastened to the lower border and carried under the thighs4 ,these bands should be of soft webbing1 and several pairs kept in store1 that they may be frequently changed and washed4 ,cauteries4 ,cautery irons4--,these are masses of iron of different shapes2 some pointed1 others rounded like buttons1 c41 set in a stem a foot long1 fixed in a thick wooden handle4 ,they are heated in a charcoal brazier or common fire to bright redness if required to destroy deeply1 but short of redness if intended only to scorch the surface4 ,as these irons are inconvenient for many cases from their bulk1 and yet soon lose their heat if made small1 other cauteries have been devised to which the heat can be quickly renewed4 ,illustration3 ,fig4 #aab4--;,gas cautery for large surfaces4 ,gas ,cautery4--,the late ,mr4 ,alexander ,bruce perfected an instrument which employs the gas flame as a source of heat 7see figs4 #aab1 #aac74 ,a blowpipe flame plays on platinum discs of various sizes1 and keeps them at a glowing heat4 ,this hot solid point can be thrust into the tissue wherever it is desired4 ,a larger form is also made for cauterising the pedicle in ,ovariotomy1 c4 ,in this a large flame is blown on a wedge-shaped surface of platinum1 #a inch long and inch broad1 and continued backwards for #b inches by wire gauze to confine the flame against the platinum4 ,the flame behind these platinum discs quickly heats them again if cooled by the blood4 ,this cautery is very portable1 and easily made ready for use4 ,illustration3 ,fig4 #aac4--;,gas cautery4 ,a4 ,elastic gas reservoir4 ,b4 ,gas jet4 ,c4 ,tube for convoying air to the flame4 #c4 ,platinum disc to be heated by the flame4 ,mr4 ,clover has also devised a cautery1 very useful for small growths4 ,a silver bead1 the size of a pea1 is set at each end of a horizontal metal rod #d inches long1 which rotates on a vertical pivot half a circle backwards and forwards1 so that one or other bead is thrown into the flame of a spirit lamp placed at a proper distance2 when the bead is heated1 a touch of the finger causes the central pivot to rotate1 which brings the hot bead away from the lamp1 and carries the cold one into the flame1 to be heated while the first is used4 ,galvanic ,cautery4--,the instrument consists of a platinum wire1 made to glow by passing through it a powerful galvanic current4 ,the wire should be thick 7about #a_/ab of an inch71 and all the other conducting surfaces sufficiently large to offer no impediment to the current where heat is not desired4 ,the battery best adapted for this purpose is a ,grove's battery4 ,the main advantage of a galvanic cautery is that the wire can be passed while cold exactly where it is required1 and then heated when it is in place4 ,it is exceedingly useful in fistul between the urethra and rectum1 or in destroying vascular growths1 nvi1 c41 where it is desirable not to destroy all the skin covering the tumour4 ,again1 by this means1 an intense heat can be applied to a very limited area1 and more quickly renewed than by any other plan1 for the wire1 even when plunged in the tissue1 is never far below a red heat4 ,of chemical caustics a host exist2 those most commonly employed are3--nitrate of silver1 solid1 or in saturated solutions 7#b drachms to the oz4 of water1 c472 fuming nitric acid2 solution of nitrate of mercury in nitric acid2 oil of vitriol made into a paste with powdered charcoal2 chloride of zinc mixed with dry starch1 then rolled into cakes and cut in slices2 ,vienna paste1 that is1 equal parts of potassa fusa and quick lime worked into a paste with spirits of wine2 potassa fusa itself2 solution of chromic acid4 ,some surgeons prefer one1 some another2 as a rule1 the liquid caustics are employed where the surface to be destroyed is uneven and spongy1 and solid caustics where the surface is smooth1 and a long continued action is desired4 ,vesicants and irritants4--,of the commonest are mustard poultices1 made by mixing mustard flour in a basin with luke-warm water1 i4e4 about #ajj ,f41 to a paste and spreading it on muslin1 which is again folded over the exposed surface of the mustard4 ,boiling water and vinegar should not be used1 for they lessen the pungency of the poultice4 ,if the full effect be desired the poultice should remain on the skin fifteen or twenty minutes4 ,if only slight reddening is wanted1 the mustard flour should be diluted with its bulk of linseed meal before mixing it with water4 ,a stronger vesicant is ,corrigan's hammer1 a button of polished steel with a flat surface1 fixed to a handle2 when used it should be plunged for a couple of minutes in boiling water1 or heated over a spirit lamp1 but care must be taken not to overheat it1 or it will bring the cuticle away with it4 ,it is pressed on the skin for ten or fifteen seconds2 this is sufficient to cause reddening and vesication4 ,blisters are raised by the emplastrum lytt1 lin4 cantharidis1 or pte epispastique1 which is milder in its effect than the two preceding preparations of ,spanish fly4 ,solution of iodine and iodide of potash1 in three times their bulk of spirit of wine1 also produces a blister when laid on freely4 ,poultices are made of linseed meal1 bread1 or starch1 and are means for applying warmth and moisture without absolutely wetting4 ,bread poultices sodden the parts to which they are applied most1 and starch least1 of the three kinds4 ,before making a poultice all the materials should be at hand and thoroughly warmed before a good fire4 ,they are--boiling water1 a broad knife or spatula1 soft old linen or muslin1 oil silk1 tapes1 strapping plaster1 bandages1 a piece of old blanket1 flannel or cotton wadding1 safety pins1 or needle and thread4 ,the linen on which the poultice is to be spread should be cut of the intended size1 and when for use about the neck or shoulder should have some tapes sewn on to it to tie it on to the body4 ,the oil silk should be large enough to cover the poultice next which it is laid to keep in the moisture4 ,the flannel or wadding are used to wrap over and keep in the heat of the poultice2 the strapping or bandage to fix every thing in situ as required4 ,when poultices are continued long1 their surfaces should be smeared with lard before application2 this protects the skin somewhat from the irritation that arises2 also when the poultice is to be laid between folds of skin or on hairy situations1 as the buttocks and perinum1 it is better to cover the poultice with a thin cambric handkerchief lest some of the meal stick to the parts4 ,the ,linseed ,poultice is made as follows3 pour boiling water into a well-heated basin till the basin is half full1 then scatter meal with the left hand on the water while that is kept continually stirred with a broad knife1 adding more and more meal until the mass becomes quite soft and gelatinous1 but too stiff to cling to the knife2 then turn it out on the linen1 also well heated at the fire1 and spread it in a layer about an inch thick1 turn up the edge of the linen for an inch all round1 and carry the poultice at once to the patient4 ,if it has to be carried far the poultice should be laid between two very hot plates2 apply it to the part to be poulticed1 lay on the oil silk1 and cover that with the hot flannel or cotton wadding1 and fasten these in place with pins or a stitch4 ,wadding is put where the part is irregular1 as the neck or axilla2 unless the wadding is well placed and the poultice is fastened by strings1 it will soon fall into a narrow band leaving the part exposed that it should warm and moisten4 ,the ,bread ,poultice is made as follows3 the materials being all at hand1 as detailed in the directions for making a linseed poultice1 crumble the inside of a moderately stale loaf until about half a pint or a pint of crumbs are prepared2 then pour boiling water into a basin1 and throw in crumbs gradually in the same manner as the linseed meal1 until a soft porous mass is prepared4 ,the remaining steps are the same as those for making the linseed poultice4 ,the poultice can be made to hold more water if it is turned into a saucepan after mixing1 and a little more water added while it simmers for half an hour at a slow fire4 ,any superfluous water must be drained off1 and the poultice covered with muslin when it is made in this way4 ,the ,starch ,poultice is made as follows3 rub a little starch in a basin with cold water till it has the consistence of cream1 then mix in boiling water till the starch is a thick jelly1 and spread it on the linen while hot4 ,starch poultices retain their heat a long time1 but yield very little moisture to the part4 ,they are chiefly used as emollients to inflamed affections of the skin1 c4 ,hot fomentations are a means for applying heat when moisture is not desired4 ,a ready mode is to take a piece of blanket or thick flannel1 soak it in boiling water and dry it by wringing in a folded towel1 and then wrap it over the part to be fomented with a piece of oil silk or a hot dry flannel over it4 ,laudanum1 turpentine1 and other applications are sprinkled over the flannel1 when soothing or counter-irritating effects are required in addition to the warmth4 ,a bag of bran makes a light warm fomentation if heated in a steam kitchen1 or steamer for boiling potatoes4 ,when absolutely dry heat is desired1 chamomile flowers1 bran1 or sand1 may be heated in an oven1 and poured into hot flannel bags4 ,dry heat is also very agreeably obtained by filling india-rubber bags and cushions with hot water3 they are rather heavy1 but retain their heat many hours4 ,lister's ,method of ,dressing ,wounds with ,carbolic ,acid4--,the properties of carbolic acid which concern the surgeon may be briefly recapitulated as follow3-- ,it is highly volatile1 and the putrefaction of organic fluids is indefinitely postponed where its vapour is present4 ,carbolic acid is soluble in different degrees in water1 alcohol1 ether1 glycerine1 fixed oils1 gutta percha1 india-rubber1 and shell-lac4 ,its varying affinity for these substances enables the surgeon to modify the application of carbolic acid in various ways2 these modifications are necessary to fully utilise its properties4 ,water dissolves the crystallised acid but sparingly1 #a part in #bj being a concentrated solution1 and allows it to escape readily4 ,the aqueous solution is therefore useful where the effects of the acid are required copiously1 but only temporarily4 ,glycerine and the fixed oils dissolve a far greater amount of the acid1 and part with it unwillingly4 ,their solutions are adapted for the continuous but abundant application of the antiseptic4 ,shell-lac1 and some other substances1 hold the carbolic acid still more tenaciously1 and are valuable as solid storehouses which yield up the antiseptic in small quantity for a considerable period4 ,carbolic acid stimulates raw surfaces1 and when concentrated even destroys animal tissues4 ,it is a local ansthetic2 with moderate doses1 wounds lose their sensibility after the first smarting of the application has passed off4 ,when given in large quantities the acid produces a peculiar kind of delirium1 and temporary paralysis of sense and motion3 fatal results have followed its internal application4 ,it is rapidly absorbed into the blood from wounded surfaces1 and through the skin1 whence it is discharged from the body by the lungs and kidneys4 ,the urine of patients dressed with carbolic acid1 though of normal colour when passed1 assumes a dark greenish-brown hue after a few hours' exposure to the air and light4 ,how much of the antiseptic must float in the atmosphere to prevent fermentative changes has not yet been determined2 ,bucholtz found that #a part of carbolic acid in #fjj of milk almost entirely prevented lactic fermentation1 while #a in #bhe did so altogether4 ,alcoholic fermentation in sugary fluids was arrested by a similar quantity4 ,when using the acid in dressing wounds1 the watery solution1 the solid mixture1 and the oily solution are necessary4 ,the first to neutralise the effects of exposure to the atmosphere and water before the wound is closed2 the second solid mixture in the form of plaster to provide a very scanty but continuous supply of carbolic vapour close to the wound3 too scanty to irritate the raw surface1 yet enough to check putrifaction in the discharge oozing from it4 ,the third1 or oily solution1 is to supply the carbolic vapour abundantly to the linen dressings1 appointed to receive the discharge when it has passed from the vicinity of the wound4 ,the tin is used to afford as close a cover as possible to the breach of surface2 for this purpose it must be as flexible as possible that it may fit the wound exactly4 ,the carbolic plaster is made of #c parts of shell-lac and #a part of carbolic acid crystals melted together and spread on calico4 ,to render the lac plaster non-adhesive that it may not stick to the tender wound1 it is painted with solution of gutta percha1 which dries and leaves a thin film of that substance covering the plaster4 ,this film is easily removed by rubbing the surface with a rough towel should an adhesive quality be desired4 ,in either state the carbolic acid continues to volatilise slowly when the plaster is laid over the wound4 ,when adopting this method of treating wounds the following materials are necessary3-- #a4 ,aqueous solution of crystallised carbolic acid 7#a part in #bj74 #b4 ,carbolic oil3 #a part of carbolic acid in #e of olive oil4 #c4 ,lister's shell-lac plaster4#a #d4 ,sheet tin4 #e4 ,lint2 old linen4 #f4 ,diachylon plaster4 #g4 ,glass syringe4 #h4 ,scissors4 #i4 ,thin calico or muslin4 #aj4 ,bandage4 #aa4 ,a wooden splint to rest the limb upon4 ,to ,dress recent ,wounds4--,when the apparatus is ready1 the piece of tin is cut and fitted to the wound1 so that it shall overlap the wound to a small extent on all sides2 then a piece of lac plaster1 large enough to overlap the tin one or two inches all round2 this plaster may be cut and notched when the surface is irregular to make it lie pretty closely2 then strips of diachylon1 about two inches broad1 are cut ready4 ,the parts around the wound are well cleaned2 dirt and clots cleared from the wound with cold water1 containing about #a of carbolic acid to #dj of water1 and the interior of the wound is freely syringed with water containing #a of acid in #cj or even #a in #bj parts4 ,the sides are brought together with sutures1 if necessary1 in the ordinary way1 and the tin laid on the wound2 the tin is freely wetted with carbolic water1 and the lac plaster laid over it and kept in situ by strips of diachylon plaster4 ,in dressing recent wounds the most dependent side of the lac plaster is left unattached1 that the serous discharge1 which is often copious1 may readily escape4 ,to receive this discharge1 a piece of calico1 soaked in carbolic oil1 is laid over the wound now covered in1 and all kept in place by a folded towel or a roller bandage4 ,this oily cloth is to be changed from time to time as it gets soaked with discharge3 at first this change is necessary every night and morning1 but after three or four days once a day is often enough4 ,the shell-lac plaster and tin need not be removed for a week unless the wound grow hot and painful1 when they can be removed at any time if the surface of the wound is immediately smeared with carbolic oil1 and kept well imbued with the antiseptic while it is being examined4 ,should it contain pent-up discharge1 the sutures must be loosened and the discharge washed out by injecting the #a in #cj aqueous solution4 ,the tin and lac plaster may be then replaced1 and the dressing renewed4 ,the same precaution must be followed when the sutures have to be removed4 ,usually there is very little swelling and no pain1 and the healing process goes on tranquilly if undisturbed4 ,should bruised parts slough1 they may be trimmed away with scissors dipped in carbolic oil4 ,when the wound has once been washed with carbolic acid1 the antiseptic should not enter the wound a second time1 as its irritant qualities excite inflammation in the wound4 ,chronic abscesses1 besides recent wounds1 are treated with carbolic acid4 ,the surface to be punctured is covered with a piece of thin muslin soaked in carbolic oil1 and the knife to be used is dipped in the oil also4 ,then1 a second piece of muslin being ready1 the surgeon opens the abscess through the muslin1 and as he withdraws the knife an assistant lays on the second piece of muslin over the wound4 ,the matter drains away from under this curtain1 and the access of atmospheric air is prevented4 ,when the matter ceases to flow1 the lac plaster is laid on1 and the oily cloth outside1 which can be changed as often as is requisite4 ,abscesses so treated usually soon cease to secrete matter1 shrink1 and fill up without delay4 ,if the abscess has burst or had communication with the external air1 the interior must be filled with watery solution #a to #bj before it is dressed1 that fermentation in the cavity may be prevented2 the further treatment is the same as for a recent wound4 ,illustration3 ,fig4 #aad4--;,irrigating a wound4 ,irrigation4--,the continual flow of ice-cold water is used to prevent inflammation of certain wounds4 ,in using cold1 it is particularly necessary that the temperature of the water remain steady1 for alterations of temperature cause alterations in the capacity of the blood vessels1 and promote congestion rather than diminish it2 hence irrigation1 badly attended to1 becomes an evil instead of a benefit4 ,the simplest way 7see fig4 #aad7 of contriving irrigation is to lay the limb in an easy position on pillows1 protected by a sheet of india-rubber cloth1 weighted at one corner to draw the cloth into a channel1 down which the water trickles into a receiver under the bed2 over the limb a jar1 wrapped in blanket1 is suspended4 ,this is filled with water from time to time1 and kept charged with lumps of ice4 ,a syphon is made by a few feet of fine india-rubber tubing reaching from the bottom of the jar to the wound1 the escape of water through the tube being moderated by drawing the end more or less tightly through a bit of cleft stick4 ,it is sufficient that the wound should be kept constantly and thoroughly wetted2 more than that is waste of cooling power4 ,esmarch's ,irrigator4--,this is a simple contrivance for washing out wounds and sinuses with a stream of water4 ,it consists of a tall can of block tin 7see fig4 #aae71 with an orifice at the lower end1 to which a couple of feet of india-rubber tubing are attached4 ,the tube is fitted with an ivory nozzle and a hook1 so that when the stream is not wanted the flow of water is stopped by hanging the nozzle on the upper edge of the can4 ,the stream can be made more or less forcible by raising or lowering the can above the wound4 ,illustration3 ,fig4 #aae4--;,esmarch's ,irrigator4 ,the ,administration of ,chloroform4--,in administering chloroform the main points to be borne in mind are--#a4 ,if the patient is fit to undergo an operation at all he may inhale chloroform4 #b4 ,the patient should be fasting2 this is the most effectual preventive of sickness4 #c4 ,he should be in an easy position1 clad in a loose but warm night-dress1 which does not interfere with ordinary or artificial respiration1 should that be suddenly required4 #d4 ,the patient must never inhale more than #d per cent4 of chloroform vapour in the air he respires2 on the other hand1 the vapour may circulate in the blood without harm for an indefinite time1 provided it never pass beyond a certain concentration4 #e4 ,chloroform is a sedative and depressant2 the pulse gives the earliest indication of syncope1 and the respiration should be constantly watched the whole time chloroform is inhaled4 ,it should be noted that the pulse often fails suddenly at the first flow of blood in an operation4 ,again1 when the patient is deeply narcotised1 the jaw may gape and the tongue sink back till it closes the glottis4 ,from this cause respiration sometimes ceases1 and danger quickly arises if the chin is not drawn up to raise the epiglottis4 ,in beginning to inhale1 the quantity of vapour should be small1 and gradually increased4 ,the patient must be cautioned not to talk1 to avoid the irritation and coughing chloroform sometimes excites while he is speaking4 ,he should also shut his eyes lest the vapour make them smart4 ,after inhalation has been continued a few minutes the patient is often quiet and inattentive1 though easily roused by pain4 ,his condition at this stage should be tested by asking him to give his hand1 or by pinching him gently2 if no notice be taken of these1 the conjunctiva should be touched1 and the amount of winking thus excited will enable the chloroformist to judge if the patient will resist when the knife is applied4 ,patients vary much in the time passed before recovering consciousness2 if they remain soundly asleep1 breathing freely and with good pulse1 it is better to avoid rousing or moving them until they wake spontaneously2 such patients suffer less confusion and vomiting than those who are quickly alive to what is going on around them4 ,signs of ,danger4--,sudden failure or irregularity of the pulse1 with pallor and arrested breathing1 are of great importance2 if these occur1 the chloroform must be at once removed1 a free supply of fresh air ensured1 the tongue drawn gently forward1 and if the breathing do not quickly begin1 it must be set up artificially 7see p4 #ahc7 without loss of time1 and continued1 if necessary1 for at least an hour before recovery is despaired of4 ,stertorous breathing is not alarming unless accompanied by feeble pulse1 shallow respiration1 and dilatation of the pupils2 with these it becomes a sign of a comatose condition4 ,as subordinate adjuvants for faintness the following are useful3--moistening the tongue and lips with brandy from time to time1 or letting the patient sip a small quantity from the spout of a feeding cup4 ,in complete syncope1 galvanism to the epigastrium1 a hot iron or scalding water to the prcordia may be employed1 but should never interfere with the maintenance of artificial respiration1 which is of far greater efficacy in restoring suspended animation than anything else4 ,chloroform is safely given on a handkerchief1 or in various ways1 if the administrator is careful to watch the pulse and respiration1 and to guard against the patient1 by a sudden deep inspiration1 taking too large a dose of vapour at once4 ,exact measurement of the quantity of liquid poured on the handkerchief at a time is of no value1 as it is no index of the concentration of the air respired by the patient4 ,of far greater consequence is it to insure a free supply of atmospheric air1 by keeping the evaporating surface a few inches from the mouth and nostrils4 ,illustration3 ,fig4 #aaf4--;,clover's apparatus for administering chloroform4 ,the safest mode of giving chloroform is by ,clover's ,inhaler 7fig4 #aaf71 now used in many ,london hospitals and elsewhere4 ,it renders it impossible to give the patient too strong a dose1 by preparing an atmosphere of known strength for him to breathe4 ,clover's apparatus consists of a bag of #h1jjj or #aj1jjj cubic inches capacity1 suspended by a loop behind the chloroformist's back1 from this a flexible tube brings the vaporised air to a mask1 fitting over the nose and mouth of the patient4 ,this mask has a flexible metal border for adjusting it to different faces2 and a valve that opens and closes1 to allow more or less common air to be respired with that drawn from the reservoir if desired4 ,the reservoir is supplied by injecting into it1 from a bellows1 #a1jjj cubic inches of air1 drawn through an evaporating box heated by hot water1 into which #cb minims of chloroform are injected from a graduated syringe each time the bellows are filled4 ,by these means1 an atmosphere of known strength is prepared for the inhalation2 that is one containing about #d of vapour4 ,this apparatus is very easy to use1 and the most efficient in producing ansthesia quickly and pleasantly4 ,artificial ,respiration4--,many plans are employed2 but the two most efficient are those to be described4 ,illustration3 ,fig4 #aag4--;,artificial ,respiration4 ,marshall ,hall's method4 #ast position4 ,marshall ,hall's ,method4--,lay the patient on the floor1 with the clothing round his neck1 chest1 and abdomen loose2 if wet1 remove it1 and throw over his body a warm blanket4 ,clear out the mouth1 and turn the patient on his face1 one arm being folded under his forehead 7see fig4 #aag71 and the chest raised on a folded coat or firm cushion4 ,next1 turn the patient well on his side1 while an assistant supports the head and arm doubled underneath it 7see fig4 #aah71 and confines his attention to keeping the head forward and the mouth open during the movements to and fro4 ,when two seconds have elapsed turn the body again face downwards1 and allow it to remain so for two seconds1 and then raise it as before4 ,this series of movements1 occasionally varying the side1 should be repeated about fifteen times a minute1 and continued until spontaneous respiration is restored1 or1 until two hours have been thus spent in vain4 ,illustration3 ,fig4 #aah4--;,artificial ,respiration4 ,marshall ,hall's method4 #bnd position4 ,illustration3 ,fig4 #aai4--;,artificial ,respiration4 ,silvester's ,method4 ,expanding the ,chest4 ,illustration3 ,fig4 #abj4--;,artificial ,respiration4 ,silvester's method4 ,compressing the ,chest4 ,silvester's ,method4--,lay the patient on a flat surface1 the head and shoulders supported on his coat folded into a firm cushion4 ,loosen all tight clothing1 and if wet replace it by a warm dry blanket1 his arms being outside the blanket4 ,clear the mouth of dirt1 blood1 c41 draw the tongue forwards1 and fasten it to the chin by a piece of string or tape tied round it and the lower jaw4 ,next1 standing at the patient's head1 grasp the arms at the elbows1 and draw them gently and steadily upwards till the hands meet above the head 7see fig4 #aai72 keep them so stretched for two seconds4 ,then slowly replace the elbows by the sides1 and press gently inwards for two seconds 7see fig4 #abj74 ,these movements are repeated without hurry about fifteen times in a minute1 until a spontaneous effort to breathe is made1 when exertion should be directed to restoring the circulation by rubbing the limbs upwards towards the body1 and by placing hot bottles at the pit of the stomach1 to the armpits1 between the thighs1 and to the feet4 ,should natural breathing not commence1 artificial respiration should be continued for two hours before success is despaired of4 ,illustration3 ,fig4 #aba4--,the ,spray-producer4 ,richardson's ,ether ,spray-,producer 7fig4 #aba7 consists of a tube on which two india-rubber bags are placed2 one1 protected by a silk net1 acts as a reservoir2 the other1 furnished with a valve1 is the pump2 these drive a constant stream of air over the tip of a fine tube projecting from a flask of ether2 this sucks up the ether and throws it in fine spray on the surface to be chilled by its evaporation4 ,the ether for this purpose must be very pure and dry1 having a specific gravity of #gbj1 or the evaporation will not be sufficiently rapid to produce congelation4 ,the first effect of the spray is a numbing aching pain with reddening of the surface4 ,this is succeeded by a pricking pain4 ,in ten seconds1 if the ether be good1 a dead white hue spreads rapidly over the skin1 and when this appears the surface is quite insensible4 ,the bottle and elastic air-pump may be attached to the glass jet seen in the corner of fig4 #aba1 which then makes an apparatus for injecting astringent solutions in spray over the nasal passages1 the throat1 and air-tubes2 but the tubes used for watery fluids are much wider than that for pulverising ether into spray4 ,tannin in solution of #c-aj grains to the ounce of water1 sulphate of zinc1 or alum in similar quantity1 may be thus inhaled with much benefit by persons suffering from chronic congestion of the mucous membranes4 ,injecting ,chloroform ,vapour into the ,uterus is a ready means of relieving pain in cancer of that organ2 special apparatus is made for the purpose1 but an ordinary elastic clyster syringe will answer the purpose1 if the flask is unscrewed and a few drops of chloroform are poured into it1 from time to time1 while air is pumped through the delivery tube1 which is passed up the vagina to the ulcerated cervix-uteri4 ,subcutaneous ,injection4--,the syringe for this operation 7fig4 #abb7 consists of a graduated glass tube holding six minims4 ,the piston works in a silver continuation of the graduated tube1 and is thus kept clear of the solutions used for injection4 ,to the nozzle of the syringe fine sharp-pointed cannul are screwed on2 they are of different lengths1 some of steel1 others of steel gilt2 the gilding renders the points very blunt1 and consequently much more painful to insert4 ,in filling the syringe1 care should be taken not to draw the fluid above the level of the graduation on the tube1 that the exact amount injected may be read off as the liquid sinks in the tube4 ,the finer the cannula1 and the sharper its point1 the less pain is caused by its introduction4 ,illustration3 ,fig4 #abb4--,subcutaneous ,injection4 ,the solution of morphia should contain a grain in six drops and be as little acid as possible4 ,in injecting morphia1 it should be recollected that grain is the usual dose to allay pain1 and produce sleep2 doses even far smaller often suffice for this purpose1 though very much greater quantities can be administered by injection1 where long use has rendered the patient tolerant of the drug4 ,some persons dread the puncture considerably2 for them the pain may be entirely prevented by numbing the surface with ether-spray 7see page #ahf7 before inserting the syringe1 though usually the prick is of so little consequence that any precaution of this kind is unnecessary4 ,the cannula should be thrust completely through the skin into the subcutaneous cellular tissue2 if the fluid is injected into the skin itself1 inflammation and suppuration of the puncture sometimes ensues4 ,after the cannula is withdrawn1 the finger should be placed for a few seconds over the puncture1 or much of the fluid will leak out again4 ,when large quantities of solution 7one or two syringefuls7 are injected the cannula need not always be withdrawn1 the nozzle can be unscrewed and the syringe charged again2 but more than ten or twelve drops injected into one place generally causes much pain1 even where the cellular tissue is very loose4 ,the syringe and cannula should be carefully cleaned1 by sending plenty of cold water through them each time they are used1 or the cannula will rust and become unfit for use4 ,collodion is much used in drawing the edges of small wounds together1 c4 ,preston's plastic collodion1 or the flexible collodion of the ,british ,pharmacopia1 #ahfg1 have advantages over the common form by furnishing a tougher pellicle1 yielding to the movements of the skin beneath without cracking4 ,collodion should be kept for use in a small wide-mouthed bottle1 with stopper and brush1 and when employed should be laid on quickly in a thick mass1 so that the crust it leaves shall be of one layer4 ,a tougher crust is obtained if a piece of muslin is soaked in the collodion and then laid on the wound1 than if the collodion is used alone4 ,vaccination4--,the lymph of the vaccine vesicle1 taken between the seventh and tenth days1 is preserved for use on lancet-shaped slips of bone #a inch long1 called points4 ,these are dipped in the lymph as it exudes from the vesicle1 and exposed to the air till dry2 they are then wrapped in paper ready for use4 ,when used1 the lymph should be moistened1 by holding them over a vessel of steaming water a few seconds before inserting them in the wound made to receive the lymph4 ,the points often lose the virus in a few days1 and should1 if possible1 be used the same day they are charged4 ,the lymph may be much longer preserved if hermetically sealed in glass tubes4 ,these are about the thickness of a darning-needle1 #c inches long1 and open at both ends4 ,when the tube is to be charged1 one end is inserted in the lymph exuding from a punctured vesicle2 a drop then enters the tube by capillary attraction1 but filling not more than half its interior3 a few shakes of the hand will send the drop a little further in4 ,the lymph end of the tube is then taken in the thumb and forefinger1 while the unoccupied part of the tube is passed once or twice quickly through the flame of a candle4 ,this rarifies the air1 and while it is warm the end is closed by melting it at the edge of the flame4 ,the second end is then closed in the same way as the first4 ,when the lymph is wanted for use1 the ends of the tube are broken1 and the lymph blown out on the point of a lancet4 ,lymph preserved in these tubes retains its efficacy an indefinite time4 ,the ,national ,vaccine ,institution1 ,russell ,place1 ,fitzroy ,square1 ,london1 ,w41 supplies to medical practitioners both points and tubes gratis on application4 ,in performing the operation the common lancet does very well2 but two or three forms of narrow-grooved lancets are employed by surgeons for this purpose4 ,the operation is most successful when the lymph is transferred direct from arm to arm2 the lancet making the puncture is then charged at the vesicle of a child vaccinated a week before1 and points are unnecessary4 ,when making the puncture the surgeon grasps the child's arm in his left hand1 puts the skin on the stretch over the insertion of the deltoid with his left forefinger and thumb1 pushes the lancet downwards between the cutis and cuticle1 about #a-ajth of an inch1 to raise the latter in a little pocket2 he then charges his lancet with lymph and inserts it in the pocket1 or if using points1 inserts the moistened point for a minute1 taking care as he withdraws the point to press the skin down on the point with his left thumb1 that the lymph may be well wiped off the point and left in the wound4 ,this process is repeated four or five times and the operation is complete4 ,the corium should not be penetrated1 or it will bleed freely and the blood will wash away the lymph2 one drop of blood is of little consequence2 indeed1 it shows that an absorbing surface has been reached4 ,the phenomena following the insertion of the vaccine virus in an infant's arm are as follows3--,on the second day the puncture is slightly elevated2 on the third it begins to grow red2 on the fifth it is marked by a distinct vesicle with a depressed centre and red areola2 on the eighth the vesicle is perfect1 of pearl-like aspect1 full of clear lymph2 the areola1 often little marked by the eighth day1 rapidly increases on the ninth and tenth days1 and reaches an inch or more in diameter4 ,this bright-red inflammatory action in the skin is essential to show the system is properly infected with the vaccine disease2 by the twelfth day the areola has lessened1 the lymph is yellow1 and often escapes by rupture of the vesicle2 on the fourteenth day the vesicle has dried to a scab1 that falls on the twenty-first day1 leaving a dotted cicatrix1 the vestige of the multilocular structure of the vesicle4 ,the three important marks diagnostic of the vaccination being satisfactory1 are--#a1 the pearly multilocular vesicle of the #hth-#ith day2 #b1 the widely-spread areola on the #ith-#abth day2 #c1 the well-marked foveated cicatrix after the scab has fallen4 ,observation shows that the number of people who take small-pox after vaccination is very small indeed1 when more than three well-marked scars exist2 and this number at least should be secured by making five insertions of lymph at the time of vaccination4 ,,footnotes3 #a ,lister's shell-lac plaster can be obtained of the ,glasgow ,general ,apothecaries' ,company1 and the sheet tin of ,messrs4 ,compton ,co41 #adh1 ,fenchurch ,street1 ,e4,c4 ,,list ,,of ,,the ,,instruments ,,and ,,appliances ,,requisite1 ,,or ,,occasionally ,,useful1 ,,in ,,most ,,of ,,the ,,important ,,and ,,ordinary ,,operations ,,in ,,surgery4 ,,preparations ,,and ,,requisites ,,for ,,operations ,,in ,,general4 ,,the ,,operating ,,room4 ,,the ,,sick ,,bed ,,and ,,bed-,,room4 ,,sedatives ,,and ,,restoratives4 ,,the ,,arrest ,,of ,h,,morrhage4 ,,operating ,,room4 ,having a good ,light and ,windows that open readily1 and a ,fire in ,winter4 #a4 ,firm table1 #d feet long1 #b feet wide1 and #c feet high4 #b4 ,pillows4 #c4 ,blankets4 #d4 ,towels4 #e4 ,old linen4 #f4 ,mackintosh sheets4 #g4 ,old carpet1 or old sheet to cover the floor4 #h4 ,tray of sawdust or sand4 #i4 ,bandages4 #aj4 ,strapping plaister4 #aa4 ,lint4 #ab4 ,oiled silk4 #ac4 ,cotton wool4 #ad4 ,tow4 #ae4 ,perchloride of iron4 #af4 ,basins1 large and small4 #ag4 ,hot and cold water1 ice4 #ah4 ,bucket and slop-jar4 #ai4 ,sponges4 #bj4 ,chloroform and inhaler4 #ba4 ,oil4 #bb4 ,pins4 #bc4 ,scissors4 #bd4 ,brandy4 #be4 ,ammonia4 #bf4 ,fire for heating cauteries4 ,,sick ,,room ,,and ,,bed4 #a4 ,iron bedstead4 #b4 ,wool and hair mattress4 #c4 ,several pillows1 soft and of different sizes4 #d4 ,air and water cushions4 #e4 ,blankets1 small single ones4 #f4 ,pieces of soft flannel4 #g4 ,six sets of sheets and pillowcases4 #h4 ,old soft linen4 #i4 ,cotton-wool4 #aj4 ,towels4 #aa4 ,soft pocket-handkerchiefs4 #ab4 ,three pieces of ,mackintosh1 #b feet #f inches square4 #ac4 ,bed cradle4 #ad4 ,light bedgowns4 #ae4 ,flannel jacket1 and flannel ,zouave drawers4 #af4 ,hot-water bottle4 #ag4 ,bed-pan4 #ah4 ,bed-urinal and bed-stool4 #ai4 ,basins4 #bj4 ,cold water4 #ba4 ,condy's fluid4 #bb4 ,sir ,w4 ,burnett's fluid4 #bc4 ,a bed-rest chair4 #bd4 ,night lights4 #be4 ,a fire1 or in summer a lamp to burn in the fireplace1 to create a draught of air4 #bf4 ,enamelled saucepan4 #bg4 ,two feeding cups4 #bh4 ,spittoon4 #bi4 ,tea-equipage4 #cj4 ,tea-kettle4 #ca4 ,medicine measure4 #cb4 ,apparatus for keeping food warm1 with lamp4 #cc4 ,flowers4 ,before a room is occupied by a patient who has been operated on1 it should be thoroughly cleaned2 the walls and ceiling should be well brushed1 the carpet taken away and the floor thoroughly scrubbed with soda4 ,all curtains and chintz furniture should be removed1 old window-blinds replaced by new green ones1 and the window made to open readily at the top and bottom4 ,a fire or oil-lamp should be lighted in the fireplace to maintain a circulation of air4 ,if the season require a fire1 the iron fender should be removed and replaced by a wooden tray of sand or ashes1 to prevent the noise of cinders and fire-irons falling on the fender and hearth4 ,it is well also to flush all the drains1 water-closets and sinks in the house with disinfecting fluid one or two days before the operation1 and a store of ,sir ,william ,burnett's1 or similar disinfecting fluid1 should be made ready to clear away the ftid odours of discharges as they arise4 ,when possible1 it is a great advantage to have two beds of similar height and size1 that the patient may occupy them alternately4 ,the cool bed refreshes the patient greatly1 and the vacated bed is easily cleaned and aired without fatigue to the sick person4 ,,sedatives4 #a4 ,tincture of opium4 #b4 ,solution of morphia and hypodermic syringe4 #c4 ,morphia suppository4 #d4 ,ice4 ,,restoratives4 #a4 ,brandy1 champagne1 sherry4 #b4 ,eau-de-cologne4 #c4 ,liquor ammoni4 #d4 ,smelling salts4 #e4 ,spirit of chloroform4 #f4 ,a fan4 #g4 ,a ,rimmel's perfume vaporiser4 #h4 ,beef-tea4 #i4 ,chicken-broth4 #aj4 ,milk4 #aa4 ,lime-water4 #ab4 ,soda-water4 #ac4 ,eggs4 #ad4 ,french bread4 #ae4 ,biscuits4 #af4 ,arrow-root4 #ag4 ,liebig's extract of meat4 ,,the ,,arrest ,,of ,h,,morrhage4 #a4 ,artery forceps4 #b4 ,torsion forceps4 #c4 ,tourniquet4 #d4 ,tenaculum4 #e4 ,hare-lip pins4 #f4 ,acupressure needles4 #g4 ,nvus needle4 #h4 ,wire nippers4 #i4 ,solution of perchloride of iron 7equal parts of the salt and water74 #aj4 ,solid perchloride of iron4 #aa4 ,richardson's styptic colloid4 #ab4 ,ice1 ice-cold water4 #ac4 ,cautery irons4 #ad4 ,galvanic cautery wire4 #ae4 ,ligatures1 silk1 fine hemp1 and whipcord4 #af4 ,lint4 #ag4 ,amadou4 #ah4 ,bandages4 #ai4 ,compressed sponge4 #bj4 ,scissors4 7,see ,list for the ,ligature of ,arteries47 ,,instruments ,,and ,,appliances ,,for ,,operations ,,about ,,the ,,head ,,and ,,neck4 ,,trephining ,,the ,,skull4 ,,operations ,,on ,,the ,,eye4 ,,hare-,,lip4 ,,resection ,,of ,,the ,,jaw4 ,,excision ,,of ,,the ,,whole ,,tongue4 ,,cleft ,,palate4 ,,excision ,,of ,,tonsils4 ,,laryngotomy4 ,,tracheotomy4 ,,trephining ,,the ,,skull4 #a4 ,scalpel4 #b4 ,trephines--several crowns4 #c4 ,hey's saw4 #d4 ,elevator4 #e4 ,stout dissecting forceps4 #f4 ,brush to clean away the bone-dust4 #g4 ,probe4 #h4 ,quill1 cut like a tooth-pick1 to clear the groove of bone-dust4 #i4 ,lenticular knife4 #aj4 ,small polypus forceps4 #aa4 ,sponges4 #ab4 ,lint4 #ac4 ,ice4 ,,operations ,,on ,,the ,,eye4 ,strabismus4 #a4 ,chloroform1 if used4 #b4 ,laurence's1 or other head-fixer4 #c4 ,specula of different sizes4 #d4 ,toothed forceps4 #e4 ,strabismus scissors and hooks4 #f4 ,fine curved needles1 and finest thread4 #g4 ,lint4 #h4 ,ice1 or cold water4 ,extirpation of the ,eyeball4 #a4 ,chloroform4 #b4 ,head-fixer4 #c4 ,speculum4 #d4 ,toothed forceps4 #e4 ,curved scissors4 #f4 ,strabismus hook4 #g4 ,small and large sponges4 #h4 ,dissecting forceps4 #i4 ,ice-cold water4 #aj4 ,perchloride of iron4 #aa4 ,fine curved needles1 and finest silk thread4 #ab4 ,lint4 #ac4 ,pulled lint4 #ad4 ,basin4 #ae4 ,bandage4 ,cataract 7,congenital74 #a4 ,atropine drops4 #b4 ,chloroform4 #c4 ,head-fixer4 #d4 ,speculum4 #e4 ,lacerating needles4 #f4 ,toothed forceps1 to fix eyeball4 #g4 ,lint4 #h4 ,cold water4 #i4 ,gelatine plaster4 ,cataract 7,senile74 #a4 ,atropine drops4 #b4 ,chloroform4 #c4 ,head-fixer4 #d4 ,speculum4 #e4 ,lacerating needles4 #f4 ,toothed forceps4 #g4 ,cataract knives4 #h4 ,scoop4 #i4 ,platinum spatula1 to adjust edges of wound4 #aj4 ,small sponges4 #aa4 ,basin and water4 #ab4 ,gelatine plaster4 #ac4 ,wool and bandage4 #ad4 ,lint4 ,iridectomy4 #a4 ,chloroform1 if used4 #b4 ,head-fixer4 #c4 ,specula4 #d4 ,toothed forceps4 #e4 ,right-angled knives4 #f4 ,iris forceps4 #g4 ,iris hooks4 #h4 ,capsule scissors1 if required4 #i4 ,light curved scissors4 #aj4 ,lint4 #aa4 ,gelatine plaster4 #ab4 ,wool and bandage4 #ac4 ,atropine drops4 #ad4 ,small sponges and basin4 #ae4 ,hot and cold water4 ,,hare-,,lip4 #a4 ,scalpel4 #b4 ,artery forceps1 or sharp hook4 #c4 ,hare-lip pins4 #d4 ,wire nippers4 #e4 ,dentist's silk twist4 #f4 ,strapping plaster4 #g4 ,silver suture4 #h4 ,collodion4 #i4 ,scissors4 #aj4 ,cheek compressor4 #aa4 ,sponges4 #ab4 ,large towel to wrap the child in4 #ac4 ,chloroform and inhaler4 ,when the bone has also to be bent back-- #ad4 ,bone nippers4 #ae4 ,sequestrum forceps4 #af4 ,a knitting needle2 and #ag4 ,spirit lamp to check deep hmorrhage by the actual cautery4 ,,resection ,,of ,,the ,,jaw1 ,,and ,,tumours ,,connected ,,with ,,it4 #a4 ,scalpels4 #b4 ,artery forceps4 #c4 ,torsion forceps4 #d4 ,ligatures4 #e4 ,retractors4 #f4 ,tooth forceps4 #g4 ,narrow saw4 #h4 ,hey's saw4 #i4 ,bone-cutting forceps4 #aj4 ,lion's-tooth forceps4 #aa4 ,sequestrum forceps4 #ab4 ,gouges4 #ac4 ,chisel4 #ad4 ,gag4 #ae4 ,hare-lip pins4 #af4 ,wire nippers4 #ag4 ,actual cautery4 #ah4 ,perchloride of iron4 #ai4 ,ice4 #bj4 ,sutures1 silk and wire4 #ba4 ,solution of chloride of zinc4 #bb4 ,lint4 #bc4 ,bandages4 #bd4 ,plaster4 #be4 ,collodion4 #bf4 ,mackintosh sheet4 #bg4 ,small sponges tied on sticks4 #bh4 ,larger sponges4 #bi4 ,chloroform and inhaler4 ,,excision ,,on ,,the ,,whole ,,tongue4 #a4 ,scalpel4 #b4 ,torsion forceps4 #c4 ,artery forceps4 #d4 ,gag4 #e4 ,archimedian bone-drill4 #f4 ,cheek retractors4 #g4 ,incisor tooth forceps4 #h4 ,narrow saw4 #i4 ,nvus needle1 and #aj4 ,half a yard of thick whipcord4 #aa4 ,stout copper wire4 #ab4 ,key for twisting the wire tight4 #ac4 ,wire cutters4 #ad4 ,stout acupressure needle4 #ae4 ,hare-lip pins4 #af4 ,two ecraseurs4 #ag4 ,needle for passing the chain4 #ah4 ,sharp and blunt hooks4 #ai4 ,stout silk4 #bj4 ,metallic sutures4 #ba4 ,ligatures4 #bb4 ,ice4 #bc4 ,perchloride of iron4 #bd4 ,cautery iron4 #be4 ,solution of chloride of zinc4 #bf4 ,collodion4 #bg4 ,small sponges mounted on sticks4 #bh4 ,brandy4 #bi4 ,chloroform and inhaler4 #cj4 ,lint4 #ca4 ,mackintosh sheet4 ,,cleft ,,palate4 #a4 ,long-handled1 narrow-bladed knife1 for dividing the palatine muscles4 #b4 ,long-handled curved scissors4 #c4 ,slender hooked forceps1 to seize soft palate4 #d4 ,long-handled small bistoury1 for paring edges of fissure4 #e4 ,long-handled needles1 with the eye at the point for passing sutures4 #f4 ,fine blue silk1 or catgut4 #g4 ,blunt and sharp hooks4 #h4 ,scissors4 #i4 ,ice1 ice-cold water4 #aj4 ,mackintosh sheet4 #aa4 ,sponges set on sticks4 #ab4 ,glass syringe for washing the mouth4 #ac4 ,smith's gag4 #ad4 ,chloroform and inhaler4 ,,excision ,,of ,,tonsils4 #a4 ,long vulsellum4 #b4 ,tonsil guillotines2 or1 probe-pointed bistoury1 the posterior two-thirds of the blade covered with lint or plaster2 or1 tonsil excisors of various kinds4 #c4 ,ice1 ice-cold water4 ,to repress ,hmorrhage from the ,tonsils4 #a4 ,a small lump of ice held in a long vulsellum against the tonsil4 #b4 ,small sponge on the end of a stick1 dipped in ice-cold solution of perchloride of iron1 or other styptic4 #c4 ,long straight polypus or gullet forceps with padded ends1 to compress the tonsil2 one blade being passed within the mouth1 the other outside against the neck4 ,,laryngotomy ,,in ,,the ,,crico-,,thyroid ,,space4 #a4 ,scalpel4 #b4 ,artery forceps and ligature silk4 #c4 ,torsion forceps4 #d4 ,silver tube1 curved on the flat4 #e4 ,tapes4 #f4 ,sharp and blunt hooks4 #g4 ,two hooked forceps4 #h4 ,sponges4 ,,tracheotomy4 #a4 ,scalpel4 #b4 ,dissecting forceps4 #c4 ,blunt hooks for veins4 #d4 ,sharp hook to draw forward trachea4 #e4 ,double silver tube and tapes4 #f4 ,torsion forceps4 #g4 ,artery forceps4 #h4 ,ligatures4 #i4 ,trachea-dilator1 to assist introduction of tube4 #aj4 ,sponges4 #aa4 ,brandy4 #ab4 ,ammonia4 #ac4 ,if a foreign body is lodged in the larynx1 forceps of various kinds to extract with4 #ad4 ,strapping plaister4 #ae4 ,silver suture4 ,,instruments1 c41 ,,for ,,operations ,,about ,,the ,,trunk4 ,,removal ,,of ,,the ,,breast ,,or ,,tumours4 ,n,,vus4 ,,tapping ,,the ,,pleura4 ,,tapping ,,the ,,belly4 ,,colotomy4 ,,ovariotomy4 ,c,,sarian ,,section4 ,,strangulated ,,hernia4 ,,radical ,,cure ,,of ,,hernia4 ,h,,morrhoids4 ,,fistula ,,in ,,ano4 ,,cleft ,,perin,,um4 ,,extirpation ,,of ,,the ,,cervix ,,uteri4 ,,amputation ,,of ,,the ,,penis4 ,,circumcision4 ,,excision ,,of ,,testis4 ,,tapping ,a ,,hydrocele4 ,,vesico-,,vaginal ,,fistula4 ,,retention ,,of ,,urine4 ,,external ,,urethrotomy4 ,,lithotomy4 ,,lithotrity4 ,,removing ,,foreign ,,bodies ,,from ,,the ,,urethra ,,and ,,bladder4 ,,removal ,,of ,,the ,,breast ,,or ,,tumours4 #a4 ,scalpel4 #b4 ,artery forceps4 #c4 ,torsion forceps4 #d4 ,dissecting forceps4 #e4 ,double hook4 #f4 ,blunt hooks4 #g4 ,tenaculum4 #h4 ,fine ligatures4 #i4 ,half-yard of stout whipcord1 for irremovable glands4 #aj4 ,wire or silk sutures4 #aa4 ,lint4 #ab4 ,diachylon plaster4 #ac4 ,sponges4 #ad4 ,scissors4 #ae4 ,three-inch wide rollers4 #af4 ,folded towel compress4 #ag4 ,chloroform and inhaler4 #ah4 ,waterproof sheet4 ,n,,vus4 ,for ,ligature4 #a4 ,nvus needles1 straight and curved4 #b4 ,suture silk1 stout compressed whipcord4 #c4 ,scalpel4 #d4 ,scissors4 #e4 ,lint4 #f4 ,chloroform and inhaler4 #g4 ,sponge and water4 ,for ,cauterising4 #a4 ,acupressure needles4 #b4 ,spirit lamp4 #c4 ,galvanic cautery4 #d4 ,gas cautery4 ,for ,excising4 #a4 ,scalpel4 #b4 ,dissecting forceps4 #c4 ,blunt hooks4 #d4 ,artery forceps4 #e4 ,sharp hooks4 #f4 ,ligature4 #g4 ,lint4 #h4 ,bandage4 #i4 ,sponge4 #aj4 ,sutures4 ,for ,injecting4 #a4 ,subcutaneous injecting syringe4 #b4 ,solution of perchloride of iron4 ,for ,passing ,setons4 #a4 ,small fine suture needles4 #b4 ,fine silk suture4 ,,tapping ,,the ,,pleura4 #a4 ,small scalpel4 #b4 ,trocar1 fitted with india-rubber tube4 #c4 ,bucket4 #d4 ,lint4 #e4 ,collodion4 #f4 ,strapping4 #g4 ,scissors4 #h4 ,brandy4 ,,tapping ,,the ,,belly4 #a4 ,body bandage 7see p4 #aj74 #b4 ,scalpel4 #c4 ,trocar4 #d4 ,suture4 #e4 ,collodion4 #f4 ,scissors4 #g4 ,lint4 #h4 ,bucket4 #i4 ,diachylon plaster4 #aj4 ,brandy4 ,,amussat',s ,,operation ,,of ,,colotomy ,,and ,,gastrotomy4 #a4 ,scalpel4 #b4 ,probe-pointed bistoury4 #c4 ,director4 #d4 ,dissecting forceps4 #e4 ,nvus needle1 threaded with thick whipcord4 #f4 ,silver sutures4 #g4 ,artery forceps4 #h4 ,fine ligatures4 #i4 ,retractors4 #aj4 ,sponges4 #aa4 ,large trocar4 #ab4 ,tow4 #ac4 ,sponges4 #ad4 ,large syringe full of warm water4 #ae4 ,chloroform and inhaler4 ,,ovariotomy4 #a4 ,room raised to temperature of #gj ,f4 #b4 ,scalpel4 #c4 ,clamp4 #d4 ,vulcanised india-rubber tubing1 to fix on cannula4 #e4 ,torsion forceps4 #f4 ,artery forceps and ligatures4 #g4 ,fine ligatures4 #h4 ,broad retractors4 #i4 ,blunt hooks4 #aj4 ,ovariotomy trocar4 #aa4 ,nvus needles1 threaded4 #ab4 ,hare-lip pins4 #ac4 ,wire nippers4 #ad4 ,strong whipcord4 #ae4 ,silk sutures and silver wire4 #af4 ,diachylon plaster4 #ag4 ,catheter for emptying the bladder4 #ah4 ,soft napkins4 #ai4 ,bandage or laced napkin4 #bj4 ,chloroform and inhaler4 #ba4 ,cautery iron4 #bb4 ,silver pins4 #bc4 ,sponges4 ,c,,sarian ,,section4 #a4 ,room maintained at temperature of #gj ,f4 #b4 ,catheter to empty bladder4 #c4 ,large scalpel4 #d4 ,straight probe-pointed bistoury4 #e4 ,director4 #f4 ,large blunt hooks4 #g4 ,large syringe and vaginal tube1 for washing out uterus per vaginam4 #h4 ,artery forceps4 #i4 ,ligatures1 fine and stout whipcord4 #aj4 ,torsion forceps4 #aa4 ,hare-lip pins1 stout and long4 #ab4 ,suture silk4 #ac4 ,fine sutures4 #ad4 ,folded linen compress4 #ae4 ,broad body roller4 #af4 ,flannel4 #ag4 ,cotton wool4 #ah4 ,warm flannels4 #ai4 ,chloroform and inhaler4 ,,strangulated ,,hernia4 #a4 ,scalpel4 #b4 ,straight bistoury4 #c4 ,probe-pointed bistoury4 #d4 ,hernia knife4 #e4 ,narrow director4 #f4 ,broad director4 #g4 ,dissecting forceps4 #h4 ,blunt hooks4 #i4 ,fine hook1 in case the sac is very tense4 #aj4 ,artery forceps4 #aa4 ,torsion forceps4 #ab4 ,ligatures4 #ac4 ,sutures4 #ad4 ,lint4 #ae4 ,diachylon plaster4 #af4 ,three-inch wide roller4 #ag4 ,compress4 #ah4 ,razor4 #ai4 ,sponges4 #bj4 ,half grain of morphia suppository4 #ba4 ,chloroform and inhaler4 #bb4 ,scissors4 ,,wood',s ,,operation ,,for ,,radical ,,cure ,,of ,,hernia4 #a4 ,razor1 or scalpel1 for shaving the groin4 #b4 ,tenotomy knife4 #c4 ,needle4 #d4 ,compressed whipcord1 well waxed and soaped4 #e4 ,glass or box-wood compress4 #f4 ,two pads of lint4 #g4 ,lint4 #h4 ,bandage4 #i4 ,scissors4 #aj4 ,suture4 #aa4 ,collodion4 ,h,,morrhoids4 ,external1--,excision of4 #a4 ,vulsellum1 or hook1 or ringed forceps4 #b4 ,knife-edged scissors curved on the flat4 #c4 ,torsion forceps4 #d4 ,lint and ,t-bandage4 #e4 ,smith's clamp4 #f4 ,cautery iron4 ,internal4 #a4 ,enema of warm water4 #b4 ,hook1 vulsellum1 or ring-forceps4 #c4 ,thin compressed whipcord4 #d4 ,nvus needles threaded1 to transfix the base of the pile4 #e4 ,scissors4 #f4 ,smith's clamp4 #g4 ,ice4 #h4 ,solid perchloride of iron4 #i4 ,lint and cotton wool4 #aj4 ,opium suppository4 ,,prolapsus ,,ani4 ,the same4 ,,fistula ,,in ,,ano4 #a4 ,probes of various sizes1 some grooved4 #b4 ,grooved director4 #c4 ,probe-pointed curved bistoury4 #d4 ,straight sharp-pointed bistoury4 #e4 ,tenaculum4 #f4 ,threaded curved needle set in a handle4 #g4 ,torsion forceps4 #h4 ,artery forceps4 #i4 ,stout ligature4 #aj4 ,cautery iron4 #aa4 ,lint1 cotton wool4 #ab4 ,sponges4 #ac4 ,compress4 #ad4 ,three-inch wide roller4 #ae4 ,oil4 #af4 ,chloroform and inhaler4 ,,cleft ,,perin,,um4 #a4 ,scalpel4 #b4 ,hook forceps4 #c4 ,curved nvus needles1 threaded4 #d4 ,stout whipcord4 #e4 ,suture silk4 #f4 ,wire suture4 #g4 ,glass rods1 or ,no4 #ab bougies4 #h4 ,collodion4 #i4 ,lint4 #aj4 ,sponges on handles4 #aa4 ,oil4 #ab4 ,chloroform and inhaler4 ,,extirpation ,,of ,,the ,,cervix ,,uteri4 #a4 ,two hooked forceps1 or long vulsella4 #b4 ,specula 7bivalve and duckbill74 #c4 ,ecraseur4 #d4 ,two wool holders4 #e4 ,small sponges on sticks4 #f4 ,scalpel4 #g4 ,straight probe-pointed bistoury4 #h4 ,bistoury curved on the flat4 #i4 ,long-handled straight scissors4 #aj4 ,long-handled curved scissors4 #aa4 ,artery forceps4 #ab4 ,ligatures4 #ac4 ,hare-lip pins4 #ad4 ,dentists' silk4 #ae4 ,cautery irons4 #af4 ,perchloride of iron4 #ag4 ,solution of chloride of zinc4 #ah4 ,ice4 #ai4 ,lint 7if plugging necessary1 see pp4 #abg1 #abh74 #bj4 ,compressed sponge in pieces4 #ba4 ,soft silk handkerchief4 #bb4 ,cotton wool4 #bc4 ,suppository4 ,,amputation ,,of ,,the ,,penis4 #a4 ,tape to tie round the root of penis4 #b4 ,straight bistoury4 #c4 ,scalpel4 #d4 ,artery forceps4 #e4 ,torsion forceps4 #f4 ,dissecting forceps4 #g4 ,scissors4 #h4 ,fine ligatures4 #i4 ,fine suture1 to fix the flap of mucous membrane of the urethra4 #aj4 ,flexible catheter4 #aa4 ,lint4 #ab4 ,tape4 #ac4 ,ice4 #ad4 ,chloroform and inhaler4 ,,circumcision4 #a4 ,small straight bistoury4 #b4 ,polypus forceps4 #c4 ,half-inch wide tape4 #d4 ,artery forceps4 #e4 ,fine ligatures4 #f4 ,silk suture4 #g4 ,torsion forceps4 #h4 ,scissors4 #i4 ,lint4 #aj4 ,ice4 #aa4 ,chloroform and inhaler4 ,,excision ,,of ,,testis4 #a4 ,scalpel4 #b4 ,large sharp hook4 #c4 ,blunt hooks4 #d4 ,stout whipcord4 #e4 ,fine ligature4 #f4 ,artery forceps4 #g4 ,sutures1 silk or wire4 #h4 ,scissors4 #i4 ,chloroform and inhaler4 #aj4 ,lint4 ,,tapping ,,and ,,injecting ,a ,,hydrocele4 #a4 ,trocar4 #b4 ,vulcanite syringe1 with nozzle to fit cannula4 #c4 ,tincture of iodine4 #d4 ,suspender for the testicles4 #e4 ,lint4 #f4 ,collodion4 #g4 ,plaister4 ,,vesico-,,vaginal ,,fistula4 #a4 ,duckbill speculum4 #b4 ,scalpels set in long handles1 curved blades4 #c4 ,long-handled curved scissors4 #d4 ,long-handled forceps4 #e4 ,long-handled hooked forceps4 #f4 ,long-handled sharp hook4 #g4 ,narrow curved spatula4 #h4 ,needles to carry silver wire suture4 #i4 ,silver wire4 #aj4 ,probes4 #aa4 ,short curved needles1 to carry fine silk suture4 #ab4 ,needle holder4 #ac4 ,suture tightener4 #ad4 ,lead clamp4 #ae4 ,awl for perforating the clamp4 #af4 ,clamp adjuster4 #ag4 ,split shot4 #ah4 ,forceps for placing and pinching the shot4 #ai4 ,small sponges set on slips of wood4 #bj4 ,large sponges4 #ba4 ,sims' catheter4 #bb4 ,ice-cold water4 #bc4 ,syringe and flexible catheter for injecting the bladder1 to test the perfect closure of the fissure4 #bd4 ,chloroform and inhaler4 #be4 ,oil4 ,,retention ,,of ,,urine4 #a4 ,flexible catheters 7,nos4 #h to 7 7,english and ,french74 #b4 ,finest gum bougies 7,no4 74 #c4 ,silver catheters4 #d4 ,long prostatic catheter4 #e4 ,oil4 #f4 ,glass syringe4 #g4 ,injecting bottle4 #h4 ,tapes and string4 #i4 ,strapping plaister4 #aj4 ,scissors4 #aa4 ,trocar for tapping per rectum4 #ab4 ,tincture of opium4 #ac4 ,morphia suppository4 #ad4 ,chloroform and inhaler4 ,,external ,,urethrotomy4 #a4 ,scalpels4 #b4 ,catheters1 silver4 #c4 ,catheters1 flexible4 #d4 ,four feet of india-rubber tubing to fit catheter4 #e4 ,probes1 straight and grooved1 with flat handles4 #f4 ,syme's shouldered narrow grooved staff4 #g4 ,marshall's long jointed grooved sound1 with flexible catheter sliding on it4 #h4 ,curved director4 #i4 ,lithotomy tapes or anklets4 #aj4 ,tapes4 #aa4 ,sponges4 #ab4 ,tenaculum4 #ac4 ,artery forceps4 #ad4 ,ligatures4 #ae4 ,oil4 #af4 ,ice4 #ag4 ,chloroform and inhaler4 ,,lithotomy4 #a4 ,firm table1 of convenient height4 #b4 ,folded blankets4 #c4 ,mackintosh sheet4 #d4 ,tray of sand1 or saw-dust4 #e4 ,pair of lithotomy tapes1 or anklets4 #f4 ,lint4 #g4 ,sound4 #h4 ,staff4 #i4 ,catheter to fit syringe1 for injecting the bladder4 #aj4 ,lithotomy scalpels4 #aa4 ,forceps4 #ab4 ,scoops4 #ac4 ,searcher4 #ad4 ,bistouri cach4 #ae4 ,syringe1 various nozzles4 #af4 ,gorget4 #ag4 ,tubes1 with and without petticoats4 #ah4 ,lithotrite4 #ai4 ,catheter to fit syringe4 #bj4 ,artery forceps4 #ba4 ,tenaculum4 #bb4 ,ligatures4 #bc4 ,half grain morphia suppository4 #bd4 ,chloroform and inhaler4 #be4 ,oil4 #bf4 ,sponges4 #bg4 ,bandages and tape4 #bh4 ,brandy1 ammonia4 ,,lithotrity4 #a4 ,lithotrites1 fenestrated and flat4 #b4 ,hollow sound1 with short beak4 #c4 ,clover's apparatus for washing out the bladder4 #d4 ,oil4 #e4 ,lithotrite catheters4 #f4 ,urethral forceps4 #g4 ,injecting bottle1 with nozzle to fit the hollow sound4 #h4 ,half grain morphia suppository4 #i4 ,hot linseed poultice4 #aj4 ,firm bolster or pillow4 ,,removing ,,foreign ,,bodies ,,from ,,the ,,urethra ,,and ,,bladder4 #a4 ,catheters1 silver1 gum1 elastic4 #b4 ,sounds of different curves4 #c4 ,bougies olivaires4 #d4 ,urethral forceps with long blades4 #e4 ,fine dressing forceps4 #f4 ,fine polypus forceps4 #g4 ,coxeter's urethral forceps4 #h4 ,urethral lithotrite forceps4 #i4 ,hunter's tube forceps4 #aj4 ,loop of wire set in long handle4 #aa4 ,leroy d',etiolles' jointed scoop4 #ab4 ,leroy's tube1 and sliding hook4 #ac4 ,charrire's hair-pin retractor4 #ad4 ,charrire's bougie retractor4 #ae4 ,three-branched forceps4 #af4 ,endoscope4 #ag4 ,oil4 #ah4 ,glass syringe4 #ai4 ,scalpel4 #bj4 ,dissecting forceps4 #ba4 ,hook4 #bb4 ,artery forceps4 #bc4 ,ligature4 #bd4 ,sutures4 #be4 ,tapes4 #bf4 ,sponges4 #bg4 ,chloroform and inhaler4 ,,instruments ,,for ,,operations ,,on ,,the ,,limbs4 ,,ligature ,,of ,,the ,,larger ,,arteries4 ,,resections1 ,,of ,,the ,,head ,,of ,,the ,,humerus1 ,,elbow1 ,,hip1 ,,and ,,knee4 ,,removal ,,of ,,necrosed ,,bone4 ,,amputations ,,at ,,the ,,shoulder-,,joint1 ,,joint1 ,,arm1 ,,forearm ,,and ,,wrist2 ,,metacarpus1 ,,hip1 ,,thigh ,,and ,,leg2 ,,by ,,syme',s ,,and ,,chopart',s ,,operations2 ,,metatarsus4 ,,ligature ,,of ,,the ,,large ,,arteries4 #a4 ,scalpel4 #b4 ,grooved director4 #c4 ,dissecting forceps4 #d4 ,broad grooved director4 #e4 ,probe4 #f4 ,blunt hooks4 #g4 ,metallic retractors4 #h4 ,aneurism needle4 #i4 ,ditto1 helix curve4 #aj4 ,waxed compressed whipcord4 #aa4 ,artery forceps4 #ab4 ,fine ligatures4 #ac4 ,sutures4 #ad4 ,scissors4 #ae4 ,sponges on sticks4 #af4 ,larger sponges4 #ag4 ,strapping4 #ah4 ,lint4 #ai4 ,bandage4 #bj4 ,chloroform and inhaler4 ,,resection ,,of ,,the ,,shoulder4 #a4 ,scalpels4 #b4 ,saw 7,irish bow-saw74 #c4 ,retractors4 #d4 ,lion's-tooth forceps4 #e4 ,blunt hooks4 #f4 ,artery forceps4 #g4 ,torsion forceps4 #h4 ,tenacula4 #i4 ,acupressure needles4 #aj4 ,linen retractors4 #aa4 ,ligatures4 #ab4 ,sutures4 #ac4 ,key to compress the subclavian artery4 #ad4 ,cautery iron4 #ae4 ,wire nippers4 #af4 ,lint4 #ag4 ,bandages4 #ah4 ,strapping4 #ai4 ,oiled silk4 #bj4 ,sponges4 #ba4 ,mackintosh sheet4 #bb4 ,chloroform and inhaler4 ,,resection ,,of ,,the ,,elbow4 #a4 ,straight bistoury4 #b4 ,retractors4 #c4 ,blunt hooks4 #d4 ,bow-saw4 #e4 ,probes4 #f4 ,gouges4 #g4 ,torsion forceps4 #h4 ,artery forceps4 #i4 ,lion's-tooth forceps4 #aj4 ,bone forceps4 #aa4 ,ligatures4 #ab4 ,sutures4 #ac4 ,lint4 #ad4 ,oiled silk4 #ae4 ,bandages4 #af4 ,strapping4 #ag4 ,sponges4 #ah4 ,mackintosh sheet4 #ai4 ,angular splint to support the arm4 #bj4 ,chloroform and inhaler4 ,,resection ,,of ,,the ,,upper ,,end ,,of ,,the ,,femur4 #a4 ,strong bistoury4 #b4 ,probe-pointed bistoury4 #c4 ,long probes4 #d4 ,bow-saw4 #e4 ,retractor4 #f4 ,blunt hooks4 #g4 ,narrow linen retractor4 #h4 ,gouges and chisels4 #i4 ,bone forceps4 #aj4 ,artery forceps4 #aa4 ,torsion forceps4 #ab4 ,tenaculum4 #ac4 ,ligatures4 #ad4 ,sutures4 #ae4 ,bandages4 #af4 ,lint4 #ag4 ,sponges4 #ah4 ,straight bracketed long splint and pads4 #ai4 ,chloroform and inhaler4 #bj4 ,mackintosh sheet4 ,,resection ,,of ,,the ,,knee4 #a4 ,straight bistoury4 #b4 ,scalpels4 #c4 ,metallic retractors4 #d4 ,bow-saw4 #e4 ,gouge4 #f4 ,chisel4 #g4 ,artery forceps4 #h4 ,torsion forceps4 #i4 ,acupressure needle4 #aj4 ,tenaculum4 #aa4 ,ligatures4 #ab4 ,sutures4 #ac4 ,tourniquet4 #ad4 ,sponges4 #ae4 ,lint4 #af4 ,bandages4 #ag4 ,oiled silk4 #ah4 ,mc,intyre's splint and pads4 #ai4 ,chloroform and inhaler4 #bj4 ,mackintosh sheet4 ,,removing ,,necrosed ,,bone4 #a4 ,scalpels4 #b4 ,straight and curved bistouries1 with sharp and probe points4 #c4 ,long and short probes4 #d4 ,directors4 #e4 ,retractors4 #f4 ,gouges4 #g4 ,chisels4 #h4 ,bone forceps 7various74 #i4 ,gouge forceps4 #aj4 ,sequestrum forceps4 #aa4 ,lion's-tooth forceps4 #ab4 ,osteotrites4 #ac4 ,artery forceps4 #ad4 ,tenaculum4 #ae4 ,torsion forceps4 #af4 ,acupressure needles4 #ag4 ,ligatures4 #ah4 ,sutures4 #ai4 ,lint4 #bj4 ,bandages4 #ba4 ,oiled silk4 #bb4 ,mackintosh sheet4 #bc4 ,chloroform and inhaler4 ,,amputation ,,at ,,the ,,shoulder ,,joint4 #a4 ,tourniquet4 #b4 ,long amputating knife4 #c4 ,artery forceps4 #d4 ,fine ligatures1 stout ligatures4 #e4 ,tenaculum4 #f4 ,acupressure needles4 #g4 ,needle nippers4 #h4 ,key to compress subclavian artery4 #i4 ,sutures4 #aj4 ,strapping cut into strips4 #aa4 ,bandages4 #ab4 ,lint4 #ac4 ,oiled silk4 #ad4 ,sponges4 #ae4 ,cautery irons4 #af4 ,ice4 #ag4 ,mackintosh sheet4 #ah4 ,chloroform and inhaler4 ,,amputation ,,of ,,the ,,arm4 #a4 ,tourniquet4 #b4 ,amputating knife4 #c4 ,saw4 #d4 ,artery forceps4 #e4 ,torsion forceps4 #f4 ,ligatures4 #g4 ,sutures4 #h4 ,tenaculum4 #i4 ,acupressure needles4 #aj4 ,wire nippers4 #aa4 ,strapping4 #ab4 ,lint4 #ac4 ,bandages4 #ad4 ,wadding4 #ae4 ,straight splints4 #af4 ,sponges4 #ag4 ,mackintosh sheet4 #ah4 ,chloroform and inhaler4 ,if a circular amputation-- #ai4 ,split linen retractor2 and #bj4 ,round-pointed straight-edged knife4 ,,amputation ,,of ,,the ,,forearm ,,and ,,wrist4 #a4 ,tourniquet4 #b4 ,large bistoury1 or small amputating knife4 #c4 ,torsion forceps1 artery forceps1 and ligature thread4 #d4 ,artery forceps4 #e4 ,saw4 #f4 ,acupressure needles4 #g4 ,needle nippers4 #h4 ,tenaculum4 #i4 ,fine ligatures4 #aj4 ,sutures4 #aa4 ,lint4 #ab4 ,wool4 #ac4 ,splints4 #ad4 ,bandages4 #ae4 ,oiled silk4 #af4 ,sponges4 #ag4 ,mackintosh sheet4 #ah4 ,chloroform and inhaler4 ,,amputation ,,of ,,metacarpal ,,bones ,,and ,,phalanges4 #a4 ,narrow-bladed bistoury4 #b4 ,bone forceps4 #c4 ,torsion forceps4 #d4 ,artery forceps4 #e4 ,fine ligatures4 #f4 ,small suture4 #g4 ,strapping4 #h4 ,narrow bandage4 #i4 ,wadding4 #aj4 ,splint to support the arm and hand4 #aa4 ,bandage4 #ab4 ,lint4 #ac4 ,oiled silk4 #ad4 ,mackintosh sheet4 #ae4 ,sponges4 #af4 ,tourniquet4 #ag4 ,chloroform and inhaler4 ,,amputation ,,at ,,the ,,hip ,,joint4 #a4 ,lister's aorta compressor4 #b4 ,long hip knife4 #c4 ,artery forceps4 #d4 ,stout and fine ligatures4 #e4 ,torsion forceps4 #f4 ,tenaculum4 #g4 ,acupressure needles4 #h4 ,needle nippers4 #i4 ,silk and silver sutures4 #aj4 ,lint4 #aa4 ,strapping plaister4 #ab4 ,sponges4 #ac4 ,bandages4 #ad4 ,ice4 #ae4 ,a bone-holder1 or lion's-tooth forceps1 if the fragment of the bone is too short to grasp in the hand4 #af4 ,chloroform and inhaler4 #ag4 ,mackintosh sheet4 7,see also the ,list for the ,operating ,room74 ,,amputation ,,of ,,the ,,thigh ,,and ,,leg4 #a4 ,tourniquet4 #b4 ,amputating knife4 #c4 ,scalpel4 #d4 ,bone forceps4 #e4 ,saw4 #f4 ,torsion forceps4 #g4 ,artery forceps4 #h4 ,stout and fine ligatures4 #i4 ,sutures4 #aj4 ,tenaculum4 #aa4 ,strapping4 #ab4 ,hare-lip pins4 #ac4 ,wire nippers4 #ad4 ,lint4 #ae4 ,bandages4 #af4 ,oiled silk4 #ag4 ,cautery iron4 #ah4 ,ice4 #ai4 ,sponges4 #bj4 ,mackintosh sheet4 ,in a circular amputation-- #ba4 ,a round-pointed knife1 and a linen retractor split into two tongues for the thigh and three for the leg1 the centre one being well waxed4 ,,amputation ,,at ,,the ,,ankle ,,and ,,foot4 7,syme's and ,chopart's ,operations47 #a4 ,tourniquet4 #b4 ,strong bistoury4 #c4 ,strong scalpel 7,syme's74 #d4 ,saw4 #e4 ,bone forceps4 #f4 ,artery forceps4 #g4 ,torsion forceps4 #h4 ,tenaculum4 #i4 ,acupressure needles4 #aj4 ,wire nippers4 #aa4 ,strapping4 #ab4 ,sutures4 #ac4 ,lint4 #ad4 ,bandages4 #ae4 ,oiled silk4 #af4 ,wool4 #ag4 ,sponges4 #ah4 ,chloroform and inhaler4 #ai4 ,mackintosh sheet4 ,,amputation ,,of ,,the ,,metatarsal ,,bones ,,and ,,toes4 #a4 ,tourniquet4 #b4 ,straight bistoury4 #c4 ,tenaculum4 #d4 ,torsion forceps4 #e4 ,acupressure needles4 #f4 ,needle nippers4 #g4 ,artery forceps4 #h4 ,ligatures4 #i4 ,sutures4 #aj4 ,lion's-tooth1 or sequestrum forceps4 #aa4 ,strapping4 #ab4 ,lint and wool4 #ac4 ,bandages4 #ad4 ,narrow saw4 #ae4 ,bone forceps4 #af4 ,mackintosh sheet4 #ag4 ,chloroform and inhaler4 ,,index4 ,a4 ,abdominal support1 #afe4 ---- tourniquet1 #adi4 ,acromion1 fracture of1 #ef4 ,administering chloroform1 #agi4 ,air-bath1 the hot1 #aed4 ,amputations1 #bac4 ---- ankle1 #bae4 ---- arm1 #bac4 ---- forearm1 #bad4 ---- hip1 #bad4 ---- leg1 #bae4 ---- metacarpal bones1 #bad4 ---- metatarsal bones1 #bae4 ---- penis1 #bjh4 ---- phalanges1 #bad4 ---- shoulder1 #bac4 ---- thigh1 #bae4 ,angular splint1 #dh4 ---- union1 #gf4 ,ankle1 strapping the1 #bg4 ,apparatus for dislocation at the hip1 #ajd4 ,arch1 palmar1 wound of1 #ag4 ,arm1 bandage for1 #af4 ,arrest of hmorrhage1 #aig4 ,artificial respiration1 #ahc4 ,ascites1 bandage for1 #aj4 ,b4 ,bandages1 #a4 ---- arm1 #af4 ---- belly1 #aj4 ---- bleeding jugular vein1 #g4 ---- breast1 #h4 ---- elbow1 #af4 ---- fingers1 #ad4 ---- foot1 #ba4 ---- groin1 #i4 ---- hand1 #ae4 ---- head1 #c4 ---- heel1 #ba4 ---- hernia1 #aj4 ---- knee1 #bb4 ---- leg1 #ba4 ---- many-tail1 #bc4 ---- plaster of paris1 #he4 ---- scultetus1 #bc4 ---- shoulder1 #af1 #ee4 ---- spica1 #i1 #aj1 #ad1 #af1 #ee4 ---- starch1 #hj4 ---- stump1 #bb4 ---- thumb1 #ad4 ---- toe1 #ba4 ,band-box cradle1 #ha4 ,bath1 the hot air1 #aed4 ---- the vapour1 #aee4 ,bed1 the floating1 #ada4 ---- the sick1 #aif4 ,bedsores1 #adj4 ---- ring of felt for1 #adj4 ---- ,brown ,sequard's treatment1 #adj4 ,belloc's sound1 #aba4 ,belly1 bandage for1 #aj4 ---- tapping the1 #bjd4 ,bicuspid tooth1 drawing a1 #abd4 ,bladder1 ice1 #g4 ---- washing out the1 #acg4 ,blanket pad for axilla1 #ec4 ,bleeding1 cupping1 #aeh4 ---- at elbow1 #ah4 ---- jugular vein1 #g4 ---- leech bites1 #afj4 ---- palmar arch1 #ag4 ---- socket of tooth1 #abf4 ---- staff1 #ai4 ---- tape1 #ai4 ,blisters1 #agj4 ,block for ,mc,intyre's splint1 #fe4 ,blood1 transfusion of1 #add4 ,both bones of forearm1 fracture of1 #dc4 ,bougies1 #acj4 ---- filiformes1 #acd4 ---- olive-headed1 #acj4 ,bread poultice1 #aga4 ,breast1 bandaging the1 #h4 ---- removing the1 #bjc4 ---- strapping the1 #be4 ,broken rib1 #cf4 ---- finger1 #ci4 ,bruce's cautery1 #aff4 ,bulbous ended catheter1 #acj1 #ace4 ,c4 ,csarian section1 #bje4 ,calcaneum1 separation of the epiphysis of1 #fj4 ,calomel fumigation1 #aec4 ,cambric rollers1 #a4 ,canine tooth1 drawing a1 #abc4 ,cantharides1 #agj4 ,cap for shoulder1 #ed4 ,capelline bandage1 #e4 ,carbolic acid dressing1 #agb4 ,carriage1 the sick1 #aee4 ,carte's tourniquet1 #adi4 ,cash's bandages1 #a4 ,casting in plaster of paris1 #aad4 ,cataract1 #aii4 ,catheters1 #abi4 ---- flexible1 #abi4 ---- passing1 #acb4 ---- ---- in the female1 #acf4 ---- silver1 #abi4 ---- tying in1 #ach4 ---- vulcanised india-rubber1 #acj1 #acf4 ,caustics1 #afh4 ,cauteries1 #aff4 ,cautery irons1 #aff4 ---- ,clover's1 #afh4 ---- galvanic1 #afh4 ---- gas1 #aff4 ,cervix uteri1 extirpation of1 #bjg4 ,chalk and gum1 #hi4 ,chassaignac's drainage tubes1 #afa4 ,chloride of zinc1 #afi4 ,chloroform1 #agi4 ---- in dislocations1 #ie4 ---- to the uterus1 #ahg4 ---- dangers of1 #ahj4 ,chromic acid1 #afi4 ,circumcision1 #bjh4 ,clavicle1 dislocation of1 #if4 ---- fracture of the1 #ef4 ,cleft palate1 #bja4 ---- perinum1 #bjg4 ,clove hitch1 the1 #ii4 ,clover's cautery1 #afh4 ---- inhaler1 #aha4 ,club foot1 #aac4 ,cold injection1 #aah4 ,collar bone1 fracture of1 #ef4 ---- ring pad for1 #ei4 ---- figure of #h for1 #ei4 ---- dislocation of1 #if4 ,colles' fracture1 #ci4 ,collodion1 #ahi4 ,colotomy1 #bje4 ,common rollers with plaster of paris1 #hh4 ,compound fracture1 openings in splints for1 #hg4 ,compress1 graduated1 #ag4 ---- for bleeding jugular vein1 #g4 ,conformation of urethra1 #acb4 ,continuous extension1 #gh1 #hj4 ,corrigan's hammer1 #afi4 ,counter extension1 #ie4 ,coxeter's elastic perineal band1 #ge4 ,cradles1 #ij4 ---- ,salter's1 #fd4 ---- of band box1 #ij4 ,cupping1 bleeding1 #aeh4 ---- dry1 #aef4 ,cushions1 water1 #adb4 ,d4 ,delirious patients1 manacles for1 #ab4 ,diathesis1 the hmorrhagic1 #abf4 ,difficulties in passing catheters1 #acc4 ,disjunction of articular surfaces1 #dg4 ,dislocations1 #ie4 ---- clavicle1 #if4 ---- elbow1 #aja4 ---- ---- distinction from fracture1 #dg4 ---- fingers1 #ajc4 ---- foot1 #aaj4 ---- hip1 #ajd4 ---- ---- reduction by manipulation1 #ajg4 ---- knee1 #aji4 ---- lower jaw1 #ie4 ---- patella1 #aaj4 ---- shoulder1 #ig4 ---- thumb1 #ajc4 ,domett's flannel roller1 #aab4 ,double inclines1 #gg4 ---- slung1 #gh4 ,drainage tubes1 #afa4 ,drawing teeth1 #abb4 ,drops for eye1 #aag4 ,dry cupping1 #aef4 ---- heat1 #agb4 ,drying starch bandages1 #hd4 ,dupuytren's splint1 #fa4 ,e4 ,ears1 syringing the1 #aag4 ,eight1 figure of1 #c4 ,eighteen-tail bandage1 #bc4 ,elastic extension1 #ge4 ---- perineal band1 #ge4 ---- socks1 #bd4 ---- stirrup1 #ge4 ,elbow1 bandaging the1 #af4 ---- dislocation at1 #aja4 ---- fracture near1 #dg4 ---- resecting the1 #bab4 ,elevator1 #abe4 ,emplastrum lytt1 #agj4 ,epiphysis of ,os ,calcis1 separation of the1 #fj4 ,epispastique1 pte1 #agj4 ,epistaxis1 #aah4 ,equinus1 talipes1 #aac4 ,esmarch's irrigator1 #agi4 ,essentials of a truss1 #afb4 ,ether spray1 #ahf4 ,extension in fractures1 #ge1 #gf1 #gh4 ---- in hip disease1 #hj4 ---- simple1 in dislocations1 #ii4 ---- in the long splint1 #ge4 ---- by weight and pully1 #gi4 ,external splint for broken jaw1 #cb4 ,eye douche1 #aaf4 ---- drops1 #aag4 ---- operations on the1 #aih4 ,f4 ,feeding by the stomach pump1 #add4 ,female1 passing a catheter in the1 #acf4 ,femur1 fracture of1 #gb4 ---- resecting the1 #bab4 ,fibula1 fracture of1 #fj4 ,figure of #h turn1 #c4 ---- bandage1 #ei4 ,fingers1 bandaging1 #ad4 ---- dislocation of1 #ajc4 ---- splint for1 #ci4 ,fistula in ano1 #bjg4 ,flannel rollers1 #a4 ---- ---- for plaster of paris1 #hf4 ,flexible catheters1 #acj4 ,floating bed1 #ada4 ,fomentations1 #agb4 ,foot1 bandaging the1 #ba4 ---- dislocation of the1 #aaj4 ,forceps1 tooth1 #abb4 ---- ---- bicuspid1 #abc1 #abd4 ---- ---- incisor1 #abc4 ---- ---- molar1 #abd4 ,forearm1 bandaging the1 #ae4 ---- dislocation of1 #aja4 ---- fracture of1 #dc4 ,four-tail bandage1 #f4 ,fractures1 #cj4 ---- acromion1 #ef4 ---- at ankle1 #fa4 ---- clavicle1 #ef4 ---- ,colles'1 #ci4 ---- elbow1 #dg4 ---- femur1 shaft of1 #gb4 ---- fibula1 #fj4 ---- forearm1 #dc4 ---- humerus1 neck of1 #ec4 ---- ---- shaft of1 #ea4 ---- ---- lower end of1 #dg4 ---- ---- great tuberosity of1 #ef4 ---- jaw1 #cj4 ---- metacarpal bones1 #cg4 ---- olecranon1 #de4 ---- os calcis1 #fj4 ---- patella1 #fg4 ---- pelvis1 #cg4 ---- phalanges1 #ci4 ---- radius1 #ci1 #dd4 ---- rib1 #cf4 ---- tibia1 #fa4 ---- transverse ditto1 #ff4 ---- ulna1 #dc4 ,french bulbous ended catheters1 #acj4 ,fumigation1 #aea4 ---- general1 #aeb4 ---- local1 #aed4 ,g4 ,gag1 for stomach-pump1 #adc4 ,galvanic cautery1 #afh4 ,gas cautery1 #aff4 ,gauntlet for fractured radius1 #db4 ,gauze1 wire1 #dh4 ,general rules1 #a4 ,glove for metacarpal bones1 #ch4 ,glue1 #hi4 ,graduated compress1 #ag4 ,groin1 spica for1 #i4 ,gum and chalk1 #hi4 ,gums1 leeches to1 #aei4 ,gutta-percha1 #cj1 #ch1 #db1 #di1 #ed1 #gj1 #gg1 #id4 ,h4 ,hmorrhage1 arrest of1 #aig4 ---- from the tonsils1 #bja4 ,hmorrhagic diathesis1 #abf4 ,hmorrhoids1 #bjf4 ,hair suture1 #aaf4 ,hammer1 ,corrigan's1 #afi4 ,hand1 bandaging the1 #ad4 ,handle for extending the thumb1 #ajc4 ,hare-lip1 #aii4 ,head bandage1 #c4 ---- ice bladder for1 #g4 ,heat1 dry1 #agb4 ,heel1 to bandage the1 #ba4 ,hernia1 #afb4 ---- spica1 #i4 ---- trusses for1 #afa4 ,hewitt's transfusion apparatus1 #ade4 ,hides' leather felt1 #hi4 ,hip-disease1 extension in1 #gi4 ---- dislocation1 #ajd4 ---- splint1 #ib4 ,hitch1 the clove1 #ii4 ,hooks1 ,malgaigne's1 #ga4 ,horizontal position in fractured clavicle1 #eg4 ,horse heel1 #aac4 ,horseshoe tourniquet1 #adh4 ,hot air bath1 #aed4 ---- fomentations1 #agb4 ---- water cushions1 #agb4 ,how to hold a roller1 #b4 ,humerus1 fractures at lower end of1 #dg4 ---- great tuberosity1 #ef4 ---- neck of1 #ec4 ---- shaft of1 #ea4 ,hydrocele1 tapping a1 #bjh4 ,i4 ,ice bladders on head1 #g4 ---- cold injections1 #aah4 ,improvised tourniquet1 #aea4 ,incisor tooth1 to draw1 #abc4 ,incline1 double1 #gg4 ---- ---- slung1 #gh4 ,injecting bottle1 #acg4 ---- syringe1 #aag4 ---- chloroform to the uterus1 #ahg4 ---- the urethra1 #abh4 ,injection1 subcutaneous1 #ahg4 ,interdental splints1 #cc4 ,intracapsular fracture of neck of femur1 #gg4 ,iodine blisters1 #agj4 ,iridectomy1 #aii4 ,irons1 cautery1 #aff4 ,irreducible hernia1 #afc4 ,irrigation1 #agg4 ,irrigator1 ,esmarch's1 #agi4 ,irritants1 #afh4 ,issues1 #afa4 ---- pea1 #afa4 ,j4 ,jacket1 strait1 #aa4 ,jaw1 fracture of1 #cj4 ---- resection of1 #bjj4 ,joints1 strapping1 #bg4 ---- to be included in starch and plaster of paris1 #ha1 #hg4 ,jugular vein1 bandage for1 #g4 ,k4 ,kite's tail plug1 #abh4 ,knee1 bandage for1 #bb4 ---- resecting the1 #bab4 ,knee-pan1 fracture of1 #fg4 ,knotted bandage1 #d4 ,l4 ,l-shaped splint for arm1 #di4 ,lamp for air bath1 #aed4 ,laryngotomy1 #bja4 ,lateral splints for the tibia1 #ff4 ,lavalle's 7,morel7 splints1 #cc4 ,leather felt1 ,hides'1 #hi4 ---- splints1 #ij4 ---- ---- for hip1 #ib4 ,leeches1 #aei4 ---- to make them bite1 #aei4 ---- to stop the bites1 #afj4 ---- in the mouth1 #aei4 ---- at the cervix uteri1 #aei4 ,leg1 bandage for1 #ba4 ,ligature of arteries1 #baa4 ,linseed poultice1 #aga4 ,lister's dressing1 #agb4 ---- tourniquet1 #adi4 ,liston's long splint1 #gb4 ,lithotomy1 #baj4 ---- position1 #adj4 ,lithotrity1 #baj4 ,local ansthesia1 #ahf4 ,long splint1 #gb4 ,lower jaw1 fracture of1 #cj4 ,m4 ,mc,intyre's splint1 #fc4 ,makeshift tourniquet1 #aea4 ,malgaigne's hooks1 #ga4 ,manacles for delirious patients1 #ab4 ,manipulation in dislocations1 #ajg4 ,many-tail bandage1 #bc4 ,marshall ,hall's method1 #ahc4 ,materials for rollers1 #a4 ,mayor's double incline1 #gh4 ,mercurial fumigation1 #aeb4 ---- ointment1 #bh4 ,metacarpal bones1 fracture of1 #cg4 ,millboard for splints1 #hj4 ,mixing plaster1 #aae4 ,molar forceps1 #abd4 ---- teeth1 #abd4 ,morel ,lavalle's splints1 #cc4 ,muslin rollers for plaster of paris1 #he4 ,mustard poultices1 #afi4 ,n4 ,nvus1 operating on1 #bjc4 ,nares1 plugging the1 #aai4 ,neck of humerus1 fracture of1 #ec4 ,necrosed bone1 removing1 #bac4 ,nipple shields1 #abf4 ---- artificial1 #abf4 ,nitrate of silver1 #afh4 ---- of mercury1 #afi4 ,nitric acid1 fuming1 #afi4 ,o4 ,olecranon1 fracture of1 #de4 ---- ---- ,hamilton's splint for1 #dg4 ,operating room1 the1 #aie4 ,operator's position1 #b4 ,ordinary bandages1 #a4 ,os uteri1 leeches to1 #aei4 ,outside splint for fractured jaw1 #cb4 ,ovariotomy1 #bje4 ---- cautery1 #afg4 ,p4 ,palmar arch1 wound of1 #ag4 ,paraffine1 #hi4 ,paris1 bandages of plaster of1 #he4 ---- plaster of1 casting in1 #aad4 ---- ---- splints of1 #hh4 ,passing catheters1 #acb4 ---- ---- difficulties1 #acc4 ,pasteboard splints1 #hj4 ,pte epispastique1 #agj4 ,patella1 dislocation of the1 #aaj4 ---- fracture of the1 #fg4 ---- ---- ,samborne's plan1 #gj4 ---- back splint for1 #fi4 ,pelvis1 fracture of the1 #cg4 ,penis1 amputation of1 #bjh4 ,perineal band1 #gc4 ,petit's tourniquet1 #adg4 ,phalanges1 broken1 #ci4 ,pistol splint1 #dj4 ,pleura1 tapping the1 #bjd4 ,plugging nares1 #aai4 ---- vagina1 #abg4 ,points for vaccine1 #aij4 ,poisons1 stomach pump in1 #adc4 ,position of bandager1 #a4 ---- for lithotomy1 #adj4 ,potassa fusa1 #afi4 ,poultice1 #agj4 ---- bread1 #aga4 ---- linseed1 #aga4 ---- mustard1 #afi4 ---- starch1 #agb4 ,prolapsus ani1 #bjg4 ,pubes1 dislocation on1 #ajh4 ,pulley1 extension by weight1 #hj4 ,pulleys1 for dislocation1 #ajd4 ,pulverised fluids1 #ahf4 ,pump1 the stomach1 #adc4 ,r4 ,radius1 fracture of1 #ci4 ---- near the head1 #dd4 ---- dislocation of1 #ajb4 ,removing a starch bandage1 #hd4 ---- a plaster of paris bandage1 #hh4 ---- foreign bodies from urethra1 #baj4 ,respiration1 artificial1 #ahc4 ,restoratives1 #aig4 ,reverse turn1 #b4 ,rib1 broken1 #cf4 ---- roller for1 #cg4 ---- strapping1 #cf4 ,richardson's spray producer1 #ahf4 ,ring pad1 #ei4 ---- tourniquet1 #adg4 ,rollers1 how to hold1 #b4 ---- varieties of1 #a4 ---- muslin1 for plaster of paris1 #he4 ,rules1 general1 #a4 ,ruptured tendo achillis1 #ei4 ,ruptures1 #afb4 ---- operation for1 #bjf4 ,s4 ,salter's cradle1 #fd4 ,sand bags1 #ij4 ,scarificator1 #aeg4 ,scarpa's shoes1 #aaa4 ,scott's bandage1 #bh4 ,scultetus1 bandage of1 #bc4 ,sedatives1 #aig4 ,separation of epiphysis of the os calcis1 #fj4 ---- of lower end of humerus1 #dg4 ,setons1 #afj4 ,shaft of humerus1 #ea4 ,shawl cap1 #f4 ,shoes1 ,scarpa's1 #aaa4 ,shot-bag weight1 #hj4 ,shoulder1 bandage for1 #af1 #ee4 ---- cap1 #ed4 ---- dislocation at1 #ig4 ---- dislocation at1 simple extension in1 #ajj4 ---- fracture of1 #ec-ef4 ---- resecting the1 #baa4 ,sick carriage1 #aee4 ---- room and bed1 #aif4 ,signoroni's tourniquet1 #adh4 ,silicate of soda1 #hi4 ,silver catheters1 #abi1 #acb4 ---- ---- tying in1 #ach4 ---- nitrate of1 #afh4 ,silvester's method1 #ahd4 ,skull1 trephining the1 #aih4 ,sling for fracture1 #eb1 #fd4 ,slinging a starch bandage1 #he4 ,slung double incline1 #gh4 ,sock1 elastic1 #bd4 ,socket1 a bleeding1 #abf4 ,sore nipples1 #abf4 ,sores1 bed1 #adj4 ,sounds1 #acj4 ,sound1 ,belloc's1 #aba4 ,spica for groin1 #i4 ---- for hernia1 #aj4 ---- shoulder1 #af1 #ee4 ---- for thumb1 #ad4 ,spiral turn1 #b4 ,splay foot1 #aad4 ,splint1 the long1 #gb4 ---- the hip1 #ib4 ,spray producer1 #ahf4 ,starch bandage1 #hj4 ---- ---- after long splint1 #gf4 ---- ---- splints for1 #hb4 ---- ---- time of applying1 #ha4 ---- poultice1 #agb4 ---- rollers1 #hb4 ,stirrup extension1 #gf4 ,stockings1 elastic1 #bd4 ,stocking-webbing rollers1 #a4 ,stomach pump1 the1 #adb4 ,strait jacket1 #aa4 ,strangulated hernia1 #bjf4 ,strapping1 #be4 ---- ankle1 #bg4 ---- the breast1 #be4 ---- joints1 #bg4 ---- ---- with mercurial ointment1 #bh4 ---- plasters1 #be4 ---- ribs1 #cf4 ---- testes1 #bf4 ---- ulcers1 #bg4 ,strictures of the urethra1 #acd4 ,stump1 bandaging a1 #bb4 ---- extending1 #bc4 ,stumps1 extracting1 #abe4 ,subcutaneous injection1 #ahg4 ,supporting interdental splints1 #ce4 ,suspending the testes1 #ab4 ,swete's carriage1 #aee4 ,syringing the ears1 #aag4 ,t4 ,t-bandage1 #aa4 ,taking off a starch bandage1 #hd4 ---- a plaster of paris bandage1 #hh4 ,talipes1 #aac4 ---- equinus1 #aac4 ---- valgus1 #aad4 ---- varus1 #aac4 ,tape for bleeding1 #ah4 ,tapping1 bandage for1 #aj4 ,tendo achillis1 ruptured1 #ei4 ,tents1 #afj4 ,testes1 excising1 #bjh4 ---- strapping1 #bf4 ---- suspending1 #ab4 ,testing a truss1 #afb4 ,thumb1 bandage for1 #ad4 ---- dislocation of1 #ajc4 ,tibia1 fractures of1 #fa-fg4 ,toe1 bandaging a1 #bb4 ,tongue1 excision of1 #bjj4 ,tonsils1 excision of1 #bja4 ---- bleeding1 #bja4 ,tooth drawing1 #abb4 ---- bicuspid1 #abd4 ---- canine1 #abc4 ---- incisor1 #abc4 ---- molar1 #abd4 ---- forceps1 #abb4 ,tourniquets1 #adg4 ---- abdominal1 #adi4 ---- ,carte's1 #adi4 ---- horseshoe1 #adh4 ---- makeshift1 #aea4 ---- ,petit's1 #adh4 ---- ring1 #adg4 ---- ,signoroni's1 #adh4 ,tracheotomy1 #bjb4 ,transfusion of blood1 #add4 ,transporting the sick1 #aee4 ,transverse fracture of the tibia1 #ff4 ,trunk1 bandaging the1 #h4 ,trusses1 #afa4 ---- femoral1 #afc4 ---- inguinal1 #afc4 ---- measuring for1 #afd4 ---- ,salmon ,ody's1 #afe4 ---- umbilical1 #afe4 ,tubes1 drainage1 #afa4 ,turns1 different1 #b4 ,tying for lithotomy1 #adj4 ---- in a flexible catheter1 #aci4 ---- in a silver catheter1 #ach4 ,u4 ,ulcers1 strapping1 #bg4 ,ulna1 fracture of1 #dc4 ,umbilical hernia1 #afe4 ,union1 angular1 #gf4 ,urethra1 conformation of1 #acb4 ---- injecting the1 #abh4 ,urethral syringe1 #abh4 ,urethrotomy1 #bji4 ,urine1 retention of1 #bji4 ,v4 ,vaccination1 #aij4 ,vagina1 plugging the1 #abg4 ,valgus1 #aad4 ,vapour bath1 the1 #aee4 ,varieties of turns1 #b4 ---- of splints for the elbow1 #dh4 ,varus1 #aac4 ,venesection1 #ah4 ,vesicants1 #afi4 ,vesicle in vaccination1 #aia4 ,vesico-vaginal fistula1 #bji4 ,vienna paste1 #afi4 ,vitriol1 oil of1 #afi4 ,vulcanised india-rubber catheter1 #acj1 #acf4 ,vulcanite splint for jaw1 #cd4 ,w4 ,waistcoat1 strait1 #aa4 ,washing out the bladder1 #acg4 ,water-bed1 #ada4 ---- can weight1 #hj4 ---- cushion1 #adb4 ,wedge-pad for fractured clavicle1 #eg4 ,weight for pulley1 #hj4 ,wire gauze splints1 #dh4 ,wood's operation for hernia1 #bjf4 ,wool1 cotton1 #ad4 ,wound of palmar arch1 #ag4 ---- opening in splint for1 #hg4 ,z4 ,zinc1 chloride of1 #afi4 ,,the ,,end4 ,,bradbury1 ,,evans1 ,,and ,,co41 ,,printers1 ,,whitefriars4