The success of the operation depends in great measure on the rapidity with which it is performed, and requires the aid of two assistants that the various steps may follow each other as quickly as possible.

Apparatus.—1. Syringe, cannula and stylet.

2. Lancet.

3. Scalpel.

4. Forceps.

5. Three yards of tape, one inch wide, and lint.

6. A silver wire suture.

7. A basin of cold water.

8. Brandy and Sal Volatile.

Step 1. See that the piston-rod works properly in the syringe, and that the instrument is fit for use; then place it in the basin of cold water with the cannula to lie till wanted.

Step 2. Place the person supplying the blood on a couch or easy chair in the same chamber, but so that he cannot see the recipient, lest he faint and his blood consequently flow feebly. Tie up the arm as for venesection; lay ready the lancet, and direct the assistant, in charge of the supplier of blood, to keep his thumb on the vein when it is opened, that the flow may be checked when blood is not required.

Step 3. Place a tape round the arm of the recipient, above the point for injection, and another below it at a convenient distance, and lay bare a vein (usually the median basilic) for an inch and a half of its course; holding the vein by the forceps, make a slit with the scalpel and introduce the cannula, which is then intrusted to the second assistant. The stylet is withdrawn, and a minute drop of blood escapes through the cannula, showing that the point has been properly introduced into the vein. The assistant replaces the stylet and slackens the ligature, while the surgeon proceeds to fill his syringe.

Step 4. The surgeon, going to the supplier of blood, makes a large opening in the vein with a lancet, or if the first assistant be a surgeon also, he may do this while the chief operator is preparing the vein of the recipient. When the vein is open and the blood flowing freely, the barrel of the syringe is inverted over it and filled with blood; when full, the nozzle is stopped by the plug and the piston attached while the syringe is carried to the recipient.

Step 5. This being reached, the plug is pulled out, the nozzle inserted into the cannula, and the blood slowly injected by depressing the piston gently, but without quite emptying the syringe. A minute should be spent in injecting one ounce and a half, and a pause of five minutes ensue before a second supply is introduced. This interval may be employed in cleaning the syringe, &c., and procuring a fresh supply of blood; 3-4 ounces of blood are usually sufficient, but 10 ounces have been injected on some occasions. The perturbation of the supplier (generally a near friend of the recipient), renders it necessary he should drink freely of brandy and water, that the blood flow forcibly when required.

Step 6. When sufficient blood has been introduced, both patients’ wounds are dressed, as after venesection (see page 20), the long incision of the recipient being closed by a point of suture under the pad.

Tourniquets.—Tourniquets are of several kinds.

The Ring Tourniquet (fig. 97) is used when pressure is desired on the main artery of such a limb as the arm. It is less easily displaced than the Signoroni, but, like that, soon becomes irksome by its continual pressure.

When hæmorrhage has to be temporarily arrested, that of Petit (fig. 98) is generally used. It consists of a strap of stout webbing and buckle, that can be rapidly tightened by a few turns of a screw. To use this tourniquet, lay a roller over the artery and carry the end once or twice round the limb to steady the roller, then pass the strap over the roller, keeping the buckle about two inches away from the screw and the screw on the anterior or outer aspect of the limb, not over the pad, lest that be displaced when the screw is tightened. The tourniquet should be screwed up as quickly as possible, that the limb be not charged with blood by obstructing the venous, before the arterial flow is checked.

In Signoroni’s Horse-shoe tourniquet (fig. 99) the extremities of the shoe can be approximated to each other by a rack screw working a hinge. The ends are furnished with pads, one broad and flat to bear on the limb away from the artery, the other rounded to compress the vessel itself. This tourniquet does not arrest the whole circulation in the limb. It can therefore be applied for a longer time than Petit’s. However, it easily slips out of place, and soon becomes very irksome and painful.

The Abdominal Tourniquet of Professor Lister is a very effectual contrivance for compressing the aorta during amputation through the hip joint, and operations where a tourniquet cannot be placed on the limb. It consists (see fig. 100) of a semicircular bar, with a broad pad to fit on the lumbar vertebræ behind, while in front it holds a long screw-pin carrying a pad. This instrument passes round the left side, and its pad is forced down into the abdomen, one inch to the left of the umbilicus, until the aorta is compressed against the spine.

Carte’s Tourniquets (fig. 101) are employed to control and diminish the flow of blood through an aneurism. They are intended to be worn for several days, and are fitted with many contrivances for obtaining a continuous pressure on the artery without completely arresting the flow of blood. They are always used in pairs; in the figure, one presses the external iliac on the pubes, the other the femoral artery. The first is fastened to the body round the hips, the second round the thigh. They are constructed as follows: an arm attached to a pad reaches round the limb to the artery, over which it supports a ball and socket joint turning in any direction, but fixed by a screw clamp. This joint has a long screw carrying the compress down to the artery. There is a little play of the screw in the ball of the joint, controlled by india-rubber bands, that the compress may yield slightly before the arterial pulse. In the solidification of an aneurism by this means, the flow of the blood is intended to continue; hence the current through the vessel need not be completely obstructed by the pressure of the tourniquet, and the elastic bands prevent that pressure from becoming insupportable.

When the tourniquets are applied, the patient must lie on a flat hair mattress, have his limb well washed and dried, lightly but evenly bandaged, and somewhat raised. If the thigh is hairy it should be shaved where the pads will press, and dusted with powdered French chalk. The tourniquets are next adjusted, as seen in fig. 101; the patient is taught to change the pressure when it grows irksome, by screwing down the second pad, and then releasing the first.

To improvise a Tourniquet.—A tourniquet may readily be formed on emergency from a handkerchief, a stone, and a stick. Fold a stone the size of an egg in the middle of a handkerchief, lay it over the main artery, tie the ends of the handkerchief round the limb, slip the stick underneath and twist it round, till the tightened handkerchief draws the stone on to the artery and arrests the flow of blood (see fig. 102).

Fumigation.—Mercurial vapour baths are contrived in various ways. The following plan succeeds perfectly well when the whole surface of the body is to be exposed to the vapour (fig. 103).

Apparatus.—A Langston Parker’s lamp made by Savigny and other instrument makers. In this a spirit lamp, holding the required amount of spirit is protected in a cage, on the top of which is a receptacle for the calomel, and a small saucer for water (fig. 104). The flame beneath boils the water and volatilises the calomel. Water is added, because the calomel vapour, when associated with steam, acts more efficiently than with dry air.

The lamp is placed under a high wicker chair, on which the patient sits undressed, and round his neck, a frame is tied, made of cane hoops, with a calico cover sewn over them; this falls to the ground and encloses his body in a chamber, where the vapour is confined while absorbed into the skin. A blanket thrown over the frame completes the preparation. If a hoop frame be not at hand a lady’s wire-hooped petticoat answers the purpose quite as well.

The patient, in four or five minutes, usually breaks into a violent perspiration, his pulse quickens much, sometimes even syncope occurs; hence, he should not be left alone until the bath is over. This, 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 hour. When the bath is over the patient should at once get into bed, and lie there a few hours; then he may rise and be well sponged with tepid water. Moderate but tolerably speedy mercurialisation of the system is thus induced.

Local Fumigation is employed when the disease is confined to a few obstinate patches of eruption. For this purpose an earthenware alembic (fig. 105) is fitted to the lamp used for general fumigation; the calomel is thrown into the bottom of the alembic. The flame plays over the outside, and heating it, sublimes the calomel; which reaches the mouth of the alembic and condenses on any part to which it is applied.

The throat may be fumigated by inhaling the vapour as it escapes from this alembic, or by sucking air through the spout of an earthenware teapot in which the calomel has been placed, and heated by a spirit lamp underneath.

The Hot Air-Bath is easily obtained by undressing the patient, putting him to bed on a mattress, and fastening across the bed two or three lengths of cane or stout wire, over which a blanket is next thrown. The patient’s body is thus enclosed in a small chamber, the air of which is then heated by putting inside, on an earthenware plate, a spirit lamp, surrounded by a kitchen lemon-grater to protect the bed clothes from its flame. Sheets should be dispensed with while the lamp is alight, lest they catch fire. The temperature of the air should be watched, lest it grow hot enough to scorch, but it must be kept up till the patient breaks into a sharp perspiration, when the lamp may be removed and the patient allowed to cool slowly down.

The action of the bath is greatly accelerated by sponging the patient all over as he lies in bed with tepid water, when the air grows warm.

Lamps protected with wire gauze, and furnished with a cradle to keep the bed clothes up, are sold at the instrument-makers, but the above arrangement answers just as well as more elaborate apparatus.

The Vapour Bath.—The patient is put to bed as in the hot-air bath, and a few feet of vulcanised india-rubber tubing, fastened to the spout of a tea-kettle on the fire, bring a supply of vapour into the bed.

The vapour bath may precede the hot-air bath, and will quicken the action of the latter very greatly.

Carriage for transporting the Sick.

The army ambulance and the carriage of the Invalid Carriage Society are excellent means for transporting sick from their homes, or wounded persons from the scene of injury to the hospital. As their cost is somewhat considerable, a cheap carriage (see fig. 106) has been devised by Dr. Horace Swete, of Weston-super-Mare, for the use of the district in which he is residing, and which may be kept for use at workhouses, hospitals, and in remote districts. It is constructed of varnished wood and iron, and in the following manner.

The dimensions of the carriage are—length, 7 feet 6 inches; breadth, 3 feet 9 inches; height, 4 feet 9 inches. Its weight is under 3 cwt., and its total cost 21l.

The body is like a skeleton hearse, without fixed floor or sides. The sides are closed by vulcanised india-rubber curtains, or by glass sliding panels. The back, a wooden panel, opens like a door. A wooden tray slides on three rollers at the bottom, and on this a mattress covered with vulcanised india-rubber is placed to receive the patient. For infectious cases straw should be used instead of the mattress, as it may be burnt when the patient is removed. The tray is narrow, and fitted with handles, that it may be carried up a narrow staircase. The vehicle runs on four wheels, is fitted with lamp, handle, shafts, and driving box, and is well hung on good springs. The material of the carriage admits of being washed, and thus readily purified, after conveying an infectious case.

Cupping—Dry, and Bleeding Cupping.

Apparatus.—1. A series or nest of exhausting glasses.

2. Different sized boxes of lancets for incising the skin, called scarificators.

3. A spirit lamp (fig. 107).

The glasses are 6 oz., 4 oz., 2 oz., and 1 oz. in size, of rounded shape, with thick smooth edges.

In dry cupping the object is to relieve internal congestion by drawing the blood into the subcutaneous cellular tissue. The back and loins, where the skin is tolerably loose, are most suitable places for this proceeding.

The Operation.

Step 1. Light the spirit lamp, direct the patient to sit forwards, and lay bare the back ready for the glasses, which should be placed on the bed within reach of the operator’s right hand.

Step 2. Rarify the air in a glass by plunging the flame into it a few moments, and then quickly clap the mouth of the glass on the skin; leave it there while a second and third glass are heated and applied, when the first should be removed and its vacuum restored before it is replaced. In putting the glasses on again, their rims should not lie exactly in the rings marked on the skin by previous applications, or the bruises may inflame and slough afterwards at these parts. The application and removal of the glasses should be done as lightly as possible to prevent all unnecessary pain.

A few repetitions of this incomplete vacuum causes the skin to puff up readily into the glasses, and much blood is thereby attracted into the cellular tissue.

Bleeding or Bloody Cupping.—When it is desired to take blood from the body the skin is punctured or scarified by the scarificators, half a dozen incisions being made at a blow by as many lancets protruding from a box, when a spring it holds is touched; the glasses are then laid over these incisions, and the necessary amount of blood removed by their exhausting power.

Junod’s Boot is a tin case, shaped like a boot (see fig. 108), but capacious enough to allow a limb when placed within it to swell freely. It is sometimes employed to draw blood and serum into the lower extremities during congestion of internal organs. When used, the leg is passed into the boot, and the mouth of the boot closed round the limb by a packing of india-rubber tied firmly round the boot and limb, and well smeared with simple ointment. The air is then exhausted from the inside of the boot by a small brass syringe, which screws into a hole in the leg of the boot, as depicted in the figure. The patient should wear the boot some two or three hours, while the vacuum is kept up by an occasional exhaustion of the syringe. Both limbs may be subjected to exhaustion, but the patient must remain in bed for twenty-four hours after the operation; this is generally necessary for other reasons, and he must wear a bandage for a few days when he gets about.

Leeches.—Each leech should draw about 2 drachms of blood, and if the bite is well fomented, another drachm will escape from the wound afterwards.

Before the leeches are applied, the skin should be well washed with soap and warm water, and carefully dried. The leeches should not be taken from their box, but the box inverted over the part, when they will quickly fasten themselves. If the leeches are applied in a dependent position, a soft napkin may be pinned round the box to support them as they grow heavy, and to enable them to suck as long as possible. They should be allowed to drop off; if pulled off they are apt to tear the wound, or leave part of their suckers in it, which causes much irritation afterwards.

The leech is put in a little glass when applied to the gums or the cervix uteri, and held against the part he is to suck.

If the leeches do not bite readily the part should be smeared with blood or warm milk, and the leeches put into lukewarm water a few minutes; immersion in small beer is also said to stimulate them to bite.

If the bites bleed longer than is desired, they may be stopped by pinching the skin between the finger and thumb, wiping the bite thoroughly dry, and filling it with a little bit of amadou or fine sponge, soaked in solution of perchloride of iron; a larger piece of amadou is placed over the first, and the whole compressed with a turn of a bandage or long strip of plaster. If this fails, a sewing needle may be passed through the skin beneath the floor of the bite, and the bleeding surface constricted by twisting a thread round it under the needle.

Leech-bites should never be left bleeding, especially in children, for a dangerous amount of blood may be lost from them in a few hours.

Tents are instruments made of some substance that enlarges as it absorbs liquid; they are employed to dilate apertures of sinuses or natural passages, as the cervix uteri, &c., and are generally short rods 2 to 3 inches long, and ¹/₁₀ to ¼ inch in thickness, made of a whalebone stem, wound round with compressed sponge, which is smeared with wax to keep it in shape. Slips of gentian root, or of laminaria digitata, which rapidly enlarge as they imbibe moisture, are also employed for this purpose.

Setons are strips of varnished calico, 6 or 8 inches long and ⅓ broad; a thread is fastened to each end, which are tied together while the seton is worn. It is employed to excite irritation either along the course of a sinus, or in some superficial situation, as the nape of the neck, to relieve congestion of internal parts. In sinuses, a few threads of silk usually produce the required amount of irritation.

Chassaignac’s Drainage-tubes are a form of seton; they are india-rubber tubes of the calibre of a wheat straw, of any requisite length, and perforated with holes at frequent intervals; they are carried into the cavity to be drained, by hitching the prong of a forked probe, made for the purpose, through one end of the tube and thrusting it along the sinus, or across the abscess. The skin is then incised over the further end of the sinus to bring the probe out, and the ends of the tube are tied together.

The advantages of these tubes are, the small amount of irritation they provoke, and the ready exit furnished for the matter along their interior.

Issues are a contrivance for keeping up irritation of the surface. A piece of diachylon plaster the size of a half-crown, with a hole in the centre as large as a pea, is laid over the skin where the issue is to be formed. A bit of potassa fusa is laid in the hole and kept in sitû by a second plaster, for an hour or till the skin is destroyed under the hole. The plasters are then removed, the wound washed, and a fresh piece of the same size put on, having at its centre a slit ¼ inch long, under which a pea is slipped into the sore and covered over by another smaller piece of plaster. The discharge that soon sets up must be washed away twice daily, and the plaster and pea renewed from time to time as they become soiled.

Trusses for ruptures. These are various, in shape, strength of spring, &c.

Whatever variety of truss is employed, care should be taken that the pressure is made in the right direction, and that it is sufficient, but not too great for the strain it has to support.

In reducible hernia the pressure for inguinal rupture should be exerted on the inguinal canal and directly backwards (see fig. 109). For umbilical rupture, the pressure should be also backwards, and confined as much as possible to the aperture in the wall of the belly. In femoral rupture the pressure should be directed upwards as well as backwards into the femoral ring (see fig. 110). The pad in all should be large enough to well cover the passage through which the rupture passes. The ease and comfort of a truss much depend on the completeness with which it fulfils these conditions.

The adequacy of a truss should always be tested by directing the patient to separate his legs, lean forward over the back of a chair, and cough or strain deeply. If the truss support the rupture during this exertion it fits satisfactorily.

For irreducible hernia large air-, or spring-padded trusses are made, which prevent further descent of the viscera, but they are exceedingly difficult to fit and often unsatisfactory in use.

In inguinal hernia the truss consists of a pad, a spring, and a neck, with guide straps.

The pad is made of various materials, fine carded wool is among the best when well stuffed into a proper shaped leather pad, and in most cases a fixed pad is better than a moveable one.

The pad should compress the canal and be convex if the patient is stout. Its size ought to be sufficient to compress the canal and the margins for a short distance on each side, but the pad should be as small as will ensure fair compression. A very flaccid bellywall, and a large gap or protrusion require a large surface on the pad. The spring should be supple and padded behind to rest on the two sacro-iliac synchondroses, without bearing on the spine. The spring, narrowing as it comes forward, embraces the pelvis; and opposite the anterior iliac spine inclines downwards, because the hernia is a little lower than the resting-place of the spring behind. When the rupture is almost reached, the spring takes a slight elbow or bend (the neck), that its pressure may be directed against the hernia more fully. Understraps, generally not necessary, should be omitted if possible.

In trusses for children when the testis is not descended, the pad should have a notch at its lower border in which the testis may rest uncompressed.

In the truss for femoral hernia, the spring bears behind the body and encircles the hips in the same manner as in the inguinal truss, but when opposite the femoral artery it turns abruptly downwards to reach the saphenous opening. The pad should fit the hollow where the rupture issues and be not oval, but rounded. The under-strap should be attached to the stud at the lower end of the pad, and pass round the perinæum and fold of the buttock, and be attached to the neck of the spring close to the pad. It should be made of knitted bandage that it may be changed and washed frequently.

When measuring a patient for an inguinal truss, the circumference of the body round the hips (between the crista ilii and the great trochanter) should be first taken, and then that between the symphysis pubis and the anterior iliac spine, half of which distance denotes the position of the internal abdominal ring, which with the inguinal canal has to be supported by the pad of the truss. For a femoral hernia the same measurement should be taken round the body, and also the distance of the saphenous opening from the symphysis pubis and from the anterior superior iliac spine. This will enable the maker to put the pad at the proper angle with the spring, so that it compresses the saphenous opening, and clears the crest of the pubes.

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 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). This truss is worn round the sound side of the body and reaches beyond the middle line to the hernial opening, with the object of directing the pressure of the spring outwards and backwards, or exactly counter to the course of the hernia inwards.

Umbilical hernia.—Spring trusses are not adapted for restraining umbilical hernia. The support consists of a broad belt fitted to the belly, made in front of elastic webbing, and on each flank, of white jean. Behind, the belt is fastened by straps and buckles, or by lacing, the better plan. In the centre, the elastic part carries a nearly flat air-cushion, measuring about 3 inches transversely and 2½ vertically. This cushion is placed against the aperture of the belly, and presses back the protrusion. The size of the pad varies with the size of the hernia, but it should always largely exceed the extent of the gap in the abdominal wall. The pad, when the apparatus is used for an infant, should not be too prominent, as it is then more difficult to keep in place, and also by pressing into the aperture hinders it from closing. The pad for an infant is best made of a disc of ivory, 1½ inch broad and ½ an inch to 1 inch thick, stitched in a little case in the centre of the girdle. 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 washed. The difficulty of keeping the belt in place is obviated by attaching two bands to the upper border, to pass over the shoulders and cross behind before fastening to the belt, like braces. Two similar ones may be fastened to the lower border and carried under the thighs. These bands should be of soft webbing, and several pairs kept in store, that they may be frequently changed and washed.

Cauteries.

Cautery irons.—These are masses of iron of different shapes; some pointed, others rounded like buttons, &c., set in a stem a foot long, fixed in a thick wooden handle. They are heated in a charcoal brazier or common fire to bright redness if required to destroy deeply, but short of redness if intended only to scorch the surface.

As these irons are inconvenient for many cases from their bulk, and yet soon lose their heat if made small, other cauteries have been devised to which the heat can be quickly renewed.

Gas Cautery.—The late Mr. Alexander Bruce perfected an instrument which employs the gas flame as a source of heat (see figs. 112, 113). A blowpipe flame plays on platinum discs of various sizes, and keeps them at a glowing heat. This hot solid point can be thrust into the tissue wherever it is desired.

A larger form is also made for cauterising the pedicle in Ovariotomy, &c. In this a large flame is blown on a wedge-shaped surface of platinum, 1 inch long and ½ inch broad, and continued backwards for 2 inches by wire gauze to confine the flame against the platinum. The flame behind these platinum discs quickly heats them again if cooled by the blood. This cautery is very portable, and easily made ready for use.

Mr. Clover has also devised a cautery, very useful for small growths. A silver bead, the size of a pea, is set at each end of a horizontal metal rod 4 inches long, which rotates on a vertical pivot half a circle backwards and forwards, so that one or other bead is thrown into the flame of a spirit lamp placed at a proper distance; when the bead is heated, a touch of the finger causes the central pivot to rotate, which brings the hot bead away from the lamp, and carries the cold one into the flame, to be heated while the first is used.

Galvanic Cautery.—The instrument consists of a platinum wire, made to glow by passing through it a powerful galvanic current. The wire should be thick (about ¹/₁₂ of an inch), and all the other conducting surfaces sufficiently large to offer no impediment to the current where heat is not desired. The battery best adapted for this purpose is a Grove’s battery.

The main advantage of a galvanic cautery is that the wire can be passed while cold exactly where it is required, and then heated when it is in place. It is exceedingly useful in fistulæ between the urethra and rectum, or in destroying vascular growths, nævi, &c., where it is desirable not to destroy all the skin covering the tumour. Again, by this means, an intense heat can be applied to a very limited area, and more quickly renewed than by any other plan, for the wire, even when plunged in the tissue, is never far below a red heat.

Of chemical caustics a host exist; those most commonly employed are:—nitrate of silver, solid, or in saturated solutions (2 drachms to the oz. of water, &c.); fuming nitric acid; solution of nitrate of mercury in nitric acid; oil of vitriol made into a paste with powdered charcoal; chloride of zinc mixed with dry starch, then rolled into cakes and cut in slices; Vienna paste, that is, equal parts of potassa fusa and quick lime worked into a paste with spirits of wine; potassa fusa itself; solution of chromic acid. Some surgeons prefer one, some another; as a rule, the liquid caustics are employed where the surface to be destroyed is uneven and spongy, and solid caustics where the surface is smooth, and a long continued action is desired.

Vesicants and irritants.—Of the commonest are mustard poultices, made by mixing mustard flour in a basin with luke-warm water, i.e. about 100° F., to a paste and spreading it on muslin, which is again folded over the exposed surface of the mustard. Boiling water and vinegar should not be used, for they lessen the pungency of the poultice. If the full effect be desired the poultice should remain on the skin fifteen or twenty minutes. If only slight reddening is wanted, the mustard flour should be diluted with its bulk of linseed meal before mixing it with water.

A stronger vesicant is Corrigan’s hammer, a button of polished steel with a flat surface, fixed to a handle; when used it should be plunged for a couple of minutes in boiling water, or heated over a spirit lamp, but care must be taken not to overheat it, or it will bring the cuticle away with it. It is pressed on the skin for ten or fifteen seconds; this is sufficient to cause reddening and vesication.

Blisters are raised by the emplastrum lyttæ, lin. cantharidis, or pâte epispastique, which is milder in its effect than the two preceding preparations of Spanish fly. Solution of iodine and iodide of potash, in three times their bulk of spirit of wine, also produces a blister when laid on freely.

Poultices are made of linseed meal, bread, or starch, and are means for applying warmth and moisture without absolutely wetting. Bread poultices sodden the parts to which they are applied most, and starch least, of the three kinds.

Before making a poultice all the materials should be at hand and thoroughly warmed before a good fire. They are—boiling water, a broad knife or spatula, soft old linen or muslin, oil silk, tapes, strapping plaster, bandages, a piece of old blanket, flannel or cotton wadding, safety pins, or needle and thread.

The linen on which the poultice is to be spread should be cut of the intended size, and when for use about the neck or shoulder should have some tapes sewn on to it to tie it on to the body. The oil silk should be large enough to cover the poultice next which it is laid to keep in the moisture. The flannel or wadding are used to wrap over and keep in the heat of the poultice; the strapping or bandage to fix every thing in situ as required.

When poultices are continued long, their surfaces should be smeared with lard before application; this protects the skin somewhat from the irritation that arises; also when the poultice is to be laid between folds of skin or on hairy situations, as the buttocks and perinæum, it is better to cover the poultice with a thin cambric handkerchief lest some of the meal stick to the parts.

The Linseed Poultice is made as follows: pour boiling water into a well-heated basin till the basin is half full, then scatter meal with the left hand on the water while that is kept continually stirred with a broad knife, adding more and more meal until the mass becomes quite soft and gelatinous, but too stiff to cling to the knife; then turn it out on the linen, also well heated at the fire, and spread it in a layer about ½ an inch thick, turn up the edge of the linen for ½ an inch all round, and carry the poultice at once to the patient. If it has to be carried far the poultice should be laid between two very hot plates; apply it to the part to be poulticed, lay on the oil silk, and cover that with the hot flannel or cotton wadding, and fasten these in place with pins or a stitch. Wadding is put where the part is irregular, as the neck or axilla; unless the wadding is well placed and the poultice is fastened by strings, it will soon fall into a narrow band leaving the part exposed that it should warm and moisten.

The Bread Poultice is made as follows: the materials being all at hand, as detailed in the directions for making a linseed poultice, crumble the inside of a moderately stale loaf until about half a pint or a pint of crumbs are prepared; then pour boiling water into a basin, and throw in crumbs gradually in the same manner as the linseed meal, until a soft porous mass is prepared. The remaining steps are the same as those for making the linseed poultice.

The poultice can be made to hold more water if it is turned into a saucepan after mixing, and a little more water added while it simmers for half an hour at a slow fire. Any superfluous water must be drained off, and the poultice covered with muslin when it is made in this way.

The Starch Poultice is made as follows: rub a little starch in a basin with cold water till it has the consistence of cream, then mix in boiling water till the starch is a thick jelly, and spread it on the linen while hot. Starch poultices retain their heat a long time, but yield very little moisture to the part. They are chiefly used as emollients to inflamed affections of the skin, &c.

Hot fomentations are a means for applying heat when moisture is not desired. A ready mode is to take a piece of blanket or thick flannel, soak it in boiling water and dry it by wringing in a folded towel, and then wrap it over the part to be fomented with a piece of oil silk or a hot dry flannel over it. Laudanum, turpentine, and other applications are sprinkled over the flannel, when soothing or counter-irritating effects are required in addition to the warmth. A bag of bran makes a light warm fomentation if heated in a steam kitchen, or steamer for boiling potatoes.

When absolutely dry heat is desired, chamomile flowers, bran, or sand, may be heated in an oven, and poured into hot flannel bags.

Dry heat is also very agreeably obtained by filling india-rubber bags and cushions with hot water: they are rather heavy, but retain their heat many hours.

Lister’s Method of Dressing Wounds with Carbolic Acid.—The properties of carbolic acid which concern the surgeon may be briefly recapitulated as follow:—

It is highly volatile, and the putrefaction of organic fluids is indefinitely postponed where its vapour is present. Carbolic acid is soluble in different degrees in water, alcohol, ether, glycerine, fixed oils, gutta percha, india-rubber, and shell-lac. Its varying affinity for these substances enables the surgeon to modify the application of carbolic acid in various ways; these modifications are necessary to fully utilise its properties. Water dissolves the crystallised acid but sparingly, 1 part in 20 being a concentrated solution, and allows it to escape readily. The aqueous solution is therefore useful where the effects of the acid are required copiously, but only temporarily. Glycerine and the fixed oils dissolve a far greater amount of the acid, and part with it unwillingly. Their solutions are adapted for the continuous but abundant application of the antiseptic. Shell-lac, and some other substances, hold the carbolic acid still more tenaciously, and are valuable as solid storehouses which yield up the antiseptic in small quantity for a considerable period.

Carbolic acid stimulates raw surfaces, and when concentrated even destroys animal tissues. It is a local anæsthetic; with moderate doses, wounds lose their sensibility after the first smarting of the application has passed off. When given in large quantities the acid produces a peculiar kind of delirium, and temporary paralysis of sense and motion: fatal results have followed its internal application.

It is rapidly absorbed into the blood from wounded surfaces, and through the skin, whence it is discharged from the body by the lungs and kidneys. The urine of patients dressed with carbolic acid, though of normal colour when passed, assumes a dark greenish-brown hue after a few hours’ exposure to the air and light.

How much of the antiseptic must float in the atmosphere to prevent fermentative changes has not yet been determined; Bucholtz found that 1 part of carbolic acid in 600 of milk almost entirely prevented lactic fermentation, while 1 in 285 did so altogether. Alcoholic fermentation in sugary fluids was arrested by a similar quantity.

When using the acid in dressing wounds, the watery solution, the solid mixture, and the oily solution are necessary. The first to neutralise the effects of exposure to the atmosphere and water before the wound is closed; the second solid mixture in the form of plaster to provide a very scanty but continuous supply of carbolic vapour close to the wound: too scanty to irritate the raw surface, yet enough to check putrifaction in the discharge oozing from it. The third, or oily solution, is to supply the carbolic vapour abundantly to the linen dressings, appointed to receive the discharge when it has passed from the vicinity of the wound. The tin is used to afford as close a cover as possible to the breach of surface; for this purpose it must be as flexible as possible that it may fit the wound exactly.

The carbolic plaster is made of 3 parts of shell-lac and 1 part of carbolic acid crystals melted together and spread on calico. To render the lac plaster non-adhesive that it may not stick to the tender wound, it is painted with solution of gutta percha, which dries and leaves a thin film of that substance covering the plaster. This film is easily removed by rubbing the surface with a rough towel should an adhesive quality be desired. In either state the carbolic acid continues to volatilise slowly when the plaster is laid over the wound.

When adopting this method of treating wounds the following materials are necessary:—

1. Aqueous solution of crystallised carbolic acid (1 part in 20).

2. Carbolic oil: 1 part of carbolic acid in 5 of olive oil.

3. Lister’s shell-lac plaster.[1]

4. Sheet tin.

5. Lint; old linen.

6. Diachylon plaster.

7. Glass syringe.

8. Scissors.

9. Thin calico or muslin.

10. Bandage.

11. A wooden splint to rest the limb upon.

To Dress recent Wounds.—When the apparatus is ready, the piece of tin is cut and fitted to the wound, so that it shall overlap the wound to a small extent on all sides; then a piece of lac plaster, large enough to overlap the tin one or two inches all round; this plaster may be cut and notched when the surface is irregular to make it lie pretty closely; then strips of diachylon, about two inches broad, are cut ready. The parts around the wound are well cleaned; dirt and clots cleared from the wound with cold water, containing about 1 of carbolic acid to 40 of water, and the interior of the wound is freely syringed with water containing 1 of acid in 30 or even 1 in 20 parts. The sides are brought together with sutures, if necessary, in the ordinary way, and the tin laid on the wound; the tin is freely wetted with carbolic water, and the lac plaster laid over it and kept in situ by strips of diachylon plaster. In dressing recent wounds the most dependent side of the lac plaster is left unattached, that the serous discharge, which is often copious, may readily escape. To receive this discharge, a piece of calico, soaked in carbolic oil, is laid over the wound now covered in, and all kept in place by a folded towel or a roller bandage. This oily cloth is to be changed from time to time as it gets soaked with discharge: at first this change is necessary every night and morning, but after three or four days once a day is often enough. The shell-lac plaster and tin need not be removed for a week unless the wound grow hot and painful, when they can be removed at any time if the surface of the wound is immediately smeared with carbolic oil, and kept well imbued with the antiseptic while it is being examined. Should it contain pent-up discharge, the sutures must be loosened and the discharge washed out by injecting the 1 in 30 aqueous solution. The tin and lac plaster may be then replaced, and the dressing renewed. The same precaution must be followed when the sutures have to be removed. Usually there is very little swelling and no pain, and the healing process goes on tranquilly if undisturbed. Should bruised parts slough, they may be trimmed away with scissors dipped in carbolic oil. When the wound has once been washed with carbolic acid, the antiseptic should not enter the wound a second time, as its irritant qualities excite inflammation in the wound.

Chronic abscesses, besides recent wounds, are treated with carbolic acid. The surface to be punctured is covered with a piece of thin muslin soaked in carbolic oil, and the knife to be used is dipped in the oil also. Then, a second piece of muslin being ready, the surgeon opens the abscess through the muslin, and as he withdraws the knife an assistant lays on the second piece of muslin over the wound. The matter drains away from under this curtain, and the access of atmospheric air is prevented. When the matter ceases to flow, the lac plaster is laid on, and the oily cloth outside, which can be changed as often as is requisite. Abscesses so treated usually soon cease to secrete matter, shrink, and fill up without delay. If the abscess has burst or had communication with the external air, the interior must be filled with watery solution 1 to 20 before it is dressed, that fermentation in the cavity may be prevented; the further treatment is the same as for a recent wound.