V^J^i^l ^^ ^ mtt)f€itpofl1mig0rk College of l^fjpgiciang anb jfeurgeong Hifararp 1 ^,}^s,^^Mj ^V/ Digitized by tine Internet Arcinive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/moderntreatmentoOOsumm THE Modern Treatment of Wounds BY JOHIST E. SUMMEES, JR, M.D. S'urgeon-in- Chief to the Clarhson Memorial Hospital; Attending Surgeon Douglas County Hospital. Formerly Professor of the Principles and Practice of Surgery and Clinical Surgery, Omaha Medical College ; Ex-President of the Western Surgical and Gynecological Association, the Nebraska State Medical Society, and the Omaha Medical Society. MEDICAL PUBLISHING COMPANY, S15 McCague Block, Omaha. 1S99. COPYRKiHTED. 1S99, BY J. E. SUMMERS, JR., M. D 7^J>/3/ PRERS OF STATE JOURNAL COMPANY, LINCOLN, NEB. To JOHN E. SUMMERS, M. D., COLOXEL AND SURGEON U. S. ARMY (RETIRED) . A SMALL TOKEN OF MY AFFECTION AS A SON. PREFACE. In the preparation of this little book 1 have tried to indicate means towards ends. An attempt has been made to keep within the subject title of the book, yet it has been thought neces- sary occasionally to discuss pathology and diagnosis in order to lead up to a rational practice. If at times some statements appear dogmatic, they will, I hope, be pardoned, because they have the merit at least of being based upon a liberal personal experience, both as a teacher and practitioner of surgery. November 1, 1899. CONTENTS. CHAPTIOIJ I. CAGE Bacteria and VVouiuls i ('lIA!'Ti':i; II. I'reparatoi-y Surgical Technique 5 CHAPTEK IJI. Operative and Accidental Wounds 14 CHAPTER IV. Operations on lul'ected Tissues 22 CHAPTER V. Accidental Wounds ^6 CH.\PTET{ \1. Punctured Wounds of the Brain 33 CHAPTER VII. Penetrating- Wounds of the Chest 36 CHAPTER VIII. Treatment of Incised and Punctured Wounds of the Abdomen 40 CHAPTER IX. The Treatment of Intra- Abdominal Lesions Following Contusions of the Abdominal Walls 4.5 CHAPTER X. Sprains and Contusions of Joints 55 CHx\PTER XI. Compound Wounds of Joints 59 CHAPTER XII. Head Injuries 64 CHAPTER XIII. Poisoned and Dissection Wounds 70 CHAPTER XIV. Specific Woutid Infections — Erysipelas 80 VIU lO.NlKMS. (•ii.\i"n:u x\'. PAGE Tetanus 87 ( ii.\i'|"i:k x\i. Treatment of Soptit- Itlood I'oisoning 93 fllAl'TKi: XVII. Compound Fractiires of Long- Bones l();j (•11.\1'T1:K Will. Tre;i1ni«Mi1 <>f ( ; misliot Wounds 1 IL' CH-M'TKIJ XIX. Treatment of limns and Frost-Hites 121 CHAPTER XX. Use of Jvubber (!auntlet.s or (Jioves 1U2 ERRATUM. Page 52, after A'i(iue)'.—{\.) . . "a right-sided abdominal section" should read "a right- or left-sided abdominal section." J. 1ST OF PLATES. PLATE I. "First Aid" use of elastic tourniquet in crusliing wounds of the lower extremities Between pages 28 and 20 PLATE JJ. A pnnctnred wonnd of the brain by a button-hook. Opposite page 34 PLATES III AND IV. Adhesive plaster dressing for sprains of the ankle-joint. Between pages 58 and 59 PLATE V. Use of Esmarch's tourniquet in operations upon the skull. Opposite page 69 PLATES YI, VII, AND VIII. The making of a window in a j)laster of Paris splint. Between pages lOS and 109 PLATE IX. Extensive burn under process of repair by Thiersch's method of skin grafting Opposite page 126 MODEPtN TEEATxMENT i)V \V(JUAJJ.S. CHAPTER I. BACTElllA AND VVOLF.NDS. Effect of Bacteria on Wound Hcaliny. — The most im- portant principles nnderljing the treatment of wounds are based upon a clinical comprehension oi' bacteri- ology, however desirable it may be lor the practitioner to have a combined laboratory and bedside knowl- edge. It should be well understood that the intro- duction of micro-organisms into wounds is responsible for most ill eti'ects, except those due directly to the nature of the wound. This introduction of micro- organisms into wounds can, in those inflicted by the surgeon, be prevented, and in the treatment of all wounds means are at command to nullify or modify any serious results caused by micro-organisms. The marvelous decrease in death rate from wounds, either surgically or accidentally inflicted, and the lim- itations of the spread of infectious diseases, are all the result of the work of laborers in the field of bacteri- ology and experimental medicine. Among the numer- ous germs we need onlj^ consider the chief ones acting as etiological factors of surgical wound diseases. Divisions of }Iicro-orf/anisms. — There are three chief divisions of micro-organisms which we have to bear in mind: 1. Micrococci, which are cells, either round or oval in form, and may be found singly, in chains, or in masses. 2. The Bacilli, which are rod-shaped cells, found singly, in chains, or swarms; their length is more than twice their breadth. 3. Bacteria, which may be rod-shaped, but when so their length does not more than equal twice their breadth; they are also oval in fo-rm, and are found single, in chains, or masses. All the different forms of micro-organisms are quite commonly spoken of under the general (1) - Ml>lH:i:.\ lUKATMICNT Ol' \\\)UNUS. lu'atliuy: oI" liurlrr'm. Thev all liavi' ilic properly ol' a uiarvc'lous loprotiiicliDU, luillions liciiiy; jjt'iu*ratt'd ii-oin a sin«;l(* liaiilhis in a lew hmiis. All bacicriii art' of \c^eiaL)li* >ies of the wound or enter the general circulation, producing more extensive local irritation or severe intoxiraliou. Or dinaiily, the only organisms (cocci) which cause the fornuition of i)us are the staphylococcus jtyogenes au- reus and albus (which form in clusters) and another much more dangerous organism, the streptococcus py- ogenes (cocci which form in chains). The Tetanus Bacillus is also of importance. When, as is a common occurrence, wounds which have been (^xposed to micro- organism infection heal without the formation of pus we know that either something prevented the pepton- izing action of these organisms upon the albuminous elements of the wound secretion (exudate), or that na- ture was ab]<' in the struggle for supremacy ilhc battle between the organisms and the vital elements of the body) to conqu(M-. Bacteria usually grow rapidly at a temperature ranging from 7.")° to 104° F. Those which grow at the lower temiierature tend to cause a i)utrefactive condition in the wound secretion; those which grow most rajudly at the higher temperatures are commonly those producing diseases of a more or less typical kind and are called iidtJiof/oiic. The his- tory of e]>idemic diseases lias pi-oven that severe cold does not kill many ltaS. 3 upon (he id mil (tl' ilic \v;iiiii .sciJHon. Dry Ik-jiI is uof a reliable a^cnl lo kill iiiici'o-or^anisiriH, but. tiioiHl liejil, boiliiii; wnlci- oi* sleain, because of its greater penetration, will kill every variety of bacteria. Many chemicals have the power of killing bacteria and at the same time, w lien usihI jurticiously, do not act in a hainifiil way upon wouvids. A utilization of o>ir kiu>wle(l^(* of the action of both lieat and these chenii- cals upon all micro-organisms is the basis upon which is built the modern treatment of woun,ds, — the Aseptic and Antiseptic Methods. Aseptic ^^i(r(/crt/. — By Aseptic Surgery is understood the employment of known means (chemical and me- chanical) in tlie sterilization of the hands of opera- tors and assistants, instruments, and all dressings and material used. The sterilization of the tissue area of the wound about to be made must also be complete and the wound protected from contamination from all sources. After the incision or puncture no chemical agents having irritating or sterilizing properties are allowed to come in contact with the raw surfaces. The dressings applied must be sterile, but contain no chemical. Antiseptic Surgery. — Antiseptic Surgery is the em- bodiment of all the details of Aseptic Surgery and in addition the use of chemicals upon the wound sur- faces during the progress and after the completion of the operation. The idea being to inhibit by the use of chemicals the possible ravages of bacteria which may have gained entrance into the wound because of a faulty technique or preparation upon the part of those concerned in the carrying out of the operation. With few exceptions all wounds not made by the surgeon demand antiseptic treatment. The employment of certain chemicals (antiseptics) is intended to kill or to weaken the power of any germs which possibly have infected a fresh wound. If suppuration is already established these chemicals stop fermentation and putrefaction, and i)rotect the patient from the more severe local and constitutional effects of wound infec- tion. •4 MOPKUN IKKArMKNT OP WOINDS. Drdlmufv. — Another cardinal piiiK-ii»al »»t antiseptic suijit^ry is to ]ir()\i(l(' for iliainai't*<;i:nated witli antiseptirs which will int'vcnt ])n- trefaction of discharges. Antiseptic dressings arc also «Mni>loyed to k(M-p ficrnis from ^ainint:: access lo a wi>un(l aflci- the coniidction of an oix'ialion, or to jnc- vi'ut reinfection of a disinfected wonnd. PBErAUATOIlY SUI{ per i-enl. carbolic acid sola tion, made by adding the acid to freshly boiled water. Silh-ivunii (Jut and i^ilrcr Wire. — These are best ster- ilized by boiling in water from fifteen minutes to half an hour immediately before using. Souie surgeons, however, consider the immersion of these materials in a o i)er cent, solution of carbolic acid in water suf- ficient for their j)ractical sterilization. Catiiut. — The most modern method for the sterili- zation of catgut is by means of formalin, the advantage being that the gut is rendered less soluble in the tissues aud therefore more reliable. After the gut has been impregnatc'd with formalin it can also be subjected to boiling in water without losing its tensile strength. The gut is first immersed in a solution of formalin of from 2 to 4 per cent., according to its size, and allowed to remain in the solution for a period of from twelve to forty-eight hours. The formalin is then removed by soaking in cleai' water for twelve hours, the water being changed frequently. It is then boiled in water for fifteen minutes, after which it is transferred to a vessel containing alcohol, whei'e it may be kept until reo.uired for use. From 2 to 4 per cent, of carbolic acid may be added to the alcohol, as it makes the gut more firm. It should be i)laced in plain alcohol for about a half hour before using. Be- fore boiling the gut. it should be wound tightly on a glass spool or di'y cork, the object being to keep the gut in a high state of tension. The coi-k has sonn' advantages over the glass rod. in that it ex])ands by the absorption of the water, and thus increases the tension on the gut. One of the best methods foi' (lie slciili/at ion of cat- gut tcifhont the use of formalin is the following: .\ I'UiiM'AitA'i'oKV .si!i{i;i< Ai, ■ri;laced in a vessel of boiling water and boiled for fifteen minutes. This boiling is repeated for three successive days, add- ing sufficient alcohol when too much evaporates. After the third boiling the gut is placed in absolute alcohol and is ready for use. When required it must be removed from the bottle with sterilized forceps. If thought best to chromicise this catgut, in order to add to its strength and resistance to rapid absorption, it is placed into this solution: Chromic acid 1 part; carbolic acid 200 ])arts; sterile water 2,000 parts. After twenty-four hours the gut is removed and placed in absolute alcohol. Bichloride of mercury should not be added to the preserving alcohol, as it renders the gut too brittle. Gatyut as Prepared and Hold hij ^Supplij Houses. — It is becoming the custom among surgeons, and, in fact, of some hospitals of best repute, to buy catgut all ready prepared. The only articles, however, which are reliable are those which are prepared in hermeti- cally sealed glass tubes, requiring the breaking of these for their use. Complex arrangements furnished by the supply houses which admit of catgut and silk being pulled out in shorter or greater lengths are dan- gerous and should be avoided, as the material remain- ing in the bottles may become contaminated from without. For the ordinary minor surgery of the of- fice and private family, needles of dilTerent sizes and curves, already threaded with silk, silkworm gut, or catgut, sterilized and sealed in glass tubes, as furnished by the supply houses, are convenient and thoroughly reliable. 2 8 MODERN TREATMENT OF WuLNDS/ KaiKjaroo 'J'citdon. — Fur buried absoibalik' suluios iu ctrtiiiu opei-atious, especially for llie radical cure of hernia, there is perhaps uo material equal to kan- garoo tendon. For its use we are indebted to Marcy, of Boston, and from him the best article, either ster- ilized or non-sterilized, is to be procured. The steril- ized article is expensive. However, a large bundle of the tendons can be bought for a moderate sum and sterilized at home. The following is the method used and advised by ^larcy: The tendons are lirst soaked in a solution of 1-1,000 of bichloride of mercury in water until supple. They are then carefully separated and dried between sterilized towels. After assorting them into small bundles, Ihey are chromicised by plac- ing them in a 1-20 watery solution of carbolic acid to which has been added 1-4,000 part of purified chromic acid. The tendons must be immersed in the solution immediately upon Ihe ])reparation of the fluid, since otherwise in a short period the chromic acid is thrown down as a sedimentary deposit. The process of chromicization goes on more or less rapidly, dependent upon heat, exposure to sunlight, the quantity of material manipulated, and requires careful watching, since, if too rai)idly effected or per- mitted to remain too long in the solution, the tendons may bo easily ruined. When properly chromicised, the tendons should be of a dark golden color. When taken from the chromicizing fluid the tendons are best dried in the sunshine between sterilized towels, and should be immediately put in a carbolic oil, the whole process carefully conducted under aseptic con- ditions, tlie bottles securely corked and sealed. When wanted for use, the tendon is carefully taken from the bottle, soaked in a mercuric solution until supple, !ind then arranged in jtnrallel strands, wi'ap])ed in a folded towel saturated with a 1 to 1,000 mercuric solu- tion, the ends of the tendons exposed so that they may be withdrawn one ;it a time as selected. If more con- venient. 1h(\v can i-emain immersed in a dish of bi- chloride solution dui'ing the operation and selected as required. The ;n;ionnt of the l)ichl TioonNiQUE, :3 ill ihe suture doew no liunu Lo Liie sUu(;Lui(%s in wiiicii it is buried; it is advantageous rather than otherwiHe, Many surgeons deem it uniuicessai-y to do more than phice tlie tendons into bichloride etiier, 1 to 1,000, lor twelve hours, and then remove them and i>iace them, strung out, into a long narrow bottle lilled with alco- hol. For use they are removed as reciuired and put into a 1-40 solution of carbolic acid in water. Dressings and Instruments. — All materials used lor covering and protecting wounds should be prepared and handled with the most scrupulous care. Dry sterile dressings are best used to protect wounds either aseptically or antiseptically made, from which little or no discharge is expected. All other wounds are more safely handled by being covered with dressings which are moist with some antiseptic iluid. If a dry dressing is employed to cover a wound which may jjos- sibly have become infected or is discharging pus at the time the dressing is applied, there will always be a greater or less accumulation of discharges under the dressing, just as pus is retained under a scab. Such a condition cannot help but interfere with the repara- tive process. Gauze (cheese-cloth) is the material usu- ally used next the wound surface. Absorbent cotton is placed over the gauze, and over all a bandage or binder. One or two layers of gauze or cotton may be fastened over a dry wound by means of sterile collo- dion applied to the borders of the dressing. Gauze may be impregnated with some antiseptic material, as iodoform or boracic acid, or either these or some other drug in powder form can be dusted upon the wound before the gauze is applied. Gheese-clofh may be bought from the dry goods houses at from 2-| to 4 cents per yard. To prepare for use, boil for fifteen minutes in a solution of carbonate of soda, 1 dram to 1 o.uart of water, and then for one- half hour in clear water; cut into sized pieces desired and put into an Arnold or Boeckmann sterilizer for one hour before using. It is desirable in transporting gauze after sterilization to put it in some sterilized glass vessel or iar. 10 MOKKUN TKKATMKNT OK WcH'NDS. lodoroiiii j^aiizr iiiav ln' ilius itrc}»ai"ed: Siilt solution soiipsiuls . 11 5 loclolnrin jK)\vtU'r I" 5 Sterili/inl g'ati/.c . . . ."> yards. Mix thoroujj^lily. Kiil> ilic solution \\r\\ imu tho nu'sbes and whou tii(»r«)U}^lil_\ iiupiciinalcd. loU loosely and keej) in colored y:lass jars. ^^'o prepare sterile ctdlodinn in this way: Ether (Squihh's), Aleoliol (absolute), . . aa 5 viss. To this add /// xvi of a s(t!ulion made by dissolving gr. XV of bichloride of mercury crystals in absolute alcohol ,') xi. Then add of "Anthony's snowy cotton"' sufficient to make a syru]». ! towels. If there is uo carpet on the iloor, this should be mopped. .\i though it is preieiable to take up a earpet from the tioor of u room to be used as au operating rot)ni, it is not essential, as the carpet may be s])rinkled with water, and that part unOer aud around ihe operating table protected with sneets. There should be no dusting or sweeping. A visit to the kitchen aud other rooms will result in the finding of an operating table, either long enough for the case in hand, or it may be made so by placing a small table at either end to suppoit the head or feet; in lieu of the small table, a box rested upon a chair does very well. In most cases a table suHiciently long to sup- port the head, trunk, and lower extremities as far as the flexure of the knees will do. A short kitchen table can usually be lengthened as described so as to answer the purposes of au operating table better than can the usual extension dining-room table, which is too wide for efficient aid from an assistant when, per- haps, it may be most needed. When the Trendelen- burg posture is required and the surgeon has not at hand a Krug frame, or some similar contrivance, the difficulty is easily overcome by tightly pinning a folded sheet or blanket around the four legs of a stiff-backed chair, the sheet or blanket being so fastened that it covers well the bottom of the chair legs. When the chair is placed upon the table in the position of a ''bed- rest" it makes a frame upon which, with the legs hang- ing over the pinned sheet or blanket, a Trendelenburg position of from 40° to 45° is obtained. One table is selected upon which to ]dace iusti-u- ments; another for dressing and sponging material. Most any piece of furniture having a flat top will do (juite as well as a table for these purposes. Chairs should be placed convenient to both the operator and bis assistant, upon wb.ich may be placed bowls to con- tain boiled water or antiseptic solutions in which their hands may be dipped from time to time. The an- esthelizei- should receive the consideration of a chair. ritJoi'AiiA'roiiv: ,suJt<;jUAL teghmquio. 13 111 the liouses oT llio very poor, one or two cliair.s, u box, and even the llooi- may be made to answer all iie- cessiLie.s. Dismfcction of the t^lcin of I lie J'allcnt. — VVlieu Lbe nature of the ease allows two or three days prepara- tory (reatment, the })atient should be given Houui in- ternal medication to stimulate the physiological func- tions of the skin, and also one or two immersion or sponge baths. During the baths sjjecial fjains must be taken to thoroughly cleanse the area of a proposed operation wound. Especially ought this to be insisted upon when either the feet, umbilicus, or hairy parts of the body are within the field of a proposed operation. On the morning of the day of operation, or the even- ing before, the skin immediately over and for a rea- sonable distance around the site of the operation must be scrubbed with soap and water, shaved, and then washed with ether or alcohol. It should then be covered with towels or pieces of clean muslin or cheese-cloth which have been saturated in and then partially rinsed out of a solution of bichloride, 1-1,000. It is well to cover this with florist's oiled paper or some other impervious material, as rubber tissue or oiled silk, which has also been washed in a bichloride solution. Over all apply a bandage. 14 MODEUN riM'.Ar.MKNr t)l" WtU NHS. CllAl'TKK 111. OPEKATIVE AM) ACCIDKN TA l> WOINDS. Ojxnitivc (1)1(1 Accidental Wounds. — WOmuls may be convenienlly classified intd those made by the sur- geon aud those not made by the surgeon. In the first class, when the nature of the wound from its bottom to surface is through non-infected tissue, the rei)arativ A<;(II)|.:.\ TAI. WOUNDS. 15 and lliis unne<"('HHai'y a.mouiil oi' lymph actH niccliajiJc- ally ill prevcnliiif;- aooniate ajiijroxijnation of raw mir- faccs one (o anollici'. IJcsidtts an amount of lympli in excoHH of llial rcfuiiicd for I he roparal ivo ])i-ocosrf is an excelleni cull me medium for the growth of any gerniH vvhieli may have neenred lodgenvnt iti the wound and i-cMuaiued ujiliarmed by I he ciiemical in tlie irrigating fluid. By this it is ])lain that this trouldc can be avoided by careful attention to aseijsis. Control of Hemorrhage, and Suturing Wounds. — When practicable, all bleeding should be controlled l)y for- ceps pressure, ligation with catgut, torsion, or hot water, and the wound sponged dry before attempting to approximate its surfaces. The deeper portions of the wound may be approximated by buried, inter- rupted, or, better still, continuous catgut stitches. The skin surface can be sewed so as to accurately bring the edges together, either by using interrupted stitches or the continuous stitch; sometimes a com- bination of both. Silkworm gut and silk are prefera- ble for the interrupted stitches, and catgut or flue iron- dyed silk for the continuous line. Whenever flne silk is used as a sewing material, the iron-dyed is the best, as it is more easily seen, and therefore can be more ac curately and neatly used than white silk. When there is little tension in the deeper portions of a dry wound the skin may be sutured and the deeper parts suf- ficiently brought together by the gentle pressure of suitably arranged dressings and bandages. When the deeper parts of a wound cannot be brought together from the bottom up, enough blood may be allowed to escape from the vessels to fill this space, and the skin closed by accurate suture. By proceeding in this way we take advantage of the well known method of repair called ''healing by blood clot." In this the clot acts as a mold into which the leucocytes and connective tissue corpuscles and derivatives in the exudate from the wound surface penetrate the clot. As a result of their combined action, connective tissue is developed throughout the clot, which is said to become organized. In this process the clot merely assists the cells, both as a framework and as a food supply. IG MODERN TRKATMKNT 01' WOUNDS. It is not wise to shut ulT parts of a deep wuiiiid lium Others by means of buried sutures, when by so doing spaces are left which do not join each other from the lowest to the surface, because, should by ehance in- fection have taken place before the closure of the wound, strong barriers are built against the escape of pent-up poisonous materials, with consequent local, and perhaps constitutional, disturbances. A drain made of sterile gauze or rubber tubing should be placed so as to facilitate the escape of any super- abundance of lymph or blood likely to accumulate in pockets. This drain should not be allowed to remain longer than twenty-four, or, at the longest, forty-eight hours. It is often wise to favor rest by the use of splints, even where no bones or joints are involved. Wounds of the face and neck should be closed with the most painstaking care, using buried catgut stitches for deep wounds, and for the skin the subcuticular stitch of Marcy ("blind stitching" of our grandmothers). Very fine silk, tendon, or catgut introduced with a well- curved needle may be employed for the skin. It is better to dispense with the needle-holder in making this stitch. A cotton or gauze collodion dressing aids in the accuracy of the approximation of the skin edges, and, in special cases, it may be a good plan, in order to secure rest after closure of extensive neck wounds, to steady the head by a plaster bandage passed over copious padding around the neck, head, and shoulders. In operation wounds in which it is necessary to sacrifice a considerable area of skin, it is often well to dissect up the flaps from the underlying tissue, in order to allow of the easier approximation of the edges. Before sewing the edges together one or sev- eral tension sutures should l)e introduced after the fashion of the quilted suture. Tension F^itturef<. — An iodoform gauze pad should be placed on the skin under the loop, and also between the free ends of the suturing material, be- fore making traction and tying. This widens the areas of pressure and prevents the suture from cut- OPBKATIVE AND AO(!1D)0.\'1'A I> VVOI.MiS. 17 ting. When i(; is imj>OHHibl<' lo dinw tlio <,'(J^'fs of u wound together, or wlien hy doing ho the niilrilion of the flaps may be in part destroyed, it is well to close the gap as much as possible without employing too great tension upon the flaps. After doing this, the raw surface may be covered with skin grafts, either immediately or after the formation of granulation tissue. It is possible, by painstaking asepsis, to bring about repair of these open wounds without the fonn;' tion of pus. Dressing of N on- Suppurating Wounds. — Aseptic wounds, from which no leakage is expected, may be sealed v/ith a collodion dressing and further protected by small quantities of dry sterile gauze and cotton, secured by a bandage. Six or eight thicknesses of dry sterile gauze in the form of a pad, somewhat larger than the field of operation, may be put directly over the wound. Absorbent cotton is placed over this and the dressing is fastened by the bandage. The cotton should be liberal in quantity and should cover any bony prominences which may be encircled by the ban- dage or binder. When drainage has been provided for, the gauze dressings should be heavier and some impermeable material, such as florists' paper, rubber tissue, etc., which has been placed in a 1-20 solution of carbolic acid, or a 1-.500 solution of corrosive sublimate is spread out between the gauze and cotton. This pre- vents infection of the wound, which might result from a putrefaction of the discharge, the germs gaining en- trance from without. In that class of aseptic wounds in which it has been impracticable to suture the skin over all of the raw surfaces, the dressing should be the same as just described, with the addition of a second piece of sterilized rubber tissue, slightly larger than the raw surface, which is placed directly upon it. The rubber prevents the gauze from sticking to the wound. Numerous openings are cut in the rubber tissue to allow of the escape of the secretions into the gauze. This same form of dressing is essential if skin grafts have been used. Behavior of Supposedly Aseptic Wounds. — After the 18 .\iiiiii:i;\ 1 i:i:ai'.\ii:n r oi' \V(»inds. closuir and clri-ssin^^ of \hv class of wouiuls uiuler roii- sideratioii. ilu'if may W a (,'t»iiij>U'i(' abseiu'c of pain, or only a little smarting complained of, the tempera- ture leniainiug at normal, or slightly above normal. Shonld the temperatni'e be 101" Fahr., or higher, and pain in the wound eomi)lained of after forty-eight hours, especially if the tongue is coated aud the patient is restless, the dressings should be removed and the wound inspected. If there are no signs of inlhimmation, the condition is probably due to a lock ing up of the seci'etions. The dressings are replaced and a brisk cathai'tic administered. Should the tem- perature remain elevated after the bowels have moved, the cause is probably some suppuration in the deeper parts of the wound, and an avenue of escape should Im? made. This is done by removing one or more stitches, preferably at the most dependent part, separating the edges at this place and exploring the deeper parts of the wound with dressing forceps. Pus will commonly be found, and the tract made by the forceps should be widened by separating the blades of the instrument on withdrawing it. A drain should be introduced well towards the source of suppuration. Years ago it was the fashion to Siiueeze and irrigate such wounds, but experience has taught that they do better if a drain is introduced and a wet antiseptic dressing applied. By following this practice there is less disturbance of the healing process in the uninfected parts of the wound, and the discharge is freely conducted out of the w^ound and rendered innocuous by mixing with the antiseptic in the moist dressing. This diessing is the same as that for an asei)tic wound where oozing is expected, and a single piece of oiled paper or rubber tissue i» used and placed between the gauze and cotton, only, in addition, the gauze is soaked in a fairly sti-ong antisep- tic solution, as 1-1,000 bichloride, and ]»arlly wrung out before being ai>i)lied against the wound surface. If the inflammation be superficial, whether there be ten- sion or not, enough stitches should be cut to allow of free drainage and the open part of the wound gently sponged with cotton soaked in a 1-20 carbolic acid OI'KKA'I'IV i; AND AOC;iI)I0.N"l'AI. WOIIN'DH. 1!) solution. Jodofonii powder dkiv Ix* diiHtf'd onto the wound, bill, ^ciHM-ally Hpcakiiig, all powdcrH tend to i'(^(ai'd lu'alinj;- W.v niixiiij^ willi ( he HccrctionH and foi-rn- ing cnisU under wliicli discliaiges are retaiued. Tlie wet bichloride dressing is best in the early stag&s f)f these ]»aialiply the dressings. Treatmcfit of Infection of Supposedly Aseptic Wounds. — Should, however, other parts of the wound, either at the edges or stitch-holes, show a further infec- tion, even if only slight, the stitches must be taken out. If pus does not show itself at the stitch- hole openings upon pressure, the lips of the wound should be gently separated and a smaller or greater amount of pus will be found. A deep wound af- fected superficially in this way, without much swell ing, deeply situated pain, or elevation of temperature, should not be further disturbed by opening it up. An attempt may be made to thoroughly destroy all germs present, both on the infected surfaces and in the tis- sues themselves, by using some strong antiseptic, which also has cauterizing properties. In liquid car- bolic acid we have such an antiseptic, and the pain and cauterizing action of the acid can be immediately con- trolled by applying alcohol directly to the surface upon which the carbolic acid is acting. For open surfaces, the acid and alcohol is applied on cotton held in a dressing forceps. For stitch-holes and small cavities and tracts, the acid and alcohol can be easily made to reach every point if applied upon cotton wrapped around a probe. After such treatment, a moist anti- septic dressing should be used and changed daily. It may be necessar^^ to employ the carbolic acid and alco '20 MODERN TREATMENT OK W»)l NDS. hol a second time. Iodoform gauze may be used \\\[h advantage as a material to be gently packed into the wound. The iodoform aets by modifying the action of pus-producing germs, although it does not prevent these germs from multiplying; the gauze acts as a drain. Should the whole, or a greater part, of the wound become infected, it should be opened up from top to bottom and managed as indicated abt>ve. Should thei'^ be a tendency to sloughing, with maceration and putrefaction of sloughs, there is no agent which will check this so (juickly as formalde- hyde (40 per cent, solution). Of this we use for s])Oiig ing and irrigation, a solution in water, of a strength varying from one dram to one ounce to the quart. If wounds remain aseptic and drainage has not been em- ployed, dressings need not be disturbed for from five to ten days, according to the character and position of the wound. Stitches and Their Extraction. — Usually stitches have served their purpose at the end of these periods, and should be removed. To remove an interrupted stitch it should be cut close to its entrance into the skin on one side and then, with a forceps, it is ex- tracted by gently drawing the long end toward the side which was cut. By taking out threads in this way there is little danger of separating the lips of the wound, should union be weak. The extraction of interrupted stitches is made easier if the knots are all tied upon one side. This tying is done by drawing one end of the stitch, after tightening the first loop, towards and across the wound, thus bring- ing the knot almost directly over the point of en- trance of the other end of the stitch into the skin. In wounds of the scalp, and often in other localities, it is especially desirable that tension upon the stitches should never be allowed, that is, post-opera- tive tension due to inflammation or the accumula- tion of fluids under the flaps. To prevent this, and still at the same time give accurate and sufficient sup])ort for normal conditions, interrupted stitches of well- softened silkworm gut sliniild be iis<'d. One end of the (»i'i<;):a'I'i\'K and aocidiontai. wor-NDS. "il sdtcli is carried Lwicc around Llie oNk-i- and lighu-jiod directly acrosH the lips of the Avoiuid. This is the ''surgeon's knot," without the final or fasten! jig loop. These slilehes give sufficient supjiort for normal i-e- ]»air, but will give away under abnormal tension. In removing a continuous stitch it should be cut along one side close to every skin puncture, and the sepa- rated parts removed as are interrupted stitches. The subcuticular continuous stit(;h, used for api)roxirna- tiou of skin edges, is removed by making traction upon one end. Stitches of absorbable material should not be interfered with, unless they j)roduce irritation, when no time should be lost in taking out every parti- cle, for they serve too well as culture media for germ growth. Aftei' the removal of stitches it is often well to give support to the newly repaired wound by using collodion, or where a strain may be expected, adhesive plaster is useful. Especially made binders are almost essential for the support of long wounds through the abdominal walls. Many surgeons insist upon their patients wearing these supporters in order to prevent the formation of hernia, which is apt to occur in a small percentage of case^ after abdominal section. In fat subjects and those having much lifting to do, the sup- port should be worn six months, or even longer. Min>i:i;\ iiji:a I'.MKN r or wounds. (MIArTEii 1\ . '.h'i:k.\ii().ns on infected tissues. W imiiils Madt into Infcclcil V'/.vm/c.v. — NN'hcii il is ucc- I'.ssarv ii)ening extending from the bottom to the surface. A drain, either of rubber tubing or iodoform gauze, should be inserted, and if after forty-eight hours thei'e is comi)lete i'vidence of the absence of inflammation in the wound, the di'ain ought to be removed. This diain acts as a safety valve, should the effort to obtain primary repair prove futile. In eithei- case, the di-essings and ti-eatment should be as indicated for non-infected wounds, or those made by the surgeon in which a faulty techuniuc was rewarded by more or less infection. If an incision is carried directly through inflamed tissues, although there is an absence of surface sup- puration, the prime object of the use of the knife \\(>ul(l lie lost unless the wound were kept open. These incisions, whether single or multii»le, long or short, are made for the purpose of relieving tension, and for the evacuation of fluids whose retention may, in a circumscribed or spi-eading fashion, tend to cause pail), jirolong illness, or even threaten limb or life. Tliloyed and OI'IOKATIONS ON I N I'MO* I'l'IOI ) 'IMSHIIKH. 23 llie j^i'cateHl; car<' iw (jsHciiliaJ, (lial. while u iM.'parative proccNSH is Kiipi)laulin<^- tlic iiillaiuinatory orio in the infeclcd tisHucs, no liiiidrancc slioiild ]>(' allowed 1o the free escape of all scercHioiis from llic de<'])('st iTT'eHsc'S to the skin edge. In acute cii'cuinsci'ilted inflamniatioiiH, with the more or less com]»lc(:e breakiiij^' down of all of the lissnes involv^ed, it is usually sulTi(Men(, after an incision, to gently irrigate the Avound cavity with an antiseptic solution of medium strength (bichloride, 1-2,000) and drain by using a light iodoform gauze ])acldng, the discharges being received into a moist antiseptic dressing protected by some impervious covering. The dressing should be changed daily until all signs of inflammation have disappeared; usually in from two to five days. Then it is better to use as a drainage ma- terial a. strip of iodoform gauze soaked in castor oil, or in castor oil and balsam Peru, 5 to 6 per cent, of the latter. Sterile p-nnze is usually quite as efficient as the iodoform gauzc, and much cheaper, but gener- ally it may be stated that until granulations begin to form for repair, iodoform gauze is better. A good sized piece of sterile gauze soaked in the oil dressing is placed over the end of the gauze drain, and over this is arranged some oiled paper or rubber tissue, and over all, cotton and a bandage. This dressing need not be changed oftener than every second or third day. Irrigation is unnecessary, as there is nothing to wash away. All of the discharge finds its escape along the drain into the medicated dressing under the impervi- ous protective. There is no drying out and sticking of the dressings so that discharges are pent up and de- composed in the wound. Gradually, as the wound fills from the bottom, the dressing should become smaller in bulk, and as the granulations reach the surface of the incision, it should be allowed to close. This may be aided often by drawing the edges towards one another, using adhesive plaster. Before applying the plaster the wound must be protected with some light non-irritating antiseptic dressing. Boracic acid oint- ment of about one-fourth strength spread on lint or 3 -i Mi"»r>EnN rriKAiMioN'r of \vi»i nds. sicrilr ^aii/.»- is ail txii'lli'iii drt-ssiii}^- at I his stage of the wound icpaii-. In infvctiotis iit/ldiniitdtions 'nnolvimj consiilt'rable areas, as, for instance, in more or less diffuse cellulitis of the exti-einities, or of the parts involved in extrava- sation of urine, the only hope of limiting the spread of the inlhinunatorv process is to establish free drain- age by suitable incisions. Such wounds have to be kept open, using large fenestrated rubber drainage lubes or gauze. The rubber tubing is ]>ref('iable, and often it is good jiractice to connect well placed open- ings by the same piece of tubing. Gentle pressure and irrigation with some antiseptic sohition is useful to remove pus and debris. Little good is to be expected from the irrigating fluid except its mechanical action. So, usually, it is best to limit this interference with repair to the purposes mentioned. Copious moist an- tiseptic dressings are essential and these must be re- moved every twelve to twenty-four hours until it is evident that inflammation has ceased to spread and that repair is well established. In addition to the tubing, gauze may also b(^ employed to aid in keeping the incisions from closing too soon, ^^■hen, as a result of the incisions, dressings, etc., the intlainmation has become a local one, the conduct of the after treatment should be along the same lines as advised in acute circumscribed inflammations. It may be evident, from the virulence of the inflammation, that more severe measures of treatment are necessary, either after the line of practice for the management of sup- jturative cellular inflammation has failed to stay its spread, or where from the first simple incisions for the purpose of drainage were recognizedly insufhcient. Open Drainof/e for Disinfeelion. — T'nder such circum- stances, it is often the best practice to lay the parts wide open by fiee incisions, not only with the purpose of gaining absolutely oi)en drainage, but also an ap- portunity to mop the infected tissues with liquid car- bolic acid or tincture of iodine (])0ssibly somewhat diluted with al<-ohol). These strong antiseptic agents will usually i)enetrat«' so as to destroy the infecting onOHATIoNH OX IM''IO<"I'IOIJ 'I'ISSIIKH. 25 (ik^iiu'iil and as a icsiili cHlahliHli Ji r<.'piii'al,ive in tli<; place ol' an inreclivc proccHH. DrcsHlng After Disinfection. — Iodoform gauze is t Ik- best material to lightly pack into Uuw. wounds, anrepared by the method given for an antiseptic operation. In addition, the lips of the wound should be se])arated and the raw surface disinfected. Great care must be taken to re- move any foreiiiu nuitcrial, and esi»ecially sliould this be insisted upon if the circumstances of the in- jury i)oint towards the jtossibility of street or stable dirt having gained entrance into the wound, because of the dan.uer of the presence of th.^ telanus bacillus in such din. Under these conditions, th:- disinfection should be most thorough. Alcohol, liquid carbolic acid, and tincture of iodine are among the most useful agents for this disinfection. If the surgeon is reason- ably certain that he has a clean wound to deal with, it ought to be sutured and some suitable antiseptic dressing applied. Under all other circumstances it is wiser to leave the wound, in part at least, unsu- tured. An antiseptic dressing must be used. If af- ter a few daj^s there is complete absence of inflamma- tion, the wound may be closed by suture or the edges approximated with adhesive plaster drawn over anti- se])tic gauze apidied next to the wound. If infection has taken place, the treatment should be as already described for similar conditions. The nature of an accidental (possibly homicidal or suicidal) incised wound may, from its anatomical lo- cation, prevent any ])riniary attemj)t at cleanliness, because of threatened danger to life from hemor- rhage, but after this has been overcome, thorough an- tiseptic details should be followed. If nerve tninks or muscles have been divided the ends should be care- fully sewed to their proper fellows before closing the wrund. These kinds of complicated incised wounds AC(1(I)10N'I'A1> WOUNDS. 27 ai/e most olteii seen near joints whci"<; muscles, Loi- dons, and nerves are situated in shallow spaces be- tween the skin and (lie bones. Incised wounds of si)ecial parts of I he body must be dealt with according to the recognized surgery of the particular structures or organs involved. Categorically speaking, it may be stated that the control of hemorrhage should be the first object. The second should be llic removal of all foreign substances, as dirt from without, or, in case of a wound of the intestine, soiling from within. Third, after thorough cleansing, all damage should be most painstakingly repaired. These must be dealt with before any attempt at closure of the outside wound is undertaken. Simple contusions, or hruises, are best treated by hot water, used by immersion if the injury is of an extremity. When the head or trunk is the locality injured, cloths wrung out of hot water and frequently changed are very effective. Tliis treatment lessens swelling, checks extravasation of blood, and relieves pain. After the first twenty-four hours, gentle mas- sage may be begun and continued daily. A flannel bandage applied directly to the skin, or over cotton or lamb's wool, is effective in giving support and in aid- ing absorption of extravasated blood and irritation exudate. Lacerated ivounds, which may be more or less con- tused or crushed, are of the most serious class of injuries the surgeon is called upon to treat. The ex- tent of destruction of both soft parts and bones is not uncommonly so great that the shock to the nervous system is overw^helming and causes death either immediately or within a few hours. Fortunately mild tearing and bruising of the tissues is the rule; the more serious injuries result from entanglement in heavy machinery, or the mutilation of limbs by car wheels. Shock. — Lacerated wounds, whatever their kind, require an especial examination. Before, however, expending any time further than to perhaps remove the clothing so as to gather a respectable idea of The 2S M(ti>i:u\ ruKAiMKNi" ok wor.Nns. charactiT ol ilu- injury, the general couditimi of ilic patient should be investigated. If there is iniiiked deran^aMuent of the nervous system, e\idenced by a small, unnaturally rapid i>ulse, paiiial miconseicuis ness. or an exhilarated state of, "riu all right," clammy skin and pale or ashen face, restorative meas- ures are necessary before any attention to the injury itself is undertaken, unless luMuorrliage is going on. When there is any hemorrhage, even though moderate in amount it should be checked, catching the bleeding vessel or vessels with artery clamps will suffice for moderate sui)erhcial bleeding, but when the blood comes from several vessels of large size and man}- small vessels, as may be the case in some injuries of the extremities, the best practice is to apply an elas- tic tourniquet so as to control the bleeding. If the patient's general condition is so bad that a furthei' examination might add to the shock, it is wrong to interfere. The shorter the distance a patient suffer- ing with severe shock is moved from the place of ac- cident to where he may receive first aid, the better. The essential restoratives are, — after checking bleed- ing and applying some protective antiseptic dressing, — absolute quiet, artificial heat, the administration of drugs. Des])erate cases require nice judgment, and in the administration of drugs to combat shock, the desire to do something often warps one's judgment. For many years alcohol and ojiium were the sheet anchors in the treatment of shock, but of late abohol is being discredited and not much is heard of o])ium. The hypodermic administration of strychnia is the remedy most relied upon, and in case of much loss of blood, its volume is replaced, in i)ait at least, by the intravenous injection of hot normal salt solution. The strychnia is given in doses of 1-8(1 gr. to 1-10 gr., repeated every one to four hours, Tr. digitalis, 10 m., 30 m. may be given hypodermically. Nitroglycerine. 1-100 gr.. and atr()]tia. 1-100 gr. are often used. It is the opinion of the writer that opium in the form of morphine is useful, in fact, a sine qua non in bringing about an equilibrium in the nervous system, it is also A(;<;n»io.\'i'Ai. wocxds. 29 51 i)OW('il'ul wliiMulunl. LivcH are occiisionall y Hacii- iiced by the administration (>f too many and too pow- erful ''heart f^limulants." Absolute quiet brouf^ht about by favoiable surroundingH and I lie use of juHt enough nioi'phine to Hoolhe the disordered nervous system are of more value than all rrhaji;if and t'Xiulative tliiids. If I lie suii;tH)ii's I'lVorts to remove all infection pro- duciii^- 8iil)slanees have* bci-n uusuceessrul, the drain- Aiif iuIk's alVord an fst-apc of inllannnatorv ]>rodiiets autl I he dan{4;er of eonstihitional i)Oisonin<^f and local intlannnatorv destruction are reduced. Copious irri- gations with some strong antiseptic Huid, as bichlo- ride l-r)(i(), l-KMM). or carbolic acid, 1-20. is demanded in the first ])reparation of the wound. Later, milder irrigating solutions can be used. Antiseptic dress- ings sliould envelope these wounds, and even when bones are uninjured, it is often wise to employ splints when the wounds are of the extremities, especially if in close proximity to joints. The quieter the parts are kept the (juicker the repair and more circumscribed any inllammatory condition that may arise. Lidivations for Ainpuiution. — iSometimes it is good practice to cut away certain soft parts, whose vitality is destroyed' but unless this tissue is merely hanging by shreds, it is wisdom to wait until nature has dem- onstrated positively the death of tissue. When, from the nature of the crushing force, combined with a care- ful examination of a resulting wounding of an ex- tremity, it is positively certain that the blood supj)ly is totally destroyed, amputation is demanded, and this operation ought to be done as soon as reaction from shock is established. This refers to profound shock, which nearly always exists when more than one ex- tremity is crushed or the injury is near the trunk, es- pecially of the lower extremity. When shock is not very marked and an extremity, or extremities, hope- lessly devitalized, the sooner amputation is done the better, as the removal of such parts lessens nerve irri- tation. Moreover, the danger of septic infection is reduced. If the blood supply left after one of these injuries is sufficient to keep up the vitality of an ex- tremity, it should never be amputated as a primary procedure. With our improved modern antise])tic sur- gery, the possibilities of repair are almost unlimited. In case of failure to preserve a useful limb, this may be removed as an operation of election. ACOiinoNTAi. woi;m>s. :',l Fourlli of July Acvidails. — There is n, roriii oT \ny gran- ulation. It ought to be borne in mind that any injui-y which leaves a foreign body other than a bullet in the tissues is liable to be followed by tetanus. Punctured wounds, whether from their anatomical location, they involve joints, organs of the chest and abdomen, the brain, or merely soft parts, are serious injuries. When the inflicting instrument happens to be a clean one the wound is less likely to be danger- ous than any other kind of wound, provided no vital organ is injured, t^ometimes these wounds cause concealed injury, such as opening into an intestine, or bladder, and the secondary inflammation may be fatal. The chief danger of punctured wounds lies in the fact that infective germs are introduced with the entering instrument, and the nature of the wound tends to re- tain these germs, so that they can gain a firm foot- hold. Wounds which bleed freely and allow of an open escape of blood are not usually infected at the time of their causation. Flowing blood does not favor germ implantation and growth. Punctured wounds, unless a large vessel is injured in the direct course of the puncturing instrument, seldom bleed much. What bleeding does take place usually extravasates around the track of the wound; therefore any germs which enter at the time of injury are securely placed for grovvth. Punctured Wounds of Hands and Feet. — Punctured wounds are met with most commonly in the feet and hands and are often followed by serious con- sequences. A deep-seated suppuration mav be set ',\2 MODKRN TRKATMKNT OK WOrNOS. Up, lomuu'iieiiig in the aponeuroses, decpor connective tissue or tendon sheaths, and because of the resisting structure of the anatomu al ariangeiin'nt, supi)uial ion cannol approach tlie siiita(c iiniil extensive iinolve- ment. even (h'stiau-tion. ol iioi unly the soft jiarts. hut also the bones has taken phice. Th 'i-e is invariably great jiain, greater oi- less swelling with dnskv red- ness. The lingers or loes soon lose ihcir motility, likewise tlte wrist, or even the ankle. If active sur- gical interference is not insiituled earl v. contraction of the teudons and palmar oi- plaiiiar aponeurosis follows with permanent disa])ility. In neglected cases, sujipuration ma.v extend upward c<)usiderable distances. High fever is the rule, and even such a grade of general infection nmy occur as to cause death. The pi-oi)er treatment of this form of inflammation is by early, fi-ee incision; tht* knife must be carried to the bottom of the infection and gauze or tultular drainage instituted. 'Sometimes several incisions are necessary. In using the knife, care should be taken not to divide tendons or the arterial arch(^s. These latter, however, are of minor importance. After di- viding the more superficial parts, the finger, or some blunt instrument, may be used to reach and open up the deei»er parts. Incisions shouhl be directed in the long axes of the tendons, never at an angle. These inflammations not infi-equently result from slight superficial abrasions sufficient to allow of tlie entrance of germs. Again, they may follow bruises without visible breaking of the skin. This is ex- plained by the fact that the bruise results in a cir- cumscribed lowering of the vitality of the tissues, and any germs ca]>able o-f exciting inflammation which may be i>resent in the circulatory oi- lymi)hatic channels in this locality, have an easy prey, the nor- mal resistance to germ action being overcome by the lessened vitality caused l»y the bruise. The treatment of all contused, lacerated, and punc- tured wounds belongs strictly to antiseptic and not aseptic, surgery. rUNOTUUFCI) VVOIINHS OF 'I'llK I'.KAIN. (UlAi'TEi; \'l. rUNCrURICI) WOUiNDH OF THE BKAIX. Clinically, tlicMc; injurioB seldom occur except through the orbital plate of the frontal bone. A very few rare cases have bo(Mi reporlcd of 11ie pniirhii-ing iustrunienl enU'riug' (hrongh the nosti'ils. An instru- ment may be driven through the skull at any part and wound the brain. A considerable variety of in- struments have been known to penetrate the brain by way of the thin orbital plate of the frontal bone, the most common having been umbrella sticks, canes, pieces ol wood, narrow-bladed instruments of war- fare, etc. The eye not uncommonly escax>es injury when the entering instrument fractures the orbital plate near the superior orbital fissure. In such cases, the wound first passes through the upper eyelid. A part of the imncturing instrument may remain in the brain. The injury to the brain is usually confined to the frontal lobes, but may involve other parts. If the brain is punctured through the optic foramen, the eye is almost certainly injured, and the optic nerve is necessarily crushed or divided, unless, perchance, the puncturing instrument is of very small diameter, like a hatpin. Besides any injury to the eye which may complicate these accidents, the main danger lies in the brain lesion. Not so much, usually, the im- mediate results from destruction of brain tissue, as the secondary inflammatory processes likely to arise as the effect of the injury. Hemori'ha.ge may be suf- ficient to produce dangerous pressure symptoms, but this will hardly occur unless the injury is through the floor of the orbit tow^ards the vessels at the base of the brain. The treatment of these injuries should be directed towards an exposure of the injured parts sufficiently extensive to enable the surgeon to examine carefully for the presence of a foreign body when from the his- 34 MODKRX TREAIMKNT OF WOUNDS. toi'jT of tlir i;is(.' siuli a body may liave remaiiieil in the wouiul. The surjreou slionld not limit his inter- ference until he has cleared a i)assag;e for careful irri- {^ation and draina}i;e of the injured brain. Allhouji^h it may be necessary to boldly open up the skull iu linni of and above the track of the wtuind. usually it will suflice if, after shavin*;' the eyebrow and using the usual antiseptic preeatitions. the orbital plale of the frontal bone is exposed by making; a free curved incision along the upi>er (nlge of the orbit down to the bone, separating the loose, celltilar tissue, and depressing the globe with a small Hat retractor. By this means sullicient spaei- will be secured for the exposure of the wound. With small chisels the open- ing through the bone is enlarged sufficiently to ex- plore the wound and provide for drainage. The accom])anying ]»hotograph was taken from a child that had fallen upon a rusty, dirty buttonhook with which it had been playing. The hook end of tlie in- strument had passed through the upper lid, the or- bital plate of the frontal bone, and into the brain. The hook had in some manner rotated so that it was necessary to remove considerable bone before it was extracted. The writer followed the practice just rec- ommended and recovei'y was entirely satisfactory. Should the brain bo punctured through the optic fora- men, the eyeball must be removed to admit of proper exploration and drainage. Tn such a case, even if the globe of the eye is not injured, the optic nei've probably is, and in any case it is better to sacrifice the eye than to invite secondary inflammatory condi- tions in the orbit, and maybe in the brain. A good general rule would be that in all cases, the bottom of the wound should be explored and drained by the most direct route, preserving the integrity of an uniu jnred eyeball when possible. Tf the eyeball is wounded and ])robably infeoted it should be removed. The inflammatory swelling of the loose connective tissues of the orbit is a source of great danger. The swelling interferes with drainage, and inflammation may pass from infected orbilnl tissues along the track I'l.ATK II. Pmu-tured wound of the brain through the orbital phxto of the frontal bone. (From a patient in tl\e riarkson Hospital.) I/UNOTUItl'M) WOIJNI>S <)[' Till; IIUAIN. ...) of the wound to the brain. Wlicn praclical>l(', I h' counHcl and aKHislance of an cxporl o(;culiHt hIiouM always bo soii^^bj in llif Ircaliiiciil of Ihesc compli- cated injuries. In those rare wounds of llic brain lliroii^h I lie nos- trils tlie base of tlie bi'ain sliould lie frecl.v exposed hy inalving an opening ihrongli the fronlal lionc. Mo»t painstakin};' antisepsis most be employed so as to limit probable infection derived from llie nasal nd away from tho lieart and clu^st (;onter, the pi-csninpiion is that comparatively little danger is to be anticipated, es- pecially if all symptoms of hemorrhage are absent. H!/iiif)foms of JTcviorrhage. — The raising of bloody sputa proves pretty well that the lung is injured. The more or less rapid accumulation of fluid in the pleural cavity indicated by the physical signs of hydrothorax or hydropneumothorax, accompanied by the usual general symptoms of internal hemorrhage, proves that blood is accumulating in the pleural cavity. If the force, size, and direction of the bullet or cutting tool indicate a lung injury, especially if some blood, even a little, is coughed up, the source of hemorrhage into the pleura is probably from a wound in the lung. The pneumothorax may come from inspired air or from air being sucked into the chest through the wound in the chest. Hemorrhage from the wound, if bright red and spurting or active, comes from an intercostal or internal mammary ar- tery; if dark and flowing in character, it is probably from the lung. Emph^'sema, when present, usually comes from air which has been inspired. The air may have come from without into the wound. The greater the shock the more serious the injury, especially if the temperature is subnormal. In a recent case of the writer's where there were two wounds made by a large bullet, the wounds of entrance and exit being five inches apart, he was able to demonstrate that the lung was not injured. This proves that in rare instances it is possible for a wound of this character to exist without perforation or even grazing of the lung. Wounds of Perkardium and Heart. — The differential diagnosis between wounds of the pericardium and wounds of the heart may be insurmountable. In both there is apt to be sharp pain, more intense if the heart is injured. Dyspnea is more marked if the heart is injured and the physical signs of the presence of fluid oS MODERN TUKAT.MKNT Ol' WOUNDS. ill ihe iH'ricaitliuiii ;irc pi-cscin aliimsi iiiiiiKMruurly and iiicicast' ia|ti(lly. In jn'i-icarilial wonnds ihc cardiac syncoin' is not so j^rcat, lu'causc ilicic is less rapid accuinulation of blood in the sac. A wonnd of [he lu-ai-t may of itsolf cause death almost immediately or in a short while, hut when death is delayed a few hours it is usually due in great i>art to overdistention of the pericardium with blood. Death may result from sec- ondary inflammation. In wounds of the ])ericardium death is due to the same causes. The trcntiiicnt of penetrating wounds of the chest involving the chest wall and lung is usually best limited to the internal administration of opium and the local ai>]>lica1iou of a primary anlise])tic dressing. If the chest wall is at all lacerated, hemorrhage should be controlled, all loose fragments of ribs and any for- eign body discoverable removed, and drainage pro- vided. If a ball has passed through the chest and lodged under the skin, it can be removed, but it is folly to probe or explore with the finger in order to discover a bullet in the lung. There is great danger of setting up hemorrhage or inflammation. Sec- ondary operations within the pleural cavity, or even the lung, are safer than too active interference in ])rimarily dangerous injuries. Unless dyspnea points towards impending death from the loss of blood and its accumulation in the pleural cavity, surgical inter- ference is not indicated. Absolute rest should be en- joined, ice applied to the chest, and opium and ergot given internally. If the source of the hemorrhage is thought to be an intercostal artery or the internal mammary artery (we can tell something about this from the relation of the wound to the ribs and its l)Osition in the chest), it should be exposed and tied. Aspiration or incision for the evacuation of blood from the i)leural cavity may be practiced if suffoca- tion threatens death, but in these cases death may follow from a continuance of the bleeding. Under such conditions there may remain nothing to ])iomise hope other than a bold resection of a suflBcieul nnudier PHNPJTKATINO WOtlNDH 01' TlIK (;UKST. I'D of ribs tO' allow oi: Iho puckiii}^ into Iho pleura and against the lung of a sufTicienI; quantity of nterile gauze to control Uio hcniorrhjigo. rneumotlioi'ax and .\1 i;.\ . 11 iiijui-i<"H, and, if roiiiHl, llicy slioiild Ik; i-(*j>;nr<;(l \>y lli«i simplest and mosl rapid methods coii»iK((!nt with ac- curacy. It is O'fteiilimcH im|K)ssil)Ie lo tell if a viscus lias been wound(Hl, no mailer what the Hhai)e of the offending instruments or the locality of the wound where it was forced through the abdominal walls. There may be little or no shock or symptoms of hem- orrhage, and yet extensive trauma exist. The; many differentiating signs between involvement and non- involvement of the various abdominal viscera after penetrating v^ounds of the abdomen are valuable, but all are unreliable and not absolutely to be depended upon, and there are no means, short of abdominal sec- tion, by which this can be positively determined. Stab wounds are more likely to be follo-wed by hemor- rhage than bullet w^ounds; yet the instrument does not so often injure the bowels, especially if they are comparatively empty. The swift-moving bullet en- ters the intestine whether distended or empty; thi cutting, slowly moving instruments may simply push them aside. The use of hydrogen gas, as recom- mended by Senn, is perhaps the most trustworthy method of determining whether or no the stomach or intestine bas been wounded, and also of determining whether or no all of the openings possibly made into the viscera have been sutured. The employment of hydrogen gas in these cases is more scientific than practical, and when shock predominates its use is contraindicated as consuming too much time. Prog)wsis.* — 'The most recent statistics of the results of operations for stab wounds of the abdomen (Gas- ton's tables) contain twenty-eight cases in which ab- dominal section was done, with sixteen recoveries; of this number, nineteen had wounds involving one or more of the viscera and of these ten recovered and nine died. If it is known that a cutting instrument has en- tered the abdomen, the wounding of the viscera is to be assumed, yet '^penetrating wounds of the abdomen * The writer recently operated upon a young man for a stab wound of the abdomen, who recovered in spite of the fact that leakage had oc- curred from two wounds of the transverse colon. The operation was done within two hours after the injury, hence the recovery. il* ilOUKli.N TKEATMBNT OF WOUNDS. wiihuiil si'i-ious vist'(-*i-al injuries aiid without the pres- euce of a. septic loreij;u body in the abdomiual cavity are fretiueiitly followed by recovery without resort to intra-abdominal treatment." In fact, in about 10 per cent, of all pi'nelraiiujjc wounds of the alulonien the viscera escape injury. This well-known truth that very many persons whose abdomens have been jjunc- tured by jagjred, blunt, or sharp-pointed instruments have gotten well without snrjiical interference brings us to what may b<^ considered the most important part of this subject, and that is: When it is uncertain what the extent of the injury may be, whether or no any viscus is wounded, we should resen^e explorative measures for the determination and the repair of such injuries to the hands of a trained modern surgeon of experience in the practical workings of aseptic sur- gery. The services of such a man can always be had nowadays, or, circumstances possibly preventing, a young man who has been taught practically how to do intestinal surgery upon the human cadaver and liring animals, and has acted as assistant in hospitals or private practice to men who do clean work in the strictest sense, should be called. The management of these grave cases should not be trusted to any oth- ers. It is rather amusing to read from time to time about abdominal suigery upon the battlefield. Of course, these effusions come from men who never saw a battle, except in prose, verse, or upon canvas. As the perfection of modern war implements has not yet done away with the saber and bayonet, it is to be ex- pected that incised and punctured wounds of the abdomen will be inflicted in future wars, and perhaps some of them come into our hands for treatment. For this reason the writer ventures to call attention to the opinions of his preceptor, one of our leading au- thorities in such matters Dr. Wm H. Forwood, United States Army Professor of Surgery in the Army Medical School. The opinions of the doctor refer more especially to gunshot wounds, but apply to the class under considei'ation just as well. He says in substance: IN(HKI*]I) AND I'lIXO'l'lIIlIOl) W0.\I i; N. l.{ ''Jiapar()4()in.y I'ov j.>,imsliol wounds (>{' I.Ik; ubdoiuijial viscera, unlike many other operations in military Hur- gery, will always be greatly restriclod in ils njtjdica- tion and usefulness by the very exiicling cojiditiijns necessary to success. Wounds id the; viscera do not admit of delay. There is no way to prevent, sepsis, as in external wounds. The time that may elajise before an operation must be done is limited to from three to five hours, after which the chances of suc- cess diminish very rapidly. ''The operation must be done at the hospital, in a warm, quiet room, protected from wind and dust, with good lights, competent assistants, plenty of time, and the advantage of the strictest antiseptic precautions. Very exceptional qualifications are demanded. of the surgeon. None but those having skill and special training in this line and who have had considerable experience at least on the cadaver and on living ani- mals should dare undertake it. The mortality from laparotomy for gunshot and stab wounds of the in- testines done by inexperienced operators will be much greater than that under the expectant plan of treat- ment. Except in siege operations, the hospitals will very rarely be established in time to offer the benefit of this operation to those wounded in the early part of an engagement. Very few of the severely wounded will be able to reach the hospital under or- dinary circumstances within five hours after the re- ceipt of their injuries. Men with penetrating wounds of the abdomen suffer from shock and hemorrhage, and often have to remain for a time on the field, and they usually have to be carried long distances on lit- ters. Such cases are brought to the hospital in the evening, or during the night, when the difficulty of operation is increased by want of proper light, or more frequently not until the following day. when it is too late. An operator with requisite skill and ex- perience will rarely be available, and when there are many wounded, the services of two or three of the best surgeons for an hour or two of precious time can seldom be given to the doubtful benefit of one among 4 ! MODKIt.N riaiAT.MENT oK WulNDS. a uuiiilifr of lilt 11 ui-<,M'iitly iict'din^- assis(aiK-o. Bat- tk's- ii'sull ill ili'fcat as well as in vii-tory on ono side or (he oilior. and among the wounded prisoners llio benelit of laparotomy will hardly be realized, al- thouffh some autemortem abdominal sections may be made by well-meaniu}? surjreons with more zeal than discretion. On the whole, the outlook for future operative interferenee in cases of penetratinj^ wounds of the viscera on the battlefield is not very promising;. But still there will be exceptional cases and especially favorable circumstances where this ]>rocedure may become practicable." Technique. — Fine iron-dyed silk and ordinary round sewing needles are the best material for closing wounds of the intestines, and if the wound is over one centimeter in lenjith we can use the continuous Lem bert sutures, otherwise the interrupted. If there is no hurry, it is best to use a double row of sutures. If the trauma demands excision of any part of the gut, and if there is no great urgency, end to end anastomosis by suture is a good method, — if the case is urgent a Mur- phy button may be employed. Blood-vessels may be tied with silk or catgut. Wounds of the liver should be sutured, or the wound of entrance may be tanii)oned, or if a through and through wound, an instrument such as a catheter may be passed through its track and a tampon of gauze drawn after it. Wounds of the spleen may be sutured or the cut sui-face^s com- pressed by a figure of 8 ligature drawn over the pro- truding ends of a threaded needle, passed at right angles across the w^ound. or the gland may be re- moved. Wounds of the kidneys should be drained by gauze packing through an incision in the loin, or it may be best to do a nephrectomy. Wounds of the bladder should be sutured and the abdominal cavity flushed and drained; indeed, flushing and draining of the abdomen is indicated after all ojterations for the repair of traumatisms of its contents. i.N'ruA-Ai;r>()Mi.\Ai- lkhioxs, 45 CHAPTER IX. TIIK 'rillOATMl':NT OK IN TUA-A I'.DOM IXAf. LICSIO.NS FOL- LOWING CONTUSIONS OF THE AJ5D0M[NAL WALLS. Falls, kicks, blows upon the abdomen, and \\u- [tas- sage over the abdomen of wagons, carts, etc., may result in simple contusion of the skin and muscles overlying the abdominal contents or else in injuries of the liver, spleen, kidneys, stomach, intestines, omen- tum, or bladder. Sometimes more than one of these is injured at the same time. Rupture of the ^pJcen Mor>i:uN trkatmiont ok wol.nus. six hours, besides the sviuplums of shock, pain, tender abdomen, and bloody urine, a tunioi- was easily dis- citvei-able in raili loin. These swellings lasted sev- eral weeks. Al'tei- ihe lirst twelve hours there was a gradual rise ot leniperalure, and this ranged from 100° F. to 103° F. for some days. The abdomen was distended and tender. There was an absence of some of the cardinal symptoms of peritonitis, especially those ot a sejitir character; however, we were some- what puzzled, and it was ditiicult to weigh the evi- dence. Later a ttuctuatiug swelling apjteared in the back on a level with the kidney areas. The greatest prominence of this tumor was in the middle line. I aspirated the swelling in the back and submitted the fluid to Dr. \V. K. Lavender for examination. He reported: "Specimen — Hpecihc gravity 1015; reatiion alka- line; color, yellow-reddish (V. Vogelj. "Centrifugal sedimentation. — ^^^edinient blood red; microscopical; (1) large number of i*ed blood corpus- cles in rouleaux, some crenated, others distorted (poikilocytosis); (2) quite a number of leucocytes, poly- niori)honuclear i)rincij)ally ; {'.\) a number of cylin- droids. A quantity of amorphous urate crystals. K. B, C. and cylindroids, with an occasional hyaline east, all of which are massed together by action of cen- trifuge. "Diagnosis — ^Fluid ])rin(ipally composed of blood and serum with decided presence of urine in speci- men." This man recovered without suppuration, although his convalescence was tedious. IL — A little girl, eight years old, fell, striking her right side against a dry-goods box. When seen a few hours later there was considerable shock, pain, and al^dominal rigidity. A tumor was readily felt in the right ileo-costal space. At the end of twenty-four liours the symptoms so simulated a commencing gen- eral peritonitis that an incision was made in the up- l»ei- (juadrant to the right of the right rectus muscle. There was no jx-ritonilis in spite of the ])ain, fever IXTIIA-AI'.DOMINAL LIOSIONS. 47 l()o° F., a.lxlomiiial (Jisloiilion, and Jiiu.scular ri^idily, but a large iiitio-peritoneal swelling (hematoma) waw disoloHed surrounding (ho kidney and Hoparating the peritoneum along i(.s lines of least resistance. The abdominal wound was sutured and an incision made in the loin, I'rom which was discharged a (juantity of blood and urine. A rent could be felt in the kidney. The wound was i)acked with sterih* gauze to control a rather dangerous hemorrhage. The child recovered, although it was about a month before urine ceased to escape through the wound. When a kidney is so lacerated that the hemorrhage accumulates in its pelvis the tumor is usually small and forms slowly, perhaps requiring several days be- fore it can be detected. In such cases either the amount of blood in the urine is rather excessive or because of a blocking of the ureter by clots little or no blood is found in the urine. When the ureter is blocked or injured so as to prevent the escape of bloody urine into the bladder the tumor may enlarge KRN ti{i:ai'.mi:m' of wot-nds. . cystostdiit' and mcit'ial erniit of a general ])eritoneal inf(^ction. in spite of an attemi)t n]»on the ])art of nattire to wall otT the injured bowel by mearis of a jilastic exudate. Ojx'ra tion was refused. Another <'ase seen for the lirst lime 1 wenty-foni* hours aftei- injury ])resented all of the symptoms of an approaching fatal termination, yet there was little distention. Death came six hours laier. On i>ost- rX'rUA-Ar.DOMINAf. LE8I0NH. 49 iii(»i-|('iii cxiiiiiinal ion, l)('sii:U\ rUKATMUNT OF wou^•D^^. (|iiantii.\ «>l' lilntidv uriiK', or if upou inlrodiiciug a raiheUM- ilu' sur^t'ou loiild romuvc only a lilllc bloody urine, tlie coiubiiicd history and lindinjjs would prove almost lo a certainty that the bladder had been rup- tured. The injection of a measured ijuantity of sterile warm salt solution through a catheter into the blad- der and lliis fluid immediately allowed to How out and be measured will determine i)ositi\('ly whether or no any, and how much, of the fluid may have escaped through a rent in the bladder. If the wound be intra- jterironeal and of large size, most of the salt solution will lia\-e i)assed into the peritoneal cavity. If the ^^ound be intra{)eritoneal and of small size, most of the solution will return through the catheter. There will be very little pain when the warm salt solution enters the i)erit()neal cavity. When the wound is extra-peritoneal, there will be considerable pain pro- duced by the forcing of the fluid into the extra-peri- toneal spaces within the pelvis and under and above the pubes. If air be injected by means of a David- son syringe through a catheter, it will, if the blad- der be intact, produce a circumscribed tymi)anitic lumor above the pubis. If an intra-peritoneal ruj)- ture is present, the air will enter the peritoneal cavity and its presence can be determined by an increasing tympany. When the rent is extra-peritoneal, the in- jection of the air is painful, and its presence outside the peritoneum can be determined by emphysema of the suprapubic and pelvic cellulai- tissue. When the w^ound is both intra- and extra-peritoneal, the symp- toms of intra-peritoneal rupture will predominate, as there is little resistance offered to the escape of the ni'inary secretion into the peritoneum. Of course, if the extra-peritoneal rupture is large and the intra- peritoneal rupture very small, the reveise will be the case. When a ru])ture of the bladder is both intra- and extra-peritoneal, there is but one wound (some- times stellated), the boundary line between intra- and (^xtra-peritoneal being the nearly horizontal line of I'cflection of the parietal peritoneum onto the bladder. I'suallv twentv-four to forty-eight hours after an IN'I'UA-AI{|J(JM1NAI. 1>I'J.SI(^NS. 51 -intra-pei'iloiK;;!! nipliiro Hyinptoiim of pciiionii is de- velop and deulli i'ollowH. If, liovvover, the uriiK; and ui'iuary passages were normal prior to the accident and no infeetiou is introduced by means of a catheter, sterile urine will enter th(» peritoneal cavily and there will be no i)eritonitis. In one of the writer's cases one gallon of urine and some clots were removed from the peritoneal cavity five days after the accident. There was no peritonitis. Extra-peritoneal rupture is almost invariably followed by a dangerous su[)purative cellular intlammaiion involving the suprapubic and pelvic retro-peritoneal spaces. Should the patient survive long enough and the inflammatory products not be evacuated by art or nature, they will extend to the anterior wall of the abdomen. TREATMENT. The few illustrative cases given have been intro- duced merely as aids in building a framework upon which to construct a rational practice in the medical and surgical treatment of the class of injuries under consideration. If the diagnosis as to the parts in- volved, and the extent of injuries and their anatomical relationship to the peritoneum, could be positively es- tablished, treatment, immediate and secondary, would involve little indecision. Of these things it seems there can never be more than uncertain deductions, because the premises are only relatively reliable. Yet we may formulate certain rules of practice in the man- agement of cases of injury to internal organs follow^- ing contusions, etc., of the abdominal walls, but these rules must be subject to modification by future knowl- edge. Liver and Spleen. — When from the symptoms of shock, localized pain, and internal hemorrhage it appears that either the liver or spleen have been rup- tured, no operation should be done, unless the pro- gressive character of the symptoms of internal hemor- rhage indicate a probably fatal ending. Opium and ergot can be used with benefit, and the chest and ab- O- MtinKUN TRKAr.MKNl' Ol" \V(U N1>S. (Idiiit'ii oil ilii- side of iiijmv iiiiiiKiliilizcd by an ad licsivc idasici- splini. Tlu' local usi- of icv may he lHd]diil. 11' an alxloininal section is d(>ne, this should Dot be dehiyed as a piiniaiy or stH-oudary proi-eduix? licyond tlio time wIumi a laxorahlc tci-mination may be hoped for. Operations which in themselves are serious should not be undertaken ujion moribund pa- tients. To perform a. tracheotomy upon a patient about lo die from sutfoeation is j)raisewoii liy and a duty. .\n abdominal section done upon a patieni in lil<(' condition from a j^rave intra-abdominal lesion, Tlic a(( urate repair of which, even under rather fa- \-oiabU* circumstances, re(|nires mucli linie and nianijtulation, is a mistake. A blcedinj;- mesenteric artery can, if recojiiii/.ed, be (juickly controlled. In like manner a ruptured ectopic prep:nancy can be managed, but staunching the hem- oirhage from a ruptured liver or s])leen is (]uile a dif- ferent ju-oposiliou. il.) The introduction of stitches, with or without gauze packing, is indicated in rup- ture of the liver. (2.) For a like condition of the spleen, the same technique given for stab wounds of tliat organ are lo be followed, viz., they may be sutured or the torn surfaces compressed by a figure- of-8 ligature drawn over the protruding ends of a threaded needle juissed at right angles across the wounds. The abdominal wound would iinder this procedure have to be treated on the "open"" ])riiiiiple, with gauze packing down to the injured spleen. (8.) Tlie gland may be removed. Kifhivi/. — (1.) Kapid inna-i)eriioneal hemorrhage from a ruptured kidney should be treated by imme- diate resort to a right-sided abdominal section, liga- ture of tlie renal vessels and removal of the injui'ed organ. (2.) Nctro-peritoncal ruptuir of the kidney witli the foiination of a tumor is usually best treated upon the exj>ectant i)hin as regards surgical interfeience. Er- got, opium, and turjientine should bi' given internally. Experience seems to show that the bowels should be kept quiet, because of the intimate relations of the INTIJA-AI'.DO.MIXAI- 1J;SI().\S. .").'{ colon l<) I lie UidiicyH. l)iHr(*^;n.) The (Icrclopniciit of .scpsi.s Collowin;; Ji rcl ro peri loncal rupture of the kidney i(M|uii-eH a jiosl-peiitoneal incision for the establJHlnnent of drainage, (4.) Life-tlircafrnmf/ hrniaturia, the rewuit of an injury to a. kidney, denitmds nejdu'ectoniy by the lumbar route. (5.) A coiiipleic or jnirtial riiphin of a ii.ic'cr should be treated by an attempt to repair ihe ureter ilirough a retro-peritoneal opening. P^iiling in this a nephrec- tomy should be carried out by carrying the incision upwards. (0.) Rupture of a kklncij, followed by an accumulating hemorrhage into its pelvis, should be treated (1) pri- marily like an extra-peritoneal rupture; (2) an extra- peritoneal incision into the kidney should be made for the purpose of relieving the pressure and threat- ened renal atrophy, unless within ten days or two weeks there are positive signs that the tumor, if large, has ceased to increase and has begun to decrease in size. This practice . is warranted because in one of my cases complete destruction of all kidney tissue re- sulted, from overdistention, in twenty-one days. (3.) It may be necessary to [a) attempt to obliterate a de- generated kidney sac by an incision and drainage, or (&) its complete extirpation may be advisable should the patient's general condition warrant such an un- dertaking. Stomach and Intestines. — (1.) If the symptoms, as be- fore pointed out, cause even the suspicion of rupture, we should be ready, upon the first w^arning that our suspicions had some good foundation, to resort to an immediate abdominal section for the repair of the injury and the cleansing of the contaminated peri- toneal surfaces. (2.) Whenever the diagnosis of rup- ture is probable or humanly sure no time should be wasted before operating. Bladder. — (1.) An intra-peritoneal rupture of the bladder must be treated bv an earlv abdominal sec- 54 MODEUN TUEATMBNT OF WOL'NDS. lion lor I he luiipose of siM\iii;j;' U|i I lie woiiikI in I hi' bladdiT, anil lor the cleansiuy, bv llioi-ongh irrij^a- tion, of llu' pei'itoni'al sac. Drainage should be em- ployed if there are evidences of peritonitis. (2.) Ex- tra-peritoneal rupture requires a median suprainibic, extra-peritoneal cut for draiuajj;e. The wound into the bladder may be sutured in i)art with an absorbable suturing material, but usually this is not advisable. In every case a rubber drain should pass into the blad- der and gauze i)acking lightly introduced into the prevesical sjtace. If there has been such extravasa- tion as not to be relieved by a median incision others are demanded where they will do the most good. Per- fect drainage must be established. A conilnned intra- and crtra-pcritoiwal rupture should be treated by a combination of the practice given above. HI-IIAINS AND OONTriHIOXS OF JOINTH. 05 CHAPTER X. SPEAINS AND CONTUSIONS OF JOINTS. Wounds of joints nre convoniciilly divided into two general classes: 1. Siini)le; lliose in wliicli the skin overlying the joint is unbroken, or if so, the wound is only superficial and does not penetrate the joint proper. 2. Compound; when not only is the skin wounded, but the wound extends through the tissues into the joint. The first class of injuries are designated as sprains and contusions, and embrace almost all injuries not accompanied by a permanent displacement of the ar- ticular surface, or a disorganization or serious break- ing up of the bones and their cartilages going to form the joint. Sprains result from indirect violence; the muscles guarding the joints being relaxed or caught unawares by some unexpected act, as a false step. Any violent twist which results in moderate or severe movements beyond the normal limitations of function stretches or tears the capsule, synovial membrane, and liga- ments to a degree depending upon the violence ex- erted. The sj'mptoms of a sprain are those common to injuries in general, viz., pain, swelling, and inter- ference with function. Except in the mildest kind of sprain, the pain is intense immediately upon re- ceipt of the injury. Swelling occurs rapidly and is due to the accumulation of synovial fluid within the joint cavity as well as the accumulation of blood and exudative fluids from the torn and irritated blood-ves- sels without the s^movial sac. Not infrequently the synovial fluid is mixed with blood. Swelling usually reaches its maximum during the first twenty-four hours. The acute pain experienced on receipt of the injury is gradually changed into numbness, which, however, is immediately replaced by agonizing pain upon any attempt at motion of the joint; especially is 5 56 MODERN TREATMENT OF WOUNDS. this so w lull ligaments have been toi-u. In sui-h cases pain on prcssnre is most severe over tlic points of in- sertion of torn ligaments wliitli usu.iUv give way at these i)hu'es. sometimes strii)[)ing or i'liipj)ing olY small pieces of periostenm or bone with them. PrognofilS is uncertain, depending in the main upon proper recognition (»f the importanee of the injury and an intelligent api>lieation of the aids of surgery to the i-estorative powers of nature. At best, many sprains are only imperfectly recovered from because the na- ture of the injury itself so changes the delicate com- ]>lexily of the joint that a return to the normal is im])ossible. Fibrinous adhesions may form because of the hemorrhage into the synovial sac. The injuries to the caj^sule, ligaments, and tendons Ixlonging to or crossing the joint may result in such permanent thick- ening as to absolutely eliminate the natural strength and motion of the injured joint. Sometimes, although there is no visible change in a joint after apparent re- covery from a sprain, s]>ecial points of tenderness may be discovered; the surface may be abnormally cold and the joint somewhat, often quite, stiff and painful when used. Tretitmcnt. — This should be directed towards reliev- ing the pain, modifying the swelling, and hastening absorption of the traumatic exudate into and sur- rounding the joint; at the same time placing lacerated and torn tissues into the most favorable condition and position for rapid repair. Moi-e relief from pain can be obtained by the em- ployment of heat than cold, and the practice is more agreeable to the patient. The writer usually in all cases of sprain, when seen within a short time after an accident, advises the long continued and frequent immersion of the injured joint in water as hot as can be borne. It is still better to add one tablespoonful of mustard powder to each gallon of water. This kind of heat relieves pain, lessens hemorrhage and irritative exudate within and surrounding the joint. The i»reliminarv treatment may be ke])t up during the first eight to thirty-six hours. In the intervals be- SPRAINS AND OONTUSIONK OP JOINTS, 57 tween the immersions, the joint sliould he surrounded by a ropions qnnntity of notion wool held in jdace by a bandage ajjplied snfficienlly tight to give support, but not to cause pain. Tlie joint should be elevatcKl so as to favor the return circulation of the blood. Af- ter the end of the first twenty-four to thirty-six hours, all swelling, the result of the injury, has taken place. The object of treatment at this time is to hasten ab- sorption of the fluids causing the swelling and at the same time prevent all irritation tending to keep up a pouring out of blood and fluid exudate from torn and dilated vessels. Gentle massage and frictions with an avoidance of passive motion is valuable, and at this time also some pressure may be employed by means of a flannel bandage laid over a little cotton wool. As the swelling begins to disappear, the massage may be made more vigorous and very gentle and moderate passive motion begun. Should this more active treat- ment be followed by continued pain, it should be abolished and massage and the bandage relied upon until most of the swelling has disappeared. At this time, varying in length from five days to two weeks after receipt of the injury, two lines of practice may be employed; the one only applicable w'hen there has been no extensive tearing of ligaments and capsule; the other being the only rational practice if such in- jury has taken place. If, upon moderate passive mo- tion after the swelling has gone down, there is no considerable reaction, the indication is to give support and then allow of a moderate and gradually increasing use of the joint. Support can be obtained by using a flannel bandage, or bettei' still, a more permanent and reliable dressing is made from adhesive plaster put on so as to make even pressure, admit of limited motion, but not to constrict and interfere with the return cir- culation. Adhesive plaster dressing can also be used with decided advantage as a primary dressing in sprains of moderate degree where there is little ten- dency to swelling. When rather active or violent reaction follows passive motion, the joint should be immobilized by plaster of Paris until repair of torn 58 MODICKN TUKAIMKNI- OF WOT'NKS. tissues li;is lalctii iilatc. In ten days to threo weeks, llu^ plaster of Paris can he removed and inassajjje with passive motion renewed and a jiradual use of the joint allowed. Some form of suj)port should be worn for a considerable period after bcuinnin^ the \ise of a joint that has been sprained. Coiitusio)is of joints follow falls, blows, or kicks. They may result in a mere bruising of the overlying joint structures or in subcutaneous tearing of not only some of these tissue.ressure, and massage. Anti- septic incisions for the evacuation of effused blood may be employed with advantage in rare instances of large extra-articular blood accumulations. Aspira- tion may also be of advantage in a very small number of intra-articular blood and synovial accumulations. Both practices to be of advantage should be done early. :, -- ^ X w *-• "^ w *r ^ ^ :^ = E ^"5 • § ^-fZ^ ^'ii^^ » tt •-* i, J-. T|^ 1— • *-' 61 r" ?: ?'■- r'rr ■- - ^ t- i • i r j^ S r* COMl'OUND WOUNDS OK JOINTS. 59 GHAPTEK XI. COMi'OUND WOUNDS Ol' .lOI.NTS. Com pound wounds of joints are oil en aiiionj^ lb»* most serious iujurjes the surgeon is called upon to treat. The seriousness ol these Iraumatisins de- pends upon two conditions: (Ij Whether or not the inflicting instrument is free from contamination by inflammation producing germs; (2) the size of tliii joint injured and the extent of the injury. Small puncturing instruments, such as shoemakers' awls and the like, when in constant use are apt to be free from germs, and punctures into joints made by these instruments are not infrequently followed by mild consequences. Especially is this likely to be so if the instrument does .not enter the skin directly over the joint, but at some distance away, or in an oblique fashion. Ice picks, axes, and other cutting tools used in cutting, storing, and distiibuting ice often make wounds of joints which, although some- times ragged and extensive, are aseptic. Most any kind of instrument capable of wounding a joint may produce an aseptic wound, but the presumption is that all wounds into joints, except those made by a careful surgeon, are apt to be followed by infection of the joint. Wounds of small joints are not of much moment as to danger to life, and if the trauma is not great, the usefulness of these joints ought to be, in part at least, restored. Wounds of the joints of the upper extremity which do not seriously damage the component parts of the joint structures are not primarily threatening as to life or future usefulness of the joint, although, of course, the functio'n of the joint may be impaired. It is hardly conceivable nowadays that as a result of such an injury amputation would be called for: rare exceptions will be met. But wounds into the main joints of the lower extremity are sometimes danger- ous as to life, and often function is most seriously impaired, amputation being occasionally required to 60 MODERN TUEAT.MKNT OF WOUNDS. save lilc. Till' st'riousiu'ss ol' jiuiislioi woiimls ami coiujiound ilislucatioiis and trafliir(.s iulo joiiiis de IK'iuls iu jj:;ri'at nicasuie upon the size dI tlie joinc and I 111* amount of injury, not only of the eonii>ouent joint structures, but also the extension of the injury to the u})per and lower ends of the bones goinjj; ti> form the joint, (iri'ater than all. it must be acknowl- edged that the future behavior of every compound joint injury depends upon the degree of cleanliness employed at the first dressing. Si/iiiitlo)us. — The escape of clear or blood-tiuj^cd synovial lluid is diagnostic of joint wound, but in some cases of {(unctured wounds no synovial tiuid escapes, and ii is practically impossible to say whether or not the joint has been opened. To de- termine this question it is best to wait for a rapidly supervening secondary symptom of joint puncture, i. e., swelling. The degree of swelling will depend upon the amount of trauma within the joint and the activity of any germs introduced. Slight or no eleva- tion of temperature will mark the absence of infec- tion. A probe should not be used for diagnostic pui- poses, because, although tlie instrument be asei>tic, in its passage it might force into tlie joint infectious germs or germ-beanng material which in the passing of the inflicting instrument had been left on the way- side without the joint. In open wounds inspection is often all that is necessary to determin<' tliat a jodnt has been injured. The eye should be aided by the aseptic finger in dieftefrmining the extent of injury in such cases. 1)1 infected compound joint injuries of oil Icinds. wliith have been infected and brought under observation too late for correct primary treatment, acute .septic inflammation follow's in the form of abscess within and often without the joint. The joint is swollen, red, hot, and painful. As the flexed po.sition allows of easiest relaxation and accommodation of effused fluids, nature brings it into this position and the patient resists and complains of excruciating pain if any attempt is made to change the position. After COMPOUND WOUNDS OK JOINTS. 61 (lu* inllainmation has Iwslcd a ininiltfr ol davs, m- l»('i''ba[>s a few weeks, tlie pants of liie joint, oilier llian the synovial nKMnbrane may be attacked, llie eaili lagies become eroded and the ligaments infiltrated and in part destroyed. The infective process may extend above and below the joint involvinf^ the bfmes, and pus travel along' the lines of least resistance be- tween the intermuscuhir pkmes. There may be great swelling of the limb due to this cellular inflammation. In moderatel}^ extensive compound injurie'S tliiw ex- tending intlammaition may begin early, because th(; injury opens up the avenues for infection. If the- openiings, however, happen to be favorably located to favor drainage, the inflammation may remain local until the avenues for discharge become blocked u[» by accumulating discharges and inflammatory swell- ing. Spasmodic jerking of the muscles crossing the joint is a symptom of extension of inflammation to the cairtilages. This is more marl5:ed during sleep. because the patient is "off guard." This jerking causes agonizing pain and patients are apt to aw^aki^ with a cry denoting great suffering. The septic ab- sorption, pain, and interruption of rest and sleep pro- duce great exhaustion; the pulse becomes fast and compressible; the temperature ranges high, the tongue is dry. Now should nature or art establish good drainage, all bad symptoms may gradually sub- side and the patient recover wdth a more or less damaged and deformed extremity. On the other hand, pyemia may develop, or septicemia and thL^ exhaustive drain cause death. The approach of these dangerous conditions is marked, in pyemia, by sweating, irregular chills, and elevation of temperature. Such a condition calls for careful subjective and objective examination of all parts of the body. The w^riter has seen death from pyemia result in less than two weeks after a com- pound injury to a joint. Exhaustive sweats, emacia- tion, red cheeks, d'iarrheia, continued fever of from 1° to 4° F. elevation; increasing frequency and loss of tone of the pulse; too rapid respiration; restlessness, sometimes drowsiness; scanty, high colored, usually 62 MODERN TREATMENT OF WOUNDS. alliuiniiKtus, iiriiu'. All iliese are the loreiimiiers of a fatal teriiiiuarion. They must be recognized early for favorable ireainieul. 'Treatment. — Punctured wouuds of joints should be treated upon the antiseptic expecUint plan. The skin covering the joint should be thoroughly cleansed with soap, water, and a brush, washed in alcohol and afterwards in a 1-lUOO solution of bichloride of mer- cury in water. An antiseptic dressing- is then ap- plied and the joint placed at rest upon a splint. Should the te^mperature renuiin down and the evi- dences of local iutlammatory trouble be moderate, nothing more will be required. If, however, the con- stitutional and local symptoms indicate infection, no time should be lost in making a free antiseptic in- cision, or incisions, into the joint. Copious irriga- tion (bichloride 1-3000) should be employed in such a way as to reach every recess of the joint. Drainage tubes should now be inti-oduced and the limb en- veloped in heav3" moist antiseptic dressings. The joint should be placed at rest upon splints and elevated, perhaps using the weight and pulley in order to prevent in-itation of joint surfaces by mus- cular spasm. The local application of cold by jjack- ing in ice is of great value in controlling inllamma- tion. The cold does no injury and undoubtedly Inhibits germ activity. To be of service it should be applied around the antiseptically dressed joint in much the same way as ice is packed around the can of an ice-cream freezer. The Leiter coil and similar appliances are tinkering tools in such cases. Con- tinuous antiseptic irrigation with ice cold fluid is often of great value. In extensive injury use the same plan of treatment, that is, painstaking anti- sepsis, irrigation and drainage, antiseptic dressings. Amputation should never be thoiight of in civil prac- tice unless the vessels, nerves, and tendons crossing the joint are so damaged that repair with usefulness is out of the question. Atypical or even tyi)ical resec- tions may be done. It used to be thought that pri- mary amputation was recjuired in gunshot and other (;(>MPOrjNI> WOUNDH Olt' .lOINTH. (»:> liiceriitiiij;' and (leHtructivo joint injurif-H. Since ex- pCM'tanl: anliHcplict di-ainagc; vvilii immobili/ation, pracl'iwd HtkI by \/,\\\<^t'\y\)ci:k and oIIum* (J(;rnian Bur- geons diJi'ing the wai- witli France liav(; j^iven rn<»t satisfactory results, Die SMrj,^eon of to-day wonld hardly be justified in amputating as a j)iMniary jn-o- cedure. Tf in infcoled joiiils tlie line of ireatracnt iu- di(%aited does not succe(;d, — and it may succeed even after wide suppuration, if only the drainage through all infeoted tissues be made ample and maintained un- til repair is well oistablished, — then amputation ought to be consiidered and not too long delayed. l*yemia may be C'heicked by extensive incisions into and above and below the primary foicns. Secondary collections must be opened and drained early. Amputation may be done, but if at all, it must be do'ne after saoondary foci have been detected and drained, and the incisions into and around the joints have proven insufficient to check infection. When hectic fever threatens de- struction by exhaustion, amputation is imperative. How to Amputate. — ^The patient should be freely stimulated by strychnia and alcohol and a rapid operation performed under as short and not too pro- found anesthesia as possible. The main vessels should be tied and oozing prevented by proper sponge packing and bandaging. Few or no stitches ought to be introduced. If the shock of the operation is sustained, recovery is usually assured. The writer has been surprised how wonderfully recovery has fol- low^ed among the apparently hopeless cases of sep- ticemia of the kind under consideration which at his hands have been treated by amputation. Heart stimulants, alcohol, and easily assimilated. perhaps predigested food, should be given; sponging of the surface, copious draughts of water, all aid in carrying the treatment of these cases to a successful termination. The employment of antistreptococcas serum would be useless in chronic cases, but might possibly be an advantage in the early periods of acute iufectiou; but here, as elsewhere, treatment should be directed towards prevention and limitation by r/mov d of the cause of infection. 64 MODERN TltKATMENT OI' WitlNDS. CHAITKK Xll. JlEAl) I.X.UKIKS. aS((///> Wvuiiih. — A (011111100 impi'essiuii pri'vaiU ihat scalp wounds dilTei* iiiiK-h in their beliavior from wounds in otlun- localities, and therefore special rules of treatment are necessary. This is not so; all that is essential is a recognition of the anatomical i»ecul- iarties of the part and the care demanded to render the wound area free from }i;erm-carrying materials. JSome scalps are loaded with oil, dirt, and ei)iiliclium, and, when wounded, require more than ordinary ef- forts to disinfect; however, a vigorous use of soap and water, alcoliol, and bichloride solutions, cinphii/ed m the order named, will disinfect efficiently. It is usu- all}' AYise to cut away the hair in the immediate vi- cinity of a scalp wound, and in all complicated cases, a large area, perhaj>s the whole scalp, sliould be shaved and then thoroughly disinfected. Incised Wounds. — Hemorrhage should be treated as elsewhere, only it must be recalled that the rather broad and firm surfaces cannot bleed much if approxi- mated by suture; hence few ligatures are required. After preparation, incised scalp wounds should be treated as skin wounds in other parts. Silkworm gut is the best suturing material, and the stitches should be introduced sufficiently close together to bring about accurate approximation, but not so close as in deep skin wounds in most other parts, where it may not infrefjuently be good practice to use supei-ficial as well as through and through stitches. The simplest wounds may be dusted with some pro- tective drying powder without an overlying dressing, but as a rule the same practice as to the dressing of wounds in general should apply to scalji wounds. Stitches can be removed in from four to six days. Scalp wounds resulting from falls, blows with clubs, canes, beer bottles, and the like, often resemble very nnicli tlie ordinarv incis(Hl wounds, onlv Ihat thev are HI'JAIJ INJIJIIIKS. Oij apt to bo ii'i-ogular and tlu; edgen i>i-0Heiit u Hlightly-cou- liiHcd iii)j)earane(' willi a tendency to (iV(;rHion. Kiich vvoniids i(Miuire the same kind of treatment an inciHcd wounds proper. '^IMiey may be very exlensive, eH])o- eially wlien du(; (o tlie liead, or in women I lie long luiii-, being caught between or in moving machinery. Large parts of the scalp have been lorn off the skull or flaps of consideral)le size lifl(Ml u[). In the former case, an attempt should be made to suture the detached scalj) in place with the hoi>e that union will occur; this fail- ing in whole or in })art, repair of the raw surface may be aided, after granulation has been established, by skin grafting. Flaps should be sutured carefully, and almost invariably it will be found that they will unite because of the abundant blood supply. When a scalp wound is complicated by a deeper in- jury through the aponeurosis of the occipito-frontalis muscle, opening up channels for infection between the muscle and the pericranium, it is unwise to use stitches at all if the wound is a small one, and if a long one, only a comparatively few stitches ought to be intro- duced, the reason being that if our efforts at disinfec- tion have not been successful avenues of escape for the products of infection must be free, because septic inflammation of a most dangerous form may occur in the cellular tissues overlying the pericranium, and this infection invade the skull through the iiumerous veins connecting with the meninges, causing either an intracranial abscess or a suppurative lepto-menin- gitis; therefore, such wounds should not be tightly closed by suture, but they should inmriaUy he drained. In case infection of the kind under consideration has taken place, the original wound must be reopened im- mediately; perhaps other openings may be required to establish free drainage. If a decided betterment, both in the local and constitutional condition (not in- frequency of an alarming type), does not follow within a few hours at longest, the skull should be carefully inspected under and in the area nearest about the original injury, and it may be that pus will be detected coming out of one or more of the numerous openings GG MODERN TliKATMENT UF WolNHS. loiincfliiig the exu-riur with ihe interior. Such a coudition would probably deiiiaud the use of the chisel or trephiue in order to iimii or prevent by disinfection and drainage a fatal intracranial alfection. Of course, if there are symptoms of mischief wilhin the skull de- terminable by known means of cerebral localization, the chisel or trephine should be used over the recog- nized area, not forgetting, however, that that part of the skull immediately under the seat of primary in- jury, and where the greatest intensity of intlammation began, is the most likely portion for attack by the surgeon, who should not be lured away by symptoms seemingly pointing in other directions, unless they are of a positive kind. In acute intracranial inflamma- tory conditions many of our usually reliable localiz- ing symptoms are untrustworthy. Contusions of the scalp are common and result from the same class of injuries as scalp wounds following blows, falls, etc. In the majority of cases the swell- ing resulting from blood extravasation and exudation is limited and of little importance; all that is neces- sary in the way of treatment being the application of very hot fomentations. Cold is a favorite remedy with many surgeons, but the writer's preference Is for moist heat. If, as not infrequently happens, the patient complains of pain and a ''hot, burning fever" in the head, the application of cloths wrung out of ice water or the use of the ice cap is most grateful. Sometimes quite extensive hemorrhage occurs un- der the scalp, causing large fluctuating swellings, which, fortunately, gradually disappear under the form of treatm-ent just recommended. It is a good rule never to incise these swellings unless there are both local and constitutional signs of infection in the swelling, then free incision, antiseptic iirigation. and the establishment of drainage are demanded. Occa- sionally a form of swelling following contusions of the scalp is met with which presents ])uzzling features to the young surgeon, and not invariably is the elder cer- tain as to its meaning when perchance the sufferer may have I'eceived such a blow ns to shake up his cere- IIICAI) INJUIIIIOH. 07 bral balancing powei-H Lo a dcgifM; I liat i-aLlic'r i]id(;iL- nite ''brain HyinpLom.s" inon; Lhun suggcHt Uie poHHi- bility ol .skull Iraciure with coniprcs.sion of tbo biain. This lonn of .swelling is cau.sed by liemori'iiago undci' the pericranium. It i.s a circumscribed Hwelling and is limiled between the sutures of the bonces which it covers. liccause of its exx>osed jiosition, tlie parietal eminence is a favored seat for this swelling, which at first is soft in character, but soon assumes hard elevated borders, the central portions remaining soft. It is this ridge-like border vv'hich causes misgivings. To the fingers examining this edge and the soft center, the sensation of fracture of the skull with depression may be experienced. But when it is remembered that the edge of the swelling is raised above the bone outside the area of injury, and also that by firm press- ure with the finger or some non-cutting instrument the border can be indented, of course the idea that fractured bone is being felt must be abandoned. The indurated border is due to a fibrinous exudation. Swellings under the scalp are found in new born babes and result from diflScult labor with or ^vithout instrumental interference. Mild forms of this swell- ing are extremely common and excite no comment, but the severer forms, especially the sub-pericranial variety, invariably cause great anxiety and apprehen- sion upon the part of parents and family. The busy and inquisitive neighbor may stir up considerable of a rumpus if the attending physician does not quiet matters by an explanation and favorable prognosis. He should not fail to mention incidentally to some relative that in rare instances the brain is injured by the compressing force of the difficult labor, but as far as the external swelling is concerned, it is of little mo- ment, and will disappear in a few days or a week or so. The treatment is as for ordinary contusions. TREATMENT OF COMPOUND FRACTURES OF THE SKULL. Every compound fracture of the skull vault, with or without depression, in which there are brain symp- toms other than those of a most transient character due to contusion (concussion") of the brain, should be 68 MODERN TRKATMENT OF WOUNDS. submitted to operative interference. Where there are symptoms of (•omi)ression of tlic Inain with slij^ht or tio evidences of depression of bone, the skull shtmld be trephined, and almost invariably one of two con- ditions will be met with, either a cloi will ix' found betwi'eii the dura and the skull (sometimes or more rarely beneath the dura), or a fragment of the internal table will be recoji!;nized which is either depressed so as to push the dura down or. liavinj; toiii llironiii;ii<-li louniicnict ;i|i|ilicil. l'ii>iliiiii uf i In- aiirstlii/cr, ttc, in an (i]p J)lSSi:CTION WUL NDS. Poisoned wounds may 'be deliued as a class a! iufec- lious it'SiiUiug from microbic, chemic, oi* mixed bio- cliemical iul'ecliou, having ceriaiu special well reccg- iiized characteiislics wliicli vary iu many respects, boCh etiologically and iu their clinical course, from wounds as met with in every-day accidental and op- era lIvc surgery. Poat-Mord'ni or Diancction Wound!^. — An iucieased knowledge oi the pathology of diseases and a better appreciation of the means at our command to prevent or control infections has diminished the freiiueucy with which post-mortem or dissection wounds are met with, which give rise to symptoms of importance. A poisonous substance developed in a dead body may enter through .a pritk, cut, or abrasion, and cause either a local inflammation or a rapid, more or less general blood poisoning. The'poison, if derived from bodies of indiWduals recently dead, is more virulent than from those in the more advanced stages of de- composition, and in general it may be stated that the" more decomposed the body, the less the danger. It must be remembered, however, that Pasteur proved that certain diseases of animals (found in man also) could be contracted by healthy animals grazing over ground in which was buried the bodies of animals long since de'ad from these same diseases. Certain specific diseases can be inoculated from the bodies of individuals dead with these diseases. Bodies dead from diseases such as erysipelas, septic peritonitis, land more especially the puerperal type are responsible for many of the most serious cases of post-mortem wounds met with; and inoculation from the living through the injured skin of the sur- geon wliile engaged in examining or operating upon patients suffering from these infective diseases may cause the most serious mischief. POISONED AND DISHKOTION WOUNDS. 71 It is .said that inoculation may take place tlirough the .unbroken skin, entering? through tlie hair follicles, etc., but this ir- llieory. No man who is actively en- gaged in using his hands in medical and surgical work can be sure that (here may not be one or more abra- sions or other minute passageways for microbic or bio^'hemfical poisoniiiig. Ordinary ocular inspeetion may not disclose these channels, but they are pi-esent just the same from lime to time. Sfir James Paget (Clinical Lectures and Essays) says: "For not all men ,can be made ill by a virus from a dead body, nor can the same man be made ill at all times; but there must be what is called a fitting soil for the virus to work in. We know no more what this soil is than we do what the virus is; Tve have to use figurative expressions; but we need not doubt that they imply facts, and that for any lining body to be made diseased by a dead one, there musit be certain living materials which can be diverted by the dead ones from their normal relations and turned into a morbid course." Two facts have 'been well recognized: First, a per- son whose duty calls him to make frequent post-mor- tem exaiminations can become almost immune against post-mortem poisoning; his system becomes protected against the virulence of poisons; second, a debilitated state of the general health predisposes to infection. The wr*iter has seen many cases of infection of the hands among butchers, cooks, and dish-washers, but these infections were almost without exception local in character and no death or dangerous constitutional conditions are recalled. Some of these people were quite ill and a few suffered serious local infections, but as the animal material handled by these people was from healthy sources, virulent poisoning was not to be expected. Types of Post-Mortem Poisoning. — Local. — As a re- sult of constant local irritation of the hands by the juices of dead bodies a form of wait is met with which is somewhat analogous to the venereal warts caused by gonorrihea and is described by Stanley Boyd as 6 iL' MoltlOHN TREATMENT OK WolNDS. llie ••Di.sftit'Liiiig poller's wari."" il results fioiu ii'ri- latiou and not infeciiuu, aud is I'ouud iipou ilic dorsal surfaces of the hands and fingers. Tiiere is no ulcera- tion, but there may be cracks and fissures. The multi- plicily of the wai-is distiu'j^iiis'h'.'^ them Ironi epi- thelioma. An annoying, but not dangerous, form of local in- fection is often found upon the hands of students engaged in dissection and sometimes also upon the hands of physicians who not infrcijuently make post- mortem examinalions. It consists in one or several jtustules whicL develop u])on the dorsum of the fingers and seem to select by preference the knuckle areas. These pustules are sometimes found upon the dorsum O'f the hands, wrist, and lower fore-arm, and when found in these latter localities, usually take on the characteristics of small boils w'ith perhaps rathi*r extensive inttaiued circumferences. Whether pustu- lar or furuncular in kind, they tend to be quite chronic, and unless treated after an especial fashion, ulcerating surfaces form beneath the scabs of their dried secretions. Intiammations of a very chronic kind are also found around about and under the nails, the result of local post-mortem infection. Treatment of Local Infection. — "NVarts are success- fully treated by the use of caustics, and for those who must continue to expose the hands to irritation this is the best treatment. The caustic must not be too powerful and perhaps glacial acetic acid applied every day or every second day is the best. It is said that Ihe constant use of extract of belladonna is curative. When radical means are desired, tlie warts should be removed with the scissors, the bases curetted, and to the raw surfaces pure carbolic acid applied. If the warts are numerous, the action of the carbolic acid may be limitcxl and pain much modified by mop- ping the cauterized surfaces with alcohol. A wet antiseptic dressing sliould be used and the probabili- ties are that repair will soon take place. A boracic acid ointment dressing may be used with advantage as repair progresses. In some obstinate cases it is neces- J'()IS AND JJISHKCTJON WOUNDH. 73 navy Lo repcuL Llie carbolic acid and alcoJiol applica- Lioua. Wiiero tis«ui-e,s aud cracks coiiipJicaLe Lliewe cawea, the carbolic acid should be made Lo reach the bottoms of these separations. The pustules may be treated by ojiening them thoroug'hly, applying car- bolic acid, aud theu a wet a uti. styptic dressing, or the pustules may be curetted out and then apply the acid anid dressing; buL it must be remembered that success in treatment depends ui>on the prevention of the ac- cuinmration of the irdtatiug pus beneath scabs or dried dressings. Local inllaimmatory conditions in- volving the nails are types of purulent onychia. Sup- puration takes place around about and also beneath the nail. The matrix will be affected in whole or in part and as la oonsequence a part or all of the nail is loosened from its bed. The matrix is converted into granuiatioin tissue. The condition is a painful one and apt to be slow in its repair. In the early stages, the tissues around the nail, usu- ally on one side, ought to be incised and pure carbolic acid or nitrate of silver stick applied to the cut sur- face. Ais soon as it is clear that suppuration has or is about to occur under the nail a piece of the nail should be cut away and the infecte'd surface beneath touched with cartbo'lic acid. Wet antiseptic dressings ought to be used. Hot foimentations are grateful. In spite of prejudice b}^ the profession, the patient will appreciate and be grateful for a hot, thick flax-seed meal poultice, mixed up by using a moderately strong solution of carbolic acid or bichloride of mercury. The constitutional effects of post-moytem wounds are produced by the entrance of poisons, microbic, chemical, or both, into the circulation, usually through the lymiphatic system. The severity of the symptoms depends upon the amount and character of the poison absorbed, as well as the individual sus- ceptibility. A septic hjmphangitis makes itself evident usually wdthin twentj-four hours after inoculation. — there is pain and throbbing of the fingers and possibly arm. In a few hours red streaks mav be observed running 74 MODERN TUKAT-MKNT OF WOUNDS. towiirds I he iK-ari-st ^laiuLs. II' the infectiou is lini- ited to the maiu Ijinphatics, these red streaks are iso- lated, otherwise all the lymphatics become iuvolved and a more or less dilTuse cellulitis develops and softened aieas can be felt. In the isolated type of lvnil>hani)ura1 ion of tlu^ axilla and even jtectoral region may occur. Constitutional symptoms may be profound; high tempei-atiire, delirium, and marked depression is ob- 5:erved. Death oecasioually follows this jxoisoning in from two to four days. Every post-mortem wound should be encouraged to bleed, and if there are no cracks upon tlie lips, it oug'ht to be sucked. This will remove some, if not all. of the poison. Tlie wound should then be cauterized with glacial acetic acid or carbolic acid, both of which drugs should al- ways be at hand when post-nini'fem woik is being conducted. Simple isolated lymphangitis requires little treat- ment except the antiseptic treatment of the point of inoculation. Hot fomentations, ;painting along the lymphatics with tr. iodine, or extract of belladonna and glycerine may possibly do some good. Suppurating glands should be incised and all forms of cellulitis treated upon the prineii)]es already laid down. Drainage and supporting cons'titutlonal treat- ment are the keys to success. Iiiscff fiiinf/s and hifra usually require no special treatment further than the local application of dilute ammonia water or spirits of camphor. Tf many bites have been received at the sam(^ time and these are clustered, there may be considcM-able swelling. Con- stitutional symptoms resulting from the absorption of the acid poison of stings and bites are in rare in- stcinces chai-acterized by a general dejiression suffi- cient to demand energetic treatment. Actively dif- fusible heart stimulants must be given internally and J'OISONIOI) AN1> IMHSK^TJON WOLNOH. to by liy])<)(l('iniic nuMjiciil ion. W'Jicii ;iii iiiHecl hMii^ or bite is followed by Hevcrct local iiillaiiiiiiatoi-y nigriH, togetiiei' with coiiKtitutioiial syinptomH indicative of sepsis, it is j)r('suiiiab]e that a mixed infection has occuirred, viz., a cliciiiical jioisoiiinj^' from tlie sting or bite combined with a mici-obic infeclion. If the sting has been brolien oft' and left in the skin, it should be re- moved. Jn any case simulating a poisoned wound, as seen in septic or ordinary bio<;li<'ini(al infection, in- cisions should be made to permit of free drainage and escape of the poisonous products. Especially should this be the rule when the sting or bite has been made in tissues where loose cellular elements abound, as the orbit, around the anus, and external genitals. Bites from the spider species are oftentimes of seri- ous consequence and require the same treatment indi- cated above. Serpent Bites. — Rattlesnake, moccasin, copperhead, and viper bites are often follow'ed by grave symptoms, and sometimes by death. In India snake-bites cause thousands of deaths every year. The rattlesnake is responsible for most of the deaths from serpent bites in the United States. Poisonous serpent venom seems to be composed of two elements, one a direct depressant or paralyzer of the cardiac and respiratory centers, the other a disorgauizer of the blood. The blood becomes thin, loses its power of coagulation, and exudes from small blood-vessels. Wide extrava- sation may occur. The red corpuscles disintegrate. The first effect of the poisonous bite is pain, rapid swelling, and a black-green or purple discoloration of the skin in the immediate neighborhood of the bite. These local symptoms develop within an hour, even within a few^ minutes. As the local symptoms make their appearance, sometimes before, constitutional signs are manifested. Nausea and vomiting are apt to be early symptoms and may follow as rapidly after the bite as vomiting from a hypodermic emetic dose of apomorphia. The heart-beat becomes rapid and fee- ble, the respiration labored, and the skin clammy. Should the poisoning end in early death, according to 70 MuDElJN TUEATMENT OF WtHNKS. \\\'h- Miiclifll iCaruialti, "local i'Xlra\asalion luav br all I hat is visibk', but il" it be [(oslpomHl tor a slioi-i lime, ilieii siiialhM- ('xti-avasatious arc I'uuud in dis- tant tissues. .Most frequent and most piououuced are isubpleural. subperitoneal, and subpericardial eecliy- moses. but the wlu>le organism is deeply allected, the tissues being congested and presenting a much darker appearance than normal. The blood does not seem to coagulate readily within cavities or interstices of the body, unless death follows almost instantly. In cases which live longer the blood remains constantly in the liquid state or coagulates imperfectly, and then only after being exposed to the air, resembling in this i)articular the state of that Huid observed in conditions of asphyxia." The greater the proportion of the peptone part of the venom, that having a paralyzing effect upon the nerve centers, the quicker the death and less the dis- organization and extravasation of the blood. Wide local extravasation commencing at the point of in- oculation proves the excess of the globulin or blood- disorganizing element in the venom. Small doses of the poison produce comparatively mild constitutional and local symptoms. Anomalous cases have been reported of the late aj)- jiearauce of both local and constitutional signs of poi- soning after bites by venomous serpents, but these must be extremely uncommon. Cases of severity which recover or which live from a considerable number of hours to as many days pre- sent quite characteristic symptoms. Prostration is marked, but the mind will remain clear, except in those fatal cases which end in coma. The swelling due to the disorganized, blackened, incoagulable ex- travasated blood soon spreads from the wound and its immediate neighborhood towards the trunk. In a case which the writer saw and o])erated upon suc- cessfully not only were the hand, forearm, and arm tensely swollen, but the shoulder, pectoral, and scapu- lar regions as well. The violet-black, tense skin seemed upon the point of bursting. Should the pa- POISOXIOI) A.\I» DISSIOCTION WOT^NDS. ( ( ticiil sui'vivc the iiiiiiic(Ii;il(' coiisl i I ill ioiiul olTccIs (>{ the venom, Hyniploiris of \n\'i'c\\(>n, siiiiihii- hoili locally {irid {'onslilutioiially lo (hose of dilTiisc cellular in fl.'ininial ion, will probably follow. Ai-cas of slouch inj!;, f4anj;i('nc?, niosl: oUxm connnencinji^ in the nci^li boihood of the bite, are indicia! ive of the paHwing of the venom poisoning into a more or Ichh diffused cellu- lo-cutaneons inflanniial ion. The condilion in a reHult of the retenJion within I lie lissnew of (lie exiravasated disorganized blood. Treatment. — ^The best way to treat rattlesnake bites is to educate the people likely to be exposed to such injury. Sportsmen and those whose occupation calls them to lead an out-of-door country life should be in- formed through sources of general information, most likely to reach their e\"es, how best to take care of themselves should they be bitten by a venomous rej)- tile. Although it is said that "a little knowledge is a dangerous thing," yet in the case of the snake-bitten victim the knowledge of how to lessen the jeopardy to his life would be (luite as valuable to him as the uses of the ''First Aid'' package to the wounded sal- dier and his comrades in the absence of the immediate services of a surgeon. It should be made known that a handkerchief, piece of a shirt, rope, or any available material should be thrown around the bitten limb, above the bite, and made as tight as possible. This is best done by tying the ends of the binding material together and then, after passing a stick (something else will answ^er the purpose) under the knot, twist the stick until the ligature constricts the limb so as to almost completely shut off the circulation below. The wound should be sucked, there being no danger in this procedure unless there be fresh wounds upon the lips or in the mouth. It might be the part of wisdom for the sufferer himself or a companion to make a free cut with a pocket knife into the skin at the site of the snake-bite. This would facilitate the escape of any poison left in the wound after sucking it. Any danger from sepsis caused by the pocket knife ought not to be considered, and as to the dan- 78 JioDERN ii!i:aimi:.\ r s. jici- (»l (UlliiiL; iiiiii.)ri;uii paris iliis would Itc uT lililc luonn'iu ; ilu' prdbabiliiit's arc tluit the nil would be iiiadr t(K) small and loo shallow, yet mucli y;ood miglit be done. W liiskcv and coffee are the only stimulants usually wiiliin icacli. and these should be given freely. If a physician's services cannot be secured for many hours at the shortest, it would be proper and perhaps necessary for the sufferer, if able, or his companion, to loosen ilic lijiature a little from time to time so as not to cause gangrene in the parts below, (ireat swelling of the limb, especially if the skin is of a dark "black and blue" color, ought to be relieved by punc- tures v.ith the point of a knife. The kind of ])eople apt to be bitten by »eri)euts are not situated wliere the services of a physician are readily available, and neither they nor their friends will hesitate to do as just advised if they understand the reasonableness of the practice. Little more than just recommended can he carried out by the victim of a snake-bite or by his friends, ex- cept to seek the services of a physician as early as pos- sible. In addition to the scientific surgical techniiiue of the practice just outlined as what should be com- mon lay knowledge, the physician should place his reliance upon the hypodermic use of large doses of strychuiue, repeated at short intervals. This drug should be given so as to produce its physiological ef- fects within the limits of safety. Nitroglycerine may be used, but only in the very early periods, because of its tendency to increase the blood extravasations. Digitalis is too slow in its effects. DilVusible stimu- lants are required to overcome the cardiac and respira- tory weakness. The injection into the tissues around the wound of a 1 per cent, solution of pei-manganate of potash has proven serviceable at the hands of some of my professional friends who practice in a section where snake-bites have to be treated. A chromic acid solution in water one-half of 1 i)er cent, has been recommended by those who have tried it. For the swelling of the limb multiple incisions must I'OISONIOI) AM) DISSKCTION WOIJNDH. TIj lie iii;i(l(', and u'licii lilc lias been spared some diiyH, and (lie swclliiij; is excessive, lliroui^li und through d)*uJnaaHsageH, iieceKHitaliri},' oi)ei-a.l,ive measures to prevent death by Hullocjjtion. {Secondary involvement of tissues other than the skiu is brought about by an invasion of auch tissues from an attack of the skin covering them. As for example, interior of joints, llie peritoneum, the [dcura and ili(i meninges of Ihe bruin. However, this is not always so, as the writer has seen examijles of secondary in- volvement of the pleura, brain, and peritoneum in cases where the disease began in the extremities. Probabl}^ all such cases are examples of blood poison- ing, the germs being carried and lodged through the circulation into distant tissues and organs, setting up a secondary inflammation. Phlegmonous Erysipelas is a serious and often- times dangerous form of disease resulting from the invasion of the subcutaneous cellular tissues, and intermuscular septa by the streptococcus erysipelatus. This inflammation results in more or less sloughing of the skin and subcellular tissues. The clinical pic- ture of this disease varies little from that of the cellulo-cutaneous inflammations caused by a penning up of the products of suppuration in infected wounds, as described in former pages when writing of the ne- cessity of drainage in deep seated suppuration. The inflammation usually begins in a wound of an ex- tremity. There is rapid swelling, with discoloration of the skin, which suffers secondarily, the inflamma- tion starting beneath and spreading toward the sur- face. The color of the skin is that of a deep red, which gradually fades into the health}^ skin instead of the abrupt border of cutaneous erysipelas. The swelling soon becomes tense, brawmy, and painful, and, as in the cutaneous varieties, bullae often form and, unless relief is given by the surgeon, local areas of gangrene develop at the points of greatest tension. The forerunners of such a condition are observed as areas of dark blue color of the skin with edema and doughiuess; some- times an indistinct fluctuation is present. Through the openings afforded by the at first circumscribed 84 M(>i>i:kn tukatmknt oi' woinhs. areas of y;angr«.'Ue lailu-i- a prurust* (listliarj;;e of pus takes place, lu eases where there has been great leu- sioL, with late relief either l»,v (he surgeon or unaided nature, extensive sloughs of the skin form. These nia.v expose the muscles, the enveloping meuibranes 111' joiuts, and in cases where the original injury oi>ened up intermuscular planes, extensive desiructlctn of mus- cles and even bone results. It is especially in the latter condition, as, for instance, where erysipehis com- lilicates a deep seated wound, that the rather slow formation of sloughs and escape of pent up pus results in blood poisoning. In such a case the pus, instead of seekiug the subcutaneous cellular tissue early, often se nis to elect lirst traveling between muscles and close to bones. The constitutional symptoms are marked by pain, fever, early depression, especially if there is profuse suppuration and sloughing. Unless there is early relief of pent up products of the inflammation, blood poisoning with or without secondary infections and suppuration in distant organs or tissues is apt to follow. Treatment. — P>ery case of erj'sipelas developing or brought into a hospital should be isolated and every knowm principle of antiseptic surgery carried out in the treatment of the case. In examining and dressing the wounds sterilized rubber gloves should be worn and the naked hand should under no circumstances come in contact with the wound, body, or bedding of the patient. If this precaution is adhered to the dan- ger of infecting others will be lessened. It will not do to rely upon wearing sterile rubber gloves at opera- tions, and at other times (after handling a case of erysipelas), in the office, private residence, or dispen- sfiry, when doing little things, use the naked hands. True it is that the hands can be sterilized so that tliey will be ordinarily safe, but it is also true that the germ of erysipelas is very poisonous and hard to wash away. The writer recalls very vividly a personal experience in Which he carried erysi})elas from a case of erysipelas of the scalp, following a minor operation in private Hl'KCAhnC WOUND INFEG'I'lONS KIIYHII'IOLAH. Sjj pi-acLi<<', (() foiii- ollici- individualH, orx; in lios|)il.iil, three in (licit.' hornes. Every i>re(;uution Heenujd to have been taken, and exactly where the leak occurred is nol known to I his d;iy, but tli<'re w;ih a leak, find al(lionji,li no fiilalily reHuKcd, much ncedlcHS siilfering did. I'recautionH against infecting others should be taken by uurs'^s as well as doctors. It is best always to have a special nurse for such cases. In spite of a prejudice against it, there is no more grateful or curative an agent in the treatment of cutaneous erysipelas than moist cold. Cloths wrung out of a cold, mildly anti- septic solution are best for application, and the wound of inoculation should be treated upon its merits after the rules laid down for the treatment of infected wounds, — drainage with antisepsis. Numerous cures for cutaneous erysipelas have been offered, and some are beneficial. xVmong them the covering of the inflamed area by an ointment of ichthyol in lanoline, one dram to one ounce. A solu- tion of thiol in water, 20 to 40 per cent., is recom- mended. This is x)ainted over the infected skin as well as for some distance beyond. Thiol is less objectiona- ble than ichthyol because of the bad smell of the latter, and it is reported to be almost a specific. Abortive measures by scarifications and the use of strong anti- sceptics are valueless to abort; at least that is the per- sonal experience of the writer. The lead and opium wash is a soothing application, and is useful and grate- ful to the patient when the wound is insignificant. Shallow or deep incisions ought to be made when there is tension sufficient to threaten the life of any area of skin. Tonics, and especially strychnine and the muriated tincture of iron, are of value. Gellulo-cutaneous erysipelas demands surgical inter- ference. An incision or incisions to the bottom of the wound of infection must be made, and early. Sloughing of the skin should be anticipated by in- cisions before the vitality of the tissues is more than threatened. Free drainage should be established and maintained by copious and frequent antiseptic irriga- 80 MODERN THEATMENT OF WOLNOS. tiuns. and the part sboultl be c'livchtpeil in lai-j;e, moist amisejilic liiessiii^s. Touics. sliuuilaiils. and fi)i'Led feeding are essential lo maintain strength and resist- ing jiuwcrs. (\>ld ai»i)lications are harmful in this form, as tending to inc-rease the danger of slonghing. Secondary comijlications may rciniic incision al a distanee. — they should be made early. I'snally care- ful dressings, skin grafting, or transplantation of large Haps will sullice for the repaii- of sjjacf's of raw surfaces nm-overed by sloughing. Occasionally, but rarely, amimintion is re(iuii-ed. It should never be done duiing an acute stage of infection. Death rarely follows acute cutaneous erysi}K'las. the mortality be- ing less than 5 per cent., except among old people and children, when it is larger. The phlegmonous variety should be rarely fatal when treated ]>roi)! ily. There will be. howevei'. occasional deaths in s])ite of oni' best directed eil'orts. TKTANUS. S7 CHAPTER XV. TETANUS. This is a disease due to a specific wound iufarts of 4tli of -Inly explosives "set off" in public streets oi* in the house yard. Every year a large numl>er of cases of tetanus are reported following little wounds from j»ar1s of the caps of toy pistols. In these last cases, proliably the germs were on the liands. and were carried into the tissues along with the pieces of jjistol caps. Tetanus has l»een known fo follow all kinds of TK'I'ANUS. 89 (>])('i ill ion vvouikIs, ImiI lliis uiis jtrior lo I lie iikxIcmii coinpi'cliciisioii of jnitiH('j)li(; hikI Mseplic surgery. Of course, in emergeucy surgery it might be iinpossible to prevent infection by the tetanus bacillus, but in operations of elcclion there (;oul(l be no excuse. As in erysipelas, I Ik; wound of (entrance of the infection may be so insignilicant that some cases have been called idiopathic, but, with our present knowledge, we must insist that no icound, no tetanus. In this connection it may be proper to refer to the case of a bull dead of tetanus of whose Ilesh several persons ate; three were seized with tetanus and two died. This observation was made manj^ years ago, 1857, by Betoli. Tetanus is found in the new born infant, infection occurring through the cord, also in the pu- erperal woman, or after abortions. These differ in no w^ay from the common varieties of tetanus. Clinical History. — Tetanus is either acute or chronic. The acute form is ushered in from a few hours to three w^eeks after infection. Most commonly two or three days elapse betw^een the time of infection until the first symptoms develop. Then the patient notices a difficulty in opening the mouth, with more or less cramping in the muscles of mastication. The neck may be a little stiff and the patient attribute the W'hole difficulty, which in the beginning is usually mild, to "taking cold.'' In some hours the symptoms become aggravated and the cramping of the muscles of mastication becomes so severe that the patient cannot open the jaw, or can at best only slightly sepa- rate the teeth (lock-jaw). The muscular contractions are painful, usually excruciatingly so, and fluids are swallowed with great difficulty. The muscles of the face and back of the neck soon become involved, causing a peculiar expression called risus sardonicu-s. Sometimes before the face muscles are involved, those of the trunk and extremities exhibit spasmodic con- tractions with cramping pains. As in experimentally produced tetanus in animals, the muscles of the parts nearest the point of inoculation are first aft'ected. so in man the first muscular spasms may appear near the ItO Mul>i:UN TUKATMli.NT (»F WiU'NPS. \\(iuii(i. Tlic iiiuscuhir ((Hii laci ions sdoii Ikn'ouii' jiliH(is( colli inuoiis; swallowing is painlnl and dilli- (ult, and ol'lcn brinjis on fresh nmsciilar spasms, in fact anv stiniulns, as a snddt'n noise, cold draft, or any iniiant oi- \()lnnlar.v cll'oii, may do tills. The back inusclfs may conn ad so as lo produce opisthoto- nus. I^ateral and forward c(»n(or(ions are sometimes observed. Excei)t durinj;- unusual muscular contrac- tions, the patient lies on his side with the head drawn back and the spinal arch exajijieraied. There is per- fect consciousness. There is relent ion of urine and tlie bowels refuse to act because of the contraction of the sphincters. The urine is albuminous. Most com- monly there is fever from the beginning which may be (luite high. More rarely there is no fever, but usually the fever of itself is not alarming. Diaphoresis is almost always a feature of the dis- ( i'.se and occurs always after severe convulsions. There is little sleep without drugs. Attempts at swallowing may bring on a renewal of convulsions; the face may become cyanotic because of the spasm preventing respiration or causing a closure of the glottis. In the intervals of spasms, the face is anx- ious and pale. Death is generally the result of ex- haustion or spasm of the muscles allowing of respira- tion. Very high temperatures are common a short time before and after death; a fatal termination occurs most often before the end of the fifth day and can occur within twenty-four hours. In the chronic form the symptoms occur later, after infection, and are milder in character. There is little or no fever. The onset of the symptoms follow's in the second or third week after the injury. The clinical picture is quite similar to that of acute tetanus, only not so im- pressive. There are remissions and even intermis- sions of all symptoms. Gradual improvement takes place and the i»atient recovers. Death may take place. Head Tetanus. — A very dangerous though rare form of tetanus follows infe(;tion of areas supplied by th(i cranial nei-ves, especially in I he neighborhood of TIOTANUH. 91 supraorbital bnmcIicH. Tlicjc is i)iiiiil.yHis of ili<; facial nerve witli triwiiiuH, and at tiinen great dilliculty in ywallowing. A. maniacal frenzy is HonietinieH ob- served. Tlierc iDay be; more or less general tonic muscviliir spiisins. Diaynosis. — There siioiild ]ut lilllc diniciilly in m;ik- ing a diagnosis of tetanus. It lias to be differentiated from inflammatory diniculties about the mouth ov temporo-maxillary joint. These can be detected by inspection and palpation, and in case of the joint being affected, this is most commonly unilateral. In tetanus there is an early rigidity of the muscles of the neck. In severe strychnine poisoning there are usually com- plete periods of intermission (found also in chronic tetanus). The muscles of the hands are rarely in- volved in tetanus, in strychnine poisoning they com- monly are. The spasms of hydrophobia are clonic. The prognosis is bad in acute tetanus, but the favora- ble signs are late onset, long duration, lengthening of intervals between attacks of muscular cramps. Sta- tistics seem to prove that an attack coming on undi^r ten days after infection only 4 per cent, recover ; after ten to fifteen days, 27 per cent.; after fifteen to twenty days, 45 per cent. — (Rose.) Treatment. — Careful antisepsis is of the greatest importance as a prophylactic measure, and besides all punctured and other kinds of wounds likely to have carried the germs of tetanus into the tissues should be freely opened, all foreign bodies removed; cleansed by, first, using peroxide of hydrogen or pyrozoue, be- cause of the anaerobic character of the bacillus; then thoroughl}' antisepticized with pure carbolic acid; wash this away with 95 per cent, alcohol. Tincture of iodine or a saturated solution of permanganate of potash may be employed. All such wounds should be treated on the open, free drainage, antiseptic plan. After the development of the symptoms, the same antiseptic plan of treatment should be followed as far as practicable. All irritation should be avoided and absolute quiet enforced; liquid food may be swallowed, or failing in this, a tube may be introduced 92 MODIMtN TUKAT-MKNT Ul' \Vl»LNl>S. tliritugh the uose and suitable noiii'ishment poured Ihrou^'h it into the stomach. Sedatives, such as thloral. bring some relief to the patient, but it is doubtful whether or no a patient was ever saved by drugs. When these drugs are used they should be given so as to produce their physiological effects an«i control the convulsicuis. No stated doses can be given. The giAing of sedative drugs is recommended chietly as a humanitarian prjictice. Chloroform is useful to control spasms. The bi'lief of the writer is thai in (he working out of the antitoxin treatment of tetanus lies our only hope of a cure. In experimental medicine much has been learned and accomplished, but practically in the treatment of the human sntTerei- from tetanus little has been accomplished. The serum to date is simply an immunizing agent and not an antitoxin or agent capable of counteracting the effects of toxins already in the blood. Immunizing injections should be given in suspicious wounds, and in the beginning of tetanus the antitoxin as made should be tried with the hope of its modifying the symploms. si'M'Tk; i;i,ooi) rftisoNixo. IK'. OHAPTEJ; XVI. TREATMENT OF SEP'I'iC r.LOOl) I'OISOXING. By septic infection we mean a general diHea«e caused by tlie entrance into the circulation of the germs of suppuration or t'he products of thc«se gei'ms. The germis gain entraiuce at the point of inoculation either through an external wound, or being present in the circulation are enabled to act deleteriously be- cause of some local depression or want of resistance upon the part of the tissue's. The clinical picture varies in accordance with the kind of infection or blood poisoning. When the action of certain germs results in the rapid production of a toxin or poison the absorption of which causes a depression to the vital centers, followed by a greater or less interference with the natural functions of the emunctories, a most sierious condition is brought about. The outcome will depend upon the quality of the toxin (commonly called a chemical substance or ptomaine), and the amount of the poison absorbed. TJie Unusual Form of Septicemia — Sapremia. — Fortu- nate'ly this form of blood poisoning is rare and its source not difficult to recognize, being more commonly tbe result of the decomposition of clofjs in the uterus aft^er abortion or full term pregnancy. It is found as the result of decomposition of clots in wounds, rarely those of a subcutaneous kind. The infection is char- acterized b}" a rapid rise of temperature, 103° F., to 105° F. There may or may not be a chill. The tem- perature continues high and symptoms of vital de- pression develop. The sldn becomes clammy, the tongue di*y, the pulse rapid, the second heart sound indistinct. Diarrhea, may develop. The patient dies in from two to five days. This is the picture seen when the expectant plan of treatment is practiced. Quite an- other picture is presented if rational surgical princi- ples are early adopted. !)4 Moiii:i;.\ iici^aimkn r oi' woinds. Treatnieut consists in the removal of all (Uh-oiu poslnir matt'iials and the use of copious irrigations, with tlu- uiaiutcnancc of j;ood tlraina^^*. Kt'coverv is iH-ouii>t, provided the source of the toxins is ree- oj^uizable, and can be reached before there is gre.it viial depression. It is to be remembered that al- though the surface temperatuiH* may not be high, possibly sub-noruKil, because of the condition of the skin, the rectal temperature will always be found at least several degrees above normal. Many times after abdominal operations this ra]>idly fatal form of blood poisoning has developed, t'he condition being attrib- uted to shock, when had the rect'al temperature been taken so soon as bad symptoms appeared, possibly lives might have been saved by an attempt to remove the cause of infection. Even though the focus from wliich the intoxicant started may be reached, usually little good will re- sult. So large a surface for the aibsoiivtion of toxins is presented within the abdomen that tlie prairie fire like speed with which the poison spreads admits of such an overwhelming dose of the toxins being ab- sorbed, that vital centers are paralyzed and death is almost inevitable. The spread of the infection over the peritoneal .surface may be -so rapid that foAV naked eye changes are observable in that membrane. The treatment is preventative, and may be stated by formulating one or two good rules. After a celiot- omy try never to leave within the abdomen any fluid or clotted blood. In most eases this can be done by a careful hemo«tasis and the 'sp'onging away of all blood from the peritoneum without or after irriga- tion. Many times raw surfaces can be covered by peri- toneal flaps, and stitches introduced at well select'3d sites will faliut off exposed areas and at the same time minimize oozing. Often, however, it is impossible to prevent some oozing and at times rathei* free bleeding from i*aw, torn surfaces. In such cases drainage must be established and maintained until the oozing be- comes serous. SKi'Tii' r.Mioi) roisoMN*;. 95 ir Die bleeding is Jr<'(', i he (ii;rni;i;.'(' is coiiihiiicd vvilli pi-cssui'ic l),y iisiii;; f^iiiizc packing. 'J'lic Mikulicz, iodolonii gauze drain m '('lie hcsl i'ov tiii.s pnipose, ])(i- oanse a piece of gauze oaunot be left beliiiul after what was supposedly a complete removal of all gauze. Besides (be pr(;'Hsure uimn and drainage of the parts involved can ho gradually reduced, and in the cai-ry- ing out of this there is less local disturbance and pain than when separate pieces of gauze are pemoved, each of which is in direct contact with the peritoneal sur- faces. A word about iodoform. It has a property that no other material is known to possess, and is of great A'alue in the preventive treatment of all forms of blood poisoning. It takes only a few hours after the applicatiom of iodoform to a fresh wound surface for the formation of a deep zone of leucocytes and con- nective tissue corpu'scles held within the meshes of fibrinous trabecular — an exaggerated fibrino plastic exudate. This rapidly formed exudate represents the developmental stage of a protective granulation tissue formation. Suppose an abscess deeply situated and partly in- accessible containing highly infective pus, and so sit- uated that it is impossible after incision to immedi- ately thoroughly remove, disinfect, and change the character of its secreting surfaces. The protective property of iodoform when applied to a cut surface in such a case is undeniable. Likewise in the incis- ions for the evacuation of tuberculous abscesses whose sources and channels of descent cannot be fJwroughhf curetted, and therefore should not be cu- retted at all, iodoform forms a safeguard against a mixed infection of the tuberculous lesion from with- out, as well as a. protection against a tuberculous spread to the tissues involved in the wound. The property iodoform has of causing the rapid formation of a protecting fibrino plastic exudate is likewise of great value when iodoform gauze is used as a packing and drainage material in intra-abdomi- nal work. Should infective germs gain entrance from !M; MOOKIiN TREATMENT OF WuUNDS. wilbuui along; the iwlDform gauze drain, and this occasionally happens as the result of carelessness or in spite of gi-eut care, any infi^-tion of the i)eriloneuni would he merely a local atfair, i. e., one with the fornuiiiou and discharge of i)us without manifest dan- gei-^us constitutionaJ symptoms. Pi/cniia. — In several ])recc7 niijiiilcs, ail lioin', or ]>ossiI)Iy ]<>ni^i:ijN ruKATMiON r t»i- \veuticH."' Quinine, iron, and whiskey had it)een given in full do'»es. Within a week after this man's death it so happened tliat an lexaetly similar case came under my care. During a few mioments of hilarity 'between dances at a frontier party, a drunken cowboy amused himself by shooting" alternately into the ceiling and floor. The last shot struck the floor, but not until after the bullet, a 44 cal. Colt's, had followed exactly the same track as dn the preceding case. The man w^as put into a wagon and brought to the hospital, a distance of forty -five miles. After scrubbing the leg and foot they were bathed in a 1 to 1,000 solution of bichloride (this drug as an antiis'eptic had just been inti'oduced into surgical practice). Fe'airing infection, a Gouley urethral dilator was passed into the wound as a guide and a free incision made in the long axis of the bullet track abont its middle third. Dradnage tubes were introduced and an antiseptic dressing applied. Irri- gations were used daily and the wound repaired with little sui)pu'ration in a short while. As an lillustration of chronic pyemia, rather infre- quently met with, the following case recently seen will serve as an example: A young man 30 years of age was attacked in August, 1898, with a right- sided pleuro-pneumonia. This ended in a sacculated empyema of the low^er part of the pleural cavity. For wrecks the pus Avas allowed to stay undisturbed. Nature finally' tried to bring about relief and the ab- scess ruptureki into a bronchus. A large quantity of putrid pus was coughed up. Following this there was improvement. Foi' several weeks the continued fever. . sw^eating, and loss of appetite were much modified. !<•() MuKKlJN TUEATMENT oi' \V«HM>S. Tbcu ilic r-.iisiii',' of ]nis i-i'iisiil aiul ai iho same time I he (.•oiisiiiiitional .syiiipluins bi'came worse. Uphill drainage uuiild uut sullke; the opening in the bron- chus closed. The patient's general condition beeame much run down. The oiu-ning into the bronchus (losed and rcoptMHMl several liuics, ilie i)atient losing ground continuously. Numerous superficial a-bscesses formetl. The skin on the extremities exfoliated in several places, i^^pecially on t'li<' hands and fivt, letiv- ing raw, bleeding surfaces. The temperature varied daily fri»m normal, sometimes sub-uomial, to two or tour degrees above normal. The tongue was usually dry, ai)petite poor; bowels souietimes quite loose. Emaciation had become extreme. There were several bad bed sores. The mind wandered; exhaustion was extreme. The pulse was mpid and feeble. The appearance of this individual when seen by me in December, 1898, was pitiable. At this time there was no drainage. It wa« suggested that a dependent opening be made by means of a trocar; slipping i\ drainagx? tube through the canula so that drainage might be established without shock. The procedure was not urged as the case seemed hopeless, death being apparently only a day or so off. It has ibeen learned that nothing was done, yet the patient lived about three weeks longer. Treatment. — Pyemia ought never to develop from a wound which can be managed from its early history according to the principles of antiseptic surgei-y. Oc- casionally cases will be met with in which from the nature of the wound it may be impossible to prevent the development of suppuration. Likewise satisfac- tory drainage cannot always be had, yet the great majority of wounds, if seen sufticiently early, can be protected against infection. If infection is suspected or has already developed in a wound and remained local, the infected focus can be disinfected and drained so as to ])revS. roiuii- or pyiMiiic. Nmilv nil of Ihe^e cases will ii- i-i>vfi' if drained eailv, and ii is not a (juesliou ol terlinitiiio (rib resec-lidii or not), but one of free and sntlitient di'aiiiaji,i' fiiv ilu* particular case, rphill or anv oilier ini'on»]>lctc drainaji'e of a se]»tif roms is not only uusatisfactorN Imi danj^crous. If in any case of }»ycniia coniplicali-d hy a septic phlebilis it is pos'sible to discover al wliai point or points ligaturi^ may be applied to the infecletl veins so as to prevent central poisouinji; from detached sejitie clots, such practice is loR'ical. The dilTiculty is in bein^- able (o detennine the limit of Ihe dol forma- ti\ (tpciaiioii, lliat the Haps of tlu' wound made l»v ihc sui-;i,('on sl(»n}:;ht'd. It slionld alsd lie ifuicndit'i-cd ihai when lut'ssurc is made directiv nuht Mil' wouiid, wide extra vasal ion niav follow ; likewise it infective }j;enus have already enteied the wound piior to the sui-jicon seeinj; the case and the ajiplication (d' his compresses, these germs nniy be forced into the tissues by the extrava- satinfj bh)od current. A wound which niiglit have been nnidi' safe by tlie en)ph)yment of antiseptics would possibly in tliis way be rendered impossible of sterilization. Therefore, for this reason, and also when marked extravasation of blood is p,oinfj on with little external hemorrhagic it is safe to presume that a large, deei)ly situated branch or a main vessel has been w^ouuded. Under these circumstances a tourni- quet should be used as just suv \\;islu'(l in soup aud water, sjxmged off with alcohol, and thi'n douched with a solution of bichloride of mercury 1-1,000. Everythiuir bcinj^- in readiness, the i)atient should be auesthetixed. After the clothes are removed, he is placed upon the operating table, bed, or floor in such a position as to allow of the easiest mauiinilalions uj)on the part of the surgeon and his assistants. The rubber sheet must be put under the injured part so as to drain away fluids into some bucket or i)an, and also arranged to shut off the wound from contamination by contact with other parts of the l»ody. bedding, etc. Of course the most painstaking care is exf Paris. A cast may be made to sunonnd tlu; limb, jiossibly cnttinj; a window over the wdund ari-a for the dressing and inspection of the in j 111 v. The writer prefers to apply plaster splints, one <)!• more, so as to allow of easy inspection ami dressing of the fracture; the whole atVair admitting of removal and reap]>lication. Plasicr of Parif< tSj)rnil.-i. — Having determined whether one or more splints are required to support the limb without covering the wound, and perhaps in some cases this may not be objectionable, suitably sized pieces of heavy muslin or Canton flannel are cut of a length, and when folded thi-ee times, of a breadth corresponding to the proportions of the pro- posed s])lint or splints. Having sj)read the muslin (or flannel) out upon a table, a thick cream of plaster of Paris is mixed in a basin. The plaster is poured upon the center part of the goods, one-eighth to one- fourth inch deep, from near one end to the other, and then one side is folded over the plaster, and the other side over this side; the plaster being covered on one side by one thickness of goods, on the other by two thicknesses. The splint is ajiidied by gi-asping the muslin near each end and placing it in the position intended. It is fastened by means of a roller bandage, the upper and lower ends being turned down and up respectively and secured with the l)andage. The splint soon hardens. One or several splints can be put on in this way, and to render the dressing more firm, one or two layers of a plaster bandage can be used. The bandage over the wound can be cut. al- lowing iuspectictn and dressing without interfering materially with support. Everything can be taken off with pocket-case scissors in a few minutes. A plaster cast without a window soon becomes a dirty affair if there be much drainage. It is a rare exception :l y M Z SCI COMI'OUiND l'ltA(rrUUKS Ol' J.().\(; I'.OMCS, 109 I'oi* u CUHC lo do oilier ilinii \\ij- ratioi), iKMtroHiH, and liccMc. H.yinplo'Dis lia.\'c i-oHiillcd, ill H})il(! of lixjilioii, drainage, and antinopHiH, and Uic vitality oC I lie palicnl is becoming sapped. Arapnla- tioii should bo done before a ''snceesHfiil opeialion,*' hut fatal tei'U) illation follow.s. Ill' MmI»1:KN IKI^AIMI^N 1 oi- WolNDS CHAPTER XVIII. I" ij i: A r.MK. NT OF (irxsiior worxns. li is inij)ossil»lt' lo jiiiciiipi iu a sin^U- cliMiiicr lo iiiiiii- ihau outiiiif I III' lult's to be followed in the sin- y,iial caiv of ^iiii-sliut wounds. The itriiuipli's in- \xdv(Hl aiv in diiccl accord with Ibosc acccjiti'd l>.\ modei'U surgeons regartlinu ilu* trealnu*n( of wounds in general. Experience has positively jirovcn that (/// bulh't wounds (with a tVw excejilions to Ix' named later) are nu)s( safely treated by the antiseptic application of a primary occlusive antiseptic dressing, WITHOUT preliminary, digital, or instrumental inter- ference or exploralion. The additional aid of splints is called for in wounds involving the integrity of bones and joints. When a bullet has cut a blood-vessel and hemorrhage is going on either externally or internally, active im- mediate surgical relief should be attemi)ted by an ex- ploration sutlicieutly free to a])ply the surgical rule, viz., ligation of the wounded vessel immediately above and below the wound. Temporizing measures, such as direct comiu-ession or the use of an impi'ovised tourni- quet, may be necessary before ligatures can be used. The application of a ligature to the proximal end of a divided artery or on the proximal side and at a dis- tance from the wound in an artery is only justifiable when the anatomical arrangement or excejitionable circumstances prevent the a])i)]ication of tlie doubl*' ligature. The suturing or resection of arteries and veins wounded by bullets has been ])racticed successfully. but can scarcely be more than the dream of a military surgeon in the field. In garrison or civil hospital fa- vorable occasions will now and then occui- foi- tliis hith degree of surgical practice. VToKuds of the ftlciilK when penetrating, whether or no thei-e be symi»toms of compression of the brain, de- OUXSIIOT VVrjI'.XDS. IV't iiiiiiid siiiT^iciil iiilo rciciice, Firwl, lii*- scjiip sliould be whuvcd and llie wound uroji most carefully pre- pared as for a serious operation within llu* skull (for example, removal of a tumor of Die hrainj. Then, after turning- hack ;i ''iiorseslioe fla]»" con(ainin{^- the Avound IJirougli (he scalp somewhere neiir its center, if this be feasible, the opening in the skull is enlarged sulficiently to determine as far as x>ossible the nature and extent of the injury to the brain. Through the enlai'ged skull wound sometimes bone fragments are removed. The bullet ought to be extracted by follow- ing its track with a suitably shaped, dull-pointed in- strument, such as a closed urethral forceps. Sharp- pointed instruments should never be used, — in fact, scarcely any kind of probe is safe, — because a false passage is apt to be made. After locating the ball (sometimes apparently impossible) it should be ex- tracted by means of a suitable forceps; the urethral forceps is scarcely strong enough.* Girdner's tele- phone probe niRj be invaluable in determining the lo cation of a bullet. On two occasions the writer has been able to follow the track of a ball through the l)rain close to the skull at a point, in one case, nearly opposite the wound of entrance; in the other, at a considerable angle below. A counter opening in each case was made and the ball extracted. Drainage should always be employed, and when a counter open- ing has been made, should be of the ''through and through" variety, because the irritation of the ex- amination and determining of the track of the ball might result in an inflammation, the outcome of which could in no possible way prove other than fatal with- out drainage. If a ball has passed through the skull, the wounds of entrance and exit had better be enlarged, all loose fragments (spicuUie) removed and the case treated, not by ''through and through"" drainage, but by the local * The use of the fluoroscope and the taking of radiographs are valuable aids in locating foreign metallic bodies in all parts of the anatomy. The writer succeeded in one case and failed in another to locate a bullet in the brain by means of radiographs — probably a fair average of success and failure in similar cases. 114 MODERN TREAT.MKNT OF NVorNHS. draiuajje ol" ciuli woiiud, siuli as om- would riiijtloy ill any ordinal y (•()inj>ound Irartm-i' of [hv skull. (iiinahut ivoiiikI.s of the vliviit liave ln'cii ri'ft'irrd to ulien disciLssing wounds of the chest, and nolhing fiir- Ihei* is net'ossaiy logaiding lliom at this time only perhaps to emphasize the importauee of uon-interfer- oiice in all cases except iliose (lii-caHMiin^- life fi-oin lieniori-hage. Wounds of the Abdomen. — When a Uall enters the abdoinoii above the umbilicus and its course is con- lined above a plane passed throuj^h and at right angles to the long axis of the body at this point, non-interfer ence is justihable under the following circumstances: 1. The absence of symptoms denoting hemorrhage. 2. If the bullet is a small one, not larger than a number 32, especially if it is a number 22. :{. If there is an ab- sence of the clinical symptoms pointing to leakage into the peritoneal cavity from the stomach or bowels. 1. The impossibility of securing suitable surroundings and skilled sui-gical experience. When a penetrating or perforating wound of the abdomen occurs below the plane above indicated, and it is possible to employ clean methods, even though the operator may not be experienced, but appreciates the necessity and can, in a practical way, be surgi cally clean, no time should be lost in opening the ab- domen, searching for and repairing all damage in- flicted by the bullet. When a patient who has suffered a gun-shot wound of the abdomen, no matter where the wound be lo- cated, can be offered all the essentials of a modern, properly conducted abdominal section, no time should be lost after the receipt of the injury liefore the opera- tion is performed. (hin-shot wounds 'niroJriii!/ ho)irs and joints are of the nature of compound fractures. However, unless the wound be inflicted by a fi-agment of a shell, pellets from a shot-gun fired at close range, or a very large, possibly explosive bullet, the treatment to be followed is usually not that recommended for compound fra(^ tures. Ordinarily, Itullcts. especially those fired fi-om OUNSIIO'l' VVOIJM^H. 115 'iiiodeni p'ikIoIs and i-ifics, do noi cjiirv f<»r('igu bodies into llic wound. Tin; (rju.k oj' (Ik; wound is ul- inos(: invai'iably froe ffoni gei-inH; tliereforo, all dif^ital and inHdumcntal exploi-ilion is (o bo dofilorcd, as ex- perience has proven tliat these classes of injuries are followed by the least loss of life and limb by the ap plication, after antisepticisinft' the skin around about the wound of entrance or entrance and exit, of a pri- mary occlusive antiseptic dr(!M.i:i:.\ rKKAT.MKNi' ttr whlm'S. jtcr (fill, in ;i nciulihorin^ lu)S}(ilal ti) his own diiriuj; I lie <;iiiiii;rmii ill I lie ('aucjisus Iit*yli(.'r saw 7 cases of uiifoiiijilicaii'tl wounds of soft parts die of i)_vt'niia; under his own i)riniary antiseptie measures, he hist one such. In another series of G5 fractures treated secondarily by antiseptic rules, 23 died — 35.3 per cent. As illustratiu"; the reduced number of cases of pye- mia, altofjether of nI ainstaking digital and instru mental exi)loration and interference, such as has been suggested in the treatment of compound fractures ex- tensive in character. These are the kind of wounds in which clothing is apt to be carried into the tissues, fascia extensively lacerated and thus conduits opened for extensive infection. When a gun shot wound has become infected, drainage and antiseptic irrigation should be the rule. Amputation should only be re- sorted to when the vitality of an extremity has been distroyed or infection demands removal. Never probe a bullet wound unless the presence of the bullet in the tissues is giving rise to symptoms justifying its re- moval. Since reading the paper of Dr. Raymond (some of whose wounded were personal friends or old patients), in 1883, immediately after its publication, the writer has invariably followed Reyher's practice. All kinds GUNSHOT WOINDS. 11.7 of wouikIh li.'ivc^ l)('(*ii iiicL Willi uiul I lie rcHiills \\avi- almost hi\ aiiably hccn i'jivoi-ahic vvlicii (Ik* iiatiiri' ol the wound did not of ilscir roi* iIh- nicliiod ol ilH virtue. TREATMENT OF (iUN-SHOT WOUNDS Ol' Till'; K'IDNKV AND LIVKH. Among a numbcn- ol' (-uses of wounds examined by an American Hurge'on visiting in Athens two (victims of the Gra3co-Turkis]i war) of successful termination of gun-shot wounds of the liver without operation were observed. Heveral like results are reported by American Surgeons at Santiago. These results bring forcibly to mind three fatal cases in the writer's prac- tice. The causes of death from gun-shot wounds of the liver, when non-complicated, are shock and hemor- rhage, the usual mortality being about 85 per cent. When from the direction of the course taken by the bullet the indications are that a wound of the lower free border of the liver has occurred, resort should be had to abdominal section, the injury to the liver repaired, when practicable, by suture, and the ab- domen closed without drainage. When the nature of the injury demands, in addition to suture, resort to tamponade, drainage, of course, must be established. If other viscera are involved the usual surgical prac- tice in such cases should be followed. All other non- complicated gun-shot wounds of the liver should be treated by elevation of the foot of the bed, absolute rest, and the hypodermic administration of morphine. Ergotal, turpentine, and gallic acid may possibly be given with advantage, but strychnia hypodermically is impei'ative. Another important point is the fixa- tion of the right side of the chest and abdomen by adhesive strips put on over the primary occlusive dressing. The adhesive plaster should be arranged s'o as to form a splint encircling the right half of the chest and abdomen from just under the axillary folds to a point one or two inches below the anterior su- perior iliac spine. 118 MOI>i;iJ.\ ritKAT.MKNT Vl' WolNDS. The objfct (»r (rciitnu'nt in these casey is to coinbal shoek aud lavor the eessatioii ol" hemorrhage. The entrance of blood and bile into the peritoneal cavity is of itself comparatively free from danger, and in the ca^^es upon which the writer has operated, although there was a considerable (luantity of clotted and free blood in the abdomen, especially the right hypochon- driac regi(»n. the active hemorrhagi' at the time of operation was not alarming, but became so and con- tinued after the removal of the clots and the intro- duction of the gauze tamponade. This has so im- pressed itself upon me that I will hardly feel justified to again resort to such a procedure unless there is plausible evidence of injury of other viscera besides the liver. When there is a complicating wound of the kidney, the o])ei'ator should content himself with a retro-peri- toneal incision, by which the wounded kidney may be explored and drainage established. If, however, this incision should disclose that probably from the na- ture and position of the wound in the kidney (and the patient's generol condition) that a rapid intra-abdom- inal hemorrhage was taking place from the kidney, resort should be had to an immediate nephrectomy through a retro-peritoneal incision and free drainage provided. The leakage of a smaller or greater amount of urine into the peritoneal cavity from a wounded kidney, otherwise a healthy organ, is of small moment, and in both illustrations of complicating Iddney wounds is best managed by gauze drainage through retro-peritoneal incisions. Uncomplicated gun-shot (also stab) wounds of the kidney should be managed exactly as just recom- mended. There may be exceptionable instances when the trans-peritoneal route may be preferable, but even in case this may be chosen, an incision should be made in the loin for the purposes of drainage. A suggestion as to the method of controlling rapid hemorrhage from the liver following a gun-shot wound not accessible to suture may be worth men tinning. The wound of entrance should be exposed, GUNSHOT WOUNDS. 119 resort being had Lo resection ol" one or moic ;il>s il neeewsury, und tlu'oug']i tlie track of tlie wound jkihh a bougie or catlieter, by which means a gauze tampon or a non-])(!rl'orated i-ubbei- lulling may be drawn so as to compresw the whole li'a(;k of the wound, and thus control the bleeding. It i« only in a case of what promises to be fatal from hemorrhage that this or any other operative pi'Of-edui'e except as indicated above is justifiable. In my first case t'liere was a complicating wound of the kidney. Treatment was by abdominal section, removal of clots, gauze tamponade and drainage through an incision in tlie loin. The patient suc- cumbed from tlie continuance of the hemorrhage. Second case. The wound was confined to the li\er. Treatment was by abdominal section, removal of clots, gauze tamponade and drainage. Death from hem- orrhage. Third case. Complicating wound of the kidney. Treatment was by retroperitoneal incision and drain- age of the kidney; abdominal section, removal of clots, gauze tamponade and drainage. Death from continuance of hemorrhage. In the first and last cases the hemorrhage from the kidney itself was trifling. The abdominal incision in all eases was at the outer side of the right rectus muscle. I feel positive that the change for the worse, in each of these cases, immediately follo"wing opera- tion, was so marked that the intra-abdominal opera- tion was a mistake. Stab wounds of the liver which may or may not be perforating, according to the nature of the instrument and the position of the wound (usually, however, not perforating), are perhaps best treated by abdominal section and suture. A few cases, notably one oper- ated upon by Dalton, of St. Louis, would indicate that this is the correct line of practice. The position taken regarding the non-operative treatment of certain gun-shot wounds of the liver may not be in touch with the advanced ideas of the skirmishers on our line of surgical progress, but much 9 ILMI MODKltN TllKATMKN'r OK WOINUS. is bfiii^ h'iiriUMi bv Aiiicritaii surji(*<»iis, as a ri'sult of •nir war with Sjtain, rcjiardin^ tlu' siibjccl ()f gun- shot wounds, and this acquired knowledge will re- sult in a higher conservatism; a bi*lter aitpreoiation of the j)owers of nature. There are limitations for good. Theiv are boundaries too oflon overstepjx'd in our zeal to prove the "harmlessuess of a surgical operation aseptically performed."' The writer siiggesttnl, when discussing gun-shot wounds of the abdomen, that "When a patient who has suftered a gun-shot wound of abdomen, no matter whore the wound is located, can be surrounded bv all the essentials of a modei-n, ]n-oj)erl.v conducted abdominal .section, no time should be lost after the receipt of the injury before the operation is per- formed." This ought to be qualified and i"ead, ''ex- cept when the wound is of the liver and uncom])li- cated, or probably so," then the suggestions just made ought to receive due consideration. I'.TJIINH AND IltoST I'.ITIOS. (JHAPTER XIX. TREATMENT OF BURNS AND FROST-BITES. Burns vary so iiincli, both locally and const iiu- tionally, according to (lie causo, duration of tin; action of the cause, locality and area ol" the action of the cause, that it would seem well to briefly consider these points. Uncovered parts of the face, body, and extremities (especially among those unaccustomed to outdoor life), when exposed, during hot weather, for some hours to the rays of the sun, suffer burns, usually quite super- ficial in character. Explosions of gases are apt to produce large burns. Burning or superheated solids and liquids cause, in the former, deep burns; in the latter, extensive burns. Of the former, metals, phos- phorus, sulphur, and resinous substances; of the lat- ter, oils and viscid solutions are the most common agents. Ohemicals also cause inflammation, and in some cases destruction of the tissue in much the same way as hot or burning solids and liquids. The fire of ordinary combustible materials, — in fact, all causes of burns are dependent in their effects upon the length of time they act on the tissues and the ex- tent of the surfaces involved, varying from a simple reddening of a small area of skin or mucous membrane to a complete cooking or destruction of a smaller or greater part of the body. Besides the direct effect of burns upon the external body, numerous internal congestions and inflamma- tions may follow as complications. Among the early complications we sometimes observe congestions of the pharyngeal and laryngeal mucous membranes, usually resulting from inhalations of hot air or steam. These may be called primary complications. Later, complications are seen in congestions of the brain, lungs, and intestinal tract. The congestion of the up- per part of the intestine sometimes ends in the forma- tion of an ulcer, the well-known duodenal ulceration 'w hich. in rare instances, perforates. ILL MiinKKN rKKA'r.\ii:N'r oi' wiunks. The* lali' coiiijilic;!! ions arc iisiiallv sc*i»lic' in rliai- acter and aiv sonieiinu's uianit't'sied by iiiliaiiuualions of (he nu'iiin^cs of llu' brain, (ho ph'ura. (he liin<;.s, and tho jtoritoni'iiin. ( 'icai licial cDniraci inns arcom- pauyinji' (ho repair of a buni, whole iheie has beeu jfioator or less destruction of tissue, oftentimes re- sults in (h'l'orniily and less of runciion of llie parts involved. Formerly it was cusiomary to divide burns into six defjrrees. but a sinijiler classification is better and more coiiiiiiehensible. In jtractice we have to meet with those burns in which (here is: il.i Hyperemia (red- ness) and swelling;. Either no vesicles are formed and repair takes place by exfoliation of the epider- mis and iti-i replacement without su])pnration,— there is no scar, — or vesicles form tilled wi(li serum. The surfaces beneath tlie vesicles may or nuiy not suppu- rate. Repair takes place with some little discolora- tion of the skin, but there is usually \r\-y lit He scar tissue formed. (-.) More or less inllamed areas, with Aesications covering varying degrees of depth of skin reached by the causative agent. Sometimes the epi- dermis is destroyed and peels off easily, leaving a juicy, grayish surface beneath. Sometimes the tis- sues are dry, yellowish, or almost black. Both rep- resent lifeless tissues. In such cases the depth of de- struction depends upon the duration of the action of the cause. When due to direct action of fire, parts may become completely charred. Repair of burns of these seA'ere kinds takes place by granulation. Sloughs form in the moderately severe and bad bni-iis l^'illeroyj. In order to formulate a line of trealmen( we may adopt a classification dividing burns into four degrees, viz.: (1.) Burns in which there is reddening, erythema or hyperemia. (2.) Burns in which there is a forma- tion of vesicles or blebs, but which do not involve the (utis or true skin. {'.">.) Burns in which the entire dei)th of the skin is destroyed. (4.1 Burns in which there is the formation of sloughs or in which there is 'liai-i-ini;-. T.UItNH AND KROH'r-l'.rriOS. ]-S., Siiiil>iiiiis will be iiK'iil i(»iH'(i liisl, l>('<;iiisus are always sure to follow. Burns of the second degree are attended by the for- mation of blebs and vesicles, which are raised above the surrounding skin, and where the blebs are rup- tured the true skin is exposed. In the treatment of this class of burns the skin around the burn should be thoroughly scrubbed with soap, followed by alcohol and bichloride 1-1,000. Then with the thumb forceps and scissors all loose cuticle and all cuticle covering the blebs should be removed, after which the whole burn should be irri- gated with 1-5,000 bichloride or 1-100 carbolic. If the surface is a large one and the pain is severe, this, as well as the completion of the dressing, may be done under an anesthetic. Now as to the dressing. It must be remembered that whatever dressing is used it must be non-irritat- ing, and must be such that its removal will not disturb the wound. One of the best dressings is perforated oiled silk or gutta percha tissue applied directly to the burned surface. The perforations must be more than * A saturated sohitiou of picric acid iu water is a grt^teful application in all kinds of mild bnrus. Orthoform in powder or mixed with sterile vaseline J dr. to 1 oz. is anesthetic and antiseptic. li'i .MohKUN rui;Ai'.Mi:Ni oi' wor.Nns. nuTt' sliis; iln-v iinisi lie lai'j;v iMioiijili lo allow I'itc esfiiiH' of siMiim and I'Xiulalr. Over this is idacinl enough moist stiM-ilizcd jiaii/c lo absorb llu' cxiulatc, ami ilu'ii altsorbt'iil cotton covered with lyarallint' pa- per ami a bandage Another splendid dressing is earbolized vasi'line spread iij)on sterilized surgeon's lint. This form of dressing is always very grateful to the patient. In sovere burns of the third or fourth degree, in whirli iIkmc is a tendency to exulxM-ani granulation, the oiled silk or rubber tissue is i»erha[ts the better of the two mentioned, as it tends to keep down granulations. These two forms of dressings ha\ e at least two advantages over the dry dressings or dusting powders: First, there are never dried hard ciusts of secretion next to the burn; second, the dress- ing is easily removed and does not have to be softened with water "peroxide," etc., before its removal is pos- sible. The dressings should no! be removed before four or five days, unless the odor of decomposition is noticed. ^A'here the surface burned is too large or it is not pos- sible to follow out the antiseptic treatment given above, or when the patient is in a state of extreme shock, either from the burn or from other injuries, it is then not advisable to spend much time trying to appl^' an antiseptic dressing. In those cases where the life of the patient depends upon as (luick relief as jtossible, one of the best things at our dis})osal is absorbent cotton saturated with equal parts linseed oil and lime water.* This excludes the air, can be applied cpiickly, and thus reduces the danger from shock, the i)atient being almost at once jiut to bed and active restorative measures begun without delay. AA'here it is possible in these extreme cases it is best to give an anesthetic, which reduces shock and gives a better opportunity to dress the case properly; but the contra-indicalions to an anesthetic must be duly considered. *Tlic use (if linseed oil and lime water ("carron oil "). flour, etc., is not in line with modern snrgii-il tlicraiieutics and should be allowed only in the e)ner?;i-ncies of great sliock or when better dressings cannot be secured. lUJUNH AN]> KUOHT-JWTKH. 125 VV^haL Jias been siiid of lli<- liisi L>i:ii.\ lUKATMENT «>F WolNDS. aiiil lor iliis i»iir[i()sc siciTai*- of /iiir, taloiiu'l. clc. may be im-niitnu'il. Kxiibi'iaiit j;raiuilaiit>ns siu-li as (sjK)k('ii ol" iiiusi he kept down, 'i'liis i« very cll'ei'liiully iloiu- Willi solid sil\( T nil rale or I'lse by snippinj; ilu-ni (iir Willi sharp scissors; liic roiiiu-r usually ^Incs iln- bt'tlcr results. Skin jjrai'tiug plays a \ciy ini|ioriaiii jian in ihe treiitinvul of burns ol" ibe iliird and lourih degrees and should be resorted to more often than it is. First — Burns of large areas may be made to rei)aii* in one oi- two weeks which otherwise would reiniire months. i^econd — Cicatricial contraction may be hugely pre- vented. Third — The repair of sii]>i)uraling burns is very much hastened l)y grafting. Tlu? Thiersch method should be used, drafting should begin just as soon as the granulating surface is tirm, that is, when there are no flabby granulations. It is not nec- essary to wait until you have a wound free from pus, for I have repeatedly done skin grafting with perfect success where much pus was present. On the con- trary, skin grafting always cuts short suppuration; nor is it necessary to curette the surface before graft- ing, as some claim. Of course the wound should be made as clean as possible. A very excellent dressing is sodium chloride and calomel, in the itroportion of one of the former to fotir of the latter. 'J'liis to l)e a])- }>lied on the day before the grafting is done. Before grafting, the burn shouhl be thoroughly irri- gated with strong bichloride, followed by boracic acid solution. All bleeding points should be controlled by jiressure. Tlie grafts sliould be a}»plied to the granu- lation surface wliich has been sponged dry. as they ad- here much better to a dry surface. The dressing is the rubber tissue, oiled silk, or else sterilized or borated vaseline. The dressing should not be re- moved for at least four days, unless conditions of suj)- I»uration or something else should absolutely demand it. When the grafting has been done under aseptic conditions the dressing may remain much longer. <' harynx and esophagus) to the surface involved of a chemical having an opposite reaction, and at the same time being non-irritating in itself. Burns caused by strong acids should be treated by the application of an alkaline substance, such as bicarbonate of soda or lime water. These will neutralize the excess of the acid. Vinegar or any dilute non-irritating acid may be used in case of burns by strong alkalies. Milk and the white of eggs should be given after the swallow- ing of either strong alkaline or acid chemicals. Whis- 1_^ MODEUN TltKATMKNT OF WOINHS. kcv (H- hraiulv must hv adiiiiuisteivd after I Ik- atri- (Iciiial taking of c-arbolic atid. Alcoliol sd chaiigi's tlu' clu'inical action of carbolir acid as i(» render it praciically inert in its elVecl upon ihe tissues. The stoniacli may be washed out witli e(|ual ]>ai'ts of whis- key and walef or a iTt pel- cenl. soluiiou of alt oliol in watei". Ii preNcnts lis absofpiion as carbolic acid. and even mi^lil ad as an anli(h)ie lo carbolic acid poisoning; if y:iveu in large doses — one initial dose of two to four ounces. This may be repeated as often as indicated. The idea being to surcharge the system with alcohol, short of danger froui the alcohol itself. Surface burns from chemicals retjuire the same treat- ment as other burns. TREATMENT OK FROST-BITE. Frost-bites of exposed parts, as tlie ears, nose, cheeks, and lingers, need little or no arienlion unless the exposure has been of some considerable duration. Under such circumstances the re-establishment of ac- tive circulation in the pale, benumbed tissues is first brt)Ught about by frictions with a warm hand. As soon as it is observed that the circulation is return- ing, the parts may be rubbed with snow or bathed in cold water. The object in using snow or cold water being to overcome as far as possible too great dilata- tion of the blood-vessels in the frost-bitten parts after the return of the blood into their paralysed walls; also the return of the blood is gradually brought about. It is this local overdistention of the blood-vessels which permits of the clinical symptoms of inriammation. In fact it is practically impossible to prevent some redness and swelling with subsequent desquamation, but the continued local ap])lication of moist cold will tend to reduce inliammaiion and its conse(jueiices. An ointment of ichthyol and lanoline, one part in eight, is beneficial in the early desquamative stage. The lead and ojuum wash is also useful. Severe frost-hite, threatening the vitality of the dis- tal parts of an extremity, is a very serious alTair. BUUNS AND I'-ltOSr-JJITES. 129 :I1 is tlic i-('Siill;iiii nillaiiiiniil ion lollowiii;:, lin- rctiii-ii of I lie riiculiitioii in pjirtH not ubHoiiilcly ioii_v tranie is coucerued, shoiiUl be trealod as one l>oiu'. No attempt at fashioninji llaps after the uiclhods of tlu' textbooks should bo inado. The bones slioiild 1m- divided just above the i)oiiils wliei-e tliev are uiipiotefled bv the grauulaliug soft jiaiis. r.v i-aiiisiaking care of the grauuhitiug sur- faees and the use of Thiersch's Haps <;ood sei'vicabk.' stuiiii)S cau be secured with the sa» rilice of the small- est amount of tissue. The impressions of an earlv experience in lu.v pio fessional career may be related with prolii. hi ilic winter of 1881-1*, while the writer was connected with 1h(^ arm.v, two soldiers whose feet were badly frost- bitten were brought to the post hospital. These men were members of a hunting party. The felt boots which they wore had become wet during the day while walking through the melting snow. In the excitement of killing and butchering a buffalo just before dark they were ignorant of the changing tem- perature and the freezing of their feet and legs until camp was reached. Foolishly the frozen parts were first thawed out by the fire, they were then wrapped in blankets and the men sent to the hospital, where they arrived a few hours later. On admission the feet were swollen and of a ripe black-cherry color, the legs to the upper parts of the middle thirds were of a dark red color. Numerous bulhe had formed con- taining a prune juice colored serum. Wet antiseptic dressings were applied, over which cotton was wrapped. During the first twenty-four hours it looked as if nothing would stop the threatening gan- grene and that the result would be a loss for both men of their feet with the lower thirds of their legs. Cold water dressings were then begun, and a change for the better was soon noticeable. The cases re- sulted in each man having one foot removed at the medio-tarsal joint and the other about one and one- fourth inches below this line. Numerous opportunities for observing similar or even worse cases have since fallen to my lot, and in many instances I have been able to saAe, by the continued use of wet cold, parts lUJUNS AND FUOST-I'.rriOH. 131 tlial by any oUkh- (r<'u(iii(;ril would have surely been Hacri/iccd. IC cxd'ciniMcH wlii<-li liav(>st'dly ivliablc otlicrs are less relia- ble. Wben not safeguarded all are objectionable, be- cause they have to include in their canyiug out the personal equation of the individual. 11 ihe most ex- perienced, worthy, and reliable may lorgei at the criti- cal moment, when of all others he should remember,^ what must be expected of the one recognized by the courts, the one of ordinary skill and intelligence! Greater still than the dangers of infecting wounds by the surgeon, who uses ordinary diligence and skill, is the danger of infecting women after childbirth or abortion by the attending physician and nurse. The nature of the general practitionei's calling; treating all kinds of disease; coming and going at all hours; occasionally, because of necessity or preference, doing ''chores" about the barn, house, and office, — all this leads to a weaning away from the practice of ideal surgical cleanliness on his part, both as physician and surgeon. Besides it takes daily painstaking practice to successfully learn how to be surgically clean. Let it be granted, for the sake of argument, that a ])hysician in attendance upon the general run of cases, such as pneumonitis, pleuritis, typhoid fever, diar- rhea, headache, indigt^stion, constipation, and such like ailments, is practically free from the danger of conveying these ailments to other patients, (.'an the same be said of all forms of ulceration, abscess, phlegmonous inflammations, erysipelas, tetanus, puer- ]>eral s(>j)sis, diptheria, scarlet fever, etc.? i know that no physician would willingly cause unnecessary suffering and danger to those who have given him their confidence and ]ilaced theii" health and IJSIO OF IIUIUUOR (JAtJN'I'MO'rS Olt (U.OViOH. !•*■> lives iiJ liis kccidiij^, ;in(l il in in (his spirii lluii I wv^^a 11i(! liJibilnal use of Hlcrili/^cd fiiblxT ^Iovck or <;;miit lets, after cleaiiHirig' the liaiidH l).y some j4oo(l iiiclliDi), in every case where one's intelligence points out the advaiila^c lo (lie i>a(i('ii(. // sJioiild he the nih: (1) in obs('ra,ling upon all forms of septic cases; (3) in the examination and treatment of all forms of septic, infectious diseases, such as ery- sipelas, seplicemia, and pyemia, in which the hands conie in con (act with ])rimary and secondary foci of infection — and this rule applies to the nurse also; (4) in operating upon cleoAi cases soon after operations done upon infected ones; (S) in the examination of fresh wounds after recent examinations of, or opera- tions upon, dirty cases; (G) in abdominal sections fol- lowing vaginal operations upon the same individual — this may be reversed, wearing the gloves during the vaginal work, taking the gloves off or donning a fresh pair before beginning the abdominal work; (7) in all forms of rectal surgery. It is a matter of choice under other circumstances whether or no gloves be worn. However, there is no (luestion but that there is less danger of infection where gloves are worn than when reliance is x>la<:'ed in an attempted sterilization of the naked hands. An impervious cotton glove is perhaps quite as good as the rubber article. The ordinary cotton glove is not safe. During the time I have been using rubber gauntlets in my work I know that my results have been more gratifying than formerly. My work has covered a very broad field. The cavities of the skull, spinal canal, thorax, and abdomen have been invaded, besides many operations of election and emergency upon the neck, trunk, and extremities have been done, a sufficient experience to base an opinion upon, and my cases have been freer from all kinds of infection than ever before. Ever}- surgeon who is in the habit of doing a great amount of surgical work, if honest, will confess that suppuration occasionally occurs in his practice where least expected; it has done so in i;i4 mohkun tickat-Mknt t»i' woinus. mint', ir I lie wcni-ini; of sicrih' ruhhcr ^Mtncs will lessen ihe ilanj:»'r of infei-iion, we sluuihl wear theui. Oteasionally 1 lunc fell conipelled lo lake oil" the •jlovos in order lo < ariv (Hil soiuv' terhnique more sat- isfactorily, but siicli ails seldom occur now. There is liiile dilVerence in ladile seiisibilily iieiween the naked linj^^-rs and those covered with a well lil led, iiood-articled rubber glove. The advantaj^cs oul weigh the possible, in rare instances, lessened tactile aeute- ness. One dozen ]»airs of the best (jualitv can be bought for ^lo. Sterilized glycerine may be used lo lubricate the hands before drawing on the gloves. A glove that cannot be reasonably easy drawn over the hand after tilling the glove with sterile water is too small. "N'aseliue or grease ruins Ihe rubber. The gloves should be either boiled or wrapju'd in a lowid and jtlaced in a steam sterilizer. Lastly, rubber gloves are a ])rolection to the ydi.vsician and sui'geon against infection. Il^DEX. Abdomen, incise.d nnd pniicl m-cd wounds of, 40. wihere to open, 40. penetrating- wounds of, 41, 42, 41). stab wounds of, 41. flusliing and draijiing- of, 44. falls, kicks, and blows upon. 45. I^assage of wagons, etc., over, 4 5. contusion of, 48. gunshot wounds of, 114, 120. Abdominal, intra, lesions, ti'eatment of, 51. intra, hemorrhag-e and shock, 45. intra, hemorrhage, fatal, 48. section, 21 41, 44, 52, 53, 119, V.',?,. wall, non-penetrating w^ound of, treatment, 40. surgery upon battle-field, 42. viscera, lapai'otomy for gunshot wounds of, 43. walls, contusions of, 45. Abscess, compound inflamiuatorj' gravitation, 49. in infected joint injuries, 60. intracranial, 65, superficial, 100. Accidental wounds, treatment of, 26. materials for disinfection and dressing of, 26. location of, 26. kinds of, 27. hemorrhag'e in, 28. shock in, 29. punctured. 31. of 4th of July, 31. of hands and feet, 31. proper treatment of, 32. Adhesions, fibrinous, 56. Adhesive plaster, use of, in approximating edges of granulat- ing wounds, 23. use of, over antiseptic gauze in accidental wounds. 26. as a, primary dressing in sprains, 57. as splint over primary occlusive dressing in gunshot w^ounds of the liver, 117. bandage, 26, 23. Air aspirated into chest, 37. Alcohol, use as disinfectant, 24, 26, 62, 69, 72. 106. use of, in preparing catgut, 6. 7, 9. use of, in treatment of shock. 28. xise of, as a stimulant, 25. 63. use of, in preparation for operation, 106. use of, after accidental burns with carbolic acid. 128. effect of, upon nervous centers, 102. 10 (135^ i;u; INDEX. Aiiiputalion, iiulicalions for, 30, :>9. 110. demaiul of, 30. shoi'k hefori', 30. when to })erforni, 30, 63. IIG. in civil practice, 02. how to perform, 63. in erysipehis, 86. Amputation, treatment after, 63. in jiunshot wounds of knee, 11.j. in case of .'^evere frost-bite, 130. in case of cooked or cliarred cxliemity, 1:2;. Anesthetics, consideration of gfiving of, 124. choice of, OS. Ankk> joint, 32. Antiseptic surgery, 3, 84, 100. gauzes, 10. solutiooi, 24, 85, 129. dressings. 24, 25, 28, 38, 62, 72, 73, 86. 101. 1U4. 112. digital examination, 29. treatment, 39, 62, 74, 110. incisions, 58. irrigation, 62, 66, 8,). 110. technique, in compound fractures of long bones, 105. precautions, in operating, 107. poultices, 129. Antistreptococcus seriim, emploj'mcnt of. in acute and chronic infections, 63. Arm, effect of septic lymphangitis upon, 73. condition of, resulting from snake bite, 76. Arnold sterilizer, 10. Artery, intercostal, 38. internal mammary, 38. Aseptic surgery, what is understood by, 3. sterilization of hands in, 3. wounds, 59. 17 (supposedly), behavior of, 17. temperature during, 18. dressings of, 18. use of iodofoi'm in, 19, 20. treatment of infection of, 19. stitches, their extraction after. 20. Aspiration of intra-articular blood and synovial fluid accamu lations, 58. Assistants, wearing of rubber gloves by, 132, 133. washing of hands by, 132. Bacteria, 1, 87, 88. effect of, on wound healing, 1. shape and size of, 1. di\-isions of. 1. location and origin of, 1, 2, required tempera tiire for growth of. 2. effect of heat and chemicals upon, 3. Bandage, 9, 13. adhesive plaster, 23, 26. IN DION. l-iT I'iciiioi-iiic, swi III ion oi', f), i:i, r.i. :i1cIm)Ii()I, 7. of nici-ciiry, 7, H. ("ther, 9. wet clressiiig, 19. Bites, of insc(!ts, 74. syiu|)tonis result i ii^' rroiii iii.-ecl stiiif^.s ;i inl l)iis, 79. treatment ol', 79. Bladder, rnptui'e of, 49. character of, 49. history of accident of, 49. : proof of, 50. intra-peritoneal, 50. extra-peritoneal, 50. combined treatment of intra- and extra-peritoneal, 5:!, 54. nse of Harris instrument, Kelley cystoscope and uretei'al catheter in determining source of hematuria, 47, 48. Bleeding, cheeking of, in accidental wounds, 28. continuance of, result, 38. tying of mesenteric vessels to control intra-abdominal hemornhage, 48, 53. bleeding of post-mortem examination wounds, 74. Blood, amount of, in arteries during shock. 29. vessels, action of digitalis upon, 29. supply, destruction of, result, 30. flowing, antagonistic to germ growtli. 31. accumulation of, in pleural cavity, 37. overdistention of pericardium Avith, 38. evacuation of, from pleural cavity, 38. vessels, matei-ial for tying of, 44. in urine, 47. synovial fluid mixed with, 55. effused, incisions for evacuation of, in contusions, 5S. supply, 65. coagulation of, 76, extravasation and exudation of, ti6. poisoning, septic, 93. treatment of, 93. Boeckmann sterilizer, 10. Bone, frontal, 33, 34, 35. compound fractures of long, 103. treatment of shock accompanying, 103. use of antiseptics on protruding, 105. simple case of injury of, 107. use of plaster of Paris splints in case of Injured. lOS. destruction of. in leg or forearm, 109. treatment of, 109. 138 INUKX. Brain, pum-luied wounds of, 31, 33. locality of injuries of, 33. tissue, 33. treatment of injuries of, 33, 34. symptoms. G7, 08. injury to, duriny liirtli, 07. contusion of, 07, OS. compression of, OS. penetration of, OS. eare of. duriny operation, OS. injury to, by {gunshot wounds, 113. meninges of, inflammations of, 122. Bruises, treatment of, 27. Bullets, chest wounds caused by, 30. lung injuries caused by, 30. indications of force, size, and directions of, 37. wounds caused by, in abdomen, 41, 114. location of, bj- means of fiuoroscDpe and radiograph.-:, 113. treatment of all wounds caused bj', 114, ll.j. lacerated wounds caused by, 110. wounds of liver and kidney caused by, 117, IIS, 119. treatment of wounds caused by, 118, 119, 120. Burns, variation of, 121. area and locality of, 121. by gases, solids, liquids, and chemicals. 121, 127. 128. effect of, upon external body, 121. primary complications of, 121. later complications of, 122. classification of. 122. of sun, 12!!. of second degree, 123. treatment of, 123, 124, 125. infection of, 125. skin grafting in treatment of, 120. general treatment for shock caused by, 127. Carbolic acid, use of. in disinfecting. 5, 20. use of. in chromicizing kangarc o tendon. S. as an antiseptic solution, 10, 11. 17. as antiseptic irrigating fluid, 1-!. power of, as a chemical. 14, l.">. power of, as an antiseiJtic, I'J. poisoning and burning, use of alcohol in, 1;.'7, 12S. Carbonate of soda, 5, 10. Carron oil in treatment of burns. 124. Catgut, sterilization of. 0, 7. as prepared by supply houses, 7. Catheters, 51, 119.' u.se of. in rupture of bladder, 44. in diagnosis of. 50. Kellev's ureteral, use of, 47. Cellulitis," diffuse, 24. Cheese cloth, preparation for use, 9. Chest, penetrating wounds of, 30. treatment of penetrating wounds of, 38. gunshot wounds of, 114. INDEX. l->-J Chloride of calciiini, 5. of ]iiri(', 5. Chlorororm, (18, \)2. Cold applications, 80. ap|)lic!i1ion of ice to chest, 38. packiiig, 63. water, 128, 129, I.'IO. Compound wounds of joints, 49. fractures of sknll, 07. treatment of, 07. fractures of long bones, 103. Compressions of brain, 08, 112. Concussio]) of brain, 07. Contusions of scalp, 60. , simple, 37. of abdominal walls, 45, 49. of joints, 55, 58. of brain, 67. Corrosive, sublimate, power of, 14. Cupping, 79. Degrees of burns, 122. treatment of, 123, 124, 125, 126. Delirium, peculiarities of, in pyemia, 98. in erysipelas, 83. nocturnal, in pyemia, 97. Diagnosis of tetanus, 91. of penetrating wounds of chest, 36. dilTerential, between wounds of pericardium and iieart, 37. Diaphoresis, a feature of tetanus, 90. Diarrhea in septic blood poisoning, 93. in pyemia, developed after compound wounds of joints, 01. Digitalis, use of, in shock, 29. tincture of, 28. properties of, 29. action of, 29. Di-aiuage, 17, 20, 29, 66, 68. provision for, in antiseptic surgery, 4, 34. tubes, 11. free, 22, 65, 85. « open, for disinfection, 24. fenestrated rubber tubing, use of. for. 24. "through aaid through," 25. of brain, 34. in rupture of kidney, 53. in peritonitis, rupture of bladder, 54. Dressing's, 14, 17. stei-ile, 3. dry sterile, 9. moist antiseptic, 9, 26. of non-suppurating wounds, 17. in accidental wounds, 19, 20. in operations on infected tissues, 22, 23. antiseptic, non-irritating, 23. medicated, 23. antise]3tic, 30. 1 iu iM>i:x. Drugs, till' adiiiiiiistratioii of, 28. Dura, ()J<. JJyspnfii ill woiimls of perii-anliuin and hiari. :;?. Edema, !S:i. causing vosii-k's ai\il builte in i-rj'sipelas, 82. Kinac'iatioji in pyemia. ('>i. U)li. Eiuphysema iu compound fractures, JOU. iu wouuds of ehest, 37. in retro-peritoneal rupture of intestiue, 49. in extra-peritoneal rupture of bladder, 51). Empyema, saeeulated. of lower pleural cavity, '.)'.». Ei)it.helioma, dilVerentiation of, from "Dissecting porter's wart," 72. Ergot in hemorrhage from rupture of the spleen and liver. 51. Ergotal in gunshot wounds of the liver, 117. Erysipelas, definition of, 80. bodies deail from, 70. discovery of germ, SO. contagiousness of, 81. symptoms of, 82, of scalp and face. s:.'. s::. phlegmonous. S:!. gangrene in, 84. isolation of cases of, iu hospitals, 84. use of sterilized rubber gloves in, 84. treatment for cutaneous, 85. cellulo-cutaneoiis, 85. dressings in, SC. skin grafting after. 86. Esmareh tourniquet, G'J. "first-aid i)ackages," 105. Ether, Squibb's. 10. Extraction of stitches, 20. E.xtra-peritoneal rupture of the bladder, 50, 54. result, 51. E.xtravasation of blood, 27, 66. of urine, 24, 45. Face, erysipelas of, 82. wounds of, closed with care. 10. Feet, puncture wounds of, .'!1. frost-bitten, i:U). Fever, high, in infected wounds of hands and feet. 32. continued, in infected wounds of joints. (;2. in tetanus, 90. Forceps, dressing, 18. control of hemorrhage by. 15. use of, in extraction of an interrupted slitcli. 20. thumb. 123. Forearms, lower, 72. disinfection of, by physicians and assistants before oper- ations, 72. Foreign body in punctured wouiul of brain, 33. 34. in gunshot wounds, 115. INDBxV. 1 i 1 Fractures, conipoiind, oj: loiif4' bones, lO:!, lot, 105. extimjivaiioii and Ireaiment of, lOr). wae of pkiHter of Paris splints in, 108. more eon i plicated eases of, lO'.i. emphysenui al)OMl eonipoiind. 101). infected compound, 110. eompotind, of skid I, G7. treatment of, 07, OS, fii). J'^rost-bite, treafment of, \2S. severe, 1^8. gangrene in, 12!). treatment of, 129. Gangrene, development of, in erysipelas, 8.1, 84. clevelo])ment of, in frost-l)ite. 129. treatment of, 129. iji snake bites, 77. Gauze, nse in wounds for diainage. 9, 24. iodoform, pad, 16. preparation of, 10. sterilization of, 10. use of, for sponging wounds, 11. Genitals, external, insect bites of, 75. Gland or glands, removal of, in wounds of spleen, 44. suppurating, 74. incision and treatment of. 74. Grafting, skin, after burns, 126, 127. after erysipelas, 86. Granulation, exuberant, in burns, 124. 125. tissue, 122. conversion of matrix into. 7.3. Gunshot wounds, 112. of abdomen. 40. 114. of the skull, 112. 113. of brain, 113. of chest, 114. of liver and kidney, 117. causes of death from, 117. treatment of. 117, 118. uncomplicated, of kidney, 118. involving bones and joints, 114. laparotomy for, of abdominal viscera, 43. Gut, silkworm, sterilization of, 6. catgut, sterilization of, 6. as sold and prepared by supply houses. 7. ligation with, 15. Gutta percha tissue. 123. Hands, punctured wounds of, 31. disinfection of. before operation. 5. of tlie anesthetizer. in treatment of fractures of the skiill, 68. iiifected wounds of. caused by bite. 79. Head, tetanns. 90. injuries. 64. 142 1M)KX. ileart. woiimls of, ;!G, 37, o'.i. stimulants, in insect bites, 74. beat, after serjient bites, ~j. Hectie fever, 03. Hematuria, use of Kelley i-vstosi-ope and ureteral dilator-s in determining source of, 47, 48. life-threatening, 53. Hemorrhage, symptoms of, 37. internal, in rupture of spleeu and liver, 15. rapid intra-])eritoneal, 52. caused by rupture of kidney, o2. cause of swelling, in contusions of joints, 5S. in incised wounds of head, 04. treatment of, 04. Hernia, of the lung, 30, 39. radical cure of, use of kangaroo tendon in, S. supporters to prevent formation of, aftei abdominal sec- tion, 21. reduction of, 3'J. Incised wounds, 26. wounds, complicated, location of, 20, 27. wounds of special parts, 27, treatment of, 27. wounds of abdomen, 40, 42. scalp wounds, 04. treatment of, 04. Incision or incisions — through apparently ihealthy tissues to reach infected tissues, 22. made to I'elieve tension, 22, 25. made for evacuation of fluids, 22. wound irrigation after, 23. suitable, free drainage established by, 24. in 4th of Juh- wounds, 31. free, for inflammation, 32. direction of, 32. for evacuation of blood from pleural cavity, 3-<. in empyema, 39. in the loin, 47. median, 54. extensive, to check pyemia, 03. made through scalp, 69. multiple, in limb after snake bite, 78, 79. Infection, prevention of, 32. in wounds of mediastinum, 30. of compoimd joint injuries, 60. absence of, temperature in, 60. Injury, injuries — concealed, catised by punctured wounds, 31. of eye, 33. location of, to brain, 33. treatment of, to brain, 33, 34. complicated, 35. of joints, 60. INIHOX. JiiduiniiialiDii, IS, ;.'(), 22, 20. siipcrficiul, IH. m;\\i(: (■ii-c'iiiusci'ihcd, 2^!, 24. ill t'cctioiis, 2'l. Kiij)j^)iir;ilivc cellular, 24. incisions to prevcjii spread oJ! celhiliir, 25. in contused and lacerated wounds, 30. secondary, in ])iin<;1ia'ed wounds, 31. treatment of. in wounds of i'eet, etc., 32. secondary, in orl>it, 35. seoondai-y, in pericardia] wounds, 38. in compound vvoiiiuls of Joints, 59. in infected joint injuries, GO, 61. the result oi" post-mortem infection, 72. after insect strings or bites, 75. difFuse cellular, in serpent bites, 77. in erysipelas, 80, 83. cellulo-cutaneoiis, treatment of, 101. result of examination of track of bullet in skull, 113. Insect stings and bites, 74. treatment of, 74, 75. Instruments, sterilization of. 10. care of, 10. Intestine, intestines — opening into, injury- by puncture, 31. protrusion of, in wounds of abdomen, 40. gunshot and stab wounds of, 43. wounds of, best material for closing. 44. small, rupture of, 49. retro-peritoneal, rupture of, 49. indications of, 49. Iodine, tincture of, 79. as a disinfectant, 26. iise of, in snake bites, 79. Iodoform, 11. gauze, preparation of, 10. powder, 10, 19. gauze, 22, 25. packing, 23. property of, 95. Irrigation, irrigations — of fresh wounds, 14. antiseptic, in treatment of joint injuries, 62, 109. in erysipelas, 85, 86. copious, in septicemia, 94. in infected compound fractures, 110. antiseptic, in joint complications, 110. of burns, 126. Jaw, muscles of, involved in tetanus, 87. effect of tetanus upon, 89. Joints, complicated inc'sed w^ouuds near. 26. 27. sprains and contusions of, 55, 56. classification of Avounds of, 55. result of injuries of, 56. treatment of injuries of, 56. 57. compound wounds of, 59. 143 144 iNi>i:x. Joints — voinlinltd. cleanliness of ilressiuifs in, 59. wounds of, of np])or extremities, ;')<). ■ results of, 5'.t, GO. infeeteii eoiupouiul injuries of, GO, Gl. all kinds of, 60. treatment of punctured wounds of, G2. coniplieations of. in compound fractures. 110. jjunshot Nvounds involviu}^' bones and, 114, 115. Kangaroo teniloii. ()reparatit)u of. use of, 8. Kidney, rupture of, 45. cases in point, 45, 46, 47. nse of Harris instrument and Kelly cystoscope and ure- teral dilators in, 47, 4S. intra-i)eritoneal hemorrhage from, 5:.'. retro-jjeritoneal. •">-. treatment of. 5~. 5.'!. development of sepsis following. 5',. life-threatening hematuria, result of injury to, 53. rupture of. accumulating hemorrhage in pelvis following, 53. complicating gunshot wound of, IIS. uncomplicated gunshot wounds of, 118. Hit. Kitasato, tetanus bacillus, 87. Krug frame, 12. Lacerated wounds, siriousness of, 27. shock, resulting from, 27. examination of, ."37, 28. contused and, 27. careful antiseptic digital exaniinat ion of, 2it. of abdomen. 40. inflicted by teeth, 79. Laparotomy, for gunshot wounds of abdnmiiial viscera, 43. for gunshot and stab wounds of intestines. 43. mortality from, 43. benefit of, in battles, 44. Leiter coil, 62. Lesions, intra-abdominal, 45. Ligatures, sterilization of, C^. use of. in jjyemia. 102. Line of demarcation in frost-bites. 129. Liver, rupture of. 45. wounds of. 44. treatment of, 44. gunshot wounds of, 117. canses of death from, when non-complicated, 117. treatment of, 117, Lock jaw. See Tetanus. Lung, hernia, 36, 39. treatment of, 39. wounds of, 36. dangers of, 36. i.\i>iox. 145 Jj.v inpliaiif^ilis, 7li, 71. septic, 7.'i. .simple, isolated, 74. Ireatineiit,, 74. Marcy, preparatioji of lcfiiif>arno tondoii hy. 8. stitch of, siibciiticiilar, IG. Mediastiiuini, penetrating' wounds of, Ht>. Mici'ohic, iiirectloii, poisoned wounds, 70. Micrococci, J. Mitchell, Weir, 70. Moist dressings, lOl. antiseptic, in cellulo-ciitaneous erysipelas, 85, 86. in int'eetions intlanunations, 2i. in frost bite, 130. Morris, Hobert T., iise of ergot and vvariu water on infected burns, ]2r). Nails, infiainniations around and under, in post-mortem in- fection, 72, 73. Nasal cavity, infection from, in pnnctui'ed wounds of brain, 35. Nephrectomy, 53, 118. Nerve or nerves, 27. trunks, sewing of, in accidental wounds, 26. Nurses, precautions against carrying infection by, 85. Ointment, boracic acid, 23. Omentum, rupture of great, 4S, 49. Open drainage for disinfection, 24. Operations on infected tissues, 22. in private dwellings, 11, 12. outfit for, 11. Opei'ative wounds, 14, 16. Opium, use of, in infection, 25. in sliock, 28. Paget, 49, 71. Pasteur's treatment after bites by rabid animals, 79. Pei'itoneal, cavity, 50. intra, I'upture, 50. extra, rent, 50. intra, hemorrhage, 52. retro, rupture of kidney, 52. intra, rupture of bladder, 53, 54. extra, rupture of bladder, 54. combined treatment of intra and extra, rupture of bladder, 53, 54. Peritoneum. 47. Peritonitis, 46, 48. Pharynx, burns of. by cliemicals, carbolic acid. 127. use of alcohol in, 127. Phlegmonous erysipelas. S3. treatment of, S3. 84, Pitcher, 115. Plaster of Paris splints, lOS. use of. in compound fractures. lOS. 14G iMii;.\. I'oisonetl wuiimls, 70. roisuiiini*. c'iubdlii- aoid, 121. Post-mortfin. t'x:iininat it)n, is woiimls, TO. l)oisonin{jr, types of, 71. tri>atnuMit of, loL-al infection in, 72. \\oun(ls con.stitutional I'lloots of, 73. J 'oil It ices, 120. Pyemia, peculiar features of, Wi. symptoms of, '.K), 1)7. I'li-almont of, 1)7, 100. delirium of, OS. chronic, '.»•). complicated by septic phlebitis, 10J. Quinine, use of, in septicemia. 09. 102. Kectum, admiiiisti-at ion of uoiirisliincnt and water per. in pyemia, 102. Kesection of arteries and veins caused by bullets. J12. JUibber gloves, 106, 107. use of, 132. 133, 134. Rupture of spleen and liver, diagnosis of, l"). of kidney, 45, 46. of stomach and intestines, 48. retro-peritoneal, of intestines, 40. of bladder, 40. intra- and extra-peritoneal, 50. 51, 53. retro-peritoneal, of kidney, 52. of kidnej', 53. treatment of, 53. Scalp, wounds, 64. incised, treatment of, 04. contusions of, 66. swelling-s inider, in new born babes, 67. shavinpr of, in fracture of skull, 68. erysipelas of, 84. ])reparation of, in gunshot wounds, 113. Senn, use of hydrogen gas. 41. test for ruptured kidney, 49. Sepsis, development of, after retro-peritoneal rupture of the kidnej', 53. Sej)tic empyema, secondary. 36. inflammation, scalp wounds, 65. peritonitis, 70. lymphangitis, 73. blood poisoning. 93. treatment of. 03. Sei)ticemia, unusual form of, sapremia, 03. Serpent bites, 75. Shock, after accidents, 27, 28. treatment of, 28. stimulants in, 29. in penetrating wounds of chest, 37. symptoms of, 46, 51. INDKX. 147 tihoiik—foiirliKlrd. reaction i'l-om, I 10. treatnieiil oF, in hiii-ns, I'll. Silkworm giit, D. for i)i1x'iT(i|j(('(l slilclu^s, !.">. Silver wii't', .sl(!riiizatioii ol', <>. Slvin, wounds, G4. grafting-, 65. in burns, 126. disc'oioratioii oi', in erysipelas, 83. siong-hing of, in erysipelas, 85. disinfection of, 13. Skull, 65. fracture of, in contusions of scalp, GT. compound fractures of, vault, 67, 65. depressed fracture of, 68. treatment of, 68. wounds of, gunsihot, 112, 113. Specilic wound infections, erysipelas, 80. Spleen, rupture of, 45. Splints, use of, in contused and lacerated wounds, 30. plaster of Paris, in compound fractures. 108. Spong'es, preparation for use, 11. Sj)rains, cause of, 55. treatment of, 56. Sterilizers, 10. Stimulants, heart, 63. in erj'sipelas, 86. Stings of insects, 74, 75. Stitches, 19, 94. removal of, in scalp wounds, 64. catgut, 15. interrupted or continuous, 15. subcuticular, in wounds of face and neck. 16. and their extraction, 20. Stomach, rupture of, 48. washing out of, after carbolic acid poisoning, 128. Strychnia as a stimulant, 29. Sunburns, 123. Suppuration, in post-mortem poisoning of hands and nails, 73. of glands, 74. streptococcus of, 81. in erysipelas, 82. Suturing, 65. of llaps, scalp wounds, 65. wounds, 15. buried, in deep wounds, 16. tension, 16. materials, sterilization of, 6. Symptoms of hemoi'rhage in penetrating wounds of chest. 37. of shock, 46, 51. of joint wounds, 60. of erysipelas, 82. constitutional, in erysipelas, 84. of pyemia, 96. 148 INDIOX. Teclmiqiie, proparatt)r,\ , siirgk-iil, ;">. in iiioisetl ami punctured wounds, 4-1. Tendons, kangaroo, S. useof. in radical cure of hernia. 3. prcjKiration of, 8. injuries of, in sj)rains, oG. Tetanus, 87. characteristics of, 87. bacillu.s, 2. 87. clinical history of, S9. head, 90. oiaf;n()sis of, IM). acute, '.»1. prognosis in, '.»1. treatment of, Dl. 'I'liierscli's method of skin grafting, 120. 'i'oiirniquet, Ksmarch, li'J. elastic, 28. Ureter, blockii^g of, in rupture of kidn( y, 47. removal of, 47. I'l'ine, extravasation of, 45. bloody, 4G, 47, 50. blood. in, in rupture of kidney, 47. Vault, skull, compound fracture of, 67, OS. Veins, resection of, 112. Viscei-a, abdominal, involvement of. after penetrating wounds of abdomen, 41. laparotomy- for gunshot wounds of, 4o. Aolkmann sharji spoon, use of, in pyemia, 101. Warts, "Dissecting porter's," 72. a type of post-mortem poisoning, 71. location of, 72. Wounds, bacteria and, 1. effect of bacteria upon healing of, 1. inflammation of, caused by bacteria, ".'. operative and accidental, 14. irrigation and cleansing of fresh, 14. suturing, 15. non-suppurating, dressing of, 17. aseptic, supposedly, behavior of, 17, 18. treatment of infection of, 19. made into infected tissues, 22. accidental, 26. lacerated, 27. contused and lacerated, 29. punctured, 31. of hands and feet, 31, 32. of brain, 33. treatment of, 33, 34. penetrating, 36. of chest, 3G. treatment of, 3^" liNDKX. II!) Won lids — coiK-liiilfd. of pericardii! Ill imd liciiil, .'J?, .'JS, ;;'.). iric'isod and |)iinc1 ined, oJ' abdomen, 40. tiTaliiicnf of, 40, 41, 42, 4'-',. oi" joints, 55. classilication of, 55. compound, 59. of upper extroniitics, '>'.). ])iMictvired, (i2. treatment of, 02. of scalp, 64. incised, 64. poisoned, 70. post-iTiorteni or dissection, 70. treatment of, 72. constitutional ett'ects of. 7:!. specific infection of, 80. tetainus, a result of, 87. gunshot, 112. of skull, 112. of chest, 114. of abdomen, 114. Involving bones and joints, 114. 115. of kidney and liver, 117. treatment of, 117, IIS. COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE ^ f C2ail 140)M lOO ^ m i^-::"^ W:^:, tUf^'^" ^ •* RD131 Su6 Summers The modern treatment of wounds. „ COLUMBIA IJNIVFRSITY LIBRARIES fhsl.stx) The iiiiKliiin [ir, ill Vi/f)iinfls 2002125455 ■iit':'" ,