Berkeley Hill

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

“ The surgeon places a graduated bleeding dish on a chair or stool within his reach, and a pledget of lint in his waistcoat pocket; he next gives the patient a heavy book, or staff to grasp in his hand. The arm being bare to the shoulder, a tape, 3⁄4 inch broad and 11⁄4 yard long, is tied round the arm tight enough to impede the venous, but not the arterial flow.
The surgeon standing opposite his patient and grasping the arm to be bled with his left hand, so that his thumb controls and steadies the swollen vein, takes his lancet between the right forefinger and thumb ”

“ In ordinary cases the limb is kept on the splint three weeks, until the irritation has subsided, and partial union is attained; the splint may then be replaced by a starch bandage, and the patient may leave his bed.
Transverse Fracture of the tibia alone, or even of both bones, when the displacement is small, is very well treated by a hollow splint on each side. Both splints are cut away opposite the malleoli, and the foot-piece of the inside one should not extend beyond the tarsus; that of the outside passes to the toes. ”

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

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

“ This protects the skin from the rough edge of the plaster splint when the apparatus is set and hard. Indeed, if the whole [Pg 87] of the surface to be covered with plaster be enveloped in a flannel roller, the apparatus is more comfortable to the patient, and in this case the grease may be dispensed with. When the limb is prepared the surgeon intrusts it to assistants, who will maintain reduction while he lays on the plaster rollers, wetting them freely as they are laid on, with a sponge at hand in a basin of cold water. Usually two layers of roller give sufficient rigidity to the apparatus ”

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

“ Fracture of the Great Tuberosity of the humerus is difficult to treat, on account of the tuberosity being carried backwards by the muscles and the humerus being rotated forwards. Hence the parts must be braced together with a firm cap of gutta-percha moulded on to the shoulder while soft, and while the fractured parts are held in apposition, which may be done by the fingers, or by putting on a wet roller firmly over the shoulder as a spica before the splint is set. When the splint is hard the bandage may be taken off, and the splint removed and finished ready for application. ”

“ When the leather is softened, a very thin even layer of cotton wadding or of lint is laid on next the skin; the splint is then moulded to the limb with the hands, and bandaged firmly; in twelve hours it will be dry and rigid. The roller is then unwound, and any parts of the splint pressing on bony projections are marked before removal. It is then trimmed, and laid between two layers of wash-leather stitched together round the edges. The splint is now finished, and can be either fastened on by a roller or by two or more straps and buckles stitched to it. ”

“ An assistant grasping the elbow in one hand, pulls down the lower fragment, while he steadies the shoulder with the other. The displacement thus reduced, the surgeon applies the splints, taking care that the inside splint does not reach too high into the axilla, lest it compress the axillary vein.
In simple cases, the splints should be drawn close by straps and buckles; where the muscles are powerful, a roller should be wound round the splints instead of straps. ”

“ The patient is laid on his back, a slip-knot made in the middle of the bandage and passed over the wrist; the hand is then made to grasp the foot, the thumb above, the fingers under the sole (fig. 92) ; one end of the bandage is carried behind and inside the ankle to the dorsum of the foot, where it meets the other end passing in front of the ankle. The ends are then carried under the sole, brought up and tied in a double bow over the back of the hand.
Bedsores are best treated by great cleanliness, and by washing the skin exposed to the discharges with spirit of wine every day. ”

“ When all is ready, an assistant standing on each side of the bed pulls steadily on the ends to keep up continuous pressure on the abdominal viscera as the fluid escapes. [Pg 11] After the fluid is evacuated the ends are wound firmly round the body in front, while the puncture in the wall of the belly is closed by a fold of lint attached with a strip of plaster.
The T Bandage is used to apply dressings, compresses, &c., to the anus or perinæum. A roller 3 inches wide is fastened by a couple of turns round the pelvis, and then fixed by a pin at the middle line in front. ”

“ Fig. 33.—Hamilton’s Splint for fracture of Olecranon.
Fractures of the Humerus near the Elbow.—These resemble dislocations of the ulna and radius backwards, but are distinguished from them by the ease with which the bones slip into place and again slip back from it when left to themselves; by crepitus; and, when the fracture is above the condyles, the common accident, by those projections retaining their natural relation to the olecranon. In children and youths the articulating surface of the humerus may separate from the shaft without carrying the rest of the lower epiphysis with them. ”

“ When the plaster is quite set the bone is immoveable and may be carried about without risk of displacement. In deciding what joints should be included in the bandage, the same rules obtain in this as for the starch bandage; no more joints should be rendered immoveable than are necessary to obtain command of the broken bone; when the fracture is near a joint, that must be confined to prevent the bones being moved with the movements of the joint ”

“ Each turn of the roller should be made as tightly as possible, for when the case dries it always grows loose by the evaporation of the water it holds. As reverses are always difficult to cut through afterwards, they should be avoided, and the bandage laid on in simple spiral or figure of 8 turns. When the perinæum is reached, the surgeon wraps round the pelvis a broad strip of cotton wool, while an assistant on each side of the patient supports his body on a folded sheet or jack-towel, and a third holds the broken limb. ”

“ Every patient should, while he wears a truss, show himself from time to time to the surgeon to see that any defect in his apparatus may be quickly remedied. It is a useful precaution also to keep two trusses at hand, so that if one breaks, the patient may at once apply the other.
Salmon and Ody’s truss consists of a spring passing round the hip from a circular pad b, which bears on [Pg 165] the sacrum to a second oval pad a. Both pads are attached to the spring by a ball and socket joint. There is also a slide for shortening or lengthening the spring if desired (fig. 111) . ”

“ The blanket should be torn into strips about a foot square, and folded thrice, thus making a long soft pad to line the axilla, one for each armpit. The patient is next seated on a stool; an assistant standing behind, draws back the shoulder while he presses on the spine with his knee; the dislocation being reduced, the surgeon fixes the bone by a figure of 8 carried round the shoulders and across the back. The forearm is then bent and fastened to the body by a few turns of the roller round it and the chest. ”

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

“ To pass the catheter in the upright position, the patient is placed against a wall or firm object, with his heels eight or ten inches apart and five from the wall, that he may rest easily during the operation. The surgeon sets himself opposite the patient and grasps the penis with the two middle fingers of the left hand, the palm upwards; he next exposes the meatus with the thumb and forefinger, and his right hand holding the catheter by its middle obliquely across the left side of [Pg 134] the patient, he draws the penis on to the instrument till the triangular ligament is gained. ”

“ The splints are next adjusted and moulded to the limb, being temporarily secured by a few ends of bandage tied round them. One assistant grasps the splints and foot at the ankle and keeps up extension, while another holds the thigh. The surgeon then proceeds to roll the bandages, first round the foot and ankle, and then up the leg, rubbing in the warm starch as he proceeds. ”

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

“ In this rare accident the main distinctions from the usual fracture are, the projection of the olecranon behind the condyles; from dislocation, the absence of the hollow of the sigmoid notch, and facility of reduction.
In ordinary cases, where the deformity is reduced without much difficulty, and the injury to the joint is not severe, lateral rectangular splints of leather, hollowed [Pg 48] wood, or wire gauze, answer very well. These are placed both inside and outside the limb, and reach from the axilla and shoulder to the wrist. ”

“ Chloroform is a sedative and depressant; the pulse gives the earliest indication [Pg 180] of syncope, and the respiration should be constantly watched the whole time chloroform is inhaled. It should be noted that the pulse often fails suddenly at the first flow of blood in an operation. Again, when the patient is deeply narcotised, the jaw may gape and the tongue sink back till it closes the glottis. From this cause respiration sometimes ceases, and danger quickly arises if the chin is not drawn up to raise the epiglottis. ”

“ The treatment of talipes frequently requires division of tendons before extension is attempted, if they are too firmly contracted to permit the bones to regain their proper position until they are lengthened by division. Thus, in varus, the tibiales and tendo achillis; in valgus, the peronci; in equinus, the tendo achillis; are often divided.
The limb must not be very tightly braced into the shoe, slight tension, if continuous, suffices to overcome the resistance; and in children if the straps are drawn tight the skin almost invariably inflames, and even sloughs where it is compressed. ”

“ The limb being thoroughly greased, the flannel is well soaked in thin plaster cream, and laid on a table while the creases are smoothed out of it.
When ready it is applied accurately to the limb, so as to fit everywhere, but leaving a narrow open space along the whole length of the limb. The flannel must be held steadily till the plaster is set, which takes place in about five minutes, and the splint is complete. If one layer is not stiff enough, a second may be laid over the first in the same way. When the splints are fitted, they are kept in place by a roller applied lightly over them. ”

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

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